ASD 6

Autism spectrum DisorDers

Foundations, CharaCteristiCs, and eFFeCtive strategies

Second Edition

E. Amanda Boutot Texas State University

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Library of Congress Cataloging-in-Publication Data

Names: Boutot, E. Amanda, editor of compilation, author. | Myles, Brenda Smith, editor of compilation, author. Title: Autism spectrum disorders : foundations, characteristics, and effective strategies / edited by E. Amanda Boutot, Texas State University. Description: Second edition. | Pearson : Boston, 2017. | Includes index. Identifiers: LCCN 2015039818| ISBN 9780133436877 (alk. paper) | ISBN 013343687X (alk. paper) Subjects: LCSH: Youth with autism spectrum disorders—Education —United States. | Youth with autism spectrum disorders—United States. | Inclusive education—United States. Classification: LCC LC4718 .A87 2017 | DDC 371.9—dc23 LC record available at http://lccn.loc.gov/2015039818

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iii

BriEf ContEnts

chapter 1 overview of Autism spectrum Disorders 1

chapter 2 Evidence-Based Practices for Educating students with Autism spectrum Disorders 21

chapter 3 Working with families of Children with Autism 40

chapter 4 Environmental Arrangement to Prevent Contextually inappropriate Behavior 59

chapter 5 teaching students with Autism Using the Principles of Applied Behavior Analysis 79

chapter 6 teaching students with Autism to Communicate 96

chapter 7 social Challenges of Children and Youth with Autism spectrum Disorders 123

chapter 8 Daily Living skills 141

chapter 9 Effective Practices for teaching Academic skills to students with Autism spectrum Disorders 157

chapter 10 Play-focused interventions for Young Children with Autism 169

chapter 11 Assistive technology for Learners with Autism spectrum Disorders 181

chapter 12 Motor Consideration for individuals with Autism spectrum Disorder 192

chapter 13 sexuality Education for students with AsD 205

chapter 14 transition to Postsecondary Environments for students with Autism spectrum Disorders 217

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iv

ContEnts

Preface viii

Chapter 1 overview of Autism spectrum Disorders 1 Chapter Objectives 1 Case Study Examples 1

Introduction 2 Autism Spectrum Disorders 3 Diagnosing Autism Spectrum Disorders 4 Causes of Autism Spectrum Disorders 6 Characteristics of Autism Spectrum Disorders 8 Development of the Individualized Education Program 16

Summary 20 • Chapter Review Questions 20 • Key Terms 20 •  Internet Resources 20

Chapter 2 Evidence-Based Practices for Educating students with Autism spectrum Disorders 21

Chapter Objectives 21

Introduction 21 Evidence-Based Practices: Definition and Rationale 23 Unestablished and Fad Treatments 30 Child and Family-Centered Decision Making 33 Selecting an Instructional Approach 35

Summary 38 • Chapter Review Questions 39 • Key Terms 39 •  Internet Resources 39

Chapter 3 Working with families of Children with Autism 40

Chapter Objectives 40 Case Study Examples 40

Introduction 42 Getting the Diagnosis 42 Parental Priorities for Their Children with Autism 44 Impact of Autism on Parents 45 Siblings 53 Family Issues Across the Life Span 55

Summary 58 • Chapter Review Questions 58 • Key Terms 58 • Internet Resources 58

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Chapter 4 Environmental Arrangement to Prevent Contextually inappropriate Behavior 59

Chapter Objectives 59 Case Study Examples 59

Introduction 61 Motivation 62 Functional Assessment and Behavior Support Planning 63 Antecedent-Based Intervention 68

Summary 78 • Chapter Review Questions 78 • Key Terms 78 • Internet Resources 78

Chapter 5 teaching students with Autism Using the Principles of Applied Behavior Analysis 79

Chapter Objectives 79 Case Study Examples 79

Introduction to Applied Behavior Analysis 80 Using ABA to Teach Students with Autism 82 Using ABA to Teach Skill Acquisition (New Learning) 82 Variations of Instructional Focus and Delivery 89 Using ABA to Address Challenging Behaviors 92

Summary 95 •  Chapter Review Questions 95 •  Key Terms 95

Chapter 6 teaching students with Autism to Communicate 96

Chapter Objectives 96 Case Study Examples 96

Introduction 97 What Is Social Communication and Why Is It Important? 97 Communication Characteristics of Learners with Autism 103 Communication Assessment and Intervention 105

Summary 121 • Chapter Review Questions 121 • Key Terms 122 •  Internet Resources 122

Chapter 7 social Challenges of Children and Youth with Autism spectrum Disorders 123

Chapter Objectives 123 Case Study Examples 123

Introduction 124 Common Social Skills Deficits 124 Social Skills Assessment 128 Social Skills Training 130

Summary 139 • Chapter Review Questions 139 • Key Terms 140

CONTENTS v

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Chapter 8 Daily Living skills 141 Chapter Objectives 141 Case Study Examples 141

Introduction 142 Core Characteristics That Impact Daily Living Skill Deficits 143 Independence 145 Concerns When Skills Are Not Developed 145 Barriers to Learning and Dependence on Others 145 Challenging Behaviors 147 Daily Living Skills—Developmental Milestones 147 Instructional Strategies 149 Development of Goals and Objectives for Daily Living Skills 152 Measurement of Goals and Progress 152 Data Collection Procedures 153 Visual Analysis of Progress 154

Summary 155 • Chapter Review Questions 156 •  Key Terms 156 • Internet Resources 156

Chapter 9 Effective Practices for teaching Academic skills to students with Autism spectrum Disorders 157

Chapter Objectives 157

Looking Ahead: Academic Expectations That Impact Students with ASD 158 Academic Outcomes 159 Connecting Research and Practice 160

Summary 167 • Chapter Review Questions 168 • Key Terms 168 • Internet Resources 168

Chapter 10 Play-focused interventions for Young Children with Autism 169

Chapter Objectives 169 Case Study Examples 169

Overview of Play Characteristics and Issues for Young Children with Autism 170 Teaching Children with Autism to Play 174 Adapting Play Materials 175

Chapter Review Questions 180

Chapter 11 Assistive technology for Learners with Autism spectrum Disorders 181

Chapter Objectives 181 Case Study Examples 181

Introduction 182 Areas of Human Function 183

vi CONTENTS

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Assistive Technology Service Delivery Systems 188 Collaboration 189

Summary 190 • Key Terms 190 • Chapter Review Questions 190 •  Internet Resources 190

Chapter 12 Motor Consideration for individuals with Autism spectrum Disorder 192

Chapter Objectives 192 Case Study Examples 192

Introduction 193 The Importance of Movement 193 Movement Taxonomies 193 Why Is the Investigation of Motor Deficits an Important Question? 194 What Is the Evidence for Motor Deficits in Children with ASD? 196 Can Motor Impairments Be Part of Early Detection? 200 What Is the Importance of Physical Therapy? 201 Standard Motor Skill Assessments 202

Summary 203 • Chapter Review Questions 204 •  Key Terms 204

Chapter 13 sexuality Education for students with AsD 205 Chapter Objectives 205

Case Study 1: Understanding the Need for Sexuality Education 205 Sexuality Education 206 Teaching Sexuality Across the Life Span 207 Case Study 2: Teaching Sexuality Education Through Collaboration 208 Collaboration of the IEP Team 208 Choosing a Curriculum to Teach Sexuality 209 Individualizing Curricula with Evidence-Based Strategies 209 Case Study 3: Individualizing Sexuality Education Training 211 Building Sexuality Education Intervention Plans 211

Summary 216 • Chapter Review Questions 216 • Key Terms 216 • Internet Resources 216

Chapter 14 transition to Postsecondary Environments for students with Autism spectrum Disorders 217

Chapter Objectives 217

Introduction 217 Overview and History of the Transition Process and Services 218 Issues and Considerations in Transition Programming for Students with ASD 220 Autism Intervention Models and the Transition Process 222 Components of Effective Transition Programming 224

Summary 231 • Chapter Review Questions 231 • Key Terms 231 • Internet Resources 232

References 233

Index 261

CONTENTS vii

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viii

This is an introductory text on Autism Spectrum Disorder (ASD). When I began in this field as a graduate student and teacher in 1990, the prevalence was 5–10 in 10,000; today it is 1 in 68, with a recent survey suggesting it is even higher. Over the years, this field has seen not only extreme growth in the number of diagnoses, but also in the number of theories as to cause and treatment. Autism has always been a field fraught with myth and mystery, and has seen its fair share of snake oil salesmen and bandwagons. The truth is that it is still enig- matic; we know more about cause (genetics; not vaccines) than we have in the past, yet we are still without a cure. Until such time as a cure is discovered, education will remain the most important and validated tool we have to help these individuals and their families. I chose to teach at a university so that I could share with others the truths, as we know them today, so that they could help improve the lives of children and youth with ASD and their families on a regular, daily basis.

This book is intended for introductory courses on ASD at both the undergraduate (pre-service teacher) and graduate (pre- or in-service teacher) student. Given the increasing prevalence of children and youth with ASD in public schools and the extraordinary number of opinions and options for educating these students, this book will be valuable for current and future practitioners seeking a deeper understanding of ASD as well as a clear explanation of intervention strategies. This book will be useful for special and general education courses covering the autism spectrum, as well as other courses dealing with ASD such as psychol- ogy, applied behavior analysis, school psychology, speech pathology, occupational therapy, and child development.

The goal in developing this text was to provide a comprehensive, up-to-date, research- based introduction to and overview of Autism Spectrum Disorders (ASD) for future and current educators and other practitioners. The primary aim was to bring together, in one text- book, all of the things university instructors need to present a broad yet in-depth overview of ASD, rather than having to pull pieces from multiple sources. The book was developed to pro- vide necessary background information so that students studying the autism spectrum would (a) understand the disorder, including its many manifestations and associated characteristics; (b) understand and appreciate the issues faced by the families of children and youth on the autism spectrum so that students could more empathetically work with them; and (c) have sufficient information on the myriad instructional strategies from which students with ASD may benefit, and based on this knowledge, be able to make an appropriate decision as to which strategy may benefit a particular student and why. Most importantly, the purpose of this text was to provide sufficient information in major areas related to educating students with ASD so that current and future teachers would not have to fall back on what is found in the media, social media, or through their own sometimes limited experiences. One of the most important concepts a student in an introductory ASD course can understand is that no two individuals with ASD are alike, and there is no quick fix or “one size fits all” for this population. I hope this message is clear in this second edition of this text. The original goal was to create a resource so that future or current teachers could be informed consumers in the field of ASD, so that they could distinguish fad and snake oil from evidence-base and fact. This second edition continues with that tradition.

PrEfACE

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text orgAnizAtion

Instructors will find that the major issues and questions faced by teachers and future teach- ers of students on the autism spectrum have been addressed within this text. The expertise of multiple individuals from a variety of disciplines (e.g., special education, speech-language pathology, psychology, behavior analysis, and motor behavior) has been brought together to provide a comprehensive resource for professionals. As with the first edition, the book has been organized to follow the scope and sequence of an introductory course on ASD, and instructors of such courses will hopefully find the progression of information as useful for their courses as I do for my own. The goal was to provide both depth and breadth, so that current and future teachers of students with ASD have a solid foundation of knowledge on ASD with which to make important educational decisions for this population of students.

upDAteD AnD expAnDeD coverAge

In preparing this edition, I, the editor, considered both the ever-changing field of ASD as well as the expected knowledge and skills of the teachers who work with these students and expanded the text to include both more in-depth foundational information as well as broader contexts. The goal was to develop a text that could serve not only as an introductory text on ASD, but also as a resource for the professional working with students with ASD on a day-to- day basis.

new to this eDition

• We have updated the first chapter on the overview of ASD for the reader. Not only do we include the current Diagnostic and Statistical Manual of the American Psychiatric Association, Fifth Edition (DSM-V) diagnostic criteria, we also discuss the current prev- alence rate, and various characteristics of ASD that may impact how these students learn.

• In Chapter 2 we have provide an expanded overview of the research-supported strategies for students with ASD.

• As professionals, one of our most important assets in our work is the child’s family. Chapter 3 covers the impact of ASD on the family across the lifespan and discusses ways to improve communication and collaboration with this important constituency.

• When working with students with ASD, behavioral issues are often one of the largest hurdles teachers face. Chapter 4 presents a comprehensive overview of environmental modifications that can assist teachers in addressing these behavioral challenges.

• In chapter 5, we provide an overview of Applied Behavior Analysis, which is considered an evident-based practice for working with individuals with ASD.

• The updated and expanded chapter on Communication Interventions (Chapter 6) pro- vides more detail on the development of language for children with and without ASD, as well as more recent evidence-base on strategies for communication instruction.

• As with the previous edition, the Social Skills chapter (7) provides an in depth review of the socialization needs of individuals with ASD as well as current research supported strategies for social skills instruction.

• Because of the importance of daily living skills instruction for many students on the autism spectrum, Chapter 8 was also expanded to include current evidence-based strate- gies and program development considerations for teachers.

• As the spectrum of autism includes not only students who have daily living skills needs, but also those who require academic skills instruction, Chapter 9 provides an overview of the current literature on strategies relevant to teaching reading, math, and writing skills to students with ASD.

• An expanded Assistive Technology chapter (11) provides up-to-date evidence-based information for teachers, who regularly make important assistive technology decisions for their students.

PREFACE ix

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• Finally, Chapter 14 provides an expansion on Transition services for youth with ASD. The chapter includes strategies and resources for instructing secondary students with ASD and suggestions for preparing for post-secondary life.

• As previously stated, the field of autism is ever changing, and this second edition was designed to keep up with these changes. Three new chapters were added to improve upon the comprehensiveness of the text and to provide more breadth for teachers of students with ASD:

Chapter 10, Play Focused Interventions for Young Children with Autism Chapter 12, Motor Considerations for Individuals with Autism Spectrum Disorder Chapter 13: Sexuality Education for Students with Autism Spectrum Disorder.

FeAtures oF the text

Each chapter begins with learning objectives, which serve as an advanced organizer to guide the reader through the more salient concepts that are presented. At the end of each chapter are study questions, derived directly from the learning objectives, to promote self-reflection of the reader. Throughout each chapter we provide real-life scenarios, anecdotes, and case studies to support the concepts presented. In addition, we provide synopses of current or classic research (Research Boxes), which further support these concepts. Information related to diversity is infused in selected chapters throughout the text in Diversity Boxes. Trends and Issues Boxes provide current information on important topics in the field. Each chapter has a list of key terms to guide study and a list of Internet resources is also available in most chapters for those wishing to take their studies beyond the text.

AcknowleDgments

I would like to thank the individuals who helped in the revision of this text. I am, as always, grateful for the support of the Pearson editing team, Ann Davis, Lindsay Bethoney, Sridhar Annadurai, and Kerry Rubadue for their unwavering support and never-ending patience as my co-contributors as I endeavored to complete this second edition. I wish to also thank those con- tributors who assisted with these edits, to make old chapters new again: Gena Barnhill, Scott Bellini, Christina Carnahan, Tricia Cassel, Charles Dukes, Jennifer Durocher, Ketty Patino Gonzales, Melissa Olive, Jonathan Tarbox, Jennifer Loncola Walberg, and Elizabeth West. I’d also like to extend a warm welcome to the authors who contributed to expanded or new chapters, bringing their wisdom, experience, and expertise to the project to make it special and unique: Christie Aylsworth, Justin Aylsworth, Amarie Carnett, Clare Chung, Stephen Ciullo, Shana Gilbert, Mark Guadagnoli, Jennifer Hamrick, Amy Harbison, Kara Hume, Allyson Lee, Anna Merrill, Lyndsey Nunes, Amber Paige, Tracy Raulston, Tal Slemrod, Jason Travers, Amy Tostonoski, Lauren Tuner-Brown, Michael Wehmeyer, Peggy Whitby, and Dianne Zager.

I wish also to thank Dr. Brenda Smith Myles. Without her vision and her faith in me as an educator, an advocate, and a writer the first edition would not have been possible. Dr. Myles gave me confidence and encouragement early in my career and for that I am grateful.

Many thanks also go to the reviewers of the first edition: Kevin J. Callahan, University of North Texas; Thomas McLaughlin, Gonzaga University; Shanon Taylor, University of Nevada-Reno; Jane R. Wegner, University of Kansas; and Thomas Williams, Virginia Tech.

Finally, I’d like to thank my family: my children Georgia and Isaac; my mom, Essie; and my partner, Sam. Their encouragement and support were instrumental in completion of this project.

EAB

Austin, Texas

x PREFACE

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1

Overview of Autism Spectrum Disorders

Chapter 1

Ketty Gonzalez, ph.D.

tricia Cassel, ph.D. Psychologists in Private Practice

Jennifer S. Durocher, ph.D. University of Miami Center for Autism and Related Disabilities

allyson Lee, M.ed., BCBa Clinic for Autism, Research, Evaluation, and Support at Texas State University

CaSe of roBert Robert was only 7 years old and his parents had no idea how they would be able to manage getting him through the next 11 years of school. While Robert had always been a bit temperamental and knew what he wanted, his parents never had any significant difficulties parenting him until he began preschool at age 3.

From the time he entered preschool, Robert was ostracized by his peers because of his lack of social graces and high activity level. In fact, Robert was labeled as hyperactive from the moment he set foot in school. He would not sit down during Circle Time, refused to share his toys, and would frequently hide under a table. Robert’s mother took him to his pediatrician, who felt that Robert was a little overactive but that he would “grow out of it.” Unfortunately, things continued to go badly in school. Robert always seemed upset about something and occasionally bit or physically fought with his peers. Time-outs had no effect, and he was kicked out of two pre- schools. Robert was labeled a bad seed. Robert’s parents did not understand why Robert would behave this way at school, while at home he could spend hours with his trains. They started to believe that the teachers were right and that they were doing something wrong.

Unfortunately, kindergarten was not any better, and his teacher sug- gested that Robert may have Attention-Deficit/Hyperactivity Disorder (ADHD). A school psychologist confirmed this suspicion. Then, in addition to his aggressive behavior, Robert began to lag behind his classmates in penman- ship and coloring. He was also terrible at sports and always the last child picked for a team. Robert started getting stomachaches every morning before school.

By the time Robert entered first grade he hated school and wondered why he did not have any friends. His parents started to consider home- schooling him. At home, his parents were sometimes puzzled by Robert. His facial expressions did not always match his mood and sometimes he would have explosive meltdowns, making his parents feel as if he were a time bomb ready to explode at any moment. His parents also began noticing that Robert did not understand jokes and had difficulty following movie plots. They began to worry that perhaps he was not very intelligent. In addition to diagnosing Robert with ADHD, doctors suggested that he may have early-onset bipolar disorder, which could explain Robert’s explosive behavior. Something called Oppositional Defiant Disorder was also mentioned. In the summer between first and second grade, Robert attended a summer camp,

CaSe StuDy Examples

Chapter ObjectiveS After reading this chapter, learners should be able to: 1. Describe the characteristics of

Autism Spectrum Disorders. 2. Explain how Autism Spectrum

Disorders are identified and diagnosed.

3. Identify the changes in the definition of Autism Spectrum Disorders.

4. Discuss causal theories associated with autism.

5. Describe instructional planning for students with autism.

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2 chApter 1 • Overview Of AutiSm Spectrum DiSOrDerS

and one of the counselors suggested to his parents that an assessment test for Asperger Syndrome (AS), a form of autism, should be given to Robert. His parents took him to a university-based clinic, where they were immediately told that while Robert certainly exhibited many symp- toms consistent with ADHD, a significant number of his problems were not explained by ADHD. After a thorough assessment, Robert was diagnosed with Autism Spectrum Disorder. Recommendations included treating the co-occurring ADHD symptoms through a combination of medication and behavioral techniques, specific behavioral recommendations, school accommo- dations, plus therapies for specific deficits. Robert’s parents were worried, but relieved, with the diagnosis. At this time, Robert is getting ready to start middle school. Although things are not perfect and he continues to struggle, he has made much progress socially and has one good friend who is described as somewhat odd himself. However, the match between the two of them has done wonders for Robert’s self-esteem and he enjoys going to school again.

CaSe of JaCoB Jacob’s parents first became concerned about his development when he was around 18 months old, when they realized he was not talking, or even babbling, like other children his age. As Jacob got a little older, he showed limited interest in playing with his toys and tended to line them up or examine them while waving them in front of his face. He occasionally babbled, but this bab- bling did not seem to be an attempt to communicate. In fact, Jacob rarely communicated with his family unless he wanted something. Even when something was important to him, he rarely made eye contact with his mother or smiled at her. Jacob frequently flapped his arms, spun around in circles, or tensed his body when he was upset or excited. Jacob’s parents had him eval- uated when he was almost 3 years old. Results of the evaluation indicated that Jacob had severe deficits in the primary areas associated with Autism Spectrum Disorder. Jacob is now 5 and con- tinues to flap his arms and rock back and forth. He does not have friends, nor does he have any interest in other children. Although he can be loving with his family, it is always on his terms. Jacob is able to say several words, but mainly uses pictures to communicate with his family. He is obsessed with Thomas the Tank Engine and carries a train with him wherever he goes.

IntroduCtIon

One in 68 individuals in the United States is diagnosed with an Autism Spectrum Disorder (ASD), according to the Centers for Disease Control and Prevention (CDC, 2014). This rep- resents a substantial increase in overall prevalence over the last two decades. In 1990, for example, that figure was 5 to 10 in 10,000. In fact, autism is the fastest growing childhood disorder and is more common than childhood cancer, cystic fibrosis, and multiple sclerosis combined (Autism Society of America, 2008). Teachers in public schools today will almost certainly encounter a student with ASD, and for those entering the field of special education, the chances are probably greater that you will win the lottery than not have a student with ASD during the course of your career. Autism is a relatively recent disorder, having only been recognized in the early 1940s. Therefore, what we know and understand about ASD is still in its infancy; there is still much unknown and misunderstood about this exceptionality. The purpose of this chapter is to provide the reader with a basic overview to help guide under- standing of the complexities of ASD as well as changes to the diagnosis. This text is written for teachers who are new to the field and for those who have taught children with autism for years. It is our intention that the information provided herein will aid you in providing the most successful learning experience possible for your students with ASD. The field of ASD is ever-changing; what we understand of ASD today is far different from what we knew of yesterday, and this will likely not be the same as that of tomorrow. Teachers are encouraged to remain current on the research, trends, and issues related to educating students with ASD, because information continually shifts and changes. The more the teachers understand the students they teach, the better able they are to teach them.

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chApter 1 • Overview Of AutiSm Spectrum DiSOrDerS 3

autIsm speCtrum dIsorders

Until recently, there were five Pervasive Developmental Disorders listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR; American Psychiatric Association [APA], 2000), the publication that psychiatrists and psychologists use to diagnose psychiatric disorders, psychological problems, and learning difficulties, among others. However, with the release of the fifth edition of the DSM, diagnostic criteria have changed. Rather than three disorders making up the formerly Pervasive Developmental Disor- ders one label of Autism Spectrum Disorder will categorize all these children according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

Classic autism

When a layperson thinks about a child with autism, he probably visualizes the child as having what clinicians may call classic autism. While autism is no longer a separate category, it will be referred to as classic autism for ease of understanding throughout the rest of the chapter. Classic autism was first described in 1943 (Kanner), but was not included in the DSM-III until 1980. To date, the definition in the DSM has been revised four times. Children with classic autism may be nonverbal. Alternatively, they may have significant language difficulties, so that their language may consist primarily of echolalia (immediate repetitions of what they hear) or delayed echolalia (repetitions of what they have heard from others prior to three conversational turns)— very commonly from television. Approximately 25% of these children may show normal lan- guage development when very young, but then regress and lose their skills (Volkmar & Klin, 2005). Children with classic autism are commonly not interested in other children, and those who are may not express this desire in a typical way. These individuals also experience behaviors commonly identified in the third group of symptoms. That is, they may rock back and forth, flap their hands, and show special interests in unusual objects or topics. However, these behav- iors may not manifest until the child is approximately 3 years of age (APA, 2000), which means that if a child is formally evaluated at age 2, he may not meet full criteria for a diagnosis.

Many children with classic autism also have below-average intelligence, with some esti- mates suggesting that approximately 75% of children with autism have a cognitive disability (Edelson, 2006). Children with classic autism are sometimes classified based on their intelli- gence quotients (IQs): Those with higher IQs (i.e., standard scores above 70) are referred to as having high-functioning autism (HFA) and those with IQs below 70 (the cutoff for mental retardation) are referred to as having low-functioning autism.

It is well established that children with autism are more likely to be male than female. Estimates from the CDC suggest that five boys are diagnosed for every girl diagnosed. Some research suggests that girls affected with classic autism are more likely to be severely impaired (Brown, 2004; Roberts, 2003), so the ratio of boys to girls is even higher in high- functioning children with autism and those with AS. Despite gender differences, there are no known racial or ethnic differences is ASD (see Box 1.1). However, in the United States, children who are Hispanic or Native American have been found to be less likely than their White, Asian-American, or African American classmates to be identified with autism for special education (Tincani, Travers, & Boutot, 2010).

Clinically, children with Autism Spectrum Disorders often display a flat affect or a lim- ited or depressed range of facial expressions. At other times, however, they may display an overly exaggerated affect. A common mistake among professionals is thinking that because a child seems attached to his parents, he cannot have ASD. In fact, many children with ASD are very attached to their parents (Rutgers, VanJzendoorn, & Bakermans-Kranenburg, 2007).

asperger disorder

Asperger Disorder was first identified by Hans Asperger, an Austrian pediatrician, in 1944. Dr. Asperger described a group of boys who had difficulty engaging in social interaction and noted that many of these boys’ family members evidenced similar difficulties. AS was not

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4 chApter 1 • Overview Of AutiSm Spectrum DiSOrDerS

introduced in the United States until 1991, when Dr. Asperger’s original paper was translated into English (Frith, 1991). It was removed as a formal diagnosis with the publication of the fifth edition of the DSM.

According to the DSM-V there are two main areas impacted in ASD. The first area relates to deficits in social communication and social interaction, which is defined by deficits in social-emotional reciprocity, deficits in nonverbal communicative behaviors, and deficits in developing and maintaining relationships. The second area relates to restricted, repetitive patterns of behavior, interests, or activities. Deficits in the second area are defined as stereo- typed or repetitive speech or motor movements, excessive rigidity and adherence to routines or resistance to change, restricted interests, and hyper- or hypo-reactivity to sensory stimuli. In addition, these symptoms must be at least partially present in childhood, although deficits may become greater as children’s age and social demands increase. The symptoms in the two areas must also impair everyday functioning.

Although prevalence is not known, it is estimated that less than 5% of children have AS (Baird et al., 2000; Chakrabarti & Fombonne, 2001; Ozonoff & Rogers, 2003; Sponheim & Skjeldal, 1998). It has been fairly well established that approximately four out of five chil- dren diagnosed with AS are boys, although there are some estimates placing this ratio at 8:1 males over females (Chakrabarti & Fombonne, 2001). Recent CDC (2014) estimates state that approximately five males are diagnosed with ASD for every female.

Children with ASD in schools are frequently identified according to the Individuals with Disabilities Education Act (IDEA) criteria (see Figure 1.1). Not all, however, are served under IDEA; some have an individualized 504 Plan and receive modifications and accommo- dations under Section 504 of the Rehabilitation Act.

dIagnosIng autIsm speCtrum dIsorders

The diagnosis of ASD has received a lot of attention from parents, professionals, and researchers in the past few years. Diagnosing a child with classic autism has been made much easier with empirically based instruments that have been developed in the past few

Box 1.1 dIversIty notes

A commonly accepted premise today is that autism “knows no racial, ethnic, or social bound- aries” according to the Autism Society of America. Unfortunately, the accuracy of this premise is called into question as researchers (and clinicians alike) have tended to pay little attention to racial and/or cultural differences in autism. Dyches and colleagues present a provocative paper raising a number of questions for further examination in the field. Specific questions for consideration included:

• Are there differences in the prevalence of autism across race/ethnicity? • Are there factors that may influence children from different races/cultures who are

identified as having ASD (including cultural differences in how symptoms are viewed and defined, stigmatization of disability status, potential bias from clinicians in diag- nosis, etc.)?

• Are there differences in family adaptation to the autism diagnosis?

Dyches and colleagues suggest that the relative paucity of research into the specific challenges faced by families from diverse backgrounds should be a concern to the profession- als who work with these families. Because of the paucity of research in this area, what we know about the characteristics of best practice in assessment and intervention for ASDs may not apply to individuals and families of different cultural, racial, and/or ethnic backgrounds.

Source: Information from Dyches, T. T., Wilder, L. K., Sudweeks, R. R., Obiakor, R. E., & Algozzine, B. (2004). Multicultural issues in autism. Journal of Autism and Developmental Disorders, 34, 211–222.

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years. However, diagnosing a higher-functioning child or adult, despite age, is part sci- ence and part art. Research, however, shows that the diagnosis of ASD made by a clini- cian is relatively stable (Chawarska, Klin, Paul, & Volkmar, 2007; Turner, Stone, Pozdol, & Coonrod, 2006).

When diagnosing ASD, the clinician (a psychologist, psychiatrist, or physician) will meet with the parent(s) and the child. Various tools may be used to help make a formal diag- nosis, yet no single assessment measure is considered the one for diagnosis. Further, in public schools, the definition may not include any specific assessment measure, although schools routinely use some formal measurement tool when determining eligibility of special educa- tion. Descriptions of some of the measures used by clinicians as well as school psychologists follow.

The Autism Diagnostic Interview—Revised (ADI-R; Lord, Rutter, & Le Couteur, 1994) is a comprehensive interview conducted with the parent or caregiver of the individual being assessed. It is designed to assess the extent of autistic symptoms in individuals with a mental age of 2 and above. The 85-page interview booklet with 93 items takes approximately 1½ to 2½ hours to administer and score. Questions in the ADI-R are in the following sections: background information, introductory questions, early development, loss of language or other skills, language and communicative functioning, social development and play, favorite activi- ties and toys, interests and behaviors, and general behaviors. Despite its length, it is still only one piece of the diagnostic puzzle and should never be used as the sole diagnostic tool. It is frequently used for research and is an important clinical tool, but can be cumbersome and time consuming.

The Autism Diagnostic Observation Schedule—Generic (ADOS-G) is a semi- structured assessment designed to assess the three areas of impairment associated with autism that were defined in the DSM-IV-TR (Lord, Rutter, DiLavore, & Risi, 1999). It takes approx- imately 30 to 45 minutes to administer. The ADOS-G consists of four modules, based on the cognitive and language levels of the individual being assessed. For instance, Module 1 is for young children or children with no language, while Module 4 is administered to adults who speak in full sentences. Modules 1 and 2 are largely play based and assess constructs such as joint attention (defined as the process of sharing one’s experience of observing an object or event, by following gaze, or pointing gestures), reciprocal play, social interest, and eye contact. Modules 3 and 4 assess imaginary play, but are largely interview based, particularly Module 4. Interview questions focus on social stressors, descriptors of emotions, adaptive behavior, and daily life events. Both modules provide an opportunity for the assessment of language and con- versational skills, appropriate eye contact, and imagination. All modules of the ADOS-G allow for an assessment of repetitive and stereotyped interests and behaviors, although these do not form part of the diagnostic algorithm (i.e., the way we quantify the findings to decide whether the individual meets criteria for ASD).

The Social Communication Questionnaire (SCQ; Berument, Rutter, Lord, Pickles, & Bailey, 1999) is a 40-item questionnaire that contains the algorithm items from the ADI-R in a yes/ no format. Designed to screen for ASD, there are two forms of the SCQ: the lifetime and current versions. The current version investigates the child’s behavior over the past 3 months.

Autism: A developmental disability significantly affecting verbal and nonverbal communi- cation and social interaction, generally evident before age 3, that adversely affects a child’s educational performance. Other characteristics often associated with autism are engagement in repetitive activities and stereotyped movements, resistance to environmental change or change in daily routines, and unusual responses to sensory experiences. The term does not apply if a child’s educational performance is adversely affected primarily because the child has a serious emotional disturbance as defined below.

From http://www.ericdigests.org/1999-4/ideas.htm, retrieved March 11, 2008.

FIgure 1.1 IDEA Definition of Autism

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The lifetime version assesses ASD symptoms across the lifetime of an individual, with a partic- ular focus on the time when a child was between 4 and 5 years of age.

The Social Responsiveness Scale—Second Edition (Constantino & Gruber, 2012) is a 65-item rating scale that measures the severity of autism spectrum symptoms, including social impairments, social awareness, social information processing, capacity for recipro- cal social communication, social anxiety/avoidance, and autistic preoccupations and traits as they occur in natural social settings. It is completed by a parent or teacher in 15 to 20 minutes.

Also available to assess autism symptoms are several screening instruments, including the Modified-Checklist for Autism in Toddlers (M-CHAT; Robins, Fein, Barton, & Green, 2001), Asperger Syndrome Diagnostic Scale (Myles, Bock, & Simpson, 2000), and the Childhood Autism Rating Scale (Schopler, Reichler, & Renner, 1980). However, some of these instruments have limited standardization and may not be appropriate for children across a variety of age and ethnic groups. Thus, while you can get an impression of the child’s symptoms by using one or more of these scales, clinical experience and knowledge are an integral part of the diagnostic process. For instance, you may need to do something more unconventional, such as taking an adult to lunch to see how she reacts to social situations. For children, observing a child at school lets one know how the child interacts with his peers during recess versus one-on-one in an adult’s office. Such observations are critical, particularly when working with children who are considered higher functioning.

In addition to obtaining a valid estimate of a child’s level of ASD symptoms, a clini- cian or the school team should obtain a reliable estimate of the child’s functioning in other areas, including adaptive behavior and cognitive functioning. Adaptive functioning refers to a child’s ability to care for himself. For instance, young children should be able to tell a parent if they are hurt or do not feel well. Teenagers should be capable of fixing simple snacks and meals for themselves and independently addressing personal hygiene needs. Unfortunately, research and clinical experience show that even children with ASD who have high IQs show delays in adaptive functioning (Barnhill et al., 2000; Lee & Park, 2007; Myles et al., 2007). There are many questionnaires designed to assess a child’s adaptive functioning. Two of the most popular are the Adaptive Behavior Assessment System (Harrison & Oakland, 2003) and the Vineland Adaptive Behavior Scale (Sparrow, Balla, & Cicchetti, 2005). Both measures have par- ent/caretaker and teacher forms.

In addition to adaptive behavior, it is also important to gain a valid estimate of a child’s cognitive abilities. The most commonly used instruments to test children’s cognitive abilities are the different Wechsler scales (e.g., the Wechsler Preschool and Primary Scale of Intelligence—Third Edition [WPPSI-III; Wechsler, 2012] and the Wechsler Intelligence Scale for Children—Fourth Edition [WISC-IV; Wechsler, 2004]). Other scales, such as the Mullen Scales of Early Learning (Mullen, 1995), the Stanford Binet—Fifth Edition (Roid, 2004), the Differential Abilities Scale— Second Edition (Elliott, 2007), and the Kaufman Assessment Battery for Children—Second Edition (Kaufman & Kaufman, 1983), can also be used with young children and/or children with limited verbal abilities.

Causes oF autIsm speCtrum dIsorders

historical Context

As recently as the 1980s, practitioners believed that the cause of autism was what was termed Refrigerator Mothers. Specifically, Bruno Bettleheim (1967), a psychologist in the 1960s, believed that autism was caused by the child’s parents (the mother in particular) not providing love or attention and was, in fact, cold to the child—hence the term refrigerator. Ivar Lovaas, well-known behavioral interventionist, also held this belief. The common practice of the day was to remove the child from his parents and place the parents in psychotherapy. Today, thanks to the work of individuals such as psychologist Bernard Rimland (1964), a father of a child with autism, we understand that autism is not caused by parents.

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role of environment

The exact cause of ASD is unknown; however, genetics is the leading suspected cause. Some believe that the environment plays a role in the development of autism as well as genetics. Environmental contributors have been theorized to include pre-, peri-, and post-natal factors (such as second and third trimester uterine bleeding, Rh incompatibility, high bilirubin levels at birth, and oxygen supplementation at birth). While other environmental culprits, such as vitamin deficiency, allergies, and toxins, have been suggested, no research exists confirming these as sole (or in some cases even contributing) causes of autism.

genetics

Researchers, practitioners, and parents are all invested in investigating possible causes of ASD. Research clearly indicates that ASDs have a genetic component (cf., Bolton, Macdonald, Pick- les, & Rios, 1994; Constantino et al., 2006; Constantino & Todd, 2003; Landa & Garrett Mayer, 2006; Pickles et al., 2000; Rutter, 2000; Veenstra Vanderweele & Cook, 2003; Watson et al., 2007; Zwaigenbaum et al., 2005). Although the extent of this relationship has not yet been determined, and no single gene has been identified as a cause in every case, “approxi- mately 5% of individuals with autism have an identified chromosomal abnormality” (Whit- man, 2004, p. 120). Faulty genes have been found on the long arm (q) of chromosomes 2, 3, 6, 7, 13, and 15 and on the short arm (p) of chromosomes 1, 11, 13, 16, and 19 (Whitman, 2004, p. 121). According to Whitman (2004), the “most commonly reported anomaly in research studies is the duplication of a section of the long arm of chromosome 15” (p. 120). Various autistic characteristics are associated with varying locations of genetic differences. For example, the 7q region impacts the development of the frontal, parietal, and temporal lobes, all of which are associated with significant functioning in autism, and speech delays are linked with an area on chromosome 2 (Whitman, 2004).

The role of genetics in autism has been clearly established. Research indicates that sib- lings of a child with autism also have a risk of related difficulties. More than 10% of siblings of children with autism show deficits associated with an ASD diagnosis, such as abnormali- ties in eye contact, imitation, social smiling, and disengagement of visual interest (Landa & Garrett Mayer, 2006; Zwaigenbaum et al., 2005). Deficits in language and cognitive abilities have also been noted in ASD siblings before the age of 5 (Watson et al., 2007), which is much higher than the risk for the general population. Other research indicates that if one identical twin has autism, the chance for the other twin to have autism is 60%, but that the risk for the twin to be somewhere on the autism spectrum is 90%. However, if autism was caused purely by heritability, we would expect the concordance rates of identical twins to be closer to 100% (Ozonoff & Rogers, 2003; Rutter, 2000).

Other psychiatric disorders, such as depression or anxiety, are found at higher-than-average levels in family members of those with ASD. Researchers have even proposed that a broad autism phenotype exists within families (Goin-Kochel, Abbacchi, & Constantino, 2007). Box 1.2 discusses these issues. This refers to a set of autistic-like subclinical symptoms in members of the families of children on the autism spectrum. Symptoms range from slow or impaired

Box 1.2 researCh notes

Children with early-onset psychotic disorders or bipolar disorder can also frequently appear to have autism. In fact, some children with chromosome deletion disorders can appear to have autism, a psychotic disorder, or both (Vorstman et al., 2006). Children with ASD generally have more psychiatric disturbances (e.g., depression or bipolar disorder) than children with- out ASD (Bradley & Bolton, 2006). Bradley and Bolton (2006), in a study of children with ASD and peers, found that 3 of the 41 children with autism had a comorbid bipolar episode while none of the comparison children had such a diagnosis.

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language development to shyness (Ozonoff & Rogers, 2003). As researchers continue to inves- tigate the genetic underpinnings of autism, the field will learn more about the broad autism phenotype.

CharaCterIstICs oF autIsm speCtrum dIsorders

Language deficits

Although some children with ASD may not speak, as noted previously, they may display echolalia. Echolalia was once thought to be nonfunctional; however, it is now recognized that echolalia may in fact be the child’s way of speaking (cf., Quill, 1995). For example, I knew a 5-year-old with autism whose speech consisted almost exclusively of echolalia in particular, delayed echolalia that included songs and quotes from television. His teacher noted increased singing during story time after recess. The school team asked if I could assist in decreasing this distracting behavior. When I came to observe, I noted that Keith sang only commer- cial themes and that they were all for food. Given that story time was just before lunch, I wondered if he might be hungry. We asked his mother to send a snack that he could eat just before story time to see if this might be the issue. Once he began eating a snack to tide him over for lunch, the singing stopped. Although Keith did not have the functional speech to tell us he was hungry, his echoed singing provided the clue necessary to get his need met. Teachers are, therefore, encouraged to become investigators when students with autism are engaging in echolalia and/or challenging behaviors.

When someone has limited or no speech, she will use other methods to communicate wants and needs. Carly, a child with autism who was completely without speech, used symbols as an alternative/augmentative communication system. One day she wanted a drink of water, but the teacher’s back was turned. Carly touched a card symbolizing water that was on a table rather than bringing it to her teacher. Because the teacher could not see Carly, she did not real- ize that Carly was asking for a drink. When the teacher did not respond to Carly’s initiation, Carly approached her teacher and bit her, effectively saying, “Pay attention to me, I want some water!” Carly’s story clearly indicates that all behaviors have a communicative function and teachers should first consider what a child might be trying to tell them when a behavior occurs.

Other children with ASD will have speech, although it may be delayed and/or limited. For these children, speech may consist of a single-word utterance or approximations of words to communicate entire thoughts. Still others may have seemingly adequate speech, but have dif- ficulties with forms of language such as pragmatics (see section below). It is important to note that language deficits in children with autism are not static; a child may have no speech, but that does not imply that he will never develop speech. With appropriate instruction, including augmentative and alternative communication systems, children with autism can develop speech.

pragmatIC Language In higher-functioning children with ASD, their functional lan- guage (i.e., grammar, sentence structure, pronunciation, vocabulary) may be adequate and their language pragmatics are almost invariably deficient. Pragmatics refers to the rules and social components associated with language. For instance, there are certain routines that peo- ple typically use when first meeting another person (e.g., saying “Nice to meet you,” shak- ing hands). A child with ASD may not necessarily understand these social norms and may, for example, immediately ask someone she met how old she is or how much she weighs. In school, a student with ASD may want to talk incessantly about his special interest and will not understand why peers are not fascinated listening to him speak about decks on cruise ships. So, while this child’s ability to produce language may not have been delayed, his ability to use language adaptively may indeed be severely delayed. It is important to remember that the needs of children with ASD vary greatly; their pragmatic deficits may range from subtle to significant. Likewise language challenges may appear different based on the structure of the learning environment and social demands.

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Children with ASD may also have difficulty understanding the semantics or the mean- ing of language. For example, in a clinical examination of a child, a psychologist introduced a set of dolls by saying that they would play with “my family.” The child looked very confused, wondering how the examiner’s family could be a set of dolls. The subtleties of language and sar- casm are lost on many children with ASD. They frequently do not understand sarcasm or sub- tle jokes and may be quite literal thinkers. For instance, a student with ASD may be the only child in the classroom who does not understand a joke. However, some parents work extremely hard to socialize their child, and the child may be able to use these learned skills in combina- tion with strong cognitive skills to understand, and even tell, jokes. For example, one child we know was chosen master of ceremonies for a school pep rally and, because of direct instruction, was able to make jokes and spontaneous, funny remarks about classmates and teachers. Do not assume that a child does not have ASD because she is funny and can use sarcasm.

Some children with ASD may also use language in unusual ways, such as using inap- propriately formal words. They may also describe things in somewhat odd or indirect ways (Attwood, 1998; Bashe & Kirby, 2001), such as calling a person by the color of her shirt rather than by her name. For example, one child we know used to call his school “1214,” which was the number in front of the school’s main building.

usIng Language In odd Ways Adrian, a boy with ASD, once stood outside his parents’ bathroom door, where they mistakenly thought they could hide while having an argument. When he knocked on the door and his parents came out, he calmly remarked, “This does not seem to be a festive moment between the two of you.”

Children with ASD frequently have difficulty in conversations and following up on statements made by others (Attwood, 1998). For instance, if somebody said, “My parents are not from this area,” a typical child may follow up and ask where her parents live, while a child with ASD may ignore this statement completely and talk about something else with- out acknowledging this remark. Conversations with a child with ASD do not generally flow as they do with neurotypical children. There may be frequent, long, and awkward pauses wherein one party will be uncomfortable, while the child with ASD will be oblivious that he should be feeling awkward. For those children with particularly intense interests, others may notice that the conversation invariably ends up on this topic. Similarly, a discussion with an individual with ASD may sound more like a lecture rather than a conversation (Bashe & Kirby, 2001). While this may be uncomfortable for the conversation partner, the child with ASD will be comfortable talking about a topic for which he has a “script.” Children with ASD have a sketchy understanding of social norms, which makes it likely that they will make inappropri- ate remarks or not notice odd turns of conversations. Even if they do notice an awkward turn, they may lack the resources they need to repair the conversation.

Individuals with ASD have challenges related to understanding nonverbal commu- nication, including gestures, facial expression, and proximity, which some experts estimate accounts for as much as 70% to 90% of communication. In addition to difficulties with non- verbal aspects of communication, children with ASD may also have difficulty processing lan- guage in highly distractible environments (Twachtman-Cullen & Twachtman-Reilly, 2007).

the LIteraL InterpretatIon oF Language The examiner told Susie that she had a friend who was a dentist who had given her several boxes of free toothpaste. The examiner told Susie, “I have so much toothpaste I don’t have anywhere to sit.” Susie looked at her and seriously said, “Maybe you should buy another chair.”

Children with ASD may also have overly formal or pedantic language (Frith, 1991; Twachtman-Cullen & Twachtman-Reilly, 2007). For example, they may always begin their questions with “I would like to inquire about. . . .” They may also speak with an unusual rate, volume, or pitch, or may speak in an extremely loud or monotone voice (Gillberg, Gillberg, Rastam, & Wentz, 2001).

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Children with ASD may use functional echolalia. While unique, this language gen- erally has an adaptive purpose. For instance, a child who has difficulty processing informa- tion or remembering a question may repeat this question to himself before giving an answer. For instance, when one child was asked “Is this like your boat?” he repeated “Is this like my boat?” several times, seemingly to help himself remember the question as he thought about his answer.

Many young children vocalize their thoughts as they play or interact with another per- son. While this is developmentally appropriate for young children, by the time a child goes to school this type of behavior is no longer acceptable. Children with ASD, however, may con- tinue this self-verbalization into their teen years (Attwood, 1998). This behavior can interfere with the ability to attend and learn in the classroom, as a child with ASD may be too busy rehearsing what to say to attend. Children or adults with ASD may also rehearse via whisper what they are going to say in a conversation to themselves before speaking, which greatly disrupts the normal flow of conversation.

social differences

autIsm From birth, human beings are social creatures; infants as young as a few hours old have been noted to look toward speakers and to attempt to imitate facial expressions. It should come as no surprise, then, that one of the earliest symptoms of autism noted by par- ents are differences in social behaviors. The word autism comes from the Greek “aut” meaning self. Kanner, in his early description of what was then called Kanner’s Syndrome, described the children as “unto themselves” and, thus, described their behaviors as “autistic.” Although the stereotyped child with autism is thought to prefer to be alone and left in his own world, many children with autism express love and affection for familiar people, including parents and teachers. As noted previously, it is a myth to think that children with ASD do not love or experience emotions. The differences we see in children with ASD frequently have to do with the way in which they experience emotions or interact.

Theory of Mind The ability to understand that others have thoughts, perspectives, and opinions other than our own is known as theory of mind or mind blindness, and there is substantial research supporting this as a deficit area for persons on the autism spectrum (Baron-Cohen, 1995; Kerr & Durkin, 2004). Many people with ASD have difficulty taking the perspective of another into consideration during conversation, may believe that others have the same thoughts and opinions as they do, and may fail to understand why someone would make a particular choice or do something because they themselves would not do so. This can contribute to significant difficulty in social situations (Hill, 2004).

Kevin, an 8-year-old with ASD, would continually attempt to talk with his teacher about events from a movie his teacher had never seen. He would become angry when his teacher would ask a question, insisting that she already knew the answer. Despite her best efforts to explain to Kevin that she had never seen the movie, Kevin continued to talk to his teacher as if she had, and continued to become angry when she “acted dumb” or asked “dumb” questions, because in Kevin’s mind, everyone had the same information that he had.

Joint Attention As noted previously, children with ASD, contrary to previously held beliefs, can form meaningful relationships with caregivers and others in their environment. They can engage in attachment behaviors, make eye contact, show affection, and even engage in routine social play. Behaviorally, lack of joint attention is observed in a lack of pointing behaviors in youngsters with ASD, such as to show someone something of interest. Further, persons with limited joint attention may not follow the point or gaze of another person or engage in gaze shift from point of reference to person and back again. Joint attention abil- ities are seen as crucial to communication—particularly nonverbal social communication— and critical for socialization (cf., Mundy, Fox, & Card, 2003; Mundy & Vaughn, 2001–2002). In fact, Mundy and Crowson (1997) suggested challenges in joint attention can discriminate

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children with autism from their peers. In addition to being a key feature of autism, joint attention may also be a critical skill for instruction.

Play Although the DSM-IV-TR listed “lack of imaginative play” as a language defi- cit, we will discuss it here as a social deficit. Play development follows a somewhat predict- able pattern. Beginning at birth, typically developing children seem almost hardwired to play (Boutot & DiGangi, 2015; Wolfberg & Schuler, 2006). However, children with autism do not follow the typical patterns of play development, preferring to play alone, with unusual objects, or seemingly not at all (Wolfberg, 2004).

Marty was 2 years old when he began therapy to learn play and language skills. As he entered the therapy room each day, he approached a yellow school bus, one of his favorite toys. However, instead of rolling the bus, or putting the accompanying toy characters in the bus, Marty would repeatedly open and close the doors, becoming extremely distressed when this activity was interrupted. Further, when offered a toy train whose doors did not open, Marty would turn it over and spin the wheels. Marty was eventually taught to play appropriately with these toys, but his initial response to them was to engage in self-stimulatory behaviors, by opening and closing doors and spinning wheels. Such unusual behaviors not only prevent a child like Marty from learning how to play appropriately with typical toys but also may limit their inter- action with other children. Typically developing children will begin to play alongside others in parallel play by age 2 and to cooperatively engage in play with another child by age 3 (Boutot & DiGangi, 2015). Children with autism, however, given their other social, language, and stereotypical play differences, often continue in solitary or parallel play well beyond what is age typical. This lack of typical play may further result in limited opportunities for development in other areas, including social, language, motor, and cognition—areas that are enhanced naturally through play for neurotypical children (Boutot & DiGangi, 2015); Many parents of children with autism report that failure of their child with autism to “play like the other kids” was one of the first things they noticed. Play differences are so important in early identification of autism that they are appearing in early autism screening measures (i.e., M-CHAT; see above section).

Imitation Typically developing children learn many important behaviors, including social skills, through imitation of others. They are able to attend to and imitate behaviors that they see as important or key to a particular goal. For example, a child who observes a sibling being given a lollipop to keep him quiet in church may determine that in order to get a lolli- pop, he too must cry. It is well documented in the literature that children with ASD have dif- ficulty with imitation skills, so much so that researchers (cf., Mundy & Crowson 1997; Stone, Coonrod, Pozdol, & Turner, 2003) have identified lack of imitation as a reliable early indicator of ASD. In order to imitate, one must first be able to attend, which is a common difficulty for persons with ASD. Difficulties with attending appear to be related to several factors, includ- ing distractibility, weak central coherence, and a general lack of interest in the social behaviors of others. For this reason, early intervention programs for children with ASD often focus on imitation as a key, or pivotal, skill (Koegel, Harrower, & Koegel, 1999). As with all character- istics, they vary from person to person.

In addition to the social deficits defined by the DSM-V and listed above, some chil- dren with ASD display more subtle social deficits (cf., Baron-Cohen, 1995; Carter, Meckes, Pritchard, Swensen, Wittman, & Velde, 2004). For example, children and adolescents with ASD may have an inaccurate concept of personal space and may stand too close or too far away from another person. Similarly, children with ASD may have difficulty walking next to or with another person. Children with ASD also show differences in eye contact. For some, their eye contact may be fleeting or extremely brief, while others may have unusually long or intense periods of eye contact. In addition, research suggests that children on the autism spectrum focus their gaze more toward a speaker’s mouth than at their eyes as compared to typically developing children (cf., Klin, Jones, Schultz, Volkmar, & Cohen, 2002).

Some children with ASD may appear uninterested in others and may be described as self-centered (cf., Wheelwright et al., 2006). In reality, they lack the skills to initiate and maintain

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interactions with others. Social attempts are also impacted by the rigid behavior of individuals with ASD, which makes it difficult for them to play cooperatively with other children. They may want to “run the show” and tell the other children what to do (the old adage “my way or the highway”). Thus, some children with ASD may gravitate toward younger or older peers and/or adults, as they are more accommodating to their needs. However, even in these situations, individuals with ASD have challenges as they may want to tell other adults or their teacher what to do or how to solve a particular problem. One child we know became extremely upset when her teacher rearranged the computers in the classroom because the teachers did not use the optimal arrangement. The girl with ASD emphatically scolded the teacher for selecting an inefficient configuration.

Given that children with AS may be extremely rigid, it makes sense that they are also rule governed (cf., Crooke, Hendrix, & Rachman, 2007; Tsatsanis, Foley, & Donehower, 2004). This inflexibility often impedes functioning. For instance, one child refused to hang his paja- mas on the hanger his mother bought for his door because the packaging noted that it was for towels. A child with ASD may turn into the class policeman, notifying the teacher of the slightest infraction, oblivious of the social repercussions.

Emotional Expressions and Affect Children with ASD may have a restricted range of facial expressions or display limited affect. For example, a parent once made the comment about her 11-year-old son that only once in his entire life had she been able to tell he was happy. Other parents may assert that their child with ASD is more negative than other chil- dren. These children may whine or cry more than others and tend to see the glass as half empty rather than half full (Barnhill, 2001). Parents and professionals may tend to think of children with ASD as always showing reduced or flattened emotional expressions. However, this is not always the case, and some children appear to be consistently happy. They may also have usual and intensely positive affective expressions. Caution is needed in the interpretation of facial expressions as they may not match emotional state.

In addition to differences in emotional expressions, children with ASD frequently have difficulty describing internal emotional states (Losh & Capps, 2006). While they are able to tell others something that makes them happy or sad, they have an extremely difficult time explaining these feelings. In addition, they have difficulty attributing how their actions may make others feel (Barnhill, 2001).

It is important for parents and professionals to remember that many children with ASD experience grave social challenges at school, and they may have more success at home when interacting with adults, with younger or older children, or are left to do as they please.

repetitive Behaviors and restricted Interests

In this section we will briefly discuss some of the repetitive behaviors (sometimes called self-stimulatory behaviors, such as rocking or hand flapping) and restricted interests often asso- ciated with ASD. As previously noted, ASD manifests in individuals in vastly different ways, and no two individuals may share the exact same characteristics. The same is true for repetitive behaviors and restricted interests. Further there are varying degrees of such behaviors, and these too differ from person to person.

Until 1988, many Americans had not heard the term autism. In 1988 Dustin Hoffman won an Oscar for his portrayal of an adult with autism in the movie Rain Man. In the movie, Hoffman’s character Ray displayed many repetitive, also known as self-stimulatory, behaviors and ritualistic behaviors, common to persons with autism. For example, Ray had to eat a particular food on a par- ticular night and had to purchase his underwear from one particular store. In addition, he would robotically repeat his needs over and over again, becoming increasingly agitated if they were not met. Ray also rocked back and forth on his heels, particularly when anxious or in a novel situation. This portrayal of an individual with autism was for many people the first glimpse of autism.

Stereotypical Mannerisms Hand flapping, finger flicking, rocking, and spinning objects or self are all examples of stereotypical mannerisms or behaviors that may be common

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for people with autism. There is some evidence to suggest that these behaviors serve to calm persons with autism when their anxiety level increases—the behaviors serving as the routine they lack and crave (see next section). While the antecedent and purpose may be unclear, what is clear is that all persons with autism, by its definition, will have some stereotypic behaviors at some time, and they may increase or decrease in frequency and/or intensity based on age and situation. It is also possible that persons with low-functioning ASD have more intense and more obvious forms of stereotyped behaviors compared with those with HFA or AS.

Insistence on Sameness According to the DSM-V, resistance to change and insis- tence on sameness are qualifying characteristics of autism. Tommy, an 18-year-old with ASD is nonverbal and also has a cognitive disability. He insists that each family member sit in a specific chair at the table. When they do not, he becomes aggressive in his attempts to physically move them to their correct location. The need for sameness can often be seen when a routine is violated or when objects are rearranged. At this time, teachers and parents may observe challenging behaviors, increased self-stimulatory behaviors, and/or attempts to escape the environment. Routines are often not obvious to families and school staff and quite often make themselves known when one is disrupted. Although nonverbal with very poor adaptive behavior skills, Hu had a keen eye for detail. One day upon entering the classroom, he bolted from the teacher and ran to fix a chair that was out of place. Before Hu could begin his day, he needed the chair to be in its correct position, which was inches from where it was when he entered the room. While sometimes inhibitory, the need for sameness can also be viewed as a strength of persons with ASD. Teachers and parents can work to create meaningful routines and a predictable environment for a child with autism to enhance independence.

Self-Injurious Behaviors and Aggression Although uncommon, some individuals with ASD, particularly those with more classic autism as described above and who are nonverbal, may engage in self-injurious behaviors (SIBs; Murphy, Hall, Oliver, & Kissi-Debra, 1999). SIBs are often thought to be related to either sensory processing or communicative issues (cf., Fecteau, Mottron, Berthiaume, & Burack, 2003). Even so, SIBs should be addressed immediately. Head banging, eye poking, skin picking, head hitting, and lip biting are examples of SIBs.

Some individuals with classic autism exhibit aggressive behavior toward others. Aggres- sion toward others should be considered within the context of communication (see the exam- ple of Hu in the previous section); in other words, the individual with ASD is attempting to communicate, and aggression is his way of doing so. For example, people with ASD may engage in aggressive behaviors when a routine has changed, when they are anxious, or when they perceive a threat. ASD is, if nothing else, enigmatic and heterogeneous.

Savant Skills Specialized or splinter skills are sometimes evident in individuals with ASD. These are also known as savant skills. In the movie Rain Man, Ray had the ability to count cards, a seemingly impossible skill given his limitations in many other areas, such as self-help and communication. Jonah, an adult with classic autism, has an ability to calculate days of the week; that is, when given any date, he can quickly indicate the day of the week on which it did or will fall. It is estimated that only 1% of people with classic autism have a splinter skill or are savant (Hermelin, 2001).

Children with ASD may show a pattern of unusual behaviors or restricted interests. In fact, in a Web-based survey, 100% of parent respondents indicated that their child had at least one interest that was unusual in its intensity of scope (Bashe & Kirby, 2001). While most children have interests, children with ASD may take their interests to extreme levels. These interests are typically unusually intense or of unusual content (Winter-Messiers, 2007). They may remain consistent over time, or they may change. In addition to changing over time, these interests may manifest differently in people of various ages, as they are frequently age appropriate, such as Thomas the Tank Engine at age 3 or Pokémon at age 7 (Winter-Messiers et al., 2007). Young children can develop intense interests in pretending to be animals or peo- ple. Children with such interests may be avid learners of their chosen topic and talk about it

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14 chApter 1 • Overview Of AutiSm Spectrum DiSOrDerS

incessantly (Frith, 1991). However, others may learn to control themselves in order to be more socially appropriate.

Children with ASD may rely greatly on routines and may have compulsions or rituals. These rituals may become more complex over time, such as lining up 12 animals before bed instead of the original 3 (Attwood, 1998). As previously mentioned this is one for the things that makes differential diagnosis with Obsessive Compulsive Disorder difficult.

Children with ASD may show a similar pattern of behavior in their play by which they repeatedly play in the same way. This type of repetitive play, also called perseveration, is com- mon in children with ASD (cf., Hill, 2004). For example, one parent commented that her child would organize shapes all day long if allowed. Another child played with his figurines by repetitively crashing them against each other.

Rigid Behavior Children with ASD are not able to adjust to change as easily as typi- cally developing children. This may translate into difficulty with transitions or difficulty with flexible thinking and problem solving (cf., Iovannone, Dunlap, Huber, & Kincaid, 2003). For example, if a child with ASD becomes convinced that a problem has to be solved in a certain way, it could be very difficult to teach him otherwise. Maria, a 12-year-old with ASD, became upset in math class when the teacher said there were two ways to solve a problem. When the teacher demonstrated both methods, Maria became very upset and insisted that one method had to be inaccurate.

This rigidity, combined with the social deficits inherent in ASD, clearly makes it difficult for these children to play appropriately with peers. Parents frequently report that their child has to play their way and that they are unwilling to give in to their peers. For instance, many typical children take their playmates’ wishes into consideration when determining what game to play. This is not the case with children with ASD, who may like to direct the game and each person’s part. When challenged by other children, they may become extremely angry or upset.

Imagination Some children with ASD show a limited ability to create an imaginary world and are content with their restricted areas of interests. However, there is a subgroup of these children who love pretend play and particularly enjoy drama. These children tend to play by themselves (at times playing each of the characters involved) rather than inviting others into their group. For some children, imaginary friends are their only companions (Attwood, 2007).

Older children and teenagers with ASD may create or appear to live in imaginary worlds. It has been hypothesized that this allows children to escape from a social world that they do not understand and where, despite trying, they are not fully accepted (Attwood, 2007). This imaginary world may coincide with special interests. For instance, a child interested in dino- saurs may pretend to live among them or write scripts about dinosaurs. Other children may appear to live in a television show that they have written.

motor deficits

Motor problems are not uncommon in children with ASD, although they are not part of the defining set of characteristics. Common problems may include dyspraxia, which is essentially difficulty with motor planning and may manifest itself in both fine/gross motor planning as well as oral-motor planning related to speech. Dyspraxia can make learning new tasks difficult, despite otherwise good motor ability (Whitman, 2004). Other issues common to children with ASD relative to motor abilities include difficulty with motor skills requiring balance (poten- tially due to disturbances in the vestibular sensory system), awkward movements, and toe walk- ing. In addition, developmentally, delayed motor milestones are commonly reported by parents, including slow to sit up, slow to crawl, and slow to walk. Fine motor issues, such as difficulty cutting with scissors and poor penmanship, are also commonly noted by teachers and parents and frequently addressed through occupational therapy. As always, it is important to note that motor difficulties are not a defining feature of ASD and are not seen in every individual.

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chApter 1 • Overview Of AutiSm Spectrum DiSOrDerS 15

Research suggests that children with ASD have difficulties with fine and gross motor coordination (Ghaziuddin & Butler, 1998). Children with gross motor deficits are often iden- tified as awkward or clumsy. Physical education classes are typically difficult for children with ASD, as they do not excel at sports requiring coordinated physical activity. For example, they frequently have extreme difficulty catching a ball or balancing on one foot. When one com- bines their social deficits with their lack of athletic ability, it is not surprising that these chil- dren are typically the last ones picked for a team or are left out entirely.

Within the area of fine motor skills, their graphomotor (motor abilities needed to write) functioning is frequently impaired (Myles et al., 2003), which makes their handwriting labored and illegible. It is thus not surprising that many report disliking writing (Church, Alisanki, & Amanullah, 2000).

Similarly, their manual dexterity is frequently poor, and using both hands together may frequently be a challenge. Seemingly simple things, such as tying shoes, can be a great chal- lenge for a child with ASD. These children may also struggle to learn to ride a bicycle or to roller skate (Attwood, 1998). See Chapter 12 of this text for more on motor development for individuals with ASD.

Learning Challenges associated with asd

Students with ASD often exhibit uneven learning profiles marked by scatter in skill develop- ment. Such students may function at or above age level in some areas, but well below age level in others. This pattern also results in a scattered profile of results on formal testing measures, as well as inconsistent performance within individual subtests that will affect not only test results but instructional programming as well.

Coupled with inconsistent skill acquisition, students with ASD also exhibit inconsis- tencies in responding, even for skills that have been mastered. Such difficulties are frequently referred to as problems with generalization. Despite having acquired given skills, individuals with ASD often have difficulties “showing what they know” in the evaluation setting and fail to demonstrate skills that they can successfully perform in the home and/or at school. Generaliza- tion difficulties also can manifest as an inability to demonstrate a skill under different conditions than those in which the skill was learned (e.g., with different materials and/or verbal instruc- tions). Deficits in skill maintenance are also characteristic of children with ASD; children may lose skills if they are not consistently practiced and/or used in the child’s daily life. Again, these difficulties have implications for the testing setting, as parents often proclaim that the child pos- sesses skills that were not exhibited during the evaluation session. This is often an accurate state- ment; however, difficulties with generalization and maintenance of skills have direct relation to instructional programming. Skills that have been mastered but cannot be demonstrated across people, settings, and materials should take first priority as instructional goals and objectives.

Challenges may also be displayed in areas associated with the core deficits of ASD. For example, there may be significant problems with orienting to the examiner and task materials and distractibility. Further, attention and persistence may vary significantly across tasks with reduced motivation for non-preferred activities. Individuals may also be hypersensitive to sounds and visual stimuli in the environment, display self-stimulatory behaviors, and become preoccu- pied by oral exploration of items. Difficulties with tasks requiring sequential steps or that have multiple stimuli and stimulus overselectivity may also be observed. Overselectivity refers to the tendency of individuals with ASD to focus on a restricted range of available environmental cues, such as focusing on one feature of an object while ignoring other equally important features. For example, a student may respond to extraneous and/or irrelevant details (such as the model of the car in a picture) and fail to pay attention to the more salient and important aspects of stim- uli on which the task depends (such as object identification, color identification, and/or object function). Overselectivity will have a significant impact on behavior during both assessment and instructional tasks.

Teachers and parents will frequently choose to use line drawings rather than photo- graphs of items for individual schedules or communication systems because of this tendency to

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16 chApter 1 • Overview Of AutiSm Spectrum DiSOrDerS

focus in on irrelevant content. For example, Keith’s teachers used photographs for his schedule system. Each picture was of an actual place or activity that Keith would encounter in his day. The picture of the speech therapist had her placed in front of a bulletin board. After a few months of school, during which time Keith had displayed great ability to use his schedule, he suddenly became noncompliant when it was time for speech therapy. Staff later realized that the therapist had changed her bulletin board; it was not the same as in the picture. Keith did not want to go into her room because he believed it to be a novel situation; he had focused on an irrelevant stimulus—the background—rather than the speech therapist.

deveLopment oF the IndIvIduaLIzed eduCatIon program

The assessment process leads directly to the development of an Individualized Education Pro- gram (IEP) for the student. The IEP is a written document that describes the special education and related services to be provided in order to meet the specific needs of a child with a disabil- ity, and is comprised of six required parts:

1. Description of the child’s present level of performance, or functioning: The first step in developing an IEP involves a description of the child as he is at the present time. This section of the IEP highlights the child’s current academic and behavioral skills, interests, and learning style, and discusses the implications of the child’s disability on academic and non-academic (e.g., social, communication) achievement. From this description, the IEP team develops a list of areas of instructional priority, often referred to as priority educational needs (PENS). Since instructional programming is based on information regarding a student’s present levels of performance, learning style, and pref- erences, and identification of PENS, the assessment process and its resulting data are critical to successful instructional planning.

2. Annual goals and objectives: Goals and objectives are based upon the information described above, namely descriptions of the child’s present level of performance and identification of priority educational needs. Goals and objectives are descriptions of the skills that the child will attain within a specified period of time. Goals are typically written to reflect annual expectations for progress, whereas objectives typically reflect short-term steps (often quarterly) toward the attainment of the annual goal.

3. Related services: The IEP also describes services that will be provided in order to sup- plement the educational services provided in the classroom. Related services are those services that are necessary in order to effectively implement the IEP and designed to ensure that the child is able to benefit from special education in the least restrictive environment. Examples of possible related services include counseling; occupational, physical, and/or speech and language therapies; parent training; and assistive technology.

4. Educational placement: Placement refers to the educational setting in which the IEP will be implemented and is chosen based on the setting in which the goals and objec- tives will be appropriately met. If the classroom setting is not a general education class- room, the IEP must specify the amount of time (if any) that the child will participate in the general education classroom and include a statement ensuring that the least restric- tive environment was considered.

5. Time and duration of services: This step in the IEP process specifies starting and ending dates for goals, objectives, and related services. In addition, the frequency of any related service is also specified. For example, the IEP might specify that speech and language therapy will be delivered twice a week for 30 minutes each session for the duration of the IEP. Because special education law (IDEA) requires annual review of services provided in the IEP, long-term duration for services should be projected no further than 1 year.

6. Evaluation of the IEP: The final step in IEP development is specifying how student progress toward short-term objectives and annual goals will be measured or evaluated.

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chApter 1 • Overview Of AutiSm Spectrum DiSOrDerS 17

taBLe 1.1 Sample objectives

poorLy Written oBJeCtiveS

• Luke will improve his communication skills with peers and adults in the classroom.

• Kelley will stop calling out in class.

• when it is time for cade to sort the silverware, he will put the silverware as accurately as possible.

• jack will increase letter recognition.

• marshall will improve his listening skills.

WeLL-Written oBJeCtiveS

• Luke will independently respond to single-answer questions by pointing to (or picking up) a picture card on four out of five opportunities during circle and snack activities.

• Kelley will independently raise her hand and wait for teacher acknowledgement before speaking during independent and group work on three out of five opportunities.

• cade will independently sort 10 forks, 10 knives, and 10 spoons into the correct sections of a silverware tray, with 90% accuracy for 3 consecutive days.

• when presented with three alphabet cards, jack will point to named letter on four of five trials over three consecutive sessions per letter. And/Or: Given a field of five alphabet cards and their corresponding matches, jack will independently match letters to sample on 9 out of 10 trials over three consecutive sessions.

• marshall will follow two-step directions when presented by the teacher during group instruction with no more than one verbal prompt on four out of five opportunities.

Following a process-oriented assessment approach will ensure that this step is not overlooked. In addition, well-written goals and objectives (described below) automat- ically build in an evaluation process by allowing for growth and development to be tracked.

Creating annual goals and objectives

Annual goals and objectives will be based upon comprehensive assessment data (both for- mal and informal). Given the challenges associated with ASD, annual goals should address, at minimum, the following areas: social functioning; nonverbal communication skills; receptive, expressive, and pragmatic language; fine and/or gross motor skills; academic skills; and behav- ioral, organizational, and/or self-help skills.

Annual goals should (a) clearly state what the student is expected to accomplish in a 1-year time frame, (b) be worded as a positive statement (what the student will accomplish versus what the student will no longer do), and (c) be worded to be clearly observable and measurable. Well-written IEP goals and objectives tend to follow a specific formula consisting of five questions, which when used, will result in a statement that is objective, observable, and measurable.

1. Who will demonstrate what behavior or skill? 2. How will this skill be demonstrated? What will the skill look like as it is demonstrated

and/or at what level will the skill be demonstrated? 3. Where or under what condition will the skill be demonstrated? 4. How frequently will the skill be demonstrated (What are the criteria for mastery)? 5. By when will the skill be demonstrated?

Examples of some poorly written goals (and their improvements) are provided in Table 1.1. Further examples are available in the following texts: Creating a Win-Win IEP

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18 chApter 1 • Overview Of AutiSm Spectrum DiSOrDerS

Box 1.3 trends and Issues notes

Guidelines for Selecting Appropriate Educational Objectives for Children with ASD Appropriate objectives should be observable, measurable behaviors that can be reasonably accomplished within a 1-year time frame. In addition, these objectives should have a direct impact on enhancing the child’s ability to participate fully in education, the community, and family life. The following areas should be targeted for development:

• Social skills that will enhance participation in family, school, and community activi- ties. Suggestions for target areas include imitation skills, responding to and initiating interactions with peers and adults, and parallel and interactive play skills with peers and siblings.

• Language and nonverbal communication skills including expressive (verbal) lan- guage, receptive language, and use of eye contact and gestures to communicate with others.

• Development of a functional and symbolic communication system that should emphasize identifying a system that allows children to communicate their wants and needs, and to make choices that affect them, to the greatest extent possible.

• Fine and gross motor skills that will assist in achieving age-appropriate functional activities.

• Cognitive skills including the development of basic concepts, life skills, symbolic play, and academics. Goals for cognitive development should be carried out in the con- text in which the skills are expected to be used and functional academic skills should be taught when appropriate.

• Behavioral goals that are focused on skill development (communication skills, self-regulation skills, etc.) to replace more challenging and/or problematic behaviors. Behavioral strategies should be positive and proactive, incorporate information about the contexts in which the behaviors occur, and include a range of behavioral techniques that have empirical support.

• Independent organizational and self-help skills that underlie successful participation in the home, school, and broader community (independent task completion, asking for assistance, following directions and instructions, etc.).

Source: Information from National Research Council (2001). Conclusions and Recommendations. Educat- ing Children with Autism. Washington, DC: National Academy Press.

for Students with Autism (Fouse, 1999), Negotiating the Special Education Maze (Anderson, Chitwood, Hayden, & Takemoto, 2008), and Writing Measurable IEP Goals and Objectives (Bateman & Herr, 2006).

Designing an appropriate instructional program requires more than just accurate assess- ment data, but it cannot be done in its absence. In addition to linking assessment data to the creation of goals and objectives within the student’s IEP (see Box 1.3), adequate instructional planning also must include a plan for actually teaching the specified skills. In this respect, educators may benefit from the use of curricula developed specifically for students with ASD to guide their instructional approaches. A list of and commercially available curricula and resources that can assist in identifying appropriate instructional targets and in writing clear, objective, measurable goals and objects is provided in Figure 1.2.

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chApter 1 • Overview Of AutiSm Spectrum DiSOrDerS 19

The Assessment of Basic Language and Learning Skills—Revised (ABLLS–R) Partington (2008) (http://www.partingtonbehavioranalysts.com/page/ablls-r-25.html)

Provides criterion-referenced information regarding current skills and deficits in 25 areas, along with a curriculum that can serve as the basis for the selection of educational objectives.

• An assessment, curriculum guide, and program monitoring device • Based on the principles of applied behavior analysis • Cooperation and reinforcer effectiveness • Visual performance • Receptive language • Motor imitation • Vocal imitation • Requests • Labeling • Intraverbals • Spontaneous vocalizations • Syntax and grammar • Play and leisure

Play and Language Program for Early Autism Intervention (PAL) (Boutot & DiGangi, 2014).

Ages 0–5 addresses five skill areas across three levels:

• Imitation and play skills • Joint attention and social interaction • Visual discrimination • Receptive language • Expressive language

Includes a curriculum guide to aid in instructional planning, instructional objectives, strategies, and progress monitoring data sheets. It also includes a Learning Styles Assess- ment for identifying areas such as prompt level, communicative intent, choice making, handedness, and so on.

TEACCH Transition Assessment Profile (TTAP)—Second Edition

Mesibov, Thomas, Chapman, & Schopler (2007) (http://teacch.com/publications/ teacch-transition-assessment-profile-ttap-kit-and-manuals)

Revision of the Adolescent and Adult Psychoeducational Profile (AAPEP). Assessment instrument developed for adolescent and older children with Autism Spectrum Disorders. Three different environmental contexts assessed. Allows for direct relation to instruc- tional planning that satisfies IDEA transition planning requirements.

• Vocational skills • Vocational behavior • Independent functioning • Leisure skills • Functional communication • Interpersonal behavior

Verbal Behavior Milestones Assessment and Placement Program (Sundberg, 2008) (http:// www.marksundberg.com/vb-mapp.htm)

Measures 16 language and language-related skills across three levels, corresponding to learner ages of 0–48 months (though the test explicitly states it can be used for learners of all ages).

FIgure 1.2 Sample of Commercially Available Assessments for Curricular Planning

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20 chApter 1 • Overview Of AutiSm Spectrum DiSOrDerS

summary

If you’ve seen one student with autism, then you’ve seen one student with autism. One of the most important concepts to remember is that ASDs are heterogeneous, impacting each individual differently. A mistake commonly made by teach- ers of children with autism is that, based on experience with a handful of children, they know autism. While they may share a great many characteristics, no two individuals with ASD are alike, and the differences may profoundly impact how they learn and process information. This chapter covered the diagno- sis and characteristics of autism, along with causal theories and

historical perspectives. This chapter also covered assessment for diagnosis and instructional (IEP) planning as well as gen- eral information on program development. This information is intended to aid teachers in better understanding the individual students with whom they work and to provide a broad base of information. It is not intended to cover the entirety of possi- bilities relative to the characteristics of autism and its presen- tation within specific individuals. Teachers are encouraged to learn all they can about autism in general, and their students in particular, in order to be most effective in their instruction.

Chapter revIeW QuestIons

1. What are the characteristics of Autism Spectrum Disorders? (Objective 1)

2. How are Autism Spectrum Disorders identified and diagnosed? (Objective 2)

3. What are the changes in the definition of Autism Spectrum Disorders? (Objective 3)

4. What are some of the causal theories associated with autism? (Objective 4)

5. How does one plan for instruction for students with autism? (Objective 5)

Key terms

Adaptive behavior 6 ADI-R 5 ADOS-G 5 Autism Spectrum Disorder (ASD) 2 DSM-V 4

Generalization 15 Goals 16 Maintenance 15 Objectives 16 Prevalence 2

Repetitive behaviors 12 Social skills 18 Stimulus overselectivity 15

Internet resourCes

Diagnosing Autism: One Family’s Journey: http://childnett.tv/videos/services?page=1

National Institute of Mental Health: http://www.nimh.nih.gov/publicat/autism.cfm

Autism Speaks: http://www.autismspeaks.org/

• Mand • Tact • Listener responding • Visual perceptual skills and matching-to-sample • Independent play • Social behavior and social play • Motor imitation • Echoic skills • Spontaneous vocal behavior • Intraverbals • Classroom routines and group skills • Linguistic structure • Math

FIgure 1.2 Sample of Commercially Available Assessments for Curricular Planning (continued)

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21

IntroductIon

As you have learned in the previous chapter, autism is a perplexing devel- opmental disorder characterized by severe social, communicative, and cog- nitive deficits (Kasari, 2002). The onslaught of children being diagnosed with autism has created a challenge for educators and therapists: how to best serve children and youth with autism and their families. Parents are often faced with the daunting task of choosing the right treatment option. Teachers are often caught between the service delivery system embraced by parents and the services the school actually provides. It is not uncom- mon for parents and educators to disagree about the manner in which services should be delivered. There continues to be great controversy sur- rounding the treatment of children and youth with autism, which can make service delivery for students with autism a difficult and complex venture (Callahan, Shukla-Mehta, Magee, & Wie, 2010; Freeman, 1997; Maurice, Green, & Luce, 1996). Whereas other disciplines may have his- torical or theoretical bases for generally accepted appropriate practices, autism is a relatively new field, fraught with myth and fad treatments, making it difficult to distinguish between that which is a truly viable treatment option and that which is not (see Box 2.1).

Although multiple treatment options are available to parents and professionals, the sometimes slow pace of the scientific process causes dif- ficulty in discerning that which is considered truly scientific practice. In essence, there is a time lag between the development of treatments and the validation of those treatments. Many disciplines define evidence-based practices as treatments or approaches that have been found effective through replicated research. Specifically, questions are posed, followed by the creation of a hypothesis, which is then tested. If a particular hypothesis is tested on several different occasions with different participants (in this case students with autism) and the results are favorable, then a tentative decision is made that the particular treatment in question has an evidence base. “Ultimately, such research should be able to demonstrate that there is a causal relationship between an educational intervention and immediate or long-term changes that occur in development, behavior, social relationships, and/or normative life circumstances” (National Research Council, 2001, p. 193). Testing a hypothesis is carried out by using a particular research design. Generally, research designs can be categorized into two broad cate- gories: single-subject designs (also known as within-subject or single-case designs) and group designs (also known as between-subject or experimental designs). Experimental designs may include matched-subject designs and control group designs and rely on appropriate reliability measures.

Evidence-Based Practices for Educating Students with Autism Spectrum Disorders

Chapter 2

e. amanda Boutot, ph.D. BCBa Texas State University

tracy J. raulston, M.ed. University of Oregon

Charles Dukes, ph.D. BCBa Florida Atlantic University

chapter OBjEctivES After reading this chapter, learners will be able to: 1. Increase awareness of

evidence-based practices for students with Autism Spectrum Disorders.

2. Increase awareness of unestablished practices and fad treatments.

3. Compare and contrast focused interventions with comprehensive treatment models.

4. Identify the components of effective instruction for students with Autism Spectrum Disorders.

5. Identify ways of determining effective treatment for students with Autism Spectrum Disorders.

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22 chAPtEr 2 • EviDEncE-BASED PrActicES fOr EDucAting StuDEntS with ASD

Box 2.1 research notes

Both the National Autism Center’s National Standards Report and the National Professional Development Center on Autism Spectrum Disorder have provided an abundance of informa- tion related to the identification of evidence-based practices (EBPs). However, despite these efforts, there remains little evidence that the gap between research and practice has been meaningfully reduced (Cook & Odom, 2013). The research-to-practice gap in special edu- cation is a recurring problem; to address this systemic issue an emerging field referred to as implementation science is gaining popularity. Implementation science is “the scientific study of methods to promote the systematic uptake of research findings and other EBPs into routine practice” (Eccles & Mittman, 2006, p. 1). Most special education teachers receive little for- mal instruction in EBPs for educating students with ASD, and the literature base of teacher preparation in this area is exceptionally scarce (Lerman, Vorndran, Addison, & Kuhn, 2004; Shyman, 2012). This is especially problematic given that both the No Child Left Behind Act of 2001 and the Individuals with Disabilities Education Improvement Act (IDEIA, 2004) include specific language requiring educators to use EBPs when working with students with disabilities in public schools (Kramer, Cook, Browning-Wright, Mayer, & Wallace, 2008). The What Works Clearinghouse (WWC) is a federally funded and comprehensive source for the EBP in education (http://ies.ed.gov/ncee/wwc/), which has just recently begun review- ing practices for students with disabilities of certain categories (learning disabilities, in early childhood special education, and with emotional behavioral disorders); still, there continues to be a need to improve the information related to students with ASD within this resource (Cook & Odom, 2013). Implementation science includes conducting and synthesizing research into applied, real-world settings, which is generally well funded. It also involves adopting and sustaining EBPs, which tends to be more chaotic and poorly funded; although with recent attention being paid to this emerging field, funding appears to be increasing. Specific efforts need to be systematically taken in order to ensure that EBPs will transfer and sustain into classroom settings. Some of these include staff selection, preservice and in-service teacher training, continued consultation, staff and program evaluation, administrative sup- port, and system interventions. Further, the EBPs chosen need to be a contextual fit for the setting. If teachers do not implement EBPs with fidelity, they will not have the same effect as the research indicates; conversely, if teachers are demanded to adhere to ridged procedures, sustained use of the practice is unlikely. For these reasons, further investigation of how to effectively disseminate information about EBP for students with ASD and of equal or greater importance, how to ensure their sustainability, is certainly necessary.

For further reading, please refer to the partial list of works below:

Cook, B., & Odom, S. (2013). Evidence-based practices and implementation science in special education. Exceptional Children, 79(2), 135–144.

Eccles, M. P., & Mittman, B. S. (2006). Welcome to implementation science. Implementation Science, 1(1), 1–3.

Shyman, E. (2012). Teacher education in autism spectrum disorders: A potential blueprint. Education and Training in Autism and Developmental Disabilities, 47(2), 187–197.

A great deal of research in the area of autism is conducted through single-subject design methodologies and case studies. There are two major reasons for the paucity of experimen- tal or group designs to answer questions. First, although the number of children diagnosed with autism is steadily increasing, autism is considered a low-incidence disability, making it difficult to secure a large enough sample of subjects for most group designs. Second, due to the heterogeneity of the population, it is challenging to match subjects according to spe- cific characteristics. For example, in a number of studies investigating the effects of schooling on children’s intelligence, many children are matched using a construct called socioeconomic status, or SES. This construct is often measured by asking mothers to identify their highest level of education. In the case of students with autism, researchers are often interested in the manifestation of symptoms (e.g., behavioral or communication patterns). It may be difficult or even impossible for a researcher to identify and match children with the same behavioral or

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communication profiles. This difficulty does not completely eliminate the possibility of using group designs, but it does mean that a number of researchers ask questions that can be more easily answered using different experimental methods. The use of single-subject designs and case studies is considered by those in the field of autism as appropriate given the challenges of experimental designs (Horner et al., 2005; Matson, Turygin, Beighley, & Matson, 2012). However, using single-subject designs can present challenges in identifying evidence-based practices for treatment and instruction for individuals with autism and leaves the door open for practices that are less appropriate or that work for fewer individuals.

evIdence-Based practIces: defInItIon and ratIonale

The Individuals with Disabilities Education Act (2004) requires that public schools use evidence-based practices, sometimes referred to as scientifically based practices, when working with students with disabilities, just as the No Child Left Behind Act (NCLB) does for typically developing children. Because there is no universally agreed upon definition for evidence based in the special education field, it can be difficult to discern such practices (Odom, Collet-Klingenberg, Rogers, & Hatton, 2010b). However, the field is moving in the direction of identifying evidence-based practices in order to inform teachers and practitioners and meet the requirements of educational agencies and insurance companies. In 2007 the U.S. Department of Education funded the National Professional Development Center (NPDC) on Autism Spectrum Disorder (ASD) in order to identify and promote the use of EBPs with infants, children, and youth with autism. The NPDC intended to utilize the results from the National Standards Report (NSP), which was published by the National Autism Center (NAC); however, due to conflicts in timing of these recent projects, the NPDC needed to identify EBPs before the NSP was completed (National Professional Development Center on Autism Spectrum Disorder, 2013). As such, currently the NPDC and the NAC have both identified EBPs via extensive literature reviews; yet, there are some conceptual differences in the findings of these two projects. For example, the treatments, or practices, are defined and organized differently, and the evaluation processes and criteria also differed. We will now give an overview of each agency’s findings.

the national autism center’s national standards report

In September of 2009, the National Autism Center published a comprehensive literature review titled the National Standards Report (NSP). In it treatments represent “either inter- vention strategies (i.e., therapeutic techniques that may be used in isolation) or intervention classes (i.e., a combination of different intervention strategies that hold core characteristics in common)” (National Autism Center, 2009, p. 27). Thus, many of the practices identified in the NSP are treatment packages that contain several procedures, and the NSP combined interven- tion strategies, which may have different names or labels but held similar core characteristics, into intervention classes. This was done in order to afford clarity regarding the effectiveness of the treatment, so that parents, educators, and practitioners could have a better understanding of the level of research support available. Each study was reviewed in terms of the quality of the (a) research design, (b) dependent measure (i.e., effect on the participant), (c) treatment fidelity (i.e., how accurately the practice was implemented during the study), (d) participant ascertainment, and (e) generalization. Scores for each area were combined and aggregated into a Scientific Merit Rating Scale (SMRS). Additionally, each study was examined in terms of treatment effects (i.e., how well the intervention worked during the study) and rated as (a) beneficial, (b) ineffective, (c) adverse, or (d) unknown. Then, the NAC combined the SMRS results with the Treatment Effects Ratings to determine the overall effectiveness of each study. Ultimately, 38 practices, some of which were intervention packages as previously mentioned, were then categorized into the Strength of Evidence Classification System to reflect the qual- ity, quantity, and consistency of research findings with regard to individuals with ASD. The four categories included in this system are (a) established, (b) emerging, (c) unestablished, and

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(d) ineffective/harmful. Established practices were those that have sufficient evidence to enable researchers to “confidently determine that a treatment produces beneficial treatment effects” (National Autism Center, 2009, p. 32). Emerging practices had one or more studies that sug- gest those treatments produce benefits for individuals with ASD, but additional high-quality research should consistently replicate the findings. Unestablished practices have little or no evidence, and finally, ineffective/harmful practices were those where sufficient evidence deter- mined that the treatment was either ineffective or harmful to individuals with ASD. Informa- tion was provided based on the treatment targeting increasing skills in the areas of academics, communication, higher cognitive functions, interpersonal skills, learning readiness, motor function, personal responsibility, placement, play, and/or self-regulation. Information regard- ing if a treatment targets behavior reduction for (a) general symptoms; (b) problem behav- iors; (c) restricted, repetitive, nonfunctional patterns of behavior, interests, or activity; and/or (d) sensory or emotional regulation were also included, and targeted age levels and specific diagnostic classification (related to the Diagnostic and Statistical Manual of Mental Disorders— Fourth Edition [DSM-IV]) were labeled as well.

outcomes The report found the following 11 practices to qualify as established practices for individuals with ASD: antecedent package, behavioral package, comprehensive behavioral treatment for young children, joint attention intervention, modeling, naturalistic teaching strategies, peer training package, pivotal response treatment, schedules, self-management, and story-based intervention package. Twenty-two practices were identified as emerging (e.g., augmentative and alternative communication devices [AACs], exercise, massage/touch ther- apy, sign instruction, structured teaching). Finally, five practices were found to be unestab- lished (academic interventions, auditory integration, facilitated communication, gluten- and casein-free diet, and sensory integrative package; see Table 2.1).

taBle 2.1 Outcomes of National autism Center’s National Standards report

eStaBliSheD praCtiCeS eMergiNg praCtiCeS UNeStaBliSheD praCtiCeS

• Antecedent package • Behavioral package • comprehensive behavioral treatment

for young children • joint attention intervention • Modeling • naturalistic teaching strategies • Peer training package • Pivotal response treatment • Schedules • Self-management • Story-based intervention package

• Augmentative and alternative communication device

• cognitive behavioral intervention package

• Developmental relationship-based treatment

• Exercise • imitation-based interaction • initiation training • Language training (production) • Massage/touch therapy • Multicomponent package • Music therapy • Peer-mediated instructional

arrangement • Picture exchange communication

system • reductive package • Scripting • Sign instruction • Social-communication intervention • Social-skills package • Structured teaching • technology-based treatment • theory of mind training

• Academic interventions • Auditory integration training • facilitated communication • gluten- and casein-free diet • Sensory integrative package

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the national professional development center on autism spectrum disorder

The National Professional Development Center (NPDC) on ASDs opted to organize evidence- based practices differently. They identified focused interventions, which were defined as “practices or strategies that teachers and other practitioners use to teach specific educational targets—skills and concepts—to children with ASD” (Odom et al., 2010b, p. 276). The NPDC accepted practices from studies that (a) were conducted with participants with ASD between birth and 22 years of age with participant outcomes as dependent measurements, (b) distinctly demonstrated the utilization of practices that were followed by gains in targeted skills, and (c) had adequate experimental control. Furthermore, the evidence had to be demonstrated by (a) at least two experimental or quasi-experimental group designs, (b) at least five single- subject studies from at least three independent investigators (e.g., different universities or agencies), or (c) a combination of at least one experimental and one quasi-experimental study with three single-subject studies from independent investigators (Odom et al., 2010b).

outcomes The NPDC has currently identified 24 EBPs, and two subgroups were created including behavioral teaching strategies, which include strategies based on the principles of applied behavior analysis (ABA), and positive behavioral support (PBS) strategies, which are strategies used to reduce or eliminate challenging behavior (e.g., tantrums, aggression, self- injury). The behavioral teaching strategies identified include prompting, reinforcement, task analysis, and time delay. Discrete trial training (DTT), also based in ABA principles, uses both prompting and reinforcement and, therefore, is a separate EBP. The PBS strategies are functional behavior assessment, antecedent-based interventions, response interruption/ redirection, functional communication training, extinction, and differential reinforcement. The remaining evidence-based practices, as identified by the NPDC, in alphabetical order are computer-aided instructions, naturalistic interventions, parent-implemented interventions, peer-mediated instructions/interventions, picture exchange communication systems (PECS), pivotal response training (PRT), self-management, social narratives, social-skills training groups, structured work systems, video modeling, visual supports, and speech-generating devices.

The NPDC staff thoroughly examined the current literature base and created briefs for each EBP, so parents, teachers, and other practitioners can easily access information (National Professional Development Center on Autism Spectrum Disorder, 2013). Each EBP brief contains an overview of the practice, step-by-step instructions, implementation checklists, and an evi- dence-based reference list, and some briefs also contain supplemental materials (e.g., sample data sheets). Those resources are available at http://autismpdc.fpg.unc.edu/content/briefs. Addition- ally, several modules are available here, for example, http://www.autisminternetmodules.org/, which is hosted by the Ohio Center for Autism and Low Incidence (OCALI). See Table 2.2 for a description of each EBP as defined by the NPDC.

evidence-Based practices: descriptions of common focused Interventions and comprehensive treatment models

vIsual supports Many of the EBPs as identified by both the NAC’s NSP and the NPDC on ASDs include visual and environmental supports (e.g., schedules, social narratives, struc- tured work systems). Such supports include a variety of visual stimuli such as providing pic- ture or three-dimensional schedule systems depicting the child’s activities for the day. These approaches teach children top-down or left-right orientation through visual supports and fur- ther provide prompts for common tasks such as washing hands or playing with toys, which involve photographs or picture symbols for each component of the task, posted in sequential order. The goal of visual supports is to fade the necessity for adult prompting, providing the child with the opportunity to practice skills independently using only the visual support. Another example of visual supports is the use of color coding. A learning environment may have colored baskets for different categories of instructional materials. For example, yellow

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taBle 2.2 National professional Development Center on autism Spectrum Disorder identified evidence-Based practices

eviDeNCe-BaSeD praCtiCe DeSCriptOr

Behavioral-Based Strategies

Prompting Antecedent strategy based on the principles of behavior.

reinforcement consequence strategy based on the principles of behavior.

task analysis teaching strategy that breaks a skill down into smaller, more manageable steps and links them together during teaching.

time delay Strategy focused on fading the use of prompts during instructional activities.

computer-aided instruction use of computers to teach academic, communication, and language skills with computer modeling and computer tutors.

Discrete trial training instructional approach that teaches skills in a planned, controlled, and systematic manner using applied behavior analysis principles.

naturalistic interventions collection of practices including environmental arrangement, interaction techniques, and strategies based on applied behavior analysis principles.

Parent-implemented interventions

Strategies that recognize and utilize parents as effective teachers for their children.

Peer-mediated instructions/ interventions

Strategies designed to increase social engagement by teaching typically developing peers to initiate and maintain interactions.

Picture exchange communication system

Practice in which learners are taught to give a picture to a communication partner in exchange for a desired item and then progress through six phases progressing in complexity.

Pivotal response training Approach that teaches the learner to seek out and respond to naturally occurring learning opportunities using applied behavior analysis principles.

positive Behavioral Support Strategies

Antecedent-based interventions

collection of strategies in which the environment is modification and/or manipulated in order to prevent a learner from engaging in interfering behavior.

Differential reinforcement Behaviorally based strategies that involve reinforcing alternative, incompatible, other, or lower rates for interfering behavior in order to replace it with more appropriate behavior.

Extinction Behaviorally based strategy that withdraws or terminates the reinforcer associated with an interfering behavior in order to reduce or eliminate it.

functional communication training

Systematic practice of replacing inappropriate communicative behavior with more socially appropriate behavior.

functional behavior assessment

Systematic set of strategies used to determine the underlying function, or purpose, of a behavior so that an effective intervention can be developed.

response interruption/ redirection

the physical prevention or blocking of interfering behavior, predominantly those that are repetitive, stereotypical, and/or self-injurious.

Self-management Method in which learners are taught to monitor, record and report data, and reinforce their own behavior.

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baskets may be used for building blocks, and blue baskets may be used for art supplies. The purpose of color coding is to aid children as they learn categorization skills as well as to help them begin to recognize expectations for different activities without an adult prompt. For instance, if the yellow basket is on the floor, the child will come to expect to build blocks, whereas if the blue basket is out, the child will come to expect to sit at the table for an art activity. In this way, independence is fostered.

Teaching students with autism to attend to environmental cues and stimuli effectively is an important consideration in a student’s educational program. Because of their perceptual and cognitive difficulties, paying attention and imitating can be challenging areas for students with autism. To address these challenges, teachers should incorporate attending skills and imi- tation (both verbal and nonverbal) into lessons. Providing children with autism with the nec- essary supports to overcome perceptual and cognitive processing challenges will help promote independence and self-reliance. Although these supports are necessary for intervention early on, the goal of fading these supports, as the child gets older and more independent, is critical. The most well-known program, also referred to as a comprehensive treatment model (CTM), utiliz- ing these approaches is the Treatment and Education of Autistic and related Communication- handicapped Children (TEACCH) model. This model was developed at the University of North Carolina at Chapel Hill. Research suggests that the TEACCH model increases independence, self-management, and task completion (Marcus, Schopler, & Lord, 2001; Schopler, Lansing, & Waters, 1983). Another model program utilizing the perceptual-cognitive approach is the Princeton Child Development Institute, which uses graduated guidance to increase imitation and completion (MacDuff, Krantz, & McClannahan, 1993). Environmental supports have been found to increase a child’s understanding of his world, acceptance of change, and independence as well as increase adaptability and flexibility during times of transition (Bryan & Gast, 2000; Orelove, 1982; Quill, 1997; Simpson & Myles, 1993). Visually supported instruction is a key component of the TEACCH program, and the use of visual supports has been linked with increases in social-communicative behaviors such as joint attention, prelinguistic communica- tive gestures, and receptive language (Quill, 1996; Quill & Grant, 1996). Further, increases in independence, less dependence on adults, less confusion and resistance to changes, improved understanding of activities and expectations, and improved generalization and maintenance

eviDeNCe-BaSeD praCtiCe DeSCriptOr

Social narratives written narratives that describe social situations in some detail and highlight relevant cues and offering examples of appropriate responding to help the learner adjust to the situation and adapt his/her behavior.

Social-skills training groups Small group instruction with a shared goal of learning social skills through activities such as role-play or practice. Learners receive feedback from a teacher or adult facilitator.

Speech-generating devices Portable, electronic devices that produce synthetic or digital speech and are used as a means of communication for the user.

Structured work systems An element of structured teaching developed by tEAcch (treatment and Education of Autistic and related communication-handicapped children) aimed at increasing independence and reduce the need for teacher correction.

video modeling teaching strategy that uses videos as the core component of instruction and allows for pre-rehearsal of the target skill via observation.

visual supports tools presented visually that enable a learner to independently track events and activities as he/she moves throughout the day.

Source: Odom et al., 2010b; national Professional Development center on Autism Spectrum Disorder, 2013.

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of daily living skills have been noted with the use of visual supports (MacDuff, Krantz, & McClannahan, 1993; Pierce & Schreibman, 1994). Social narratives are another EBP that incor- porate visual supports. One type of social narrative is the Social Story (Gray & Garand, 1993), which is often used with high-functioning students with autism to improve social, communi- cation, and behavior skills. Numerous studies are under way or have been published indicating that this type of visual support is effective for this population (Bernad-Ripoll, 2007; Crozier & Tincani, 2007; Gray & Garand, 1993; Okada, Ohtake, & Yanagihara, 2008; Reynhout & Carter, 2007). Similar to the visual supports mentioned above are the use of graphic sym- bols and phrases and sentence strips to improve language competence. Use of these types of visual supports has improved labeling, commenting on actions, asking “wh” questions, sponta- neous commenting, and functional communication with peers (Hunt, Alwell, & Goetz, 1985; Kistner, Robbins, & Haskett, 1988; Quill, 1992; Wolfberg & Schuler, 1993).

comprehensive treatment models

Parents, teachers, and other stakeholders are often bombarded with treatment options for stu- dents with ASD, and it can be difficult to know what is the right approach. The NPDC pro- vides multiple resources on the 24 focused intervention practices described above. Many of those strategies are designed to teach specific skills or reduce interfering behaviors (Odom et al., 2010b). In contrast to a focused intervention practice is a comprehensive treatment model (CTM). A CTM is an intervention approach that consists of “a set of practices designed to achieve a broader learning of developmental impact on the core deficits of ASD” (Odom, Boyd, Hall, & Hume, 2010a). These are also known as branded interventions as they are often asso- ciated with a name or acronym (e.g., Lovaas Model, TEACCH, STAR). CTMs usually require an extended period of time for intervention (e.g., more than one year), and they are applied with intensity and contain multiple components. Odom et al. (2010a) identified a total of 30 CTMs for ASD and evaluated them in terms of (a) operationalization (i.e., how well the model is documenting via a manual or procedural guidelines), (b) implementation measures (i.e., documented fidelity of the described treatment, (c) replication (i.e., evidence of implementers outside of the company replicating the treatment), (d) type of empirical evidence (i.e., the quality of the published results of the treatment), (e) quality of the research methodology, and (d) complementary evidence from studies of focused interventions (i.e., components of the model). The authors used the SMRS as described by the NAC in the NSP in order to rate each CTM and generate a score (ranging from 0 to 5) in each evaluation dimension. Table 2.3

taBle 2.3 Degree of Development of Comprehensive treatment Models

StrONg MODel DevelOpMeNt partial MODel DevelOpMeNt liMiteD MODel DevelOpMeNt

• Denver Model • Learning Experiences: An

Alternative Program for Preschoolers and Parents

• Lovaas institute • May institute • Princeton child Development

institute

• Autism Partnerships • center for Autism and related

Disorders • children’s toddler Program • Dir/floortime (Developmental,

individual difference, relationship-based model)

• Douglass • Pivotal response training • responsive teaching • StAr (Strategies for teaching

based on Autism research) • tEAcch (treatment and Education of

Autistic and related communication- handicapped children)

• hanen • higashi • Eden • Summit • Lancaster • Son rise

Source: Odom et al., 2010a.

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lists CTMs that have strong model development meaning that overall they had scores of 5 and 4 across at least four of the dimensions and thus are procedurally well documented, have been replicated, and have some level of efficacy. CTMs with partial model development had ratings of 5 and 4 on less than four domains, but had relative strengths, and some CTMs received low rates across all dimensions, and therefore we have described them as having limited model development.

The majority of the CTMs identified by Odom et al. (2010a) are based on the principles of applied behavior analysis. For example, The Lovaas Model, pivotal response training, and LEAP (Learning Experiences: An Alternative Program for Preschoolers and Parents) are all multicomponent comprehensive behavior analytic treatments. ABA is a scientific approach to examining human behavior that relies heavily on careful observation, measurement, and recording to bring about socially valid behavior change (Schreibman & Winter, 2003). A com- mon misnomer is that ABA is equivalent to discrete trial training. While DTT is one specific EBP under the ABA umbrella, there are many other evidence-based practices that also fall into the category of ABA such as modeling, naturalistic teaching, PECS, PRT, and positive behav- ior support strategies.

dIscrete trIal traInIng In discrete trial training, skills are taught through dis- crete teaching trials that consist of a trainer-provided antecedent (instruction and/or stim- ulus), a behaviorally defined response from the child, and a consequence that rewards a correct response or marks an incorrect response known as the three-term contingency (Mastergeorge, Rogers, Corbett, & Solomon, 2003). The three-term contingency refers to the antecedent, the behavioral response, and the consequence; together they make up a dis- crete trial. It is critical to target specific skills and teach them to students with autism. In the absence of directed, structured, and frequent learning opportunities, students with autism may not acquire the skills necessary to engage in appropriate interactions in several different environments. DTT has been shown to help students with autism develop skills in labeling and requesting objects, asking questions, initiating and maintaining conversa- tion, describing items, and making social greetings (Lovaas, 2002). The wide-scale success of DTT has brought both praise and debate about the merits of the technique. In spite of the many documented success stories, there is concern that the lessons learned within the contrived learning environments do not generalize across more natural environments (e.g., home and community). Although the controversy rages on, many families and professionals experience great success.

naturalistic Behavioral teaching practices

pIvotal response traInIng Pivotal response training is a naturalistic, behavioral intervention for students with autism targeting pivotal behaviors that impact many areas of functioning (Schreibman & Winter, 2003). The naturalistic behavioral interventions, while still grounded in ABA, grew out of a call for different teaching techniques that began with child-initiated communication and sessions conducted “without a table and chair.” The approach requires professionals and parents to “follow the child” through a session and allow the child to learn communication through natural opportunities (e.g., requesting a cup of juice from the table). Mastergeorge and colleagues (2003) identified a number of key differ- ences between DTT and naturalistic approaches like PRT: (a) child initiation of communica- tion rather than adult directed, (b) use of intrinsic rather than extrinsic reinforcement, and (c) instruction in the natural context rather than at a table using drill and practice. There are four key behaviors that PRT aims to teach: being responsive to multiple cues, motivation, self-management, and self-initiation. Through these key behaviors, PRT aims to facilitate generalization, increase spontaneity, reduce prompt dependency, and increase motivation of children with autism (Suhrheinrich, 2011).

Other naturalistic teaching procedures, including environmental arrangement, inciden- tal teaching, and milieu teaching, share many components of PRT and have the common goal of using behavioral principles within natural settings and with natural reinforcement to teach

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a variety of skills, most commonly communication (Charlop, Schreibman, & Thibodeau, 1985; Hart & Risley, 1968; Koegel, O’Dell, & Koegel, 1987; Koegel & Williams, 1980). Another category of CTMs includes those that are developmental and relationship based and are concep- tually different ABA-based models. Some of these include the Denver Model, DIR (Develop- mental, Individual-differences, Relationship-based model) / Floortime, and RDI (Relationship Development Intervention) (Odom et al., 2010a).

early start denver model The Early Start Denver Model (ESDM) is derived from the Denver Model and is a developmental, relationship-based comprehensive treatment model that blends developmental teaching approaches with the science of ABA (Rogers & Dawson, 2010). The ESDM seeks to utilize a normal developmental sequence and parental involve- ment. Further, there is a focus on interpersonal exchange, positive affect, and shared engage- ment with joint activities. The ESDM uses a specific developmental curriculum and a specific set of teaching procedures for delivery. Many of the teaching procedures involve common ABA techniques such as prompting, fading, shaping, and chaining. The literature base for the ESDM has recently expanded significantly. For example, in 2010 the Journal of Pediatrics published a study that used a randomized clinical trial and showed that children who received ESDM therapy for 20 hours a week over 2 years showed greater improvement in cognitive and language abilities and adaptive behavior and fewer symptoms of autism when compared to children referred for other commonly available interventions (Dawson et al., 2010).

the star program Strategies for Teaching based on Autism Research (STAR) (Arick, Loos, Falco, & Krug, 2004) is described by its authors as a “comprehensive behavioral program for students with autism . . . [which] uses applied behavioral analysis methodology to provide an instructional base for teaching” (p. 1). The STAR program uses a combination of three instructional strategies including discrete trial training, pivotal response training, and the use of functional routines instruction. The authors conducted a study of 67 children with autism ages 2 to 6 (at baseline) using the STAR program (Arick et al., 2003). After staff received comprehensive training and several baseline assessments were conducted with each of the chil- dren, the children participated in home- or school-based STAR programs. At the beginning of the program, children were given a pretest. At the end of 16 months, the children were given a posttest, and results were analyzed based on the pretest and posttest. At the posttest, significant gains were found in socialization and language. Specifically, over the 16-month period, 36% of the participants showed gains of 16 months or more; the average gain for all children was 10 months (Arick et al., 2003). Further, significant decreases in autistic behavior and social characteristics associated with autism were noted. Another study by Young (2006) found similar results, specifically that children taught via the STAR program made an average of 1 month’s gain in expressive verbal language for each month of intervention. Both studies reported that there appeared to be no correlation between a participant’s chronological age and these language gains; “children were just as likely to make gains at any chronological age” (Arick et al., 2003, p. 81). These studies suggest that using a comprehensive approach that targets specific, individual areas of child need can lead to improvements in targeted skills.

unestaBlIshed and fad treatments

The NAC on ASDs identified five practices as unestablished treatments (academic inter- ventions, auditory integration training, facilitated communication, gluten- and casein- free diets, and sensory integrative package). Currently, these treatments have little or no evidence to support their use (National Autism Center, 2009, p. 72). Further, the NAC asserts that there is no reason to assume that these practices are effective, and we can- not rule out the possibility that these treatments are ineffective or harmful. Academic interventions are defined as those that use traditional methods of teaching instruction to improve academic performance. Some of these practices include picture-to-text matching,

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the expression connection, and completing cloze sentences. These findings suggest that individuals with autism need interventions that address the specific symptoms of their dis- ability; thus, generic special education practices are insufficient. Auditory integration train- ing “involves the presentation of modulated sounds through headphones in an attempt to retrain an individual’s auditory system with the goal of improving distortions in hearing or sensitivities” (National Autism Center, 2009, p. 73). Gluten- and casein-free diets involve the elimination of naturally occurring proteins from gluten and casein from an individ- ual’s diet, and sensory integrative therapy seeks to create an “environment that stimulates the individual to effectively use all of their senses as a means of addressing overstimulation or understimulation from the environment” (National Autism Center, 2009). See Box 2.2 for more information.

Perhaps the most alarming unestablished treatment is facilitated communication, which is an intervention involving a communication facilitator supporting “the hand or arm of an individual with limited communication skills, helping the individual express words, sentences, or complete thoughts by using a keyboard of words or pictures or typing device” (National

Box 2.2 trend and Issues #1

Two of the unestablished practices as identified in the National Standards Report are sensory integrative package and gluten- and casein-free diets (National Autism Center, 2009). Both of these treatments have recently gained enormous popularity and could be considered fad treatments as the current evidence base is lacking. Sensory integrative package, more com- monly referred to as sensory integration therapy (SIT) is a common treatment often delivered by occupational therapists in which specific forms of sensory stimulation are given in doses to improve the nervous system’s ability to process sensory stimuli (Lang et al., 2010). Common activities implemented during SIT include wearing a weighted vest, being brushed, sitting on a bouncy ball, being squeezed, and other similar events. Such activities target provision of tactile, vestibular, and/or proprioceptive sensory stimulation, which support a child’s self-regulation, sensory awareness, or movement. In a recent literature review, Lang et al. (2010) identified 25 studies that examined SIT, and of those, only three suggested reported positive outcomes of SIT. All three of the studies that reported positive outcomes were found to have methodological flaws within the research designs. We assert that many of the activ- ities common to SIT may be enjoyable and fun for children with and without autism; and therefore, we are not suggesting that these activities be eliminated. However, we warn teach- ers and practitioners that providing access to sensory activities contingent on problem behav- ior may actually reinforce that behavior. Thus, we advise practitioners and teachers to collect data when implementing any intervention.

Gluten- and casein-free (GFCF) diets have also recently gained ubiquitous acceptance. The theory behind eliminating gluten and/or casein from the diet of an individual with autism is referred to as opioid-excess theory (Mulloy et al., 2010). This theory is predicated on the basis that individuals with autism experience insufficient enzymatic activity, increased gastrointes- tinal permeability, and the absorption of toxic byproducts of incompletely digested proteins from dairy (casein) and cereals (gluten). Mulloy et al. (2010) reviewed 14 studies involving the treatment of ASD using diets that restricted the intake of gluten and/or casein. Of this limited literature base, no studies were capable of providing conclusive evidence. Therefore, it is recom- mended that until conclusive evidence is found in support of GFCF diets to treat symptoms of ASD, restrictive diets should be utilized in the case of food allergy or if intolerance is detected.

For further reading, please refer to the partial list of works below:

Lang, R., O’Reilly, M., Healy, O., Rispoli, M., Lydon, H., Streusand, W., . . . Giesbers, S. (2010). Sensory integration therapy for autism spectrum disorders: A systematic review. Research in Autism Spectrum Disorders, 6, 1004–1018.

Mulloy, A., Lang, R., O’Reilly, M., Sigafoos, J., Lancioni, G., & Rispoli, M. (2010). Gluten- free and casein-free diets in the treatment of autism spectrum disorders: A systematic review. Research in Autism Spectrum Disorders, 4, 328–339.

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Autism Center, 2009, p. 72). Because the NAC followed strict inclusion/exclusion criteria, a large number of studies on FC were excluded in the NSP: (a) those that involved participants over the age of 22, (b) those that contained participants with infrequently occurring comorbid conditions, and (c) those that focused on the adult facilitators (as opposed to the participants with ASD). Thus, although the NAC labels this practice as unestablished, many organizations, such as the American Psychological Association (1994), advise against the use of FC as it causes “immediate threats to the individual civil and human rights of the person with autism” (as cited in National Autism Center, 2009, p. 72). See Box 2.3 for more information related to FC.

Some of the unestablished treatments above could also be described as fad treatments. A fad treatment is one that is adopted rapidly by consumers without validating research to support its use and eventually fades away as research disconfirms its use (Vyse, 2005). The field of autism is an easy target for fad treatments because although understanding of the etiology of autism is growing, there continue to be missing links and no cure currently exists (Mulloy, Lang, O’Reilly, Sigafoos, Lancioni, & Rispoli, 2010; Offit, 2008). We urge stakeholders, including families and educational teams, to be aware of unestablished and fad treatments and to seek rep- utable agencies such as the National Autism Center and the National Professional Development Center on Autism Spectrum Disorder when choosing treatments for individuals with ASD.

Box 2.3 trends and Issues #2

Children with autism frequently require significant intervention in order to develop func- tional communication. For many children with autism who do not gain adequate speech to meet their communication needs, augmentative and assistive communication systems are often chosen to help meet these needs. There are specific types of aided AAC systems, such as picture exchange communication system and speech-generating devices, which meet the standards for evidence-based practices (National Professional Development Center on Autism Spectrum Disorder, 2013). However, there are other methods that are deceptively similar to these for which there is no evidence base or for which there is evidence against its use (Tostanoski, Lang, Raulston, Carnett, & Davis, 2013). Facilitated communication (FC) arose in the early 1990s; it consists of a therapist, called a facilitator, supporting the FC user at some part of the user’s arm while he or she types a message on a device with a keyboard. By the mid-1990s, there was strong evidence to indicate that the messages typed during an FC session were created by the facilitator guiding the user’s body, rather than having any author- ship by the FC user. Despite this evidence and the irreparable damage that has been caused by FC use, such as false accusations of child abuse and violation of the personal rights of its users, FC still has its proponents and can be observed to this day under its new name: supported typing. A similar technique known as Rapid Prompting Method (RPM) was brought to the United States in 2001. Training for a child using RPM initially looks much like training a child to use PECS using prompts; an RPM user eventually moves on to using a therapist-held stencil to select letters, then typing on a keyboard. However, there is no system for fading prompts in RPM, and this creates doubt that children using RPM are the authors of their purported messages. In addition, RPM lacks an evidence base; at this time, one empirical study has been performed on RPM, and it did not address the issue of authorship of messages conveyed in RPM sessions. It is advisable to use caution when considering AAC systems for a child with autism; the proper choice can boost the child’s independence and overall quality of life, while choosing a system in which the child may not be controlling the output may, at best, do nothing, and at worst, cause serious harm.

For further reading, please refer to the partial list of works below:

Boynton, J. (2012). Facilitated communication—What harm it can do: Confessions of a for- mer facilitator. Evidence-Based Communication Assessment and Intervention, 6(1), 3–13.

Offit, P. (2008). Autism’s false prophets: Bad science, risky medicine, and the search for a cure. New York, NY: Columbia University Press.

Tostanoski, A., Lang, R., Raulston, T., Carnett, A., & Davis, T. (2013). Voices from the past: Comparing the rapid prompting method and facilitated communication. Developmental Neurorehabilitation, 17(4), 219–223.

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chIld and famIly-centered decIsIon makIng

The decision regarding the skills to be taught, and the best method through which to teach them, should be based on a valid and up-to-date assessment as well as on the wants and needs of the individual child and family. Each child has abilities, strengths, and skill deficits that may be more successfully enhanced or remedied in response to one methodology than another. Boxes 2.4 and 2.5 discuss the role of families in decision making as well as cultural influences that should be considered when working with families.

Box 2.4 dIversIty notes #1

The vast diversity in the United States is readily apparent with no more than a cursory look at the changing demographics of schools, clinics, and the like. This trend has far reaching impli- cations for the diagnosis and service delivery to families from diverse backgrounds. Welterlin and LaRue (2007) reviewed a large sample of the current knowledge available on serving the needs of immigrant families who have a child with a disability, most notably autism. In spite of the paucity of information, this work yielded notable information regarding the way families interpret disability and some recommendations for service delivery to families. In regard to interpretation of disability, it is known that families from diverse backgrounds may interpret both symptoms and behavior differently than families from the majority culture. For example, it is not uncommon for Native Americans to view an individual with a disability as possessing special insight into our world. Second, the well-accepted Western notion of intervention, spe- cifically for the purposes of ameliorating the effects of disability, may be a foreign concept to immigrant families. Some families may view themselves as holding primary responsibility for any intervention, whereas others may feel as if interventions intended to change behavior are simply misguided. The implications of this review are twofold. First, practitioners should be aware of the families’ interpretation of disability and their current strengths that may contribute to the success of a treatment plan. This information will assist both families and practitioners to ensure that treatment plans are acceptable to all. Second, practitioners should incorporate strategies into any treatment plan that respect and promote the knowledge of families. This rec- ognition of perspective should also facilitate the development of effective treatment planning.

In 2011, Travers, Tincani, and Krezmien examined data from 1998 to 2006 regarding identification of individuals with autism by racial categories and found that racially diverse groups were underrepresented. White students were more likely to be eligible for special education services under the category of autism than students from any other racial category. Hispanic and American Indian students were the least likely to be identified as having autism. Interestingly, African American students were overrepresented in 1998 and 1999; yet, in subsequent years this group was considerably underrepresented. The study identified two factors that could be contributing to this disproportionality. First, educational classification within administrative categories of eligibility of special education services may have changed over time due to differences in assessment practices. Second, there could be a lag in the time a racially diverse student receives a diagnosis when compared to White students. Racially diverse students may be less likely to receive a diagnosis of autism outside of the school setting, and therefore, public school special education screening and assessment processes may play an especially vital role to these populations. If children with autism from racially diverse ethnicities are being identified later, it is very likely that these children are not receiving access to evidence-based practices such as comprehensive behavior treatments for young children. Additionally, if these children are being misidentified (e.g., identified as having an intellectual disability), they may be receiving services that are not specific to autism and therefore also are at risk of being deprived of evidence-based practices. Several implications for practice arise from this study including the need for dissemination of information regarding early signs of autism to racially diverse families and the need for culturally responsive professional development for assessment staff and other educational team members.

Sources: Welterlin, A., & LaRue, R. H. (2007). Serving the needs of immigrant families of children with autism. Disability and Society, 22(7), 747–760.

Travers, J., Tincani, M., & Krezmien, M. (2011). A multiyear national profile of racial disparity in autism identification. The Journal of Special Education, 47(1), 41–49.

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data-driven Instruction

One cannot know the effectiveness of any instructional approach, no matter how well doc- umented in the research, unless data are collected and analyzed regarding its use within the framework of an individualized instructional program. Thus, the use of applied behavior analysis

Box 2.5 dIversIty notes #2

Families of children with autism are often faced with a number of different challenges in car- ing for their children. Often, these difficulties are not confined to diagnosis, but persist well after. As parents attempt to negotiate different social service agencies, schools, and medical facilities, there is often a need for parental support. There are a number of different sources of family support, but a common source of support is found in a support group. Currently, there is little information available about families who join support groups or why. Mandell and Salzer (2007) conducted a study to investigate these questions. The researchers distrib- uted their survey through community-based service agencies. A total of 1,018 respondents answered questions about themselves and provided reasons why they chose to attend a sup- port group. Information from the study was split into different categories for analysis. Specif- ically, respondents were divided into those who reported attending a support group at least once and those who reported never attending. The most interesting findings are based on those reporting attending a support group at least once. Two-thirds of the sample reported attending a support group at least once. Of this sample, an overwhelming majority were White, earned incomes over $40,000 a year, lived in a suburban area, had a college degree, were married or living with a partner, and were referred to the support group by a trained cli- nician. Perhaps most significantly, African American families were much less likely to partic- ipate in support groups. The authors offer some interpretation for this finding. It may be that some groups take comfort in talking about their concerns, or some groups may have more time and resources to seek out different support mechanisms. The availability of information about families from diverse backgrounds is so spare that it is difficult to draw any broad con- clusions, but this work is a worthy beginning.

More recently, Clifford and Minnes (2013) conducted a follow-up study aimed at iden- tifying characteristics of parents (e.g., mood, beliefs, coping styles, and social support). In this study, a Self-Regulatory Model (SRM) was used to choose predictors of support group involve- ment. The SRM theoretical framework posits that a person’s belief about illness, coping strate- gies, and social input from family and friends contributes to decisions about seeking treatment or help. Ultimately 149 parents were divided into three groups: (a) never used support groups, (b) past support group use, and (c) current support group use. This study found that the reasons some parents do not attend support groups is not because of perceived lack of benefits, but may be due to factors including location, meeting time, and lack of child care available. The parents who currently attended support groups reported using more coping strategies such as seeking emotional and instrumental supports. Many support groups focus on sharing information and teaching rather than emotional support and bonding; thus, parent support groups may not be meeting the needs of some parents. Further, there appears to be a subgroup of parents who may benefit from other methods of support because they have not found support groups to be beneficial and/or they do not seek support as a form of coping. Such parents may benefit from respite in order to reenergize, parent-to-parent support, or parent-led groups, which could focus on bonding and building relationships rather than the traditional information sharing. Improving understanding of the needs of families and characteristics that influence those needs will help us build the framework to support parents and families more effectively.

Sources: Mandell, D. S., & Salzer, M. S. (2007). Who joins support groups among parents of children with autism? Autism, 11(2), 111–122.

Clifford, T., & Minnes, P. (2013). Who participates in support groups for parents of children with autism spectrum disorders? The role of beliefs and coping style. Journal of Autism and Developmental Disorders, 43, 179–187.

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techniques for data collection, analysis, and documentation is advocated. Ongoing formative as well as summative evaluation must be conducted and changes in programming made to ensure maximum success of each student.

systematic generalization

Once skills have been mastered, they should be systematically revisited to ensure they are maintained across time. Further, systematic generalization of skills must be planned in advance to ensure that such generalization of skills will occur.

The ultimate goal of intervention is threefold. First, interventions should lead to the child’s maximum and age-appropriate participation in the natural environment and with typical peers. Second, intervention should be age appropriate and functional for the child. Third, intervention should support the child and her family in maximizing the child’s potential both now and in the future; as such, generalization of skills and independence are paramount.

ImplIcatIons for practIce The treatment of autism is currently a challenge for teachers and families alike. The selection and implementation of an intervention may “look” different for each child in need of services. For this reason, it is necessary to conduct research in several areas to gain insight into the utility and effectiveness of the selected intervention package. It is possible that some of this information will come directly from many of the education programs designed to deliver services to students with autism. Thus, we suggest several questions that may help to guide critical reflection as well as ignite research so that both professionals and families can gain a better understanding of appropriate programming. First, we pose a question for critical reflection: What are the current intervention packages teachers and parents use and how are these packages chosen? (The reasons behind mak- ing such choices will be of special interest.) The final two questions are intended to ignite research, but have implications for classroom practices. How do intervention packages differ for children of varying ages? (Many families choose entirely different interventions after their child reaches the age of 6.) There is not only a need to understand the decision-making process educational professionals (i.e., teachers) use to choose and implement interventions, but it is also critical to understand how and why families may embrace or perhaps com- pletely reject a particular intervention. Communication and cooperation between school and home is essential. Thus, it is important to understand how and why both professionals and families make decisions about interventions. Our final question deals directly with the out- comes of interventions: How effective are treatment packages and in what combination? It is important for teachers and families to thoroughly understand how intervention packages can be formulated for the most efficient and effective results. The severity and impact of autism on families requires that teachers and families choose the most appropriate treatment package for students with autism. Effective treatment for children with autism is possible and has been demonstrated in a number of different settings under a host of conditions. Yet, questions remain about how such programming can be identified and implemented on a wide scale.

selectIng an InstructIonal approach

We have provided an overview of what it means for an intervention approach to be evidence based according to different agencies. However, how does a team (including a child’s teacher and family) use this knowledge to make appropriate decisions? To begin to examine how one makes programming decisions for students with ASD, let us first consider the goals. Spe- cifically, what is the purpose of the education we seek to provide? The ultimate goal of any educational program is to provide the student with the skills necessary to be maximally inde- pendently functioning within his natural environment. In order to achieve this goal, we sug- gest consideration of four principles of educating students with ASD.

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principles of educating students with asd

Westling and Fox (2004) provide us with a philosophy for educating students with significant disabilities, including autism. According to this philosophy, students with ASD should:

• Receive an education that is qualitatively equal to that received by students without disabilities or those with other disabilities

• Receive an Individual Education Plan that represents their unique individual needs • Spend time with others, especially those without disabilities (e.g., not in isolation) • Receive early intervention services as soon as possible • Receive training until they are ready for adulthood • Receive an education that “maximizes their learning, growth, and development” (p. 31) • Receive an education that is not unnecessarily intrusive or different from the education

of others • Receive an education that promotes independence and self-sufficiency

According to this philosophy, the goal is to provide students with ASD with educational opportunities to participate actively and successfully in the mainstream of society by promot- ing the principles of self-determination, independence, normalization, and functionality.

prIncIple of self-determInatIon Individuals are said to be self-determined if they can (a) make choices, (b) make decisions about their actions, (c) set goals for themselves, (d) recognize their own abilities (strengths and needs), and (e) advocate for themselves. People with disabilities have long had a history of potential learned helplessness, particularly those with more significant disabilities (Scheuermann & Webber, 2002). Learned helplessness occurs in individuals when they become conditioned to allowing others to make decisions and do things for them. Consider the case of Jonathan, a 17-year-old with autism and intellectual disabilities. Jonathan had learned to do many things for himself at school, and his parents were surprised to learn at his transition meeting that he was able to make his own snacks, do laundry, and tie his shoes. His mother stated that she had been tying his shoe laces every day since he first began to walk, and it never occurred to her to allow Jonathan to do it himself. She stated that she had attempted to teach him when he was in elementary school, but it took him so long to get them tied in the morning that they were often late getting out of the house. This represents an example of learned helplessness. Jonathan was capable, but allowed his mother to tie his shoe laces because she always had and she would. If we are to prevent learned helplessness in people with autism, we must give them ample opportunities to perform skills on their own, as well as teach them how to do so. Further, as teachers, it is incumbent that we ensure that families and other caregivers are aware of the individuals’ abilities and are willing to give them more independence, even if it means that it takes longer to get out of the house in the morning.

Although independence is key to self-determination, one can receive support and still be self-determined. It is necessary for people with autism to have a voice and choices in order to achieve self-determination. People with autism must be given opportunities to enjoy a myr- iad of experiences, just as typically developing children do, if they are to be aware enough of their options to make informed choices as they grow older. Consider April, a 15-year-old with autism. Her family met with the school team to discuss community-based instruction opportunities that might provide April with work experience the following school year. When asked what she wanted to do, April was unable to come up with a response, even with prompt- ing by family and teachers. Her family admitted that they rarely went anywhere on weekends except to the homes of relatives or to church. April had not had enough experiences to be aware of jobs she might enjoy. The teaching staff spent the next school year providing April with as many different community experiences as they could. At the end of that year, she was able to tell them that she wanted to work at the community pool because she had learned to swim and loved to be near the water. If provided opportunities, children with autism, like all children, will have a broader base from which to make personal decisions. Further, they will

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have a better awareness and understanding of their own abilities and limitations, which also aid in decision making. However, choices about one’s career are not the only choices we make as individuals. Many students with autism have difficulty making decisions as simple as where to sit at lunch or what shirt to wear because they are accustomed to someone making those decisions for them. Teachers and families should start early teaching children with autism to make their own choices by providing multiple opportunities throughout the day for them to make choices. For example, when Gigi was 3 years old, her family gave her two choices for as many things as they could think of throughout the day: the pink dress or the purple one, the red bowl or the yellow one, hold Mommy’s hand or Daddy’s, and so on. When she was older, Gigi was able to make her own choices and speak for herself, rather than wait for someone to do it for her. Teaching young children to make their own choices and have their own voice teaches early self-determination.

prIncIple of Independence A primary goal of education for students with autism is to maximize their independence in all activities and across all settings. Independence is achieved when one uses only those supports that are absolutely necessary for functioning. Although teachers and parents frequently must use some level of prompting when teaching new skills, prompts and cues must be faded to promote independence. Further, independence cannot be achieved until individuals have opportunities to do things for themselves in the natural set- ting (e.g., the real world) and are provided training in doing so. Therefore, goals and objec- tives for students with autism should include statements of how skills are to be generalized to the natural setting, as well as prompt-fading techniques that will be used to promote maxi- mum independence.

prIncIple of normalIzatIon Normalization occurs when the activities, materials, and settings in which a person engages are the same as those in which persons without disabili- ties of the same age, gender, and culture are engaged (Nirje, 1969; see Perske, 2004, for an updated review). In short, normalization helps individuals with autism “fit in” with those without disabilities. Fitting in cannot occur if the person with autism is not provided oppor- tunities to participate in the activities and environments in which others without disabilities are participating. In other words, the first step is opportunity. Second, teachers and families need to ensure that once in the environment, the child with autism has the skills necessary to engage in the same or similar activities as others. Finally, we know that persons with autism often have difficulties, including social-skill deficits, language deficits, or stereotypical behav- iors, that may set them apart from typically developing peers, especially in a “typical” activity or setting. Therefore, teachers and families must ensure that these differences do not pose a barrier to successful fitting in for the person with autism. Consider Austin, a 10-year-old with high-functioning autism. His family wanted him to play soccer and signed him up to play on one of the local teams. His parents decided that since Austin could speak well enough, they would not tell the coaches and players about his autism; they felt it might negatively impact their impression of him and prevent him from making friends. After several prac- tices, during which Austin could physically do everything that the other players could do, his parents felt that their decision was a good one. However, at the first game, Austin was very excited and began engaging in more of his self-stimulatory behaviors than he had at practices. He flapped his hands wildly in front of his face and made a loud “eeeeeee” sound whenever someone came near him on the field. When on the sidelines, he sat on his heels and rocked, only flapping when the players came near where he was sitting. His parents noticed that the coaches and some of the boys (both on their team and the other team) began to look at him warily, and some boys were even imitating Austin’s hand flapping and laughing. His parents began to question their decision not to inform his coaches and teammates, which in hindsight may have made them more tolerant of Austin’s differences. As this scenario illustrates, simply being in the same location does not guarantee fitting in. Although the Inclusion Movement has helped to make students without disabilities more tolerant of those with autism (Boutot & Bryant, 2005), misunderstandings can occur when the behavior of children with autism is

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very different from what is expected, or when they lack the appropriate skills to fit in and par- ticipate in an activity. Therefore, along with providing opportunities, successful participation should be incorporated into programming for individuals with autism in order to promote the principle of normalization.

prIncIple of functIonalIty A skill is said to be functional when someone has to do the skill for the child if the child cannot do it himself (Brown, Nietupski, & Hamre-Nietupski, 1976). In other words, a skill is considered functional only if it is something the child actually needs to be able to do in his everyday life in the natural environment. Functional skills can also be thought of as those skills that are meaningful to the child, necessary for current or future independence, and/or when they promote opportunities to fit in with age and cultural groups. For example, skills that can assist in meeting the principle of normalization may be considered functional. Consider the case of Chloe, who is a 7-year-old with low-functioning autism. Her occupational therapist wants her to work on her pincer grip (used to pinch and pick up items). Chloe’s teacher created a game wherein Chloe uses her pincer grasp to put clothespins on and take them off of a coffee can over and over. In Chloe’s natural environment (home and school) clothespins are never in use (except for this activity). One could argue that while this activity does aid with improving her pincer grasp, the act of taking off clothespins and putting them on a coffee can is one she will rarely (if ever) use in the real world. A better idea might have been to provide her with chip clips to take off and put back on her favorite bag of chips (thereby including a natural motivation for the task), or picking up raisins (a favorite food) using the pincer grasp. In other words, the teacher should think of materials and activities for this skill that will better meet the principle of functionality.

determining appropriate strategies for Individual students

Although research supports ABA as the evidence-based strategy for working with students with autism (as will be discussed in more detail in Chapter 6), determination of the exact com- bination of strategies from the differing perspectives must be made on an individual basis. It would be unethical for us to prescribe a combination for each and every student with autism, because each has his own unique needs, which may be addressed in a number of different ways.

summary

From the first moment a family receives a confirmation that a child does indeed have autism, thoughts about treatment begin. The path from diagnosis to treatment can be rid- dled with challenges and uncertainties, but there are efforts to facilitate an easier process for families when making choices about treatment. The communities of profession- als who serve children with autism have been and continue to be highly concerned about making the best possible treatment available to all families. In fact, recent federal legislation has also addressed this issue (e.g., NCLB and IDEIA). Clearly, there are efforts on a number of fronts to identify and disseminate information about effective treat- ments. In this chapter, we have discussed a number of the issues surrounding the identification and dissemination of effective treatment. First, even referring to a treatment as evidence-based is a task within itself. The criteria for evi- dence are not always easily accessible because the progres- sion of science takes time. Nevertheless, there are clearly treatment options that have a great deal of support behind them and should be considered when making treatment

decisions. Second, the issue of dissemination can also be a challenge. How exactly does information get disseminated to ensure that families and practitioners not only access the information but also truly understand its application? Finally, making treatment decisions is one of the most sig- nificant challenges a family can face. Of the treatments available, which one should be chosen? This question is by no means simple, as there are a number of implications from any one choice that is made regarding treatment. In spite of these challenges, there is clearly a light at the end of the tunnel. The professional community has and will continue to identify effective treatments for children with autism. In addition, families are becoming ever more engaged in treatment for their children and are making sound decisions about treatment and in turn helping other families make the same sound decisions. Although there is a need for further investigation to identify ways to effec- tively implement and sustain evidence-based practices, we have a store of knowledge that is readily available for our use, and the prospects seem to be bright for the future.

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chapter revIew QuestIons

1. List evidence-based practices for educating students with autism. (Objective 1)

2. Define the terms unestablished treatment and fad treatment as they relate to Autism Spectrum Disorder. (Objective 2)

3. Describe the differences between a focused intervention and comprehensive treatment models. (Objective 3)

4. What are components of effective instruction for students with Autism Spectrum Disorder? (Objective 4)

5. What are ways of determining effective treatment for individual students with autism? (Objective 5)

key terms

Applied behavior analysis 29 Comprehensive treatment model 28 Discrete trial training 29 Evidence-based practices 21 Fad treatment 32 Focused intervention 25

Functionality 38 Naturalistic behavioral

interventions 29 Normalization 37 Self-determination 36

Strategies for Teaching based on Autism Research (STAR) 30

Systematic generalization 35 Unestablished treatments 30

Internet resources

Autism Internet Modules: http://www.autisminternetmodules.org/

Division TEACCH: http://www.teacch.com/welcome.html

National Autism Center: http://www.nationalautismcenter.org/

National Professional Development Center on Autism Spectrum Disorder: http://autismpdc.fpg.unc.edu/content/briefs.

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40

CHAPTER 3

CHAPTER OBJECTIVES After reading this chapter, learners should be able to: 1. Discuss the impact of autism

on all members of a family. 2. Describe selection of

interventions in home-based services.

3. Discuss the changing effects of ASD through the life span.

4. Discuss transition issues and their impact on the family.

5. Describe ways to support family members with a child with ASD.

E. Amanda Boutot, Ph.D. BCBA Texas State University

Jennifer L. Walberg, Ph.D. DePaul University

Working with Families of Children with Autism

CAsE of WiLL Soon after Shannon and Matt were married, they discovered they were expecting their first child. They were elated. They notified their families, registered with the baby store, and cleared out the spare room of their house. Their own parents were thrilled; this would be the first grandchild on either side. Shannon’s pregnancy progressed without much concern; she was only 32 so did not need to have an amniocentesis, although she did opt for a blood test to be sure that the baby was otherwise healthy. It was. At her 20-week appointment, the doctor did an ultrasound and informed the parents that they were having a boy. They were ecstatic. They painted the room blue, Matt’s parents sent a crib and other baby furniture, and Shannon’s mom began knitting a blanket to welcome home the baby; they began thinking of names. After much debate, they decided on William Sullivan, to honor each of their grandfathers. When she was 34 weeks along, the couple’s best friends Susan and Steven threw a baby shower at their favorite restaurant and invited all of their friends and family. Despite the burden of being 8 months pregnant, Shannon was overjoyed, and looking more and more forward to meeting baby “Will.” Finally, at 39½ weeks, as she was preparing for bed one night, Shannon’s water broke. She and Matt hurried to the hospital, calling fam- ily and friends on the way: “HE’S ALMOST HERE!” A little more than 12 hours later, Shannon gave birth to a 7-lb., 6-oz. baby boy with a healthy APGAR score and a loud cry. The new parents were exhausted, but overjoyed; Will was perfect.

The days and weeks that followed were a blur for the couple. Shannon was breast-feeding, but Will had trouble latching on. He finally learned to suck correctly, but still he slept in fits and starts, and seemed to have trou- ble finding a comfortable spot. Whenever Shannon tried to pick him up to console him, it seemed only to trouble him more; he seemed to quiet down only when in her arms when he was feeding. Shannon was exhausted and Matt could do little to help her. Will would scream when anyone other than his mother held him. At his 2-week visit to the pediatrician, the doctor told the couple that this was perfectly normal and suggested that they give Will some breast milk in a bottle so that Matt could feed him, too. They tried this, but Will seemed to prefer to be fed lying down in his crib, which resulted in him spitting up most of what he drank. The couple was begin- ning to get frustrated. The pediatrician then suggested that perhaps Will

CAsE sTuDy Examples

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CHAPTER 3 • WORkIng WITH FAmIlIES OF CHIldREn WITH AuTISm 41

needed a different type of milk and suggested a formula for “fussy” babies. Matt immediately went out and bought four large containers, thinking that this surely would be the cure for Will’s constant crying. However, even with the new formula, Will cried and cried when he wasn’t eating or sleeping. Shannon read everything she could find on the Internet about fussy, colicky babies and tried every home remedy she found. Despite all their best efforts, Will continued to be a very fussy baby.

The first 6 months with Will were difficult on the couple, who were still newlyweds. Matt’s parents took over for them one Saturday night so that the couple could take a much needed overnight “vacation” to their favorite bed-and-breakfast. This would be the last trip they would take as a couple for the next 4 years.

As Will approached his first birthday, Shannon, who was staying home with him, began to worry about how he was developing. She and Will belonged to a Mother’s Morning Out program at the neighborhood recreation center, and she had developed a friendship with some of the other moms. One day she noticed that many of the other children were interacting with their mothers, trying to speak, and engaging in more social forms of play than Will. She asked Jamie, one of the other moms, how long her son Mac had been doing those things. She did not like Jamie’s response: “Oh, I don’t know; he’s been like this almost from the beginning! He’s just a social butterfly, I guess.” Shannon began to worry; why wasn’t Will a social butterfly? Why, for exam- ple, did he seem to actually dislike being around other people, even his parents? Why did he still put everything in his mouth and not seem to want to play with regular toys? Why didn’t he like being hugged by his own mother? Shannon took her concerns to the pediatrician at Will’s 1-year checkup. The doctor told her not to worry because some babies were “slow to warm up.” At 18 months, Shannon told Matt that she believed something might be wrong with Will: He was walking later than the other children, still resisted engaging with others, and wasn’t playing with the other kids. Most concerning, he hadn’t yet started talking. Matt, though sympathetic, felt that Shannon was overreacting. After all, Will was a beautiful, healthy boy. What could possibly be wrong with him? Shannon’s mother suggested that Will was simply an “intellectual” who preferred things to people and reminded her that her cousin hadn’t talked until age 3, but then in full sentences. “When he has something important to say, he will.” At his 2-year doctor’s visit, Shannon again told the doctor of her concerns, this time explaining that Will had still not said his first words. Finally, the doctor took notice of Shannon’s concerns. She asked Shannon a series of questions about Will’s social skills, play behaviors, and communication (which at this time consisted primarily of grunts, whines, and tantrums). When she was finished, the doctor sat Shannon and Matt down and explained that Will might have autism. The couple was devastated. Matt, for one, did not believe it, and refused to entertain the possibility. For Shannon, though heartbreaking, the news came almost as a relief; she had known something wasn’t right. Now it had a name: autism. Their beautiful, auburn haired, blue-eyed angel was not as perfect as they had first imagined. Suddenly, the Will they had wished for, dreamed of, and imagined they had, was gone. In his place was the new Will, the one with autism. Although the answer had finally come, it brought with it many more questions and a roller-coaster ride of emotions and issues that would last for a lifetime.

CAsE of CARLy Rachel is a single mother of two daughters, one 18, the other 6. Six-year-old Carly has autism and mental retardation. She does not speak, does not respond when spoken to, does not feed herself, and wears diapers. She has beautiful, long curly brown hair and the face of an angel, although she rarely smiles. Carly spends her days in self-stimulation: flapping her hands in front of her face and walking on her tippy-toes back and forth, in about a 4-square-foot area. Carly’s father and stepmother do not believe that anything is wrong with Carly. They think Rachel has overreacted, saying “She can’t be ‘retarded.’ Look at her—she’s beautiful.” They think the reason Carly doesn’t talk and will not comply with even the simplest directions is the result of Rachel’s bad parenting; however, they will take her only one afternoon a month. Rachel’s mother is elderly and unable to assist her with child care, and Carly’s sister, Eden,

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is married with her own baby. Rachel has applied for respite care with a local agency, but is on a waiting list, and it may take another 6 months to a year before Rachel receives any help. Rachel can’t afford a babysitter, and the teens in the neighborhood won’t stay with Carly because of her tendency to “get loose” and run down the street. With the train tracks and the highway nearby, it’s just not safe to have anyone other than Rachel stay home with Carly.

On her way home from picking up Carly at after-school care one day, Rachel must make a stop at the grocery store. She avoids going out in public with Carly at all costs, but they are out of milk and Carly won’t drink anything else. “I’ll just run in and out; surely she can handle that,” Rachel thinks to herself as she parks in the handicapped spot, thanks to the sticker her doctor reluctantly gave her so she didn’t have to worry about Carly getting away and getting hit in by a car in the lot. Inside, Rachel quickly puts Carly into a cart and races to the back of the store to the dairy section. She grabs the milk and is almost to the checkout line when Carly spies something in one of the aisles. Rachel does not know what it is because Carly can’t tell her and does not point. She knows only that Carly has seen something that she apparently wants and is now writhing back in the seat as if in pain, screaming as though she is receiving a shot. When she gets to the front of the line, Rachel picks up screaming Carly and tries to console her, knowing this will not work; it never does. Carly drops to the floor and begins scratching her mother’s legs while simultaneously biting her own wrist. Rachel apologizes to the patron in front of her and tries to pick Carly up. Carly screams even louder and cannot be moved. After what seems like decades, a store manager and a police officer approach Rachel. In her fury, Carly has kicked the milk open and it has spilled on the floor; Carly’s wrist is bleeding. The manager asks Rachel to come with him; the officer approaches to take Carly. They have called Child Protective Services, they say, and they want to question her. They believe Rachel is abusing Carly, and they want an investigation. Rachel begins to cry. This is not the first time the police have been called. She assumes it won’t be the last. “She has autism!” Rachel screams; the policeman and the store manager look at her as if she’s spoken a foreign language. “Ma’am, you’ll have to lower your voice and come with us.” Rachel, with the help of the officer, gets Carly up and goes to the manager’s office. It will be another hour before she is allowed to leave the store, and the social workers will come over tomorrow to investigate the abuse allegations. Rachel is tired. Carly is tired. They are still out of milk. Rachel goes home and wishes for help. She wishes that Carly could just tell her what she wanted in that store.

InTRoduCTIon

The case of Will is fictional. Shannon, Matt, and Will are all characters representing the lives of millions of families with children on the autism spectrum. Whereas there is no typical when it comes to Autism Spectrum Disorders, the story of Shannon and Matt provides a glimpse into some of the issues that are faced by families with a child on the spectrum: a nagging concern that something is off about the child or his development; continued attempts at reas- surance from family and professionals that the child is fine; realization that there is something wrong; shock, disbelief, and even denial in the face of the diagnosis; and then moving forward with the loss of what was to the unknown of what is to come.

This chapter provides information on the issues and needs faced by families of children with Autism Spectrum Disorders (ASDs) across the life span as well as how professionals in education can assist families in overcoming and meeting these needs. One purpose of this chap- ter is for the reader to recognize and respect what the families of children with ASD have been through, as well as the obstacles they continue to face. Through empathy and understanding, teachers can make a big difference in the lives of children with ASD and their families.

GETTInG THE dIAGnosIs

As Shannon and Matt’s case illustrates, getting an early diagnosis can be a complicated process. Although the story you read above is fictional, the lag between parental suspicions regarding developmental delay and an actual diagnosis of autism is documented in the literature and is

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CHAPTER 3 • WORkIng WITH FAmIlIES OF CHIldREn WITH AuTISm 43

I am often asked to describe the experience of raising a child with a disability—to try to help people who have not shared that unique experience to understand it, to imagine how it would feel. It’s like this . . .

When you’re going to have a baby, it’s like planning a fabulous vacation trip—to Italy. You buy a bunch of guidebooks and make wonderful plans. The Coliseum. The Michelan- gelo David. The gondolas in Venice. You may learn phrases in Italian. It’s very exciting.

After months of eager anticipation, the day finally arrives. You pack your bags and off you go. Several hours later, the plane lands. The stewardess comes in and says, “Welcome to Holland.”

“Holland?!?” you say. “What do you mean Holland? I signed up for Italy! I’m supposed to be in Italy. All my life I’ve dreamed of going to Italy.”

But there’s been a change in the flight plan. They’ve landed in Holland and there you must stay.

The important thing is they haven’t taken you to a horrible, disgusting, filthy place full of pestilence, famine and disease. It’s just a different place.

So you must go out and buy new guide books. And you must learn a whole new lan- guage. And you will meet a whole new group of people you never would have met.

It’s just a different place. It’s slower-paced than Italy, less flashy than Italy. But after you have been there for a while and you catch your breath, you look around . . . and you begin to notice Holland has windmills . . . Holland has tulips. Holland even has Rembrandts.

But everyone you know is busy coming and going from Italy . . . and they’re bragging about what a wonderful time they had there. And for the rest of your life, you will say, “Yes, that’s where I was supposed to go. That’s what I had planned.”

And the pain of that will never, ever, ever, ever go away . . . because the loss of that dream is a very, very significant loss.

But . . . if you spend your life mourning the fact that you didn’t get to go to Italy, you may never be free to enjoy the very special, the very lovely things . . . about Holland.

Source: From Kingsley, E. (1987), Welcome to Holland. Retrieved April, 10, 2008, from http://www .upkidsoflawrencecounty.com/POEM.html

FIGuRE 3.1 Welcome to Holland

a source of frustration for parents (Smith, Chung, & Vostanis, 1994). Parents’ first concern is often around language development, and these concerns happen even earlier for parents of children with more severe autism characteristics. In one study, parents of children with autism reported concern over development at 17½ months but did not seek assistance until about 22½ months (Coonrod & Stone, 2004). When parents bring language and behavior concerns to primary caregivers, such as a pediatrician, many are told to wait and see. A survey of parents with children with autism found that the median time from noticing a problem to the autism diagnosis was 9 months with a range of 0 months to 13 years (Harrington, Patrick, Edwards, & Brand, 2006). So although there may not be a consensus on the exact amount of time between noticing symptoms and receiving a diagnosis, there is undoubtedly a period that may be better used for intervention. It is no wonder that parents often have lit- tle confidence in a physician’s ability to diagnose autism (Harrington et al., 2006). The wait- and-see approach wastes valuable time and can have long-term financial implications. Early cost–benefit analysis estimates that early intensive behavioral intervention can save more than $2 million over the life span of the child (Jacobson, Mulik, & Green, 1998).

Once a diagnosis of autism has been established, many parents begin a grieving process. Koubler-Ross’s (1969) famous stages of grief are as follows: denial, anger, bargaining, depression, and acceptance. These stages have been used to describe what a parent might experience when given a diagnosis. The loss parents feel is real and must be acknowledged. This grief over diagno- sis has been written about by parents in works such as the essay “Welcome to Holland” by Emily Kingsley (1987). See Figure 3.1 and the essay “Holland Schmolland,” by Laura Krueger-Crawford (2008), a response to “Welcome to Holland.” In “Welcome to Holland,” the mother comes to terms with her child’s diagnosis by comparing autism to vacationing in Holland—a place she had not intended to go (her original destination was Italy), but a nice place nonetheless.

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44 CHAPTER 3 • WORkIng WITH FAmIlIES OF CHIldREn WITH AuTISm

If I could wave a magic wand, here are my wishes . . . By: Liz Bullington

• First and foremost, accept and include him as a part of your class—just like everyone else. • Try to understand and respect his differences. He did not choose to have autism and

learning to live with it is harder for him than it is for us. • Be patient with his limited communication skills. • Encourage him to try new things, but go slow. New experiences can be scary for him. • Give lots of praise for his accomplishments, no matter how small. • Understand that he learns differently, but believe that he can learn. • Help him feel comfortable in the classroom. Give him the space he needs, but don’t

isolate him. • Embrace the fact that he is a visual learner. Pictures and examples are better than just words. • Encourage him to interact with his classmates when appropriate, but realize that social

situations are difficult for him. • Focus on the positive, and be careful not to reinforce the negative.

Finally— • Have realistic expectations, but don’t underestimate his potential. As the old saying

goes—if you don’t expect much, you won’t get much. Even though some things are harder for my son, you’ll be amazed at what he can achieve. His successes may not be the same as the rest of the class, but they are still something to be proud of.

FIGuRE 3.2 A Mother’s Wishes for Her Son with Autism

In “Holland Schmolland,” the mother takes a different look. She goes on to describe Schmolland as a “nation” where its citizens “lick walls,” line up toys, and bounce on the couch for hours. In this analogy, it is not Schmolland that is difficult to deal with; rather, it is “people from other countries” and even those from Schmolland, who present the occasional challenge.

Together, “Welcome to Holland” and “Holland Schmolland” provide some insight into what it is like raising a child with autism. Specifically, “Holland Schmolland” provides some perspective on how it feels being an outsider, not just an outsider to those with typically developing children but also an outsider to those with other children on the spectrum. The differences each family faces are highlighted in this passage, reminding professionals that just as no two children with autism are the same, no two families with a child with autism are the same. We must be willing to recognize and respect these differences and also to appreciate that one parent’s “Holland” may be another’s “Schmolland.”

Some parents feel a sense of relief upon hearing an autism diagnosis. Whereas few are glad to hear that their children have a disability, having a diagnosis means that there is a reason and a name for what is going on. As one parent states, upon hearing the diagnosis of autism, “I was so thankful. I finally had something that made sense. Other labels did not make sense” (Hutton & Caron, 2005).

PAREnTAl PRIoRITIEs FoR THEIR CHIldREn wITH AuTIsm

Like all parents or primary caregivers, parents of children with autism have hopes and dreams for their children. They also have worries and concerns. This section will provide information on those issues cited most frequently in the literature as important to parents of children with autism. It is important for teachers to be aware of these generalities but to also make efforts to learn the dreams and nightmares of the individual families with whom they work. Consider this example of a sec- ond-grade general education teacher who truly shared concerns over the education of one of her students, and how she worked with the parent to understand the student and his needs better. The teacher asked the mother, Liz, “If you could wave a magic wand, what would you wish for your son?” The mother’s response appears in Figure 3.2. Liz was very impressed with the teacher for asking; no one had made such an attempt to get to know her son in the entirety of his education (since age 3). Liz’s response was so moving that the building principal printed it in the school newsletter (under a pseudonym) for all parents and teachers to see what it would take to help a youngster with autism.

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CHAPTER 3 • WORkIng WITH FAmIlIES OF CHIldREn WITH AuTISm 45

Liz’s list of wishes reflects many of the priorities of parents of children with autism. Researchers (Ivey, 2004; Spann, Kohler, & Soenksen, 2003) have found the following priorities as most important to families for their children with autism:

• Play with classmates. • Have friends. • Receive an invitation to a birthday party. • Improve language skills. • Have adequate vocational and leisure skills. • Be happy. • Receive acceptance in the community. • Live independently.

Sadly, when asked whether or not they perceived that the school was addressing these priorities, nearly half of the 45 families surveyed as part of the research by Spann and col- leagues (2003) stated that they felt the school was doing little or nothing.

With regard to worries or concerns, Biernat (2000) discusses concerns about accep- tance and prejudice toward both her son and herself by her community, friends, and family. Another concern is fear that someone will take advantage of their child. In addition, par- ents are also highly concerned about ensuring their children’s safety from physical harm (Ivey, 2004).

ImPACT oF AuTIsm on PAREnTs

The impact of autism on the family has been the focus of some, although few, research studies in recent years. Chief among the issues facing parents are their concerns about raising their child with autism, as well as stressors and depression that occur as a result of raising such a child.

sTREss According to Boyd (2002), “Mothers of children with autism are one of the most stressed parental groups” (p. 214). Boyd further emphasizes that parent and child variables contribute to the level of stress felt by a parent or other caregiver of a child with autism. Specifically, children with lower-functioning autism “place a greater degree of stress on their mothers because of their potential for long-term dependency” (p. 213). Boyd (2002) explains children with autism who exhibit the most challenging behaviors create increased stress not only because of the difficulty in raising these children but also because of fear of public scrutiny, from both strangers as well as friends and families. Further, behavioral challenges may limit a parent’s ability to obtain social supports (known to relieve some of the stress), thereby exacerbating the stress (Boyd, 2002). Finally, stress for any parent often comes with perceived difficulty in parenting; for parents of children with autism, “consis- tent and pervasive stress makes it even more difficult to parent” (Boyd, 2002, p. 214). This stress over behaviors of a child with autism, combined with the lack of reinforcement in the parenting process, culminates in an even more stressful situation for the parent (Siklos & Kerns, 2007). A variety of factors may influence the stress level felt by parents of children with ASD. Cultural differences are discussed in Box 3.1, while in Box 3.2 a study is pre- sented that suggests that parent involvement in treatment may be a factor in a parent’s level of stress.

dEPREssIon Along with stress, depression is the most common associated negative impact of autism on families. Hastings et al. (2005) found greater depression for mothers than fathers, although mothers were also more positive toward their child with autism than were fathers in the study. Fathers’ stress and perceptions (positive or negative) were based on maternal depression; mothers’ stress was dependent on their partner’s depression, suggesting a cycle of interdependency and influence of psychosocial well-being among married parents or partners of children with autism. In this same study, the authors point out that the greater the behav- ioral problems of their children, the greater the mothers’ stress.

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Box 3.1 dIvERsITy noTEs

It must be noted that the family research in autism, particularly around diagnosis and fam- ily stressors, consists mostly of a Caucasian and middle-class subject pool (Dale, Jahoda, & Knott, 2006; Kuhn & Carter, 2006). Whereas there is an emerging base of literature that includes children and families from a variety of cultures, this is an area that requires further investigation.

Cuccaro, Wright, Rownd, Waller, and Fender (1996) point out that the common symptoms of autism vary little across “culture, ethnic group, and socioeconomic status (SES)” (p. 462). In other words, autism is readily recognizable as such regardless of where you go in the world. This is supported by a recent test of validity of instruments such as the ASQ in British and Japanese cultures, which found no differences in the ability to detect autism or Asperger Disorder in both groups of children despite the fact that they come from vastly dif- ferent cultures (Wakabayashi et al., 2007).

If autism looks the same regardless of culture, it is worth investigating whether culture may play a role in how a parent deals with the diagnosis and challenge of raising a child with autism. This chapter has already discussed the impact of autism on maternal stress; however, we did not make a distinction between cultures. Research from Blatcher and McIntyre (2006) indicates that Latino mothers have levels of stress similar to those of their Caucasian counter- parts. However, Latino mothers may have significantly higher levels of depression, while at the same time are better able to see the positive impact of the disability. The authors suggest that more research is needed on these and other differences within the Latino culture if profes- sionals are going to better support these families.

Race may also play an important role in the age at which low-income children with autism first receive a diagnosis. A study of Medicaid-eligible children with autism found that while Caucasian children receive a diagnosis at an average age of 6.3 years, African American children were diagnosed at an age of 7.9 years (Mandell, Listerud, Levy, & Pinto-Martin, 2002). It is theorized that these differences may result from the fact that different racial groups have different styles of interaction with medical professionals; some may ask for help right away, whereas others may wait longer.

The studies discussed above all suggest that culture and race influence how families deal with autism. Much more research is needed in order to enable school professionals to properly address the needs of all families of children with autism. In the meantime, teachers must be sensitive to cultural practices when interacting with families.

Box 3.2 REsEARCH noTEs #1

In 2007 researchers examined the extent to which intensity of applied behavior analysis (ABA) therapy impacted family stress and the well-being of mothers in particular (Schwichtenberg & Poehlmann, 2007). Forty-one mothers of children with autism ages 3 to 14 (mean age of 6.9) completed a five-item assessment protocol consisting of questionnaires related to autism characteristics/behaviors, family needs, depression, personal strain, and the child’s ABA pro- gram. The average number of hours per week of ABA therapy ranged from 6 to 50 with a mean of 22. The average number of hours per week that mothers spent involved with their child’s ABA program ranged from 0 to 30 with a mean of 3.1. Two important findings were noted in this study. First, symptoms of depression were fewer for those mothers whose children were in more intensive ABA programs compared to those in less intensive programs. Second, mothers reported more “feelings of personal strain” (p. 603) when they spent more hours per week involved in their child’s ABA program. The researchers report that their findings sup- port intensive ABA programs but do not support using mothers as therapists or as therapy coordinators.

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PosITIvE ImPACT A small fraction of the literature supports the idea that families, par- ticularly parents and primary caregivers, experience positive effects of raising a child with autism. In a two-part special series on parenting children with autism, the journal Focus on Autism and Other Developmental Disabilities published several pieces written by parents of indi- viduals with autism. In their own words, parents provide insights into the positive effects of raising a child with autism, relating the greater impact it has had on their lives beyond the well-published difficulties. “Daily life with our son is such a pleasure and truly makes us feel that we are the lucky ones who have been blessed with this handsome and bright child . . . . Even on those days when I am at the end of my rope, I sit back and am very thankful for Josh” (Welteroth, 2001, p. 9). Patricia Roth (2001, p. 19) states that “the experience of having this rather unusual son has considerably expanded my mind.”

ImPACT ovER TImE There is also longitudinal research that suggests that the impact of autism on a family changes over time. Grey (2002) conducted a 10-year follow-up of parents of children with autism and found that initial concerns of parents, including high levels of emotional stress like depression and anger, were still present in the sample 10 years later but at much lower level. Overall parents had developed some coping methods, and it was mostly the parents of children with severe aggressive or obsessive behaviors that still experienced high levels of stress. All of this points to the idea that teachers must be sensitive to the changing needs of families of children with autism.

Family needs

Families of children with autism face a number of obstacles related to caring for their child with autism. In addition to the emotional burdens they may face, treatments may be expensive or require a great deal of time, taking away from other duties and family members. Common needs associated with raising a child with autism include:

• Financial support • Emotional support • Respite care (child care) • Resources to aid in understanding the child’s disorder • Resources for dealing with the child’s disorder

Teachers may find themselves wondering what their role is in addressing these needs for the families of the children with whom they work. In truth, meeting these needs may not be feasible. Few of us have enough of our own resources (time or money) to donate to another person. However, teachers can play a crucial role in empowering families to meet their own needs. Teachers can provide information to families upon request about community and state resources that can help meet financial, emotional, informational, and respite care needs. For families that may be uncomfortable asking for help, teachers may choose to have a “Fam- ily Information Center” (e.g., a bulletin board) in or just outside their classroom containing contact information for a variety of resources. Or, teachers may send home a monthly news- letter highlighting a new community resource each month. Still other teachers may hold an “Information Night,” inviting parents to come to the classroom and learn about community resources both from the teacher and from other parents. On such an occasion, the teacher may make his classroom computer (if connected to the Internet) available for families with limited Internet access to browse the options within their community. Teachers may wish to conduct a Family Needs Assessment (see Figure 3.3) to determine areas of need for the individual fami- lies with whom they work and prepare information sessions accordingly. Another way to assist families with meeting their needs is to be empathetic to the fact that the families of students with autism have unique needs that may be very different from your own needs or those of other students with disabilities. The first step to helping a family in need is to be receptive to their issues and have an open mind.

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To help us better understand your family and your child’s needs, please respond to the fol- lowing questions. You are free to skip questions that either do not apply to your situation or that you would rather not answer. Use additional paper as needed. Thank you for your time.

1. What are your child’s greatest strengths? 2. What are your goals for your child in the next 6 months? 3. What are your goals for your child in the next 2–3 years? 4. What are your goals for your child when she is an adult? 5. What one skill, if your child had it or was improved in it, would make your life or that

of your family easier? 6. What does your family like to do together? Does your child with autism participate in

these activities? 7. What activities does your child participate in with the family? 8. What activities would you like to see yourself or your family be able to do with your

child with autism, and what is currently preventing you from doing them? 9. What are your child’s favorite activities or areas of interest?

10. What does your child enjoy most with each member of the family? 11. What are your child’s least favorite activities? 12. What are your child’s favorite toys or objects? 13. What are your child’s least favorite toys or objects? 14. Does your child engage in play or other activities independently? Please describe. 15. Describe your favorite moments with your child. 16. Describe your least favorite moments with your child and how you feel at those times

(e.g., frustrated, sad, angry, helpless). 17. What are your greatest hopes and dreams for your child? 18. What are your greatest fears for your child? 19. What are your expectations for the services that we may provide for your family and

your child? 20. What other things would you like us to know about you, your family, or your child that

you think may assist us in our work?

FIGuRE 3.3 Family Needs Assessment

Family Involvement

“Parent involvement is widely acknowledged to be a critical ‘best practice’ in the education of young children with ASD” (Benson, Karlof, & Siperstein, 2008, p. 47). For children with autism, family involvement is necessary for a number of reasons, including generalization of skills, parent support and training, collaboration across home and school, and ensuring that necessary skills are being addressed through the education plan. (See Box 3.3 for a study on the use of parent training to aid with generalization of skills.) It is often observed by teachers that parents of children with autism are some of the most well informed when it comes to their child’s disability, their needs, and the family’s rights. This should be seen as positive, rather than something to be defensive of. In this section, we discuss some of the ways that parents should be encouraged to be involved in their child’s education, how teachers can encourage parents to do so, and how to bridge gaps and foster positive collaborative relationships with families.

legal mandates

EARly InTERvEnTIon The Individuals with Disabilities Education Act (IDEA, 2004) includes a provision providing for the development of an Individualized Family Service Plan (IFSP) for every child served under age 3 receiving services for a disability, which must be completed by a team of individuals including parents. By law, parents must be a part of all decisions made relative to the education and treatment of their child with a disability. However, how much and what type of involvement are not clearly delineated within the

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Box 3.3 REsEARCH noTEs #2

Training parents to apply applied behavior analysis strategies has often been a key component to a home-based program for children with autism, despite some evidence that suggests that it may not be personally satisfying for the parents to do so (see Schwichtenberg & Poehlmann, 2007). Of particular benefit is the generalization of skills to the natural environment when parents are trained in and can continue skill training beyond the therapy session (see Lovaas, Koegel, Simmons, & Long, 1973). Crockett and colleagues conducted a study in 2007 that investigated the effects of parent training on acquisition and generalization of specific teaching procedures (discrete trial teaching [DTT]). Participants were two parents (mothers) of 4-year-old children diagnosed with autism (one was also diagnosed with mental retardation). The parent training model used by the researchers was individualized for each parent and consisted of between 6 and 9 weeks of weekly trainings lasting 2 hours each. Training involved lecture, demonstration of both correct and incorrect DTT procedures, role- play with feedback, practice with their own children with direct and immediate feedback, and videotaped practice with feedback. Results indicated that both parents were able to learn appropriate DTT procedures and to generalize them to skills beyond the training model. However, despite the gains in parental skill acquisition, child skill acquisition as a result of parent training was only minimal in the current study. The authors suggest that the duration of the study was insufficient to realize any meaningful gains in child skill acquisition, and that longer-term treatment is necessary for gains to be observed.

law; in fact, it is up to early intervention (EI) personnel and parents themselves to determine the degree of participation parents will have beyond the minimum required by law.

The IFSP itself is perhaps a more family-friendly document than the Individualized Education Program (IEP), with which most teachers are familiar. The IFSP requires that the team consider not only the child’s needs and services but also those of the family. If the parents require training or support, it can be written into the IFSP and becomes the responsibility of the EI agency to ensure that the services are provided. The authors of Part C of IDEA (which covers services for infants and toddlers) made a good observation: In order to best serve an infant or toddler with a disability, we must also serve the family. The family is the child’s first teacher, the primary caretakers, and may themselves have needs, which, if not addressed, could prevent successful intervention for the child. Furthermore, because non–school-aged children are cared for primarily in the home or child care facility, significant training and support should go to the parents, grandparents, child care providers, and so on—hence, the IFSP.

Early interventionists typically do a satisfactory job of including the family and sup- porting their needs during the EI years (birth through age 3); this job is, after all, required by law. What is less clear is the nature of family involvement in the IEP process, as required by Part B of IDEA. We will examine this next.

sPECIAl EduCATIon Many, though certainly not all, children with autism will transition from services outlined in Part C of IDEA to those in Part B of IDEA at age 3. Part B is com- monly referred to as traditional special education and includes children between ages 3 to 21. It is important to note that families may be alarmed by the sudden lack of focus on their needs, having moved from an Individualized Family Service Plan to an Individualized Education Plan, which focuses solely on their child. Further, there may be some terminology, requirements, and paperwork that are new to the family that may contribute to the family’s feeling “left out” or of less importance than the professionals. It is important for teachers working with young children, especially those transitioning from Part C, to make the family feel welcome, and to be cognizant of the fact that up until that time, the family was central to the services and the meetings to determine those services. A smooth transition, then, concerns itself not only with the child but also with the family.

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Even if a child has not received Part C services, when he comes into Part B, or special education, teachers need to be aware of the family’s needs. At whatever age the child enters special education, the process will likely be new to the family, and there will be an understand- able period of adjustment. Schools are required to provide a handbook of special education to the parents, but we suggest taking it a step further. For example, teachers should offer to sit down with parents before the first IEP meeting and discuss the handbook with them, explain- ing things that may be unclear and helping to familiarize them with the processes. In addi- tion, because parents sometimes feel more comfortable speaking to other parents rather than to school personnel, we suggest that teachers ask parents of children already in the program if they would be willing to speak with families coming into the program for the first time to help put them at ease. Having available a handful of parents who will allow you to give their e-mail or phone numbers to new parents is suggested for all teachers who may receive newly diagnosed students into their programs. Finally, we want to remind professionals that the use of educational jargon can be confusing and off-putting to parents, particularly those new to the system. When families do not understand the lingo, some will ask for clarification, but others may not, which leaves them confused and feeling particularly inept and left out. It is the role of the special educator to bridge the gap between the family and the school during IEP meetings so that true collaboration can be achieved.

The IEP meeting itself may be overwhelming for families because of the differences between Part C (which focuses on the needs of families) and Part B, which, according to Stoner and colleagues (2005), “included new vocabulary, new staff, new agency cultures, and a new set of assumptions, which can cause confusion for families. All families in this study reported feelings of confusion during their initial IEP meeting, which was their first formal contact with the special education system” (p. 47). There are some tips that can help to put the family at ease and create a feeling of collaboration rather one of confrontation (see Figure 3.4).

Collaboration

As professionals in the field, the authors of this chapter have frequently heard teachers com- ment on the lack of cooperation from parents of students with autism and, as a consequence, a lack of collaboration between home and school. There are a number of reasons cited in the research that may foster a lack of collaboration between home and school. We examine this literature here.

sTRuGGlE FoR dIAGnosIs Stoner et al. (2005) note parents of children with autism may come into the educational system having already met with an array of difficulties with pro- fessionals, chief among them being the difficulty in obtaining a diagnosis for their child as described above. Among the difficulties experienced by parents in an attempt to get an accu- rate diagnosis for their child are “being rebuffed or dismissed by . . . professionals, and request- ing referrals repeatedly” (Stoner et al., 2005, p. 47). As a result, according to the authors of this study, many parents of children with autism come to distrust professionals, which in turn negatively impacts their relationship with educational personnel (Stoner et al., 2005). The authors further submit that as a result of these early rejections, “parental trust in the rec- ognized experts . . . was reduced while parents’ trust in their own instincts was reinforced” (p. 47). As Stoner and Angell (2006) note, parents’ “repeated and often negative interactions with experts and professionals . . . left them skeptical and cautious” (p. 185).

FIGHTInG FoR sERvICEs According to a study by Stoner et al. (2005), because parents felt that they had to fight for services, their trust in the educational system charged with pro- viding help for their children decreased. The authors write, “Once reduction in trust occurred between the parents and the education professionals, parents became increasingly watchful and diligent in their efforts to ensure that their children received all services they deemed nec- essary to meet the needs of their child” (Stoner et al. 2005, p. 47).

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• Start and end each communication (face-to-face, written, or via telephone) with a posi- tive statement about the child.

• Send communication (make phone calls or send e-mails or notes) regularly, not just when something is wrong. Send “Bragging Notes” as well, because all parents love to hear someone else praise their child.

• Send home a draft agenda for each meeting (including the time allotted), requesting that the family add their needs or concerns to the agenda before the meeting.

• Come to meetings on time and avoid giving the impression that you are in a hurry to leave. Encourage others to follow this example.

• Remember that although it may be “just another meeting” for you, it is not just another meeting for the parents, as it concerns the well-being of their child. Show parents through your actions and words that meeting with them, whether annually or at other times, is important to you as well.

• Start each meeting by allowing the family to discuss how they feel about their child’s education. Encourage them to ask questions or put items on the agenda.

• Continue to ask the family for their input throughout the meeting, not just at the beginning.

• Make sure that the family has understood each discussion item before moving on; avoid using jargon that the family may not understand.

• Position yourself at the meeting near the family, rather than having school represen- tatives on one side of the table and the family on the other. Sitting next to the parents conveys your support for them and also gives you more opportunity to lean in and check for understanding periodically.

• Disagreements sometimes arise; we recommend these strategies for dealing with upset parents in a professional manner: 1. Make every attempt to meet with the family immediately upon discovering there is

an issue. 2. If a parent approaches you with a problem unexpectedly, try to schedule a meeting

at a later time so that you can have time to prepare for it; ask politely what the issue is and explain that you will look into the matter and get back to the parent.

3. Keep written documentation of the meeting. 4. If possible, have a third party present when you meet with the parent (e.g., an

administrator) who can serve as a mediator if necessary (many school districts have parent/family liaisons who may be available to serve in this role).

5. Listen to parents with an open mind, rather than thinking about how to respond; save thinking about how to respond until you have heard all of what they have to say.

6. When the parents have finished speaking, convey that you heard what they said and rephrase it back to them to ensure that you heard them correctly (e.g., “I appreciate your taking time to share this with me. I hear you saying that you feel that Polly is not spending enough time in general education, is that correct?”)

7. Ask the parent to share what actions they feel will resolve the issue and give consid- eration to those that are within your school or district policies.

8. Before leaving, make a list of actions for both you and the parent to take and come to agreement on what steps need to be taken, by whom, and in what time frame, to resolve the matter.

9. End the meeting on a positive note by sharing something positive about the child with the parent.

10. Follow up with a phone call, e-mail, or note expressing again your appreciation for the opportunity to discuss the issue with the parent and reiterating the actions to be taken that you discussed.

11. Keep a written log of the actions as they are accomplished and share that with the parent; follow up after all actions listed have been completed to ensure that the parents’ issue is resolved.

FIGuRE 3.4 Tips for Working Collaboratively with Families

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CommunICATIon Communication, often cited as critical to the family–educator rela- tionship, takes on added importance when the student is unable to speak or otherwise com- municate what happens on a daily basis. Unfortunately, some research suggests that families are dissatisfied with the communication between themselves and their child’s teacher. “‘Communication is a one-way street,’ ‘I have to do all of the initiating,’ ‘The only time the teacher sends me a note is when there is a problem’ ” (Spann, Kohler, & Soenksen, 2003, p. 235). Informal means of communicating with parents can be very important, espe- cially for those families whose children lack sufficient functional communication skills to relay information about their school day. Informal options such as communication logs or notebooks sent to and from home daily, e-mail, or periodic conferences may be useful in establishing open lines of communication with families. Even if a child lacks functional communication, parents of nonverbal children are able to determine the success of a day based on their children’s behavior (Stoner & Angell, 2006). Stoner & Angell (2006) find trust is a critical factor in communication between school personnel and parents; as parental trust of the school increased and perceived problems decreased, the need for communication by the parents increased.

TRusTInG RElATIonsHIP As illustrated in previous sections, trust is central to a collabora- tive partnership between home and school. In their research with parents, Stoner et al. (2005) identified teacher dispositions that either enhanced trust or reduced trust. Trust-enhancing characteristics in teachers included “having the heart to teach,” being consistently positive, and being willing to do whatever was necessary to assist the parents’ child (p. 48). Trust-reducing characteristics included negativity, limited or insufficient communication, and personnel doing no more than they were forced to do. In addition, increased communication is associated with greater trust, and shared desires and priorities are associated with enhanced communication, also resulting in greater trust. Again, teachers are encouraged to get to know not only their students with autism but their families as well.

Getting to Know the Child and Family

The author remembers when her daughter went to kindergarten. About a week before school even started the teacher sent home a questionnaire for her and her husband to fill out so that the teacher could get to know their child to some degree. In first grade, about a week before school, a postcard arrived in the mail from the teacher just to say hello and to welcome the family and child to the class. Both teachers made the author, as a parent, feel more at ease and a part of the going-to-school process. This is important for all teachers to do, especially considering the close relationship that often forms between teachers of children with dis- abilities and their parents. Figure 3.3, the Family Needs Assessment presented earlier, is an example of a questionnaire that can be filled out by parents to help teachers learn more about a student and her family. It can be adapted for any age level; its intent is to elicit from fam- ilies information to help teachers teach their child better. Figure 3.5, a “Who Am I?” sheet, includes more open-ended questions that family members can answer to provide teachers with even more information about the children in their class. Figure 3.6 is a completed “Who Am I?” sheet. To complete the “Who Am I?” sheet, start with a picture or drawing of the child in the center of the page. Then add prompts written in the first person, such as “My favorite thing to do is         .” We recommend that you elicit information from a variety of family members (including the students themselves as appropriate) at least once per year, and especially when they are coming into the program for the first time. You might com- plete the sheet with the family in the form of an interview or simply send the sheet home. Either way, it is important to follow up with parents to determine if they have anything to add that was not addressed and to make sure you understand everything they are sharing. Taking the time to interact with parents and solicit their input can prevent or diffuse the trust issues mentioned above.

Keep in mind, however, that some parents may feel uncomfortable answering some of the questions or completing a “Who Am I?” sheet. Don’t pressure them; an informal

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Who Am I? My name is                                       I like to be called                                       Some of my favorite things/activities are                                                          Some things I do not like are                                                                            I am really good at                                                                                         I am not so good at                                                                                           One thing my family wishes you knew about me is                                                                                                                                                                     

Figure 3.5 Who Am I? Sheet

conversation may be a better option for these parents, or you may need to wait until they are more comfortable with you and special education before you try again. Showing genuine inter- est and making efforts to get to know the child are the objectives.

SiblingS

Autism affects the entire family, not just the parents. There may be grandparents, aunts and uncles, or other family members who are equally as involved as the parents. Teachers may feel that their primary involvement with the family is with the parents. However, understanding the needs of the family unit and recognizing that the family unit impacts the overall develop- ment of everyone in the family (including the child with autism) is an important part of being a teacher of children with autism. In this section, we will examine the impact of autism on one familial group in particular: siblings.

impact of Autism on Siblings

Siblings of children with autism have been the focus of research in recent years for a variety of reasons. Children with autism frequently require a great deal of their parents’ attention, time, and energy. When there are other children in the family, parents may worry about the effects of autism on their other children (Biernat, 2000). Although some research has shown that having a sibling with autism has a positive impact on children (Hastings, 2003; Kaminsky & Dewey, 2001), the majority of studies have found that siblings of children with autism are negatively affected. Some negative impacts include less intimacy, fewer interactions, less nurturance, and negative relationships with parents (Hastings, 2003; Kaminsky & Dewey, 2001; Orsmond &

Figure 3.6 Completed “Who Am I?” Example WHO AM I

Stephanie Frey/Shutterstock

Wants to be the first woman president

Loves cooking, arts/ crafts, and playing

Does not like mean people

Can run really fast, is a good reader

Sometimes gets distracted

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Seltzer, 2007; Rivers & Stoneman, 2003). Rivers and Stoneman (2003) found that the greater the stress level of the parents, the more negative the sibling relationships, particularly when there were marital stressors. Most research, however, has focused on the psychosocial and emo- tional adjustment of children when they have a sibling with ASD. Results of these studies have been inconsistent, as noted by Macks and Reeve (2007): “Some studies have reported poor adjustment, higher rates of depression, and poor social competence . . . . However, other studies have reported siblings . . . are typically well-adjusted, with positive self-concepts and good social competence . . . .” (p. 1061). Most recent research supports difficulties with adjust- ment for siblings of children with ASD, although Macks and Reeve (2007) report a paucity of ASD sibling research.

AdjusTmEnT Previous studies have identified a number of factors associated with increased risk for adjustment problems for siblings of children with autism, such as number of children in the family, socioeconomic status (SES), gender, and birth order (Macks & Reeve, 2007). Specifically, “females and siblings from two-child families are at a greater risk for poor adjust- ment” (Macks & Reeve, 2007, p. 1061). The number of children in the family may affect adjustment. For example, when there are more children, they can share the responsibilities of helping to care for their sibling with ASD among them. In addition, siblings in families with more than two children have someone they can talk to and relate to about living with someone with ASD (Macks & Reeve, 2007). Age of siblings may also be a factor: “Older sib- lings appear to have greater difficulty with feelings, behaviors, and coping abilities . . . [as well as] higher rates of internalizing and externalizing behavior problems” (Macks & Reeve, 2007, p. 1061). Despite inconsistent evidence regarding specific factors associated with poor adjustment, recent research supports that adjustment problems may be an issue for siblings of children with ASD.

Ross and Cuskelly (2006) assessed psychological adjustment of 25 siblings of children with ASD using maternal report as well as structured sibling interviews. Of interest in this study was the degree to which the sibling’s understanding of ASD and/or the strategies they used to cope with the siblings impacted their adjustment. Consistent with other researchers, they found significantly higher levels of both internalizing (e.g., depression) and externalizing (e.g., aggression) behaviors than would be expected in the normal population. Whereas 84% of siblings in this study were found to engage in aggression toward their sibling with ASD, the authors note that this may reflect typical sibling interactions and may not be directly related to the ASD. Neither coping strategies nor understanding of ASD were found to be correlated with level of adjustment, suggesting that these areas do not impact the degree to which a sibling of a child with ASD will have internalizing or externalizing behaviors greater than the norm.

In their study comparing 51 siblings of children with ASD to 35 siblings of children without disabilities, Macks and Reeve (2007) found that the siblings of children with ASD had a more positive self-concept than siblings of children without disabilities. “They were much more likely to have a positive view of their behavior, intelligence, scholastic performance, and anxiety than were siblings of non-disabled children. These children also had a more positive view of their overall personal characteristics” (p. 1065). The researchers posit that these positive responses may be attributable to the siblings of someone with ASD comparing themselves to that sibling. “It would only be natural to assume that these children would view themselves favorably in such a comparison” (p. 1065). Another explanation offered by Macks and Reeve is based on Gray’s (1998) findings that siblings of children with autism are frequently more mature than those of children without disabilities. “Perhaps this maturity leads to improved behavior, better social skills, and improved academic performance, thereby increasing their over- all self-concept” (p. 1065). Interestingly, parental reports in this study were more negative than the siblings’ self-reports. The authors suggest this may be due to less opportunity to observe the behaviors of their children without autism, given the time and attention taken by the one with autism. One purpose of the study was to identify risk factors that would predict poor psychological adjustment among siblings of children with autism. These risk factors included

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gender (male), low SES, more than one sibling, and being younger than the child with autism. Though inconsistent with the findings of Macks and Reeves (2007, as noted previously), these findings are consistent with the work of Hastings (2003) who found that younger siblings of children with autism and those who were male had more behavioral problems. Interestingly, having a sibling with autism did not itself appear to be a risk factor, but instead was a positive factor. The authors conclude that “children with autism may even have a positive influence on the life of the non-disabled sibling. However, when multiple . . . risk factors are present, it becomes more difficult for the non-disabled sibling to deal with the child with autism. . . . Hence, the presence of a child with autism appears to have an increasingly negative effect on the non-disabled sibling as the number of . . . risk factors increase” (Hastings, 2003, p. 1065).

In the previous sections we have identified how siblings of children with autism may be impacted as a result of their sibling’s autism. Given the discrepancies, more research is needed to clarify these risk factors as well as to determine how teachers and parents can help these children overcome these issues. One additional area with regard to siblings cannot be overlooked—that of adulthood. For many of these siblings, once their parents are no longer alive or able to care for their adult child with autism, the burden falls to the sibling or siblings. Although research supports that finding a suitable living situation for their adult siblings with ASD (e.g., a group home) is a common experience of surviving children once their parents pass away, they may feel guilty about having to move their sibling from their parents’ home, even though no one remains there to care for them (Benderix, Nordstrom, & Sivberg, 2006).

FAmIly IssuEs ACRoss THE lIFE sPAn

In this section we examine the changing role of families as well as their changing needs across the life span of an individual with ASD.

Infancy and Early Childhood

As discussed earlier in this chapter, upon initial diagnosis, parents and other family members may mourn the “loss” of the child they had hoped for. Although they may come to terms and accept the disorder as a part of their lives, it is important that professionals realize that depression, anger, and denial can recur at any time, especially in the early years after diagnosis. Further, this is the time when families may be having more children, thereby creating some of the sibling issues and concerns mentioned in a previous section. Parents may become con- cerned over the well-being of their other children or feel guilty over the time and attention they bestow on their child with autism. Finally, intensive early intervention may take time and resources that the family would otherwise share among their children, which may foster feelings of guilt in the parents or resentment in the siblings. In these early years, families are learning to navigate the educational system, researching treatments, and perhaps trying a vari- ety of options to determine that which brings about the most success. Many parents mention a feeling of urgency as the child gets older, and this urgency may create a feeling of panic or that time is running out to find the best treatment approach. Further, with some parents and even professionals suggesting that autism can be cured with a particular treatment, or that children may outgrow their autism, the early years may be a time of both hope and disappointment as parents begin to face the reality that autism is a lifelong disorder. The move from early inter- vention to early childhood special education is the first of many transitions for a child with autism. IDEA 2004 allows for an EI professional to accompany a parent to an IEP meeting to help ease transition issues and to help the parent feel more comfortable with the process.

Elementary school years

Issues at home are at the forefront even when children with autism head off to school. Whereas there may have been some help through the EI system to address problem behaviors that influence the activities of daily life, many parents still struggle with routines such as getting a

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child ready for school. Dependency on sameness can hamper spontaneous family activities and create difficulties in the daily transition from home-to-school environments (Larson, 2006).

Parents of children in elementary school may have decided on the treatments that they believe work best for their son or daughter and may be more relaxed in their pursuit of knowl- edge about this disorder. During this time, however, physicians may prescribe a variety of medications and make adjustments to those medications for the child with ASD. The school years may be the time when a child with Asperger Syndrome is first diagnosed. Families of these children will face the same issues as those with younger children when their child is first diagnosed (e.g., stages of grief). It is important to be sensitive to the reaction of diagnosis by families and to have available resources for families to help them better understand both the disorder and their options for treatment at home and school.

Also during the elementary years, families may become more aware of the differences between their child and others without autism. As children age, the gaps in their language and cognitive abilities become more pronounced. Families may have concerns over a lack of friends and social opportunities for their child with ASD. Whereas some families may encour- age inclusion in order to promote more interactions with typically developing peers, others may have concerns that being in a general education classroom will further exacerbate and draw attention to their child’s differences and challenges. The siblings of children with autism also may have concerns during the elementary school years. For example, some siblings may have issues with going to the same school as their sibling with autism. Consider Mark, whose younger sibling Madeline has autism. When the school team decided to move Madeline from the early childhood special education program she was attending to kindergarten in her neighborhood school, Mark began to act out behaviorally in his third grade class. His teacher reported a short temper, noncompliance, irritability, and even cussing—behaviors she had never before seen in Mark. One of Madeline’s team members realized Mark’s behavior might be a result of concerns over having his sister with autism at his school. When the counselor talked with him about it, he discovered that Mark had told only a handful of friends about his sister’s disability, believing that no one would ever find out. Now with her impending arrival on the home campus, Mark feared what his peers would think both about him and about his baby sister. During elementary school, professionals may need to be more considerate of the siblings and willing to provide support and information when needed.

Transition needs for the child and family at the end of the elementary school years include preparing students for differences in middle school and high school. Often this is the first time students are exposed to an interdisciplinary approach where students go to different classes every 50 minutes or so. Because children with autism often have difficulty with transi- tion, professionals will need to work with the family to make sure proper supports are in place to make these daily transitions as smooth as possible.

Adolescence

The teen years, beginning in middle school, are often challenging even for families of typically developing children. Many parents of children without disabilities dread the onset of puberty. The same is true for parents of children with autism. However, for some parents, particularly of children who are lower functioning, puberty may take them by surprise. Having heard their child described as functioning at a lower level for most of her educational career, the onset of puberty may be a wake-up call for families that heretofore thought of their child as always a child. Families must deal with many issues when their child with autism enters puberty. For females, the onset of menstruation is of greatest concern. Hygiene skills become criti- cal during menstruation, and because of the relative infrequency of opportunities to practice using feminine products, these skills may take a while to teach. For males, puberty brings a very different, but just as challenging, issue. While higher-functioning children can be taught that masturbatory behaviors in public are not appropriate, the concept of appropriateness may

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be more difficult for lower-functioning students. Further, until the lesson is learned, teachers must deal with the issue. A common recommendation is to remove the student from view of others so as not to draw attention to the issue and also to find ways to prevent the stu- dent from becoming aroused in the first place (e.g., wearing belted pants rather than elastic banded waists may prevent manual access). Professionals are cautioned to speak with families immediately when masturbation becomes an issue. Although some families will accept mas- turbation as a normal part of puberty, others may have religious or cultural beliefs that impact their reaction to this change in their son’s behavior. Teachers should be considerate of any and all such cultural beliefs. It is also important for teachers to understand that females may also engage in masturbatory behaviors. Finally, with regard to puberty, lessons in sexuality may be necessary to educate and protect youth with ASD. Parents often cite concerns over sexual predators; still others have concerns over their child’s sexual acting-out behaviors and the message they send to others.

In addition to puberty issues, adolescents with ASD are like all other teenagers: They want increased independence and autonomy. Consider Alan, who at age 17 realized that most of his peers were driving, prompting him to decide that he should be driving as well. Although verbal and mostly independent in many areas, Alan has autism, and his parents were con- cerned for his safety if he were to get behind the wheel of a car. However, they conceded that he could take a driver’s education class, suspecting rightfully that he would quickly discover how difficult such a task would be for him. The instructor convinced Alan that he needed to wait a while before attempting to get his license. However, his father continued to teach him, and when he was 20 Alan got his first driver’s license. When asked how he felt about this, Alan responded, “GREAT! Finally I don’t have to have my parents with me everywhere I go!” Increasing opportunities for independence should be a priority for adolescents with ASD. In addition, teachers should work with families to identify age-typical activities that the child with ASD can participate in actively and successfully.

At adolescence, transition becomes less about moving from class to class and more about deciding and planning for what children with autism will do once they leave the school envi- ronment at the age of 18–21. IDEA mandates that a formal transition plan be in place by the time a child is 16, but most professionals begin the process of transition as soon as the child enters high school. Any plan for a child’s postsecondary outcomes must be made in consulta- tion with the families. Some families want their child to have a job and live independently or in a group setting, while others expect a child to live at home. Each of these options has very different implications for how a teacher will help prepare a student for life outside of school. Parents, therefore, must be at the center of this planning process.

Adulthood

Children with autism grow up and become adults with autism. Although teachers will work with a particular child only during their childhood and/or youth, families will be responsible for that child’s well-being throughout his life. As discussed in the previous section, as adults with autism age, and their parents pass on, siblings begin to take on increased responsibility for their care—a task they may not be emotionally, psychologically, or financially ready to take on. As teachers, we need to be aware of potential difficulties in adulthood and to be willing to discuss these difficulties with the entire family before the child with autism graduates or ages out of public schools. Preparing the family for adulthood requires careful research on the part of professionals, who may be the first to broach the subject with families. Teachers should familiarize themselves with adult service agencies within their community that work specifi- cally with individuals on the autism spectrum. If possible, visit these places to determine their appropriateness for the students with whom you work and compile a list of reputable and suc- cessful agencies and programs that families may contact as they near transition to adulthood for their student with autism.

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summARy

Autism presents a variety of challenges to the family, from getting a diagnosis, evaluating treatment options, navigating the special education system, and minimizing the effect on siblings. Teachers must be aware of how the characteristics of families with children with autism may differ from those of families of children without

disabilities. Further, educators must be aware that families’ needs may change over time and differ by culture. By collaborating with families, developing a relationship, and recognizing that parents know their child best and have valuable information to share, teachers can help promote positive school experiences for all.

CHAPTER REvIEw QuEsTIons

1. How does autism impact parents? How are siblings affected by autism? (Objectives 1 and 2)

2. What are a parent’s options for supplemental services for a child with autism? (Objective 3)

3. What effects does autism have on the family during infancy? Once the child is ready for elementary school? As a teenager? (Objective 4)

4. What impact does transition from high school to adult life have on the family? What support services are available for family members? (Objective 5)

KEy TERms

Cost–benefit analysis 43 Early intervention 49 Individualized Family Service Plan

(IFSP) 48

Longitudinal research 47 Part B of IDEA 49 Part C of IDEA 49 Stages of grief 43

Transitions 55 Vocational 45

InTERnET REsouRCEs

National Dissemination Center for Children with Disabilities: http://www.nichcy.org/resources/autism.asp

Families for Early Autism Treatment: http://www.feat.org/Default.aspx

Autism Society of America: http://www.autism-society.org/site/PageServer

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59

Environmental Arrangement to Prevent Contextually Inappropriate Behavior

Chapter 4

Jason C. travers, ph.D. BCBa-D University of Kansas

Lyndsey Nunes, M.ed. BCBa University of Massachusetts Amherst

Case of BoB Bob is a 17-year-old junior in a public high school with Asperger Syn- drome. He lives with his mother, father, and 15-year-old brother who also is diagnosed with Asperger Syndrome. Bob is impulsive, has lim- ited social skills, engages in contextually inappropriate behavior, has poor organization skills, and has anxiety. He has little interest in outdoor activ- ities and is happiest when playing video games or surfing the Internet. Bob is extremely talented with all computer operations. He easily dis- mantles computer hard drives to add more storage or reconfigures the cir- cuit boards. He becomes enraged when his family enters his messy room without permission. Specifically, he yells loudly at his family for 30 to 60  minutes. In some cases he will instead ignore them for hours. The daily chores need to be written on his dry erase board and verbal notice provided a day in advance in order for them to be completed. Bob follows a strict diet that consists of specific foods. Every day he eats the same three meals for breakfast, lunch, and dinner. He prefers to eat baked sweets and will often eat so many that he does not want any other food. Bob wakes up every day at 6:00 am but needs several prompts and supports to complete his morning routine and rarely arrives to school on time. He has refused to take the school bus since having a verbal altercation with another student in the sixth grade about a video game. His parents drive him to school, but this has become increasingly challenging because they frequently are late for work.

Bob’s academic performance varies by subject. He performs above grade level in mathematics but performs below grade level in English, his- tory, and science. He is most successful in quiet environments with lim- ited distractions. He often will put his head down, ignore the teacher, and/ or rip up paper assignments that are difficult or non-preferred. Bob passed statewide assessments with accommodations (e.g., extra time, small groups/ individual testing room, and optional breaks) as well as all classes neces- sary for graduation. However, while Bob strives to be organized by writing down all of his assignments, he has not been very successful. Papers often fall out of his backpack or locker and assignments usually are misplaced at home or school. His poor organizational skills are exacerbated by a fear of being late to his next class. Some teachers have given Bob a 3-minute warn- ing to allow him time to properly pack up before the bell rings, but other teachers refuse to give him the warning.

Case stuDy Examples

Chapter OBjECtIvEs After reading this chapter, learners should be able to: 1. Understand how concepts of

motivation, including states of deprivation, satiation, and aversive stimuli, impact contextually appropriate and inappropriate behavior.

2. Explain the rationale and steps for completing functional behavior assessment of contextually inappropriate behavior.

3. Describe the various ways that antecedent conditions contribute to contextually inappropriate behavior.

4. Synthesize several antecedent- based interventions to increase the preventative effects on contextually inappropriate behavior.

5. Analyze the benefits and limitations of embedded instruction on the learning of various academic, social, and communication behaviors of students with autism.

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Social situations with peers frequently result in heightened anxiety and contextually inappropriate behaviors. He doesn’t immediately respond to conversation starters and rarely makes eye contact when approached by peers. He only stays engaged in a conversation if it is about a preferred topic (e.g., computers, bathing suits). He prefers to engage with adults rather than peers. Bob typically will choose to work independently rather than in groups. Bob has a dry sense of humor. He does not understand sarcasm, most jokes, or body language. Peers make many attempts to interact with him by telling jokes, but Bob typically responds by staring, which peers often interpret as rude. Also, Bob will yell at his teacher or peers if they provide him any constructive feedback or unwanted directions. Bob’s special education teacher is having a difficult time programming for him; she states that she doesn’t know what else she should teach because he has passed his classes, works well independently, and soon will graduate.

Case of MitCh Mitch is a 4-year-old boy with autistic disorder who just began attending a full-day inte- grated preschool program. He lives with his mother and twin 8-year-old sisters. His father lives an hour away and only sees Mitch on the weekends. Mitch is very social and affectionate toward family members. He likes holding hands and frequently tries to hug his family mem- bers or other familiar people. He has significantly delayed communication skills, exhibits preoccupation with parts of objects (e.g., wheels of toy cars, doors on doll houses), and tan- trums. He also frequently engages in repetitive behaviors like hand flapping when excited, jumping, and rolling his eyes while vocalizing for extended periods of time. Mitch appears to prefer to play alone or with adults who respond to his preferences, but his play often resembles obsessive behavior (e.g., lining up cars, putting dollhouse furniture and characters in the same places). Mitch’s favorite toys are trains. He likes little toy trains, big toy trains, toy trains on the computer, and toy trains on television. He will spend hours lining up train cars and some- times pushes his trains around. He rarely leaves the house without a train in hand. Although he has some speech, his words are often rote phrases from television programs or are repetitive sounds that are unrelated to the activity or topic. Mitch will repeat a word when asked, but he does not spontaneously use the word out of that context. For example, Mitch will say the word truck when shown a toy truck and asked to say the word, but he will scream when he sees the toy truck in someone else’s possession and wants access to it. Mitch will occasionally point or bring someone over to an item he wants but cannot reach or access independently.

Mornings typically are the most difficult part of Mitch’s day. His mom often carries him into school and puts his items (e.g., backpack, lunchbox) in his cubby. Circle time (i.e., morning meeting) begins after all the students have arrived and Mitch often tantrums throughout the cir- cle time activities. The first half of the day often is teacher directed with afternoons tending to be more exploratory with activity-based intervention. The morning is highly structured, has many rules, and includes very few opportunities for independent choice making. Brian, a classroom paraprofessional, supports Mitch during all morning activities. Brian frequently reminds Mitch what he should be doing and rarely praises him.

Mitch often engages in tantrum behavior when transitioning to non-preferred activity. Teacher-collected data indicates that Mitch spends 80% of the morning engaging in tantrum behavior. Tantrums are defined as loud sobbing and/or screaming while lying on the floor, stomping his feet, and banging the ground with his hands. Mitch rarely engages in tantrum behaviors in the afternoon. He usually chooses the art center or the music center during free choice time. He only paints with blue paint while in the art center, and in the music center he only plays the drum with the red drumstick. Mitch becomes very agitated if someone attempts to interrupt or alter his play (e.g., asking him to use another color when painting or to use dif- ferent instrument or drumstick). He will be in preschool for one more year but his teacher has expressed the need to increase appropriate behaviors and decrease contextually inappropriate behaviors.

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Case of peytoN Peyton is a 10-year-old, fourth-grade student with autism. She is very friendly and outgo- ing and loves to be around her peers. However, her social-skills deficits result in difficulty interacting appropriately with peers. She lives with her grandmother and two older siblings, Joe (13 years) and Steve (17 years). When not at school, Peyton spends her time watching television, listening to music, and tagging along with her brothers to the park. Peyton finds schoolwork boring and/or difficult and often refuses to complete homework assignments or study. Her grandmother has tried to motivate Peyton to complete homework and chores by offering extra television time if she completes her work. When her grandmother with- holds TV time as a consequence for not completing tasks, Peyton yells/screams and becomes destructive. Peyton’s behavior will escalate until her grandmother offers her TV time in order to calm her down.

Peyton is a fluent reader, but her difficulty with reading comprehension negatively affects her performance in all academic subjects. She also has difficulty recalling spoken information and content from written assignments. She will talk loudly to peers and tell jokes when she is unable to answer a question, complete independent assignments, or other- wise participate in class. Peyton never asks for help and, if her teacher tries to assist her, she becomes defensive and repeatedly shouts, “I am all set!” Peyton also gets out of her seat and walks around the classroom when given a difficult assignment. She regularly completes math assignments at school, but has completed only a few reading assignments during the school year.

Peyton’s grandmother is concerned with Peyton’s reading skills and recent increases in the frequency and intensity of her destructive behavior at home and school. She is happy that Peyton enjoys interacting with peers, but is worried that she may become a victim of bullying and be sexually taken advantage of. Her teacher says she knows that Peyton is very smart and capable of learning, but isn’t sure what she can do to motivate her or assist her learning.

IntroduCtIon

All behavior has a purpose. The context of behavior determines whether behavior is socially appropriate or inappropriate. Yelling is appropriate on the playground or at a basketball game, but is inappropriate during teacher lecture or while in a library. The three case studies describe contextually inappropriate behaviors. Bob is yelling at his teachers and running through the hall. Mitch has tantrums when transitioning to a non-preferred activity. Peyton yells at her grandmother and becomes destructive when asked/told to do her homework. While the behavior of students with autism may seem unpredictable, an understanding of principles of behavior and an examination of the contexts of behavior allows us to reliably predict and change behavior to meet social norms. Understanding the contexts of inappropriate behav- ior and changing the environment rather than trying to suppress it is critical to supporting appropriate behavior. The intent of behavior support planning is to change the environment to promote contextually appropriate behavior. This requires an understanding of how factors in the environment impact and explain behavior. Special educators and other professionals who do not understand principles of behavior or dismiss them in favor of other explanations (i.e., internal, inconsistent, ambiguous, circular, and untestable explanations) will not likely modify student behavior to meet social norms. This chapter discusses the importance of moti- vation and strategies to prevent inappropriate behavior as part of a comprehensive approach to creating sustainable and meaningful behavior change in students with autism. A rationale for this approach is followed by an overview of the functional assessment process, types of antecedent-based interventions, and explanations of how to incorporate prevention strategies into the environment.

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MotIvatIon

Early investigations of motivation in the experimental and applied analysis of behavior tended toward improving our understanding of the relationship between consequences that followed behavior (Michael, 1993). Thus, reinforcement and punishment to modify the behavior of people with autism and other developmental disabilities became better understood and now is the cornerstone of behavior analysis (Friman & Hawkins, 2006). Consequences indeed have substantial influence on behavior, but relying exclusively on consequence strategies to change the behavior of students with autism is commonplace. For example, a child with autism may tantrum during instruction intended to increase his vocabulary. Instead of pointing to a card with the image that matches the instructor’s spoken instruction, the child screams, pinches and scratches the instructor, and attempts to throw the stimuli. The instructor may presume that she must continue to enforce the demand so as to not allow escape via tantrums, and that enticing compliance with access to preferred items or activities is the solution (e.g., “You have to work if you want the fire truck.”). However, once the item or activity loses value, compliance again decreases and the instructor begins searching for new reinforcers that compel compliance. The interventionist may conclude that enticement of compliance is a necessary component of behavior-based intervention for students with autism. Such an approach is problematic for var- ious reasons, but a main concern is that continuously searching for items or activities to entice compliance fails to account for factors related to motivation of noncompliant behavior.

In folk (i.e., “commonsense”) psychology, motivation has something to do with whether a person will behave given that he already knows how to behave (Michael, 1993). The “doing” (i.e., behaving) is dependent on the person wanting to do something. This commonsense belief about wanting as the cause of behavior is not helpful for changing behavior, especially in children with autism. For example, to say that a student wanted to have a tantrum tells us nothing about the actual causes of (i.e., the environment preceding and following) the tan- trum. We cannot and should not rely on explanations of motivation derived from unobserv- able phenomenon like feelings (e.g., “frustrated,” “angry,” “bored”) as they only invite more questions about causality (e.g., “Why was he frustrated/angry/bored?”) and yield little or no useful information for intervention planning. Furthermore, when inappropriate behavior is attributed to inner causes, professionals and related personnel may conclude that very little (if anything) can be done to change the behavior. For example, explaining that Bob had a tantrum because he was frustrated and/or wanted to manipulate the instructor tells us noth- ing about the actual causes of the tantrum and absolves us of our responsibility to intervene because Bob’s behavior is perceived as an attribute of his personality. If the goal is to modify behavior to meet social norms and improve quality of life, then educators must recognize that (a) the environment explains why contextually appropriate and inappropriate behavior hap- pens, (b) they are responsible for the environment and therefore responsible for the behavior of their students, and (c) combining antecedent-based interventions with consequence-based strategies will yield better student outcomes.

Positive reinforcement occurs when a behavior is followed by some desirable conse- quence that, as a result, leads to an increased occurrence of that behavior (Cooper, Heron, & Heward, 2007). Negative reinforcement occurs when a behavior is followed by the removal, reduction, or postponement of an undesirable consequence that, as a result, leads to an increased occurrence of that behavior (Cooper et al., 2007). In both cases, the behavior pre- ceding the consequence is reinforced, meaning that it continues to occur. Thus, any behavior, including behavior deemed inappropriate (e.g., hitting, kicking, screaming, running), that continues to occur is somehow being reinforced by the environment.

An antecedent is the environment preceding a behavior (Cooper et al., 2007). Anteced- ents may be referred to as triggers for behavior, inaccurately implying them as the cause of behavior. Consequences cause behavior, but antecedents are more accurately characterized as signals that consequences likely will follow a behavior (Skinner, 1953). For example, the deliv- ery of a demand by a teacher may be an antecedent, but the cause of any behavior that follows is attributed to the consequence of that behavior (e.g., attention from adults, escape from

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the demand, access to preferred activity). An antecedent may be easy or very difficult to rec- ognize. In one instance, a tantrum may be predicted by taking away a preferred item like a cookie. Taking away the cookie may sometimes or always predict the tantrum, regardless of time, location, or some other environmental factor. In other circumstances, a tantrum might be preceded by a combination of various salient and convoluted stimuli including level of energy, previous access to cookies, presence and/or availability of other preferred stimuli (e.g., milk, candy), the temperature of the environment, tone of voice when asked to give up the cookie, the smell (or absence) of freshly baked cookies in the air, the moisture of the cookie, a preference for chocolate over vanilla, and a history of getting cookies after tantrums. Any unique combination of these factors may be a reliable antecedent, but the complex combina- tion makes it more difficult to identify.

Consequences and antecedents both play a motivational role in behavior. Differences in the availability of consequences influence behavior and the salience of the antecedents that precede them. For example, if Bob has just eaten several cookies or is not hungry, then he is less likely to engage in behavior that historically has been followed by access to cookies. If Bob has not had cookies in several days and is hungry, then he will be more likely to engage in behavior that results in getting cookies. If the presence of the person giving instructions is an aversive stimulus, then Bob may be more likely to engage in behaviors that result in escape from their presence than comply with a demand in order to get a cookie, even if he hasn’t had cookies for a few days and/or is hungry. While these examples seem straightforward, antecedents often seem inconsistent because several conditions may or may not converge to influence behavior. For example, on some days Peyton appears enthusiastic about doing reading tasks and is totally compliant. On other days her noncompliant behavior may indicate that the same reading tasks are extremely aversive. These and similar circumstances are likely common experiences of teach- ers who may often conclude that the students behavior is highly erratic and unpredictable of children and youth with autism. Unfortunately, teachers will overlook antecedent-based inter- ventions and instead heavily or exclusively rely on consequence strategies that induce student compliance (Luiselli, 2006). Antecedent-based intervention may require the completion of a functional behavior assessment to inform the development, implementation, and evaluation of a comprehensive intervention plan for students with contextually inappropriate behavior.

FunCtIonal assessMent and BehavIor support plannIng

The National Professional Development Center for Autism Spectrum Disorders identified functional behavior assessment (FBA) as an evidence-based practice for determining the pur- pose(s) of a behavior in order to develop a behavior support plan (Collet-Klingenberg, 2008). This multistep process includes the following: (a) establishment of a team, (b) identifying and defining behaviors to be assessed, (c) initial data collection, (d) development of a hypoth- esis statement(s) of behavior(s), (e) testing hypothesis, (f) developing intervention plans, and (g) plan monitoring and evaluation (Neitzel & Bogin, 2008). Functional behavior assessment often is a thorough investigation that attempts to identify the causal factors related to inap- propriate behavior. The obtained information is then used to develop a comprehensive behav- ior support plan that makes the inappropriate behavior irrelevant, inefficient, and ineffective (O’Neill, Horner, Albin, Sprague, Storey, & Newton, 1997). What follows is a brief overview of the FBA process. Teachers interested in conducting functional assessment should refer to Collet-Klingenberg, Neitzel and Bogin, and O’Neill et al.

establishing a team and Identifying Behaviors

Neitzel and Bogin (2008) provide an excellent description of the process for conducting FBA. They explain that the first step is to organize a team comprised of teachers, related service providers (e.g., speech-language pathologists, occupational therapists, behavior specialist,

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school psychologist), and parent(s)/caregiver(s). Each of these stakeholders has unique per- spectives, experiences, and expertise that enhance the quality and accuracy of the assessment results. One of these team members should serve as the primary contact and coordinator during the FBA process, but the person should have a thorough understanding of principles of behavior and training in FBA. If appropriate, the person with autism should be included as a team member as they also may provide important information about their behavior. The team can then proceed by identifying behavior(s) to be assessed.

The team should list and prioritize contextually inappropriate behaviors for inclusion in the assessment. Importantly, behaviors that are dangerous to the student with autism or others should be prioritized over those that are minimally disruptive, irritating to the teacher, or other- wise mildly problematic. Initially, the team may refer to behaviors using vague terms (e.g., aggression, tantrums, self-injury, self-stimulation). Imprecise definitions compromise the accu- racy of FBA and therefore should be given significant attention prior to data collection. The use of vague terms is convenient when having discussions with team members, but each definition must be operationally defined with specific language that describes the behavior in observable and measurable terms (Alberto & Troutman, 2013). Typically, it is helpful to define the behavior based entirely on what the student does and/or says. It may be helpful to consider where behav- ior happens, time and location of the behavior, and the people who witness the behavior when developing definitions. Each definition should describe the behavior without attribution to inner (i.e., unobservable) causes as these can influence the validity and reliability of FBA results. For example, the definition “Mitch hits with a closed fist when he is frustrated ” can influence the data because collectors may have different opinions about when Mitch is frustrated. Related, including conditions like this may lead to assumptions and bias about the function of hitting behavior before data have been collected, compromising the accuracy of the assessment results.

Collecting Behavior data

Collecting data for a FBA is no small task. The team should consider collecting data from indirect sources as well as observations of the student in the typical environments. Indirect sources of data include interviews, record reviews, and behavior rating scales. The functional assessment interview (O’Neill et al., 1997) is a tool that can aid in the collection of informa- tion about aspects of behavior and its contexts (e.g., settings, time, onset, people, demands, preferences, interests, aversions). The team should examine records related to the child’s educa- tional (e.g., academic, social, behavioral, and communication) and medical history. It is possi- ble that previous teams have encountered similar behavior problems and intervened. Previous records may reveal information about the successful and failed attempts to change behavior, which then can be used to inform the rest of the process. Similarly, behavior rating scales like the Behavior Rating Scales for Children-2 (Reynolds & Kamphaus, 2004) or the Vineland Adap- tive Behavior Scales-2 (Sparrow, Cicchetti, & Balla, 2005) may provide important information about contextually inappropriate behavior.

Direct observation of the student is a critical component of developing hypotheses of behavior. The process of collecting data may initially begin with observing the student in a variety of contexts to collect anecdotal information. Anecdotal data may result in refining or completely changing the definitions of behavior, changes in priorities, or, on rare occasions, identification of a likely function. Importantly, the information gleaned allows a better under- standing of the contexts of both contextually inappropriate and appropriate behavior. Under- standing when inappropriate is not likely to occur can be just as useful as understanding when it will occur. The team should proceed with scatterplot data, antecedent-behavior-consequence (ABC) data, and, if necessary, a more systematic behavior observation to inform hypothesis development after indirect data and observations are completed.

Scatterplot data can be used to identify a pattern of contextually inappropriate behav- ior. A scatterplot may reveal that contextually inappropriate behavior occurs more frequently during a specific activity or time of day. A scatterplot is simply a matrix of time/activities by date in which exact or approximate frequency of behavior is recorded. Figure 4.1 is an example

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of a scatterplot data sheet. The activities and times during the day are listed along the left col- umn. Dates are listed along the top row. In each box, tally marks are written to represent each occurrence of the contextually inappropriate behavior. After a few days or more of scatterplot data, a pattern may emerge indicating that specific times of day are much more likely to have inappropriate behavior than others. Similarly, scatterplot data may reveal that certain days of the week are more problematic than others. For example, a student may have much higher rates of contextually inappropriate behavior on Monday when compared to other school days. Perhaps the student, like Mitch, spends the weekend with a different parent who is less likely to administer medication, adhere to a bedtime routine, or provide breakfast before school on Monday. Further, the scatterplot data may result in conversations about specific activities that are highly correlated with inappropriate behavior. Perhaps, like Peyton, the contextually inap- propriate behavior is most likely to occur during times of day that require reading. These find- ings may not only result in interventions that can reduce contextually inappropriate behavior, but can guide the team in ABC data collection.

Antecedent-behavior-consequence data are similar to anecdotal data, but with greater emphasis on recording details about the environment before and after the behavior. Typically, ABC data include (a) a brief statement about the behavior in observable and measurable terms, (b) the relevant details about the environment before the behavior occurred, and (c) the rele- vant details about the environment after the behavior occurred (see Figure 4.2). Importantly, the person recording the ABC data should avoid drawing conclusions about the function of behavior for each incident as this may generate bias toward a specific function. The amount of ABC data needed to develop an accurate hypothesis will depend on a number of occurrences, but extensive ABC data usually is unnecessary and may be counterproductive. Instead, teams should think about whether the ABC data they have is sufficient to form a hypothesis. Also, because analyzing ABC data for patterns consistent with a function can be difficult, or in cases where a scatterplot, ABC, and other data do not yield a clear function, teams should consider conducting a more systematic behavior observation.

sCatterpLot assessMeNt

Student: Peyton Observer: Mr. Skinner Starting Date: July 1, 2013 Behavior: Peyton out of her seat and/or talking to peers around her. \ - First (or 3rd, 5th, 7th, etc.) occurrence X - Second (or 4th, 6th, 8th, etc.) occurrence

Time in ½ Hour Intervals M T W Th F M T W Th F

8:00-8:30 English X \ X X X \ X \ X X X \ X

8:30-9:00 Art

9:00-9:30 Art X \ X

9:30-10:00 Choice X \

10-10:30 Social Studies X \ X X \ X \ X X X \

10:30-11:00 Math X X X X X X

11-11:30 Science X \ X X X X \

11:30-12:00 Lunch

12-12:30 Science X X X \ X \

12:30-1:00 Physical Education

1:00-1:30 Physical Education X X

FIgure 4.1 Scatterplot of Peyton’s Interfering Classroom Behavior

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aBC Data sheet

NaMe of stuDeNt: BoB CoMpLeteD By: BoB’s teaChers

Date and time

setting event(s) (e.g., illness, bad bus ride, hungry,

med change)

antecedent What happened right before the behavior? (e.g., direction given,

something taken away)

Behavior What did the behavior look like? How long

did the behavior last?

Consequence What happened

immediately after the behavior?

11/12 11:13 am

Talking about a test in English class at 1 pm

Teacher was trying to finish the lesson closure when the bell rang

Ran out of class screaming “I’ll never make it” down the hall to his locker

Principal stopped him at his locker and attempted to talk to him about his day

11/12 11:41 am

Hungry New worker at lunch charged him the wrong amount for his burger with no bun and fries— peer told him “it would be ok”

Yelled at his peer, put his head down on the table

Peer got up from the table and went to sit with other students

11/12 12:25 pm

In science class Teacher hands out a pop quiz

Bob screams very loud, rips up the paper, and puts his head down on the desk

Teacher ignores the behavior and does not give him a new quiz

11/12 12:46 pm

Science class working w/ lab partners (group of 3)

Bob fills the beaker with the wrong amount of water. His peer corrects him

Bob yells at his peer and walks away from the group

Teacher tells Bob he can finish the lab at a station by himself

FIgure 4.2 Sample of ABC Data Sheet Completed by a Teacher for Bob

Systematic observation may combine information from indirect and direct assessments to develop or confirm a hypothesized function of behavior. One popular tool is the functional assessment observation form (FAOF) (O’Neill et al., 1997). The FAOF emphasizes events rather than occurrences of behavior and therefore integrates elements from scatterplot data (relevant times or activities), antecedents, potential functions (i.e., what the student gets or escapes), and actual consequences (e.g., what adults typically do, how peers react, what hap- pens to/for the student) into a single recording form. The form is rather straightforward and can help develop a hypothesis of behavior via a visual representation of events in ways that other data collection methods cannot. Once the team agrees that sufficient (and not excessive) indirect and direct data have been collected about the behavior(s) in question, the next step is to develop a hypothesis about function of behavior.

developing and testing hypotheses

A hypothesis statement is a short paragraph summarizing the results of the functional assess- ment. A hypothesis will include the learner, behavior, setting events for behavior, antecedent for the behavior, and consequences maintaining the behavior. Figure 4.3 includes three exam- ples of hypothesis statements. Once developed, a hypothesis can be tested for accuracy using functional analysis (Hanley, Iwata, & McCord, 2003). However, functional analysis should

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only be conducted by a well-trained behavior analyst or, in cases of severe or dangerous behav- ior, completely avoided. In many circumstances, the FBA results will be sufficient for develop- ing a hypothesis to inform the development of a positive behavior support plan.

developing Behavior support plans

A hypothesis of behavior is used to develop a comprehensive behavior support plan. A behavior support plan will include a replacement behavior that serves the same function as the contex- tually inappropriate behavior. For example, if a student is screaming to escape a demand, then he should be taught to escape a demand using a socially appropriate behavior (e.g., asking for a break by saying “break,” pointing to an icon, exchanging a symbol). The functionally equivalent replacement behavior must be equally or more efficient and equally or more effective than the inappropriate behavior. Replacement behaviors that require more effort or work less frequently will not replace an inappropriate behavior that is effective and easier to perform. For example, raising a hand to get attention is socially appropriate, but it requires the teacher to constantly watch the student in order for it to be effective. Further, raising hand usually requires more effort than talking out, especially if the student must raise his hand for several or more seconds. In this example, a support plan to increase raising hand is not likely going to be effective.

An effective and efficient functionally equivalent replacement behavior serves as a short- term objective. An ideal behavior that serves a different function (O’Neill et al., 1997) should be identified as the long-term goal of the support plan. For example, if a student is screaming to escape a demand, then the team might identify task completion that is maintained by atten- tion from adults (e.g., praise) and/or good grades as the ideal behavior (i.e., long-term goal) of the support plan. Deciding what the student must learn is a matter of determining priori- ties. Teaching functionally equivalent replacement behaviors and progressing toward the ideal behavior will require planning and instruction that, in many circumstances, is more important than purposes of other lessons (e.g., adding coin values, reading stories). Inducing compli- ance with demands will have little educational value if the student is engaging inappropri- ate behavior. Learning academic or functional skills will have limited value if inappropriate behavior prevents the person with autism from accessing the environments (e.g., community, home, school, employment) where skills typically are used. Lastly, inducing compliance for an ideal behavior at the expense of teaching functional skills may be a main cause of limited stimulus and response generalization.

Based on information collected through interviews and systematic observations, it is hypothesized that:

Bob: When given a difficult or non-preferred task, Bob will engage in yelling, property destruction (ripping up work), or putting his head down on the desk to avoid the tasks. The teacher removes money (i.e., tokens) from his bank. This is more likely to occur when Bob hasn’t taken his medication.

Peyton: When given a reading assignment in the classroom, Peyton will get out of her seat, walk around the class, and tell jokes to peers. The teacher ignores Peyton’s inappropriate behavior. This is more likely when Peyton has gone 20 minutes or longer without interacting with preferred peers.

Mitch: When transitioning to the next scheduled activity, Mitch will engage in tantrum behavior (loud sobbing while lying on the floor, stomping his feet, and banging the ground with his hands). The teacher then gives Mitch 3 more minutes to finish the activity before transitioning. This is most likely to occur when Mitch is in the block play area.

FIgure 4.3 Examples of Hypothesis Statements Derived from Functional Assessment

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The team also should develop consequence strategies (i.e., how the environment will change or not change based on the emission of a behavior) as part of the behavior support plan (O’Neill et al., 1997). The use of extinction procedures (i.e., withholding reinforcement for behavior) alone will not be sufficient for eliminating inappropriate behavior. Because all behavior is functional, eliminating consequences that have historically served as reinforcement for inappropriate behavior (e.g., ignoring screaming that has historically been followed by attention) will not also eliminate the person’s need for attention. If extinction is the only con- sequence strategy used, then teachers should expect inappropriate behavior to continue either in a different form (e.g., hitting instead of screaming) or intensity (e.g., screaming louder and for longer periods). Extinction should be used in conjunction with differential reinforce- ment of the functionally equivalent replacement behavior. The student will learn to use the functionally equivalent replacement behavior because the consequences that maintain inap- propriate behavior are no longer available (i.e., extinction) and are now contingent upon an easier and more effective behavior. After the replacement behavior is mastered and general- ized and the contextually inappropriate behavior is eliminated (remember that similar-look- ing behaviors may continue to occur if they serve other functions), then the team can begin gradually enforcing demands and differentially reinforcing them to attain the ideal behavior. However, as many inappropriate behaviors are maintained by escape from demands (Luiselli, 2006), special education and related professionals should consider antecedent-based interven- tions that will make contextually inappropriate behavior irrelevant for the student. While antecedents have long been a component of comprehensive behavior support planning (O’Neill et al., 1997), they’ve received little attention from researchers and practitioners until recently (Miltenberger, 2006).

anteCedent-Based InterventIon

O’Neill et al. (1997) included in their diagram of a comprehensive behavior support plan options for setting event and antecedent strategies to prevent inappropriate behavior. The logic for including prevention strategies was that inappropriate behavior could be made irrelevant to the learner via modifying the environment. Specifically, if inappro- priate behavior was determined through functional assessment to serve an escape func- tion, then modifying the environment to increase interest and make escape irrelevant could improve behavior and learner outcomes. While this logic is sound, many educa- tors and related professionals tend to emphasize compliance and conformity via rewards. Essentially, special educators induce student compliance by making bigger and better rewards contingent upon task completion without giving consideration to how factors in the environment (e.g., tasks, demands) motivate student escape. Consequently, the value of rewards diminishes with increased access (i.e., satiation) until the motivation to escape the demand is stronger than the desire to obtain the reward. This results in a cycle of appropriate and inappropriate behavior that almost seems like a characteristic of students with autism.

Rather than continuing to search for new rewards that can effectively compete with escape-maintained behavior, special education and related professionals should consider using antecedent strategies as part of comprehensive behavior support planning. Anteced- ent strategies also are effective for positively reinforced behavior. For example, a student who engages in inappropriate behavior to gain attention tells us that the environment is not sufficiently meeting her needs for attention. We likely can decrease inappropriate behavior maintained by attention by increasing the amount of attention in the environ- ment before the student engages in inappropriate behavior. Similarly, a student who engages in inappropriate behavior to escape a demand tells us that the demand has aversive qual- ities that motivates escape. We may prevent escape-maintained behavior by changing the qualities of the demand to decrease the aversive nature of the task. These are just a couple of examples of antecedent-based interventions, but there are a number of strategies that can be employed to make inappropriate behavior irrelevant to the learner. These include the

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following: incorporating learner preferences, embedding demands into reinforcing activ- ities, increasing the predictability of the environment, providing opportunities to make choices, modifying features of instruction, eliminating or decreasing discomfort or pain, and creating a positive atmosphere. Inappropriate behavior can be more aptly modified, teacher effectiveness enhanced, and student outcomes improved when behavior support plans include antecedent-based interventions.

using learner preferences

Many students with autism will engage in contextually inappropriate behavior during non-preferred activities or aversive situations in order to escape. Over time, these behav- iors become the primary means of communicating the need to escape (Neitzel, 2009b). To decrease the likelihood of challenging behaviors motivated by escape, Neitzel suggests that special education and related professionals incorporate learner preferences into aversive activities. For example, Bob does not enjoy English and will often yell when he is given corrective feedback. One intervention that may be effective is to allow him to send a text message from a smartphone expressing his frustration instead of yelling. By incorporating technology, the team can prevent yelling and teach a more socially appropriate behavior for expressing his dissatisfaction. Peyton very much dislikes reading and destroys materials and equipment to escape the demand. However, if given books that included characters from her favorite TV show, she might be willing to look at the book and say a few words on pages when asked by the teacher. Mitch tantrums when transitioning to non-preferred activities. The team could incorporate into each non-preferred activity his favorite toy train charac- ter. Mitch may be more willing to go to the writing table and draw pictures if his teachers offered blue and red crayons to complete tasks. This individualized approach of incorporat- ing student interests is a fundamental component of special education law, philosophy, and practice and can have dramatic positive effects on behavior (Individuals with Disabilities Improvement Act, 2004; Smith & Tyler, 2010). However, it may be difficult to find ways to integrate student preferences into every activity, particularly those the student with autism finds highly aversive. Special education professionals should consider how instruction might be embedded into preferred activities rather than searching for ways to make aversive tasks less aversive.

embed demands into reinforcing activities

While incorporating preferences into activities may prevent inappropriate behavior by decreas- ing the aversive qualities of the activity, teachers of students with autism should consider that students are more likely to respond appropriately to demands that are part of a reinforcing activity (Carr & Carlson, 1993; Miltenberger, 2006). Rather than blocking out periods of time to focus on one or two specific skills/behaviors (e.g., reading period, writing time), embedding demands into reinforcing activities can yield many more opportunities to practice variations of a skill/behavior (Pretti-Frontczak & Bricker, 2004). For example, the teacher may identify a series of engaging, motivating, and stimulating activities based on student interests. The teacher then can identify how targeted skills (i.e., Individual Education Plan (IEP) objectives, curriculum objectives) can be embedded into each activity. For example, a teacher may arrange a series of preferred activities (in the classroom, school, community, or home) and identify ways that instruction in reading, social skills, communication, writing, money math, and so on, can be embedded into each activity. This is a significantly different conceptualization of teaching as it tends toward student-directed learning rather than teacher-directed approaches traditionally used in schools and autism intervention in particular. An embedded approach requires teachers to act as facilitators of student learning via arrangement of the environment and delivery of supports rather than a commanding adult who controls reinforcing stimuli and delivers demands. Despite being distinctly different from traditional discrete trial approaches, this embedded instruction approach is a behavior analytic as it focuses on changing the environment to modify behavior.

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Embedding demands (i.e., activity-based intervention [Pretti-Frontczak & Bricker, 2004]) will require significant planning and organization as the emphasis is on arranging the environment in ways that are conducive to skills and behaviors that are targeted for intervention. Accordingly, the selection of activities and the instruction to be embedded is individualized, resulting in a series of lessons that likely will require more time to pre- pare than typical lesson plans. However, very little time is needed to modify lesson plans once planning is completed. An activity matrix (Pretti-Frontczak & Bricker, 2004) can be combined with lesson plans and objectives to embed instruction. Figure 4.4 is an example of a planning matrix for embedding instruction. Along the left column is a list of the daily activities. The top row includes an objective number that corresponds to an IEP objective. The teacher considers ways to incorporate as many objectives as possible into each activity. Importantly, the intent is to create an environment that provides multiple opportunities to practice variations of the skill throughout the daily activities (Pretti-Frontczak & Bricker, 2004). By incorporating many opportunities throughout the day, and by requiring vari- ations of the same behavior across different situations, the embedded approach promotes functional skills acquisition that are generalized across stimuli and behavior (i.e., stimulus generalization and response generalization). For each marked box in the matrix, a cor- responding lesson plan for the skill can be generated that includes materials and teach- ing procedures (e.g., natural cues, prompts, fading prompts). These plans can then be

aCtiVity-BaseD iNterVeNtioN MatriX

stuDeNt NaMe: persoN(s) CoMpLetiNG MatriX

Directions: Write in your daily activities schedule with corresponding times and person(s) responsible. Then identify a student and write in their IEP objectives. Then use the brainstorming sheet to identify ways the student could practice the skill/behavior during each activity. If the behavior can be practiced during the activity, then place an X in the corresponding box. Try to be creative and check as many boxes as possible.

DaiLy aCtiVities

tiMe & persoN(s)

resp oBJ. #1:

LaNGuaGe oBJ. #2 soCiaL

oBJ. #3 reaDiNG

oBJ. #4 Math

oBJ. #5 Motor

oBJ. #6 WaitiNG

oBJ. #7 WritiNG

oBJ. #8: eye CoNt.

Circle Time/ Meeting

8:15-8:45 X X X X X X X

Center/ Choice Time

8:45-9:15 X X X X X X X X

Small Group Instruction

9:15-10:30 X X X X X X X

Art Activity 10:30-11:15 X X X X X X X X

Circle Time/ Meeting

11:15-11:30 X X X X X X

Recess 11:30-11:50 X X X X X

Lunch 11:50-12:15 X X X X X X

Story Time 12:15-12:30 X X X X X X

Small Group Instruction

12:30-1:15 X X X X X X X

Math Instruction

1:15-2:00 X X X X X X X X

Center/ Choice Time

2:00-2:45 X X X X X X X

Clean up/ Departure

2:45-3:00 X X X X X

# Opp: 12 # Opp: 11 # Opp: 9 # Opp: 11 # Opp: 8 # Opp: 12 # Opp: 5 # Opp: 12

FIgure 4.4 Activity-Based Intervention Matrix

Mitch Mr. teacher

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iep oBJeCtiVe: Mitch will verbally answer “wh” (e.g., who, what, where, why, and when) questions in regards to himself or current environment (toys, activity) with 90% accuracy across all measured opportunities each week for any 9 out of 12 weeks.

Circle time Who: Teacher, paraprofessional

Ask questions about the morning Ask questions about the night before Ask questions about the upcoming day/what the teacher said

Centers time Who: Teacher, Paraprofessional

Asking questions “what’s that/this” Who are you playing with?

small Group instruction Who: Teacher, Paraprofessional

What are we doing? Comprehension questions if a reading activity What do you have? (lesson w/math materials) Wh-questions related directly to topic of lesson

art activity Who: Art Teacher

Ask questions about project Questions about name, age, where Questions about colors, materials used

Circle time/Meeting Who: Teacher, Paraprofessional

What did you eat for breakfast? Who are you? What day is it?

recess Who: Para, peers Spontaneous wh-questions regarding personal self (what is your name, mom’s name, etc.)

Lunch Who: Teacher, Paraprofessional

Ask him what he has to eat Ordering food (hot lunch) what do you want to eat

story time Who: Teacher, Paraprofessional

Comprehension questions

small Group instruction Who: Teacher, Paraprofessional

What are we doing? Comprehension questions if a reading activity What do you have? (lesson w/math materials) Wh-questions related directly to topic

Math instruction Who: Teacher, Paraprofessional

What do you have? (lesson w/math materials)

Center/Choice time Who: Teacher, Paraprofessional

Asking questions “what’s that/this” Who are you playing with? Questions regarding the day

Clean up/Departure Questions regarding the day what did you eat for lunch? What did you do today?

FIgure 4.5 Sample Activity-Based Lesson Planning Worksheet

disseminated to other adults who support the child, including paraprofessionals, related service personnel, and parents (see Figures 4.5 and 4.6).

The resulting matrix, objective plan, and activity plan can be used for extended peri- ods of time with occasional modifications in accordance with student progress monitoring. The extensive amount of planning up front pays time-saving dividends in the long run. Further, paraprofessional effectiveness is enhanced because embedded instruction provides explicit out- lines of student expectations during all activities. Teachers may decide to create guides for para- professionals that align with their planning, especially for paraprofessionals who are untrained or experiencing difficulty supporting student appropriate behavior. Importantly, the preventative effects of this embedded approach can be complemented by other antecedent-based strategies.

Increase predictability of environment

Highly structured environments enhance student behavior, regardless of (dis)ability (Zirpoli, 2012). Students with autism typically have difficulty understanding and predicting the envi- ronment and especially benefit from predictability in their environment (Heflin & Alaimo,

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2006). Predictability of the environment is enhanced by providing information about upcom- ing activities and, because students with autism often have difficulty understanding spo- ken language, should be provided via a visual schedule of activities and expectations (Rao & Gagie, 2006). Visual schedule is an evidence-based practice that has prevention qualities (Hume, 2008) and therefore should be used regardless of teaching approach or philosophy, but it can easily be combined with an embedded approach to behavior intervention. Visual schedules can prevent contextually inappropriate behavior by communicating what activi- ties will occur during the day, what activity will follow the current one, and when preferred and non-preferred activities will occur (Dettmer, Simpson, Myles, & Ganz, 2000; Iovannone, Dunlap, Huber, & Kincaid, 2003).

The information to be included in the visual schedule (i.e., size, pictures, words, analog or digital time, combinations) and the location of the schedule (e.g., on the wall, whiteboard, student’s desk, portable) should be based on the individual’s needs. Timers and reminders also may be used in conjunction with visual schedules. Teachers can direct the student’s attention to the timer if they become less engaged, anxious, or agitated during the activity. Warnings about upcoming changes (i.e., transitions to the next activity or differences in scheduling later in the day) can be combined with visual schedules to remind the student that a preferred activity (e.g., lunch) will follow the next non-preferred activity (e.g., reading). Students with autism are more likely to complete non-preferred activities if they are followed by preferred activities (Miltenberger, 2006).

To the extent possible, each day should utilize the same activities, routines, and pro- cedures in the same order so that students become accustomed to the expectations of the environment (Zirpoli, 2012). Predictability of environment not only decreases inappropri- ate behavior but also increases the efficiency of student transitions and conserves teacher resources (e.g., time). However, dealing with unpredictable aversive activities is a critical adaptive daily living skill and can help students with autism learn to cope in natural environ- ments, thereby improving quality of life. The use of visual schedules and consistent routines provides the structure necessary for teaching tolerance for unanticipated changes in routine

Figure 4.6 Sample Lesson Plan Summary for an IEP Objective and Multiple Activities

Transition to lunch: lunchbox, lunch money (coin identification **),

fruits in basket, datasheet, reinforcers

Who: special education teacher

Snack time: Materials: fork, knife, spoon, napkin, juice,

maintenance datasheet Who: Bob, teaching

assistant

Food/dinner words (home):

Materials: fork, knife, spoon, napkin, juice, milk, glass, plate, maintenance

datasheet Who: sister, mom,

dad

Morning routine: Materials: backpack,

coat, lunchbox, datasheet, reinforcers

Who: Beth (Special education teacher)

PE: Materials: basketball, softball, jump rope,

maintenance data sheet Who: adaptive PE

teacher

= IEP benchmark

Simon will vocally identify objects using 1- to 3-word phrases when presented

with a picture and the question, “What is this?"

Sample Lesson Planning

Coin identification** see Math Benchmarks

Student: Date implemented: Date for review of progress:

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(Bondy & Frost, 2011). Bondy and Frost describe how a “surprise” (e.g., a star) icon can be included in the visual schedule so that students recognize that something unpredictable is going to occur without knowing what exactly the activity will be. Initially the surprise should be something fun and, as tolerance for the unpredictable activity increases, shift to a neutral then non-preferred activity. Visual supports are critical for establishing predictability in the environment, can easily be infused into a classroom that uses embedded and/or a tra- ditional teacher-led approaches, and can effectively prevent challenging behavior frequently observed in students with autism.

provide opportunities to Make Choices

Providing choices is an established method for preventing inappropriate behavior (Geiger, Carr, & LeBlanc, 2010; Neitzel, 2009a), but perhaps more importantly, making choices is crucial for becoming a self-determined adult (Wehmeyer & Bolding, 2001; Wehmeyer & Garner, 2003; Wehmeyer, Kelchner, & Richards, 1996; Wehmeyer & Schwartz, 1997). Students with autism often will use inappropriate behavior to escape tasks, but offering choices can decrease the aver- sive qualities of a task (Geiger et al., 2010). For example, providing the opportunity to choose between two non-preferred academic tasks can increase task engagement and reduce disruptive behavior (Dunlap et al., 1994). Special education and related professionals may easily integrate choices into preferred and non-preferred activities to preventing contextually inappropriate behavior while instilling a sense of autonomy (i.e., self-determination) in their students.

Teachers also may arrange for choices beyond activity type including: choice of materials to be used for a task, location or setting to complete the task, peers to work with during/on the task, length of the task, and/or equipment to be used (e.g., tablet computer, desktop PC, assistive devices, mobile device; see Box 4.1). Importantly, the teacher maintains control over the environ- ment by only offering certain options (e.g., what to eat or drink during snack/meal times, what games can be played during leisure, where reading activities can be completed). Also, it may be effective to provide a choice in how much time the student must engage in the activity (e.g., “Do you want to do math for 10 minutes or 15 minutes?”) and gradually increase the length of time for each option until an ideal length is identified. A main benefit of offering choices is that both the teacher and the student attain a sense of satisfaction and empowerment. The teacher is able to maintain in the student an appropriate level of productivity and prevents inappropriate behavior by making it irrelevant. However, as mentioned previously and throughout this book, students with autism typically have deficits that limit their understanding of spoken language. It likely will be necessary to utilize visual supports (e.g., icons of activities, pictures of locations or equipment, people, actual materials) to help students understand what their options are when making choices.

Modify Features of Instruction

Most antecedent-based interventions tend to address negatively reinforced inappropriate behavior. Indeed, much behavior is motivated by escape from aversive situations (Geiger et al., 2010). This means that education and related professionals must examine how qualities of their curriculum and instruction contribute to problem behavior. Specifically, students might be motivated to escape a demand that is too easy, difficult, boring, repetitive, or lengthy. Further, demands that are presented too quickly, too slowly, and/or require behavior that is not functional (i.e., meaningless) for the student can motivate escape-maintained behavior (Geiger et al., 2010; Roxburgh & Carbone, 2012; Wacker, Berg, & Harding, 2006). Lastly, and per- haps more likely, is that combinations of these qualities of instruction and other antecedents affect a student’s motivation to escape. While specific strategies to address qualities of instruc- tion are explained below, it’s important to consider that a multicomponent antecedent-based approach will likely result in better student outcomes. Choosing one strategy isn’t likely going to produce broad and substantial changes in behavior.

FunCtIonally relevant InstruCtIon Arguably the most important outcome of your instruction has to do with whether it results in learning a functionally relevant skill. Recall that Mitch was able to say the name of desired objects when asked by an adult, but

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that he couldn’t spontaneously request the object when he wanted it. Professionals commonly explain that this phenomenon is a result of poor generalization of skills in people with autism. Importantly, this explanation is inconsistent with behavior analysis as it attributes absence of behavior to some inner quality of the learner rather than deficiencies of the instructional approach being used. Further, such an explanation may result in professionals who fail to consider the limitations of their curriculum and instructional methods. For example, Mitch’s team thought it critical that he learn to say the names of objects when shown a miniature ver- sion of objects and, eventually, a photograph of the objects. The team failed to consider that their teaching approach might result in a behavior that has little functional value to Mitch and would not likely result in generalized behavior. Rather than teaching Mitch to identify hundreds of objects while sitting at a table and ask “What is this?,” the team could have invested in teaching Mitch to request preferred items and activities by saying or approximat- ing the word, exchanging a symbol, or some other means. While learning to request things in the environment in which the items are normally encountered may have taken more time, it likely would result in generalized requesting behavior as well as natural opportunities to fur- ther build functional vocabulary, early literacy, and communication skills (Koegel, Vernon, & Koegel, 2009).

QualItIes oF InstruCtIon Tasks that are mundane and menial are likely to increase motivation to escape. Instruction that is interesting and stimulating to the learner may prevent inappropriate behavior (Miltenberger, 2006). Understanding and capitalizing on student interests and preferences is a cornerstone of special education. Given this value, it is important that teachers and related professionals consider using curriculum and instructional methods that incorporate appealing stimuli (e.g., favorite cartoon charac- ters, technology, animation, multimedia, music, toys, materials). Interesting and stim- ulating instruction can prevent challenging behavior because it makes escape from the demand irrelevant to the student. Similarly, tasks that are too easy or too challenging may lead to inappropriate behavior to escape. Special education and related professionals may try altering the difficulty of demands to prevent inappropriate behavior and to ensure instruction is appropriately rigorous. This strategy involves the gradual increase in the frequency or difficulty of tasks (Miltenberger, 2006). Initially the frequency and diffi- culty of the aversive task is substantially decreased or eliminated to prevent contextually inappropriate behavior maintained by escape. The frequency and/or difficulty of the task is then gradually increased in a manner that is unnoticeable to the student until, over time, performance is consistent with expectations. While this antecedent-based interven- tion seems simple to implement, Zarcone, Iwata, Mazaleski, & Smith (1993) found it to be ineffective without use of extinction procedures. This means that intervention teams may need to formally identify via FBA escape as the function of inappropriate behav- ior, develop a comprehensive behavior support plan, and use differential reinforcement with an extinction protocol that ensures student safety in conjunction with the gradual increase in demands (see Box 4.2).

Students also may engage in inappropriate behavior when required to engage in an activity or task for extended periods of time, even if it is a preferred activity. Accordingly, professionals may need to evaluate their arrangement of the environment (e.g., length of cen- ter activities, duration of free time, unstructured or “down” time) to prevent inappropriate behavior without compromising student learning. Rate of instruction also has been shown to contribute to inappropriate behavior. While some students with autism will require slow and deliberate instruction, others may be more likely to complete tasks if instruction is pre- sented more rapidly (Roxburgh & Carbone, 2012). Preventing some behavior problems may simply require changing instruction to make it more stimulating and engaging, changing the level of difficulty of tasks, and/or setting an appropriate length of time for each activity. As with other previously explained interventions, any of these qualities of instruction might be combined with others to improve the prevention effects on contextually inappropriate

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behavior. For example, Peyton appears to be motivated to escape most academic-related tasks at school. It is likely that one or more of the aforementioned factors related to quality of instruction contribute to her inappropriate behavior. Task completion may increase if academic instruction was (a) more engaging and stimulating, (b) aligned with her current ability, (c) long enough to ensure engagement but not too long so as to generate fatigue, and (d) appropriately paced. As stated previously, consideration and implementation of these and other prevention strategies (e.g., embedding instruction, incorporating preferences, offering choices, integrating visual supports) will require extensive and careful planning that likely will exceed the planning time necessary for traditional teacher-led approaches found in pub- lic schools and early intensive behavioral intervention. However, while consequence-based strategies (e.g., token economy) are well established in special education, emphasis on pre- vention strategies is becoming increasingly important to practitioners and researchers alike (Axe, 2013).

eliminate or decrease pain or discomfort

Students with autism are more likely engaged in contextually inappropriate behavior when they are experiencing pain or discomfort (Carr & Owen-DeSchryver, 2007). Teachers should attempt to eliminate or attenuate pain and discomfort because (a) it is morally and ethically imperative, (b) frequency and intensity of inappropriate behavior often is correlated with ill- ness, pain, and discomfort (Carr, Smith, Giacin, Whelan, & Pancari, 2003), and (c) behaviors that become established (i.e., have historically been reinforced) are more difficult to mod- ify (Horner, Carr, Strain, Todd, & Reed, 2002). Teachers should give breakfast or a snack to decrease hunger when a student has missed breakfast. Students who have headaches or stom- achaches might be given aspirin or antacids before school by a parent or by the school nurse. The alleviation of hunger or attenuation of pain will likely prevent inappropriate behavior that historically has been followed by access to food or medication. For example, Peyton appeared to her teacher to be engaging in behavior that was maintained by escape from a demand, but the intensity of her behavior seemed out of the ordinary when data were compared to previous months. Two weeks later, an abscess caused by an unnoticed cavity was discovered near one of Peyton’s molars. After treatment by a dentist, the frequency and intensity of Peyton’s inappro- priate behavior returned to previous levels.

Create a positive atmosphere

Teaching students with autism can be very stressful, even when things in the classroom are going well. The stress of frequently addressing inappropriate behavior combined with the responsibility of teaching a variety of skills to students with highly specialized edu- cational needs may lead to teacher fatigue, frustration, and negative mood. The demeanor of the teacher and support staff in the classroom can serve as an antecedent for inappro- priate behavior and previous negative interactions between adults and students may act as a setting event for inappropriate behavior (Miltenberger, 2006). Given the propensity for inappropriate behavior resultant of negative mood from adults and the stress associ- ated with teaching these students, educators and other staff will need to use strategies to create and maintain a positive mood in the classroom. Teachers should always attempt to use a genuinely enthusiastic and positive demeanor when interacting with students. Teach- ers should use a positive tone of voice, deliver authentic praise, and exaggerate body lan- guage to contribute to a positive atmosphere. Sarcasm and punitive criticism (e.g., harsh tones, repeated and unnecessary correction procedures) should be avoided. It may be diffi- cult to ensure everyone is contributing to a positive atmosphere in classrooms with mul- tiple adults. Teachers will need to lead by example, but may also need to actively work to change the mood and demeanor of team members who are consistently unpleasant, angry, and frustrated by the students.

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Box 4.1 researCh notes

Computer-Assisted Instruction Computers have long been used as a reward for task completion; practitioner use of multi- media instruction has been relatively underutilized (Harlacher, Roberts, & Merrell, 2006). Given that motivation, engagement, stimulation, pace, predictability, and multimedia all have the potential for preventing inappropriate behavior, it seems obvious that computer- assisted instruction (CAI) would be a highly effective intervention for students with autism. Indeed, CAI is an evidence-based practice that educators can use to teach a variety of skills to individuals with autism (Collet-Klingenberg, 2009).

Travers et al. (2011) compared the effects of two instruction conditions, CAI and teacher-led group instruction, on the alphabetic skills, attention, and inappropri- ate behaviors of preschool children with autism. Seventeen children ages 3 through 6 years attending preschool programs designed for children with autism in a large urban school district participated in the study. A pretest-posttest design with main- tenance checks were conducted along with comparisons of behavior across conditions. The CAI included an app developed for the study based on the qualities of software design for students with disabilities (Boone & Higgins, 2012). Alphabet books that utilized similar features and a scripted instruction were developed for the small group instruction. Results indicated CAI had similar effects on acquisition and maintenance of alphabetic knowledge. Rates of attention and inappropriate behavior also were simi- lar across conditions, with high attention and low inappropriate behavior in both con- ditions. Travers et al. concluded that well-designed instruction can promote an early literacy skill in young children with autism and suggested future studies examine whether well- designed literacy instruction actively prevents inappropriate behavior and promotes desirable behavior.

Other studies have found similar positive effects of CAI for students with autism. Whalen et al. (2010) found significant improvements in language and cognitive measures of 47 students who received a CAI and supplemental instruction when compared to a con- trol group. Smith, Spooner, and Wood (2013) used CAI presented on a tablet computer to promote science-related vocabulary to middle school students with autism and intellectual disabilities who were included in the general education science class. They found a functional relationship between instruction presented with the tablets and student science knowledge. The participants also demonstrated response and stimulus generalization generalized the skill to other situations. Smith et al. suggested that embedding technology into inclusive second- ary science classrooms can be beneficial to students with autism and intellectual disabilities.

The efficacy of technology for teaching students with autism may be attributed, in part, to the theorized benefits of antecedent-based interventions. Behavior analysis is grounded in the theory that behavior is purposeful and caused by the environment. While decades of research have examined the relationship that consequences have on behavior (e.g., schedules of reinforcement, token economy systems, extinction proce- dures, differential reinforcement), the field has begun to investigate how conditions preceding behavior affect the value of consequences that serve various functions of behavior. The historical and emerging research on CAI is indicative of the potential for supporting appropriate social and academic behavior in students with autism. Prac- titioners can expect during the next decade to learn new ways to integrate technology into their classrooms as the body of evidence on CAI continues to accumulate. Ideally, teachers will be prepared with the skills necessary to incorporate emerging technologies and a better understanding of how to optimize environments to prevent inappropriate behavior will yield better outcomes for students with autism (More & Travers, 2013; Travers & More, 2013).

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Box 4.2 dIversIty Box

Contextual Fit Some professionals select behaviors for intervention because they perceive them to be inappropriate, only to later discover the behavior is consistent with the student’s culture (Apichatabutra, 2009). Contextual fit is the extent to which a behavior support plan (BSP) aligns with the attitudes, beliefs, values, skills, resources, and routines of the peo- ple responsible for implementation, including family members (Crone & Horner, 2003). A well- designed BSP includes input from the student with autism (when possible and appropriate), her immediate and extended family, other relevant stakeholders (e.g., mem- bers of the family’s church, neighbors), and school-based team members. Importantly, the intent is to consider how and to what extent cultural factors will influence the success of the BSP. However, merely including a variety of members in the process of developing a BSP does not ensure good contextual fit. Rather, team members supporting students with autism should use instruments designed specifically for measuring contextual fit. For exam- ple, Horner, Salentine, and Albin (2003) designed the Self-Assessment of Contextual Fit in Schools for evaluating BSPs. This brief survey style instrument requires evaluating the BSP for knowledge of element in the plans, skills needed to implement, values consistent with plan, resources available, administrative support, effectiveness of BSP, alignment of BSP with student interests, and efficiency of BSP implementation. Similarly, the Goodness- of-Fit Survey (Albin et al., 1996) is a 20-item survey that requires parents or caregivers to rate items in order to assess the contextual fit of a BSP as it relates to the family’s ecology (Lucyshyn et al., 2007).

There are many circumstances that may affect the contextual fit of a BSP. For example, a single parent who works multiple part-time jobs that require inconsistent scheduling will make it difficult for him to implement support during homework rou- tines in the evenings. The parent may not be at home and may not be able to convince, train, or find in-home child care providers to implement elements of a BSP. Similarly, a couple with limited time and/or resources may not be able to frequently take their child with autism out into the community to practice and reinforce specific behaviors. Lastly, some families may place a high value on the use of punishment procedures, including corporal punishment rather than reinforcement. Given that corporal punishment remains legal in many states, developing and implementing a BSP that relies exclusively on pre- vention and reinforcement may be difficult. School-based team members may need to provide parents with training and/or literature on the benefits of reinforcement and lim- itations of punishment before implementing BSPs. Importantly, teachers should always prioritize the use of reinforcement and reserve punishment (e.g., loss of earned privileges) for rare circumstances when FBA and comprehensive positive behavior support plans have been ineffective. Importantly, corporal punishment should never be used as a behavior modification strategy for students with autism (or any students, for that matter) because it confers serious, long-term psychological effects (MacKenzie, Nicklas, Waldfogel, & Brooks-Gunn, 2012).

These few and relatively straightforward ways to ensure contextual fit may seem easy to account for when developing and evaluating the effects of a BSP, but consistent delivery behavior support across various conditions and with several people usually is difficult to achieve. Special education and related professionals therefore will need to carefully reflect on their own values to understand how they may conflict with parent values to compromise behavior support. Education and related professionals will need to take steps to ensure BSPs, including those that incorporate prevention strategies, have good contextual fit with the student and her family and community.

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suMMary

Many special educators and other professionals emphasize the use of consequences to entice student compliance with demands in the environment. Rewards are the primary tool for teaching students with autism and can be effective for modifying behavior, but this strategy is not without its lim- itations. Motivation, specifically states of deprivation, sati- ation, and aversive stimulation have much to do with what and how students with autism behave and learn. Immediate escape from a demand often is more valuable than earning a reward for compliance, even when students seem to regret their choice later. Functional behavior assessment is the process for understanding why contextually inappropriate behavior continues to occur and is the foundation of positive behavior support plans that include prevention strategies.

Positive behavior support plans include multiple components that make inappropriate behavior irrelevant, inefficient, and ineffective. Of particular concern in this chapter was the use of antecedent-based strategies that prevent inappropriate behavior. Such prevention strategies include using learner preferences, embedding demands into preferred activities, increasing the predictability of the environment, provid- ing choices, ensuring functional relevance of instruction, changing the qualities of instruction, gradually increasing demands, eliminating pain or discomfort, and creating a pos- itive attitude. Importantly, these intervention strategies are not exhaustive and will require individualization to meet the needs of a racially, culturally, linguistically, ethnically, and economically diverse students with autism.

Chapter revIew QuestIons

1. Explain three limitations and/or problems related to the exclusive use of consequence strategies to modify the behavior of students with autism. (Objective 1)

2. What are the steps for completing functional behavior assessment; why should it be conducted, and who should be involved in the process? (Objective 2)

3. Give five examples of antecedent-based strategies that may be effective for addressing one of Bob’s, Mitch’s, or Peyton’s behaviors. (Objective 3)

4. In pairs or groups, create an activity matrix for teaching a behavior to Bob, Mitch, or Peyton. Be sure to choose activities and behaviors that are derived from the case examples. (Objective 4)

5. Explain why contextual fit is important for developing and implementing behavior support plans for students with autism. (Objective 5)

Key terMs

ABC data 65 Antecedent 62 Aversive 68 Behavior support

plan 67 Consequences 62 Contextual fit 77

Contextually inappropriate behavior 78

Direct assessment 66 Extinction 68 Functional behavior assessment 78 Functionally equivalent replacement

behavior 67

Negative reinforcement 62 Positive reinforcement 62 Punishment 62 Scatterplot data 66 Setting event 66 Visual supports 73

Internet resourCes

http://nichcy.org/schoolage/behavior/behavassess#assess http://www.pbis.org http://autismpdc.fpg.unc.edu/content/antecedent-based-interventions-abi

http://www.specialconnections.ku.edu/~kucrl/cgi-bin /drupal/?q=behavior_plans

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79

Teaching Students with Autism Using the Principles of Applied Behavior Analysis

Chapter 5

Melissa Olive, ph.D. BCBa Center for Autism and Related Disorders

e. amanda Boutot, ph.D. BCBa-D Texas State University

Jonathan tarbox, ph.D. BCBa-D Center for Autism and Related Disorders

Case Of enrique Enrique is a 3-year-old male who was referred to his school district from the local early childhood intervention team. Enrique has a delay in expres- sive and receptive language as well as delays in social skills. Enrique engages in high rates of stereotypical behaviors such as hand flapping, vocalizations, and eye gazing. Enrique also slaps himself in the head and he has recently begun slapping his parents. Enrique’s parents speak Spanish and they are learning English. They have expressed a desire for Enrique to learn English and they report that they speak to Enrique in English. Enrique participates in the school district’s early childhood special education program for half days, 5 days per week.

Case Of JashOnne Jashonne is an 8-year-old girl who was diagnosed with Asperger’s Syn- drome at age 4. Her language vocabulary is equivalent to that of an 11-year-old child. However, Jashonne has delays in her social skills. She often stands too close to her peers and teachers. She also insists that all conversations, games, and activities include princesses. Jashonne becomes very upset if she is not allowed to talk about princesses. She often asks to include princesses appropriately on the first attempt. If she is told no, she begins to ask louder. If she is told again, she begins crying, stating that she wants to have a princess and thereupon she leaves and cries in a corner.

Case Of aiDan Aidan is a 16-year-old male with autism. He cannot read or write and his verbal expression is limited to simple phrases such as eat, drink, bathroom, and video. He engages in challenging behavior almost daily. His behaviors include elopement, aggression, and self-injury. Aidan can complete some self-care skills independently but he needs close supervision to ensure that he is thorough. He is learning some job skills but he does not remain on task for very long.

Case stuDy Examples

Chapter OBjecTiveS After reading this chapter, learners should be able to: 1. Describe and use the discrete

trial training techniques. 2. Describe and use errorless

teaching strategies. 3. Describe and use error

correction procedures. 4. Describe generalization and

maintenance strategies. 5. Describe and use incidental

teaching strategies. 6. Describe and use basic data

collection.

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IntroduCtIon to applIed BehavIor analysIs

Applied behavior analysis (ABA) is the utilization of the basic principles of learning and motivation to address socially important problems. The principles of learning and moti- vation, also known as the principles of behavior, upon which ABA is based, are found in Figure 5.1.

First, all behavior is learned. Individuals learn through two mechanisms: classical con- ditioning and operant conditioning. In classical conditioning, individuals learn to associate an unknown stimulus with a known stimulus. The best example of this was Pavlov’s exper- iment with his dog (Pavlov, 1927). Pavlov rang a bell each time he presented his dog with food. His dog began to associate the bell with the food. In the future, when the bell rang, the dog began to salivate in anticipation of food presentation. Operant conditioning involves the modification of stimuli following behaviors in order to change the occurrence and/or form of the behavior (Skinner, 1953). When an infant learns to make a raspberry sound, his parents often cheer or giggle. The raspberry sound is the behavior of interest and the cheering and giggling are the stimuli following the behavior. If the baby enjoys hearing cheering and gig- gling, he will learn to engage in more raspberry behaviors in order to obtain more cheering and giggling.

The second principle of ABA is that all behavior serves a purpose. Each person has her own reasons for engaging in behaviors and the reasons may change based on age, contextual situations, and prior experiences. Behaviors may be exhibited in order to obtain a social outcome, or behaviors may be exhibited in order to experience an inter- nal feeling. Social outcomes may include access to or avoidance from social interaction or tangible outcomes. These may include getting a preferred chair color during instruc- tion or avoiding difficult activities such as math instruction. Students may engage in behaviors for nonsocial outcomes as well. The nonsocial outcomes, or what behavior ana- lysts refer to as automatic reinforcers, may include access to feelings of euphoria and pride. Nonsocial outcomes may also include avoiding things such as headaches, loud noises, and embarrassment.

The third and final principle of behavior analysis is that all behaviors are contextual. Behaviors are influenced by contextual factors within the student’s learning environment. The contextual factors may be stimuli associated with environments, or behaviors may be related to states of deprivation (e.g., lack of access to stimuli) or satiation (e.g., exposure to too much stimuli). The contextual factors that influence behaviors may also be related to the culture of the environment. For example, kicking is a widely accepted behavior in school activities such as cheerleading, football, dancing, karate, and kickball. Conversely, kicking is not gener- ally accepted in environments such as basketball, reading instruction, lunchtime, baseball, or hallway transitions.

• Through association learning (classical conditioning)

• Through operant conditioning

• Functions vary from person to person

• Some functions may include escape or avoid- ance of task, attention, to obtain something tangible or a preferred activity, or for self-soothing/self- stimulation

• Behavior is influenced by the environment in which it occurs; some- times referred to as the trigger for behavior

• Antecedent events in the immediate environ- ment or setting events that have happened previously

FIgure 5.1 Principles of Behavior

all BehaviOr is learneD

all BehaviOr serves a purpOse

all BehaviOr is COntextual

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ABA has been used to address a large variety of issues, including anxiety, depression, weight management, substance abuse, job performance, and behavior disorders (Greene, Winett, Van Houten, Geller, & Iwata, 1987). Autism is just one of the many areas addressed by ABA. Procedures and areas of specialization within ABA go by various names, includ- ing discrete trial training (Smith, 2001), incidental teaching (Hart & Risley, 1975), pivotal response teaching (Koegel, Camarata, Valdez-Menchaca, & Koegel, 1998), verbal behavior (Wallace, Iwata, & Hanley, 2006), and positive behavioral supports (Sugai & Horner, 2002). All of these approaches are part of the field of ABA, all are based on the same principles of learning and motivation, and all require advanced training in the science of ABA. Compre- hensive ABA programs for children with autism often include some elements of each of these approaches.

Research has demonstrated that for a significant proportion of children with autism, intensive early intervention will result in increases in appropriate behaviors and decreases in inappropriate behaviors (e.g., Lovaas, 1987; Sallows & Graupner, 2005). For some children, the outcome has been so great that the children with autism become indistinguishable from their typically developing peers (e.g., Lovaas, 1987).

The first controlled study to evaluate long-term, intensive, early ABA intervention for children with autism was conducted by Lovaas (1987). This study compared a group of children who received intensive (40 hours per week) ABA intervention to two control groups—one who received 10 hours per week of ABA intervention and the other who received 10 hours per week of non-ABA intervention. All children received interventions for 2 or more years. Assignment to groups was not random but based on availability of staff that could provide therapy. However, the groups did not vary significantly on any measures at intake. At follow-up, 47% of the children in the intensive ABA group achieved both normal IQ and successful first-grade placement in general education classrooms. Children in the control groups, however, made much smaller gains, with only 2% of children across both control groups achieving normal intellectual functioning and placement within gen- eral education settings. In 1993, McEachin, Smith, and Lovaas published a follow-up study, wherein participants in the intensive ABA group were reevaluated at a mean age of 11.5 years. Eight of the nine participants demonstrated intellectual and adaptive function- ing within the normal range.

Subsequent studies on intensive ABA have produced similar results. Sallows and Graupner (2005) found that 48% of children who had received 4 years of intensive early ABA scored in the normal range on measures of intelligence and adaptive behavior. The children were able to transition to general education with no support. Cohen, Amerine-Dickens, and Smith (2006) studied the effects of 3 years of intensive ABA for young children with autism and found that children receiving intensive ABA outperformed controls on measures of intel- ligence and adaptive behavior. Moreover, 28% of participants were successfully transitioned to general education placements, whereas only 4% of controls were placed in general education.

Eikeseth, Smith, Jahr, and Eldevik (2007) extended previous research by evaluating intensive ABA intervention for slightly older students with autism. They found that students who began intensive ABA at ages 4 through 7 attained statistically significant increases in intellectual and adaptive functioning when compared to a control group who received the same amount of services consisting of “eclectic” special education services.

A number of reviews of the research on ABA for children with autism have been com- pleted. The most recent review (Eikeseth, 2009) noted that four studies demonstrated that children who received ABA made significantly more gains than control group children in a variety of measures. These four studies also met the highest criteria for scientific merit. Simi- larly, in their review of autism treatment research, Rogers and Vismara (2008) concluded that early intensive ABA is the only “well-established” treatment. Reichow and Wolery (2009) recently completed a meta-analysis of early intensive behavior intervention for children with autism. They reported that on average, ABA is an effective treatment for these children. In summary, research has demonstrated that intensive ABA can produce substantial gains in children with autism.

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The robust research base supporting ABA treatment for children with autism has led to widespread endorsement by independent entities, including the U.S. Surgeon General (U.S. Department of Health and Human Services, 1999), the New York State Department of Health (New York State Department of Health, Early Intervention Program, 1999), the National Academy of Sciences (National Academy of Sciences, 2001), and the American Academy of Pediatrics (Myers & Johnson, 2007). Major public policy changes have also begun to occur, including state funding being allocated to ABA for autism treatment and state-level legisla- tive decisions mandating insurance coverage for ABA treatment (e.g., “Steven’s Law,” Arizona House Bill 2487).

usIng aBa to teaCh students wIth autIsm

A comprehensive approach to teaching new skills to students involves a variety of ABA pro- cedures. Everything that a student with autism needs to learn is viewed as a skill that can be taught, including daily living skills, language, social skills, academic skills, motor skills, per- spective taking, and advanced or meta-cognition. Each skill area is broken down into small, teachable units and then taught systematically. Each student’s unique strengths are built upon in the gradual process of teaching all skills the student needs to know in order to catch up to her typically developing peers. The two major ways that ABA is used to teach students with autism will be described further (a) using ABA to teach new skills and (b) using ABA to address challenging behaviors.

usIng aBa to teaCh skIll aCquIsItIon (new learnIng)

discrete trial training

Discrete trial training (DTT) is a particular ABA teaching strategy that enables the stu- dent to acquire complex skills and behaviors through multiple practice opportunities. Dis- crete trial training is comprised of multiple and repeated discrete trials. A discrete trial includes what is known as the three-term contingency, which includes an antecedent, a behavior, and a consequence. The first step is the antecedent or discriminative stimulus (SD). For example, when teaching a child to say “car,” the adult models “Say ‘car,’ ” which is the antecedent for the desired behavior. The student says “car,” which is the targeted behavior. Then the student is given access to the toy car, which is the consequence or reinforcer for say- ing “car.” Figure 5.2 shows an example of a three-term contingency learning opportunity for this example.

The key element to this single discrete trial is that the student must be interested in the car when the instruction begins. If the student is not interested in the car, then other reinforcers may be needed to reinforce the child when she says car. If the student is not capable of saying “car,” she is allowed to use an easier version of the skill such as touching a picture of a car, signing the word car, or touching an assistive technology device that says the word car for her. As the student masters easier versions of the skill, the adult scaffolds the student’s learning by increasing the behavioral expectations (e.g., moving from “car” to “I want car”).

antecedent “Say car”

Behavior “Car”

Consequence Child is given car

If the car serves as a reinforcer, the next time someone says, “Say car” there is a high probability the learner will do so.

FIgure 5.2 Three-Term Contingency

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The DTT procedure used for any particular student is customized to match the diffi- culty of the task and to the current skill level of the student. For example, when first introduc- ing a new skill, a “mass trialing” procedure may be used wherein the same task is presented repeatedly several times in a row. Mass trialing has been shown to result in faster skill acqui- sition (Losardo & Bricker, 1994). An everyday analogy for mass trialing is teaching a student to shoot basketball free throws or teaching a student to play scales on a piano. The student is required to repeat the same skill over and over until the skill is mastered. Once the student is able to perform the basic skill, then that skill is mixed with other skills in “random rotation” wherein the student must switch back and forth between varieties of learned skills in order to ensure that all skills are truly mastered.

Discrete trial training requires training and practice for teachers in order to become flu- ent in instructional delivery. (See Box 5.1 for review of a research study on teaching DTT to paraprofessionals.) There are a number of variables that can negatively influence the learning opportunities, which make learning for the student difficult. Teachers can prevent or reduce the negative factors by adhering to several key “rules” for DTT instruction (see Figure 5.3).

First, it is important that the student is motivated to participate in the learning oppor- tunity. A preference assessment may be necessary at the start of each training session to deter- mine what the student wants to work for. For example, the teacher may have a box of several of the student’s favorite items. The teacher can place the box in front of the student and record what he seems most interested in. For students who are verbal, teachers may ask students what they would like to work for. A second preference assessment strategy is to hold two known reinforcers in front of the student to see which he chooses. If a student is not motivated to learn, learning is not likely (Iwata et al., 1997). When instruction moves to natural environ- ments, reinforcers will become more natural. For example, if the child is playing in the house- keeping center, his motivation may be to obtain the pretend sandwich for his pretend picnic.

The second variable to consider in a discrete trial is the student’s level of focus or readi- ness to learn. Securing the student’s attention and focus prior to delivery of the SD is known as instructional control. Instructional control includes having the student sit up straight, hands in lap, and looking toward the teacher. Securing instructional control between each trial will aid in successful student responses, and it will help students learn to notice the appropriate stimuli on which to focus.

Third, teachers should try to use the most natural cue or antecedent for each skill, which is also known as the SD. In the initial phases of instruction, it is important for teachers and their teaching assistants to keep the SD the same, which helps the student learn more quickly. Once the student has demonstrated an understanding of the instructional task, the SD should be varied gradually to ensure that the student learns to use the skill in a variety of situations. For example, when teaching students to respond to greetings, the teacher initially says, “Hi Enrique!” After Enrique learns that he should say “hi,” the teacher moves to “Hey Enrique!” or “Hello Enrique” or even “What’s Up?” It is unlikely that Enrique will be able to generalize his skill to the playground or neighborhood park if the SD does not match the different ways that students greet each other.

Box 5.1 researCh notes

The provision of appropriate programming for students with autism in public schools is frequently a collaborative effort among multiple professionals, including teachers, therapy providers, and paraprofessionals. In a study by Bolton and Mayer (2008), the effectiveness of a training package for paraprofessionals was examined. Because of the increase in the num- ber of paraprofessionals providing services to students with autism, adequate training is of highest concern. In this study, discrete trial teaching was taught to three paraprofessionals working in a state agency serving children with autism. The study implemented a train- ing package using “didactic instruction, modeling, rehearsal, and performance feedback” (p. 104). A delayed multiple baseline across subjects design was used to determine the effi- cacy of the treatment package as well as the generalization of skills beyond the training

(Continued)

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setting. Each of the participants took part in a 30-minute training session using a PowerPoint presentation on ABA and DTT. Following the presentation, baseline data for each participant was taken to determine the level of accuracy in implementation of seven steps in the DTT process (see below). Immediately following baseline measurement, participants were provided with an additional 45 minutes of specific instruction, which involved lecture and demon- stration of the seven steps. Following the more specific instruction, general case instruction, in which “multiple teaching examples are chosen systematically to ensure that they sample the span of stimulus and response variations that occur within the environment where the behavior is desired” (p. 104) was provided. Ten different programs were used in this train- ing sample, including such skills as “responding to name, pointing, gross motor imitation, identifying body parts, object discrimination, matching, color identification, object identifi- cation, verbal imitation, and toy play” (p. 106). Paraprofessionals spent the remainder of the training session practicing DTT for each of the programs and received performance feedback on each trial from the trainer. Treatment data were collected for each paraprofessional partici- pant during the practice trials. For generalization, each paraprofessional was observed provid- ing DTT to an assigned child with autism in the natural setting—in this case either the home or a community-based setting. Data was collected on the performance of each paraprofessional during generalization and compared to both baseline and treatment performance.

The training package examined in this study incorporated several aspects of training shown previously in the literature to be effective in teaching professionals to perform DTT, including general case instruction, performance feedback, and the use of common stimuli (e.g., toys and other materials during the training that were most likely to be used in actual child instruction). The study demonstrated that this rapid training program was successful in teaching three paraprofessionals, each of whom had little to no prior training in DTT, how to implement the steps of DTT. In treatment, each participant was able to achieve 98% to 100% accuracy while in generalization each was able to achieve 90% to 100% accuracy on the seven steps of DTT with a child with autism. Both treatment and generalization accuracy levels were higher than baseline, which were between 50% and 63%. This study supports that training for para- professionals is effective in achieving high levels of accuracy of teaching strategies and that such training may be effective in a relatively short amount of time, given appropriate procedures. In this case, the general case instruction, performance feedback, and programming common stim- uli were cited as components of the training package leading to the gains of these participants.

Seven steps of DTT:

1. Have materials ready

2. Gain child’s attention

3. Present discriminative stimulus

4. Prompt

5. Reinforce

6. Use correction procedure as necessary

7. Collect data

Source: Information from Bolton, J. & Mayer, M. D. (2008). Promoting the generalization of paraprofes- sional discrete trial teaching skills. Focus on Autism and Other Developmental Disabilities, 23(2), 103–111.

Some things to keep in mind during DTT

• Ensure motivation to learn • Establish instructional control • Use natural cues when possible • Clear the field between trials • Keep the ABC separate; no overlapping • Reinforce immediately • Use errorless learning for new skill acquisition

FIgure 5.3 Discrete Trial Training

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A fourth suggestion to improve DTT efficiency is to remove teaching materials from the student’s view between trials (for multiple trial sessions), which is known as “clearing the field.” Clearing the field ensures that each new trial is presented “cleanly,” which prevents the student from getting confused during learning opportunities. For example, if a teacher is teaching Enrique to learn colors, the teacher will use a simple color card. At the beginning of each trial, the teacher brings out the red card and says “touch red.” When Enrique touches red, he is given brief access to his reinforcers while his teacher removes the red card from his line of sight and records his response on the data sheet. Then the teacher begins the instructional trial again by presenting the red card and simultaneously delivering the SD. As with SD delivery, it is important that instructional materials remain consistent until the student demonstrates an understanding of the learning opportunity. When the instruction moves to more natural con- texts, it is important to have many materials present to ensure that the student learns to focus his attention on the appropriate learning materials.

Fifth, teachers must ensure that the components of the discrete trial do not overlap. For example, the SD must precede response prompts, so that the response prompt does not become accidentally “chained” to or associated with the SD. For example, when Enrique’s teacher prompts him to “touch red,” she waits to prompt him until after the red card is presented and after she has said, “touch red.”

A sixth consideration is that the reinforcement must be delivered immediately fol- lowing the correct behavioral response, regardless of the level of prompting. Initially during instruction, the student will receive a reinforcer immediately following each correct response that has been emitted following the SD. When the student demonstrates an understanding of the learning trial, then the reinforcement is “thinned.” Thinning reinforcement consists of requiring more behaviors before reinforcement is delivered. Initially, Enrique receives a rein- forcer following each instance that he touches red when asked to touch red. Over time, he will need to have two correct responses before the reinforcer is delivered. This is adjusted to three and so on until he can work for an extended time before earning reinforcement. Further, rein- forcement should be as natural as possible. Initially, reinforcers may be contrived (e.g., candy or tokens). Figure 5.4 shows a hierarchy of reinforcement from least to most natural. Over time, the student learns to work for social praise with the ultimate goal being that the student works for internal motivation. Although some students will require more extrinsic reinforce- ment than others, it is important that teachers plan for and fade reinforcement as quickly as the student’s learning will allow. Moving students to more natural reinforcers will also ensure that maintenance (i.e., ability to perform the skill over time) and generalization (i.e., ability to perform the skill with novel teachers, teaching aids, instructional materials, and settings) will occur (Stokes & Baer, 1977). Paying careful attention to the way one is using DTT can help teachers ensure student success.

errorless learning

Effective prompting is also an important part of any ABA program. A prompt is additional help that is provided to a student to make sure each learning attempt is successful. For example, when teaching a student to name objects, one might hold up a picture of an apple

• Reinforcement Strategies: • Verbal Social More Natural • Physical Social • Token • Item • Activity • Edible Less Natural

FIgure 5.4 Hierarchy of Reinforcement from Most to Least Natural

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and say, “What is it?” Rather than simply taking a trial-and-error approach and potentially allowing the student to make frustrating errors, the student is given a response prompt that assists him in answering correctly on the first few trials. For example, initially the instruc- tor may say, “What is it? Apple.” This process of instruction is referred to as most-to-least prompting or errorless learning. Errorless learning has been shown to be effective in teaching new skills to students, particularly in that the student has less frustration (Touchette & Howard, 1984).

Once a student demonstrates mastery of a skill, maintenance is addressed by adjust- ing the prompts accordingly. The instructor moves to a least-to-most prompting strategy and provides a prompt only if the student does not engage in the correct response. This approach helps ensure that students do not become dependent on prompts but rather learn to use new skills independently. Figures 5.5 and 5.6 present a hierarchy of prompt- ing procedures that may be used during instruction and an overview of prompt-fading procedures.

Error Correction Procedures

During instruction, prompts should be faded systematically. However, it is possible that a student will make an error at some point during instruction. When this occurs, teachers must use appropriate error correction procedures, sometimes called correction trials, in order to prevent such errors from happening in the future. When the student makes a mistake, the teacher should clear the field for the next trial, ensure instructional control is regained, and re-present the SD as in the previous trial. This time, however, the teacher should immediately provide assistance in the form of a prompt to ensure the student does not make the error a second time.

The level of prompt used in the error correction procedure is selected based on data collection from previous lessons (see data collection strategies later in this chapter). Data from previous trials will indicate the last known prompt level required for that partic- ular skill. In other words, if the student has previously been able to perform the skill with a gesture prompt, the teacher would use a gesture prompt rather than a full physical prompt.

FigurE 5.5 Hierarchy of Prompting Strategies from Most to Least Independent

Hierarchy of Prompts — Stimulus Independence — Gestural — Model — Partial Physical — Full Physical Dependence

FigurE 5.6 Overview of Prompting Systems

• Moving from a more intrusive/less independent prompt to a lesser intrusive prompt contingent on student’s need for less support

Most-to-Least

• Moving from a less intrusive/more independent prompt to a more intrusive prompt contingent on student’s need for more support

Least-to-Most

• Moving from more to less physical support; used only for physical prompting

Graduated Guidance

• Inserting a short wait between the SD and the prompt

Time Delay

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If a physical prompt was used when only a gesture prompt was needed, the student may develop prompt dependency. In such a case, the teacher would either deliver a gesture prompt or a prompt one level up from that (e.g., a model prompt) to support the student’s success. If that prompt level does not lead to the correct response, then a most-to-least prompting procedure should be reinstated until the student regains the skill. Figure 5.6 details the prompt-fading procedures used in ABA.

After the student performs the correct behavior with the prompt, the student receives the reinforcement. The teacher may at this point either (a) re-present the same trial with- out the prompt to probe the student’s ability to perform the skill independently or (b) move on to another skill for two or three trials and then come back to the corrected trial without the prompt. In either case, the least intrusive prompt should be used and the correction trial repeated until the student can reliably perform the skill on her own. Figure 5.7 provides an overview of error correction procedures.

discrimination training

Another critical component within an ABA program is discrimination training. Many types of discrimination training exist, but receptive language training is among the most important. When students learn receptive language discrimination, a basis is formed for later instruction. In receptive language discrimination training, an instructor makes two or more items avail- able to the student and asks the student to respond to one of them. For example, a red car and a green car might be placed on a table. The instructor says “Where’s red?” and then prompts the student to touch red. After the student learns to discriminate red, another color is taught. In this manner, the basic building blocks of language comprehension are taught. As the stu- dent progresses, the complexity of the instructor’s language expands (e.g., “Where’s the red car?” versus “Where’s the red truck?”).

shaping

Complex behaviors are taught through the use of ABA strategies such as shaping, chaining, and modeling. Shaping is the process of reinforcing successive approximations of the desired behavior (Skinner, 1953). Over time, closer approximations of the behavior are required before reinforcement is provided. Interestingly, this instructional strategy is used by parents every day. One example is a parents’ desire to teach their child to walk. Parents do not expect their child to walk before it is developmentally appropriate to do so. However, parents use shaping to encourage a child to get closer and closer to walking. Specifically, parents teach their child to pull up to a table. The child is reinforced when she learns to do this because her parents clap and cheer. The child soon learns that fun things are located on top of tables so this becomes a natural reinforcer for pulling up. Once the child learns to pull up consistently, her parents stop cheering for her when she pulls up. Now, her parents will cheer only when she takes steps while holding on. Soon, the parents stop cheering for taking steps and now they cheer only when she no longer holds on to the table. Before long, the child is walking and the parents cheer madly. Within weeks, the child walks in the absence of cheering.

error Correction

• Trial 1: mistake • Clear field, present Trial 2 with prompt (at last required level prior to mistake) • Reinforce prompted trial • Clear field, present Trial 3 at level to Trial 1 • Repeat until child can perform skill at the desired level • Variation: insert easy trials between prompted trial and repeated mistake trial

FIgure 5.7 Error Correction Procedure

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One example of using shaping in behavior analysis is when a student is taught to say a word. Initially, the instructor will reinforce a sound such as “m.” Then the instructor refrains from reinforcing the “m” sound and reinforces only sound blends such as “mu.” When that skill is acquired, the instructor stops reinforcing “mu” and reinforces only when the student says a word approximation such as “muk.” Finally, the instructor provides reinforcement only when the student says “milk.”

Chaining

Chaining is another instructional strategy that is used to teach a series of behaviors. Behavior chaining occurs when a series of behaviors occurs in the presence of a specific stimulus. The instructional aspect is that students are taught to put multiple behaviors together in succes- sion (Skinner, 1953). Putting on a coat, brushing teeth, and hand washing are all examples of behavior chains. When teaching a student to chain behaviors together, instructors may use forward chaining (McWilliams, Nietupski, & Hamre-Nietupski, 1990). In forward chaining, the student is taught to engage in the first and second behaviors together. When the two behaviors are exhibited together, then the student is taught to do the first three skills together and so on.

Backward chaining is another way to teach a series of behaviors (cf., Hagopian, Farrell, & Amari, 1996). In this approach, the instructor teaches the student to chain together the last two behaviors in the sequence. When those two behaviors are learned, then the preceding behavior is taught. This continues until the student successfully engages in the chain of behav- iors from the beginning.

Finally, the instructor may use total task presentation wherein the entire chain is taught simultaneously (cf., Werts, Caldwell, & Wolery, 1996). For example, when a student is learn- ing to wash hands, he learns to turn on the water, get soap, rub hands together, rinse, turn water off, and dry hands. Each of those steps is an individual behavior that is not really mean- ingful unless performed in the chain.

Chaining could be used to teach Aidan how to complete work tasks. For example, teach- ing Aidan how to shred paper includes many steps: (a) retrieve paper from bin, (b) insert paper into shredder, (c) hold paper until shredder begins, (d) empty shredder when full, and (e) adjust shredder should it become jammed. Initially, Aidan will be taught how to shred one single sheet of paper. When he learns this skill and receives reinforcement for engaging in the skill, then he will be taught to shred single sheets of paper successively. Once he is able to shred single sheets successfully, then he is taught to retrieve paper from each person’s office before he begins his shredding job. Once he is able to do this set of skills, he is taught how to make adjustments to the shredder if it becomes too full. Over time, Aidan is taught to shred more paper before receiving reinforcement (e.g., 10 sheets, 20 sheets, 30 sheets).

modeling

Modeling as an instructional strategy is the process of demonstrating a behavior for a student to imitate; modeling may also be referred to as imitation learning. There are several types of models for students to imitate. A live model is most often used. However, written, picture, and audio models are also effective forms of instruction. Recently, many studies have shown the effectiveness of video modeling in teaching students with autism (e.g., LeBlanc et al., 2003). Before modeling can be used, however, the student must have prerequisite skills. These necessary skills include the ability to:

• Attend to the model • Remember the behavior to be performed • Reproduce the behavior

Finally, the student must be motivated to attend to and reproduce the behav- ior. Jashonne would benefit from video modeling as part of her social-skills instruction.

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Specifically, a social-skills interaction could be shown to her on a video. Following the video, the teacher could ask Jashonne what behaviors the models used. The teacher could also use pausing during the video. Specifically, when the video is paused, the teacher could ask Jashonne to look at facial expressions of the models and interpret their thoughts. The teacher could also have Jashonne predict what might happen in the conversation based on what the models have said.

progress monitoring

An essential element to any comprehensive ABA program is the use of progress monitoring. The most widely used progress monitoring is observational recording or what teachers may refer to as data collection. Data are collected on each and every trial that a child experiences during DTT. Trial-by-trial data collection involves recording the child’s response to virtually every learning opportunity occurring during daily therapy sessions. Each child’s response is recorded as one of the following: independently correct, correct but prompted, incorrect, or no response. All child responses are summarized at the end of each therapy session (e.g., 2- to 3-hour blocks of therapy). For each individual skill, data are summed and graphed as a rate or percent correct. All instructional data are graphed and visually analyzed daily. Instructors modify their instruction based on the accomplishments achieved in the previous instructional session. As the child moves to more naturalistic intervention, data collection opportunities are then modified to ensure that representative samples of data are collected during an intervention session.

This chapter does not allow the space necessary to fully describe different progress monitoring techniques. Readers are referred to Applied Behavior Analysis for Teachers by Alberto and Troutman (2008) for additional information on ABA and progress monitoring.

varIatIons oF InstruCtIonal FoCus and delIvery

Early phases of ABA instruction are often referred to as drill and practice because instructors present multiple discrete trials in close succession, hence the term discrete trial training. In DTT, the instructor may teach in blocks of 10 trials allowing the student short work breaks between blocks. However, as students acquire simple behaviors, instructors alter their proce- dures to reflect a more flexible instructional sequence. This alteration is done through the pre- sentation of varied discriminative stimuli as well as through the use of naturalistic behavioral teaching procedures such as natural environment training, incidental teaching, and pivotal response teaching.

maintenance and generalization

Quality instructional programs must be developed with a plan for maintenance and gener- alization. Years of research in behavior analysis have shown that instruction using multiple exemplar training, intermittent schedules of reinforcement, and natural reinforcement are likely to promote both maintenance and generalization (Stokes & Baer, 1977). Additionally, procedures such as sequential modification, mediation, and general case instruction can be used to promote generalization.

One way of using multiple exemplar training is to transition from strict presentations of the discriminative stimuli (SD) and uniform phrases (e.g., “Hi Johnny!”) to more generalized or loose SD presentations (e.g., “Hi,” “Hello,” “How’s it going?”), which is often referred to as training loosely and is used in programs designed to facilitate generalization (e.g., Horner, Eberhard, & Sheehan, 1986).

Contingency management is another strategy that has been shown through research to promote generalization and maintenance of skills (e.g., Baer, 1999; Craft, Alber, & Heward, 1998; Hoch, McComas, Thompson, & Paone, 2002). Contingency management is accom- plished by changing the type and schedule of reinforcement. Specifically, reinforcement is

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moved from primary and contrived reinforcers (e.g., candy or “good job”) to natural and secondary reinforcers (e.g., access to requested item or high five). Contingency management may also include teaching students to ask for reinforcement in the generalization setting. Meanwhile, the reinforcement schedule is faded from a fixed predictable schedule to a more variable and natural schedule. For example, during the early stages of learning, students gain access to the reinforcer on every trial. However, when skills are acquired, the schedule of reinforcement must change to meet a more natural schedule of reinforcement. For example, when a student is first learning body parts, he may be praised each time he touches his nose. Once the skill is acquired, the reinforcement is faded to an unpredictable and more natural schedule.

A comprehensive ABA program should consider various strategies for instruction based on the skills to be taught as well as the individual student. While ABA is proven via decades of research to be effective, the specific programs vary from student to student and include the myriad of approaches discussed here.

Incidental and milieu teaching

Incidental and milieu teaching strategies are used within the context of the natural environ- ment and often during daily routines. Some environmental arrangement strategies may be used to elicit language or to increase the likelihood of manding (Hemmeter & Kaiser, 1994). Environmental arrangement strategies include sabotage, blocking, missing pieces, and small portions. Sabotage involves setting up a learning opportunity in advance so that the desired behavior is most likely to occur. For example, a teacher places a preferred magazine on a high shelf and waits for Aidan to show interest in obtaining it. When Aidan shows an interest in the magazine, the teacher prompts Aidan to request the item if Aidan is in skill acquisition. If Aidan is in maintenance and generalization, the teacher uses a time delay prompt to see if Aidan will request independently. Another example would be handing the student a closed container that he cannot open and prompting him to ask for help. Blocking is used inciden- tally when the student attempts to gain access to a desired item or activity and the teacher blocks access contingent on a specific requesting behavior. Missing pieces may be used in a number of situations. For example, the teacher may present Jashonne with a puzzle that she is motivated to complete, but the teacher withholds one or more pieces. When Jashonne notices the missing pieces, the teacher uses the situation to capitalize on social-skills instruc- tion. Another example would be to give Enrique something to eat but not give him a fork. The teacher would use an appropriate prompt (e.g., most to least or least to most) depending on Enrique’s learning phase. Enrique would obtain the fork, but only after the desired behav- ior of requesting the fork.

In each of these examples, the behavioral response is communicative. Other examples of incidental teaching include teaching self-help skills during naturally occurring opportu- nities. For example, when it is time to go outside, the teacher may take that opportunity to teach Aidan the steps of putting on his jacket. Discrete trials may also be used during inci- dental or learning opportunities. For example, at recess on the playground the teacher may deliver the SD “slide” and then prompt Enrique to slide down the slide. Enrique receives a high five for sliding when asked to slide. It is a common myth that DTT must be done “at a table” or only in multiple trials. Boutot, Guenther, and Crozier (2005) successfully taught a 4-year-old with autism to engage in typical play activities through the use of DTT in the natural environment.

verbal Behavior

In the past two decades, comprehensive ABA programs for students with autism have incor- porated a consideration of “verbal behavior.” Verbal behavior is the term B. F. Skinner (1957) coined for a behavioral approach to language. The primary contribution of incorporating Skinner’s analysis of verbal behavior into instructional plans is that it reminds us to consider

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all possible functions of language during instruction. For example, asking for a car when you want a car is not necessarily the same thing as mentioning that you see a car when you are walking past one. Similarly, being able to imitate the word car is not the same thing as being able to have a conversation about cars. For typically developing children and adults, learning word meaning often results in being able to use that word in whatever manner is desired. However, research has shown that if individuals with developmental disabilities are taught to use a word in one manner (e.g., to label something), they may not necessarily be able to gener- alize the use of that same word for other purposes (e.g., to request something) (Sigafoos, Doss, & Reichle, 1989). Therefore, assessing and teaching each individual function of a word is often necessary when working with individuals with autism who are beginning to learn language.

Although language is commonly divided into expressive or receptive skills, Skinner pro- vides us with expanded components of language that go beyond these more simplistic types and include the function of the language, rather than just its form (Barbera, 2007).

Echoics are typically one of the first verbal operants taught in behavioral intervention programs for children with autism. Echoic instruction teaches students to imitate spoken words. This is also the same as a verbal model prompt. Specifically, the teacher says, “Say ‘ball’ ” and the student echoes or imitates this by saying “ball.” Learning to engage in echoics is the foundation of all remaining verbal behavior because it teaches the student the ability to imi- tate vocal model prompts during future instruction.

Concurrent with echoic instruction, most verbal behavior programs focus on teaching basic mands, or requests (Barbera, 2007). The primary advantage of beginning with mand instruction is that it builds upon the student’s natural motivation (Barbera, 2007). For exam- ple, a teacher may hold an item the student wants, such as a cookie, just out of reach and prompt her to sign “cookie”; the consequence is receipt of the cookie. Mand training helps the student build simple associations between desired items and the words that represent them, which in turn increases the likelihood that she will make that sign or say that word to get the item in the future.

Tact instruction is often used to increase a student’s vocabulary. Tacting consists of basic naming, labeling, and commenting on stimuli in the environment. Tacting in typical develop- ment is often observed when toddlers “show off” newly learned names of objects by pointing out those objects every time they see them. Tact instruction should focus on establishing inde- pendent or spontaneous tact abilities by preventing prompt dependence as much as possible. Tact instruction is also used to increase a student’s vocabulary for a variety of words, including common nouns, verbs, adjectives, adverbs, and prepositions.

Receptive language instruction may precede tact instruction or they may occur simul- taneously through what is known as a transfer trial. A transfer trial transfers the behavior from one language form to another in two back-to-back discrete trials. For example, the teacher places two color cards on the table in front of the student and delivers the SD, “Show me red.” When the student points to red, the teacher praises the student, then immediately picks up the card and delivers the SD, “What color is it?” Having just heard the teacher name the color as red, the student is more likely to say red in response to the SD than if the tact trial had been presented in isolation, thus eliminating the need for a prompt. One must be careful in transfer trials that the student does not become dependent upon the receptive trial to get the expressive or tact trial correct. Probing tact trials in isolation will determine whether or not the student is able to truly tact the item.

An intraverbal is a verbal behavior that occurs in response to another verbal behav- ior (Skinner, 1957). Examples of intraverbal instruction include teaching higher-level verbal skills such as categorization (Petursdottir, Carr, Lechago, & Almason, 2008) and antonyms (Pérez-González, García-Asenjo, Williams, & Carnerero, 2007). Intraverbal instruction may also include “fill-ins.” In a fill-in, the student essentially finishes a sentence delivered as the SD. For example, the teacher may say, “You sleep in a . . .” and the student is expected to finish or fill in the sentence with the intraverbal, “bed.” Intraverbal instruction can include answer- ing questions, asking for more information, and carrying out conversations. A critical element of intraverbal instruction is to teach multiple examples and vary instructions frequently in

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order to avoid rote learning. For example, when teaching a child to respond to the instruction “Name some animals,” one should take care to teach as many different animals as possible answers and to not always list the same ones in the same order.

In the very early days of ABA programs for students with autism, some programs focused on teaching receptive and expressive labels only. This resulted in the failure to address spontaneous requesting, spontaneous commenting, and conversational skills. Therefore, a comprehensive approach to ABA for students with autism should include a consideration of verbal behavior skills and a range of communicative functions when developing instructional plans for skill acquisition.

usIng aBa to address ChallengIng BehavIors

Increased prevalence of challenging behaviors, such as stereotypy, tantrums, aggression, self-injury, and property destruction are common in students with ASD. As such, a founda- tional component of an instructional package is a positive, functional approach to addressing challenging behaviors.

Before any intervention plan is developed for challenging behaviors, a functional behav- ioral assessment should be completed in order to determine the antecedents and consequences that are evoking and/or reinforcing the challenging behavior. Intervention plans are then developed based on the function of the behavior. Chapter 4 provides a comprehensive descrip- tion of functional behavioral assessment and the development of behavioral interventions for students with ASD.

Family Involvement

As discussed in Chapter 3, family involvement is not only required by law (e.g., Individuals with Disabilities Education Improvement Act, 2004) but is also critical to student success. A key component to ABA programming is stakeholder participation in decision making. Specifically, skills that are to be taught within an ABA program must be “socially import- ant” (Schwartz & Baer, 1991). Thus, in order to determine the social importance of a partic- ular skill, family members should be consulted. Further, cultural differences and priorities of the family should also be considered. (See Box 5.2, Diversity Notes, for more suggestions.) Identifying and teaching skills that have social importance and are agreed upon by the fam- ily increases the likelihood that we are teaching skills that (a) the student needs to learn for his everyday life and (b) will be supported in the natural environment of the home and community.

Another component of family involvement that should be considered within a compre- hensive ABA program is family training. Although family members may not wish to be their child’s “therapist,” research supports that the more families understand and are able to carry out the various ABA strategies within the context of their daily routines, the more oppor- tunities their children have for learning specific skills (Lovaas, Koegel, Simmons, & Long, 1973). Early childhood professionals have long suggested that parents are their children’s first teachers (Sandall, Hemmeter, Smith, & McLean, 2005). For typically developing children, this teaching includes incidental strategies that are often not even considered true “teaching.” However, because children with ASD may require more direct and systematic instruction and may not learn skills just through exposure to them, teaching families to use specific, proven ABA strategies is a way of ensuring that when learning opportunities present themselves the child has the opportunity to be successful in that learning.

determining Intensity of Individual Instructional time

weekly IntensIty oF InterventIon The recommended intensity of intervention is an often debated topic. However, the research on intervention intensity should be used to deter- mine the amount of intervention that is recommended for students.

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The initial Lovaas (1987) study included a group of children who received low-intensity and high-intensity ABA. Low-intensity intervention was defined as approximately 10 hours per week while high-intensity intervention was defined as 40 hours per week. Results showed that children in the high-intensity group had significantly better outcomes in intellectual and adaptive functioning.

Eldevik, Jahr, Eikeseth, and Smith (2006) compared low-intensity ABA to a con- trol group. There was no high-intensity group in this study. The authors conducted a study wherein children with autism received low-intensity ABA therapy (approximately 12 hours per week) for 2 years. These participants achieved statistically significant gains when com- pared to a control group, but the gains were considerably lower than those found in studies of high-intensity ABA. Reed, Osborne, and Corness (2006) descriptively compared 9-month outcomes of a group of children who received a mean of 30 hours per week of ABA therapy to a group of children who received a mean of 12 hours of ABA therapy per week and found that the high-intensity group achieved significantly greater gains. Smith, Groen, and Wynn (2000) evaluated the effects of 25 hours per week of ABA therapy for 2 years. Results indicated that the ABA group achieved gains that were statistically significant when compared to a control group but that were considerably lower than those produced by studies of higher-intensity ABA (e.g., 30 to 40 hours per week). Taken together, the four studies summarized above appear to indicate that 1:1 intervention at less than 25 hours per week is not likely to result in as many developmental gains. On the other hand, optimal outcomes are associated with ABA instruction that is provided at higher weekly intensities.

It is often difficult for classroom teachers to provide instruction at such intensive lev- els. Rarely do classrooms have a 1:1 ratio of staff to students to support high-intensity levels. Therefore, teachers must develop creative ways to deliver instruction as intensively as possible.

Box 5.2 dIversIty notes

In one of the few studies available examining the impact of culture on application of the principles of ABA for students with autism, Wang and colleagues (2007) examined the role of cross-cultural competence in using positive behavior supports (PBS) to change the chal- lenging behavior of a 14-year-old Chinese-American girl with autism. The authors define “cross-cultural competence” as “ ‘the ability to think, feel, and act in ways that acknowl- edge, respect, and build upon ethnic, socio-cultural, and linguistic diversity’ ” (Lynch & Hanson, 1993, p. 50, as cited in Wang, McCart, & Turnbull, 2007, p. 38). The researchers provide tips for professionals working with culturally diverse families when implementing PBS to change a challenging behavior at each of three stages in the process. In the first stage, the planning stage, the researchers suggest that professionals should reflect on their own cul- tural values and beliefs and learn the families’ expectations, their perceptions on the disabil- ity, their discipline practices, and their nonverbal communication style. In the second stage, during the conducting of a functional behavioral assessment and development of the behavior intervention plan, they suggest taking time to build trust and rapport with the family using a mediator (e.g., a family friend) to help build this trust, identify natural supports within the family and/or community, communicate honestly, clear up misunderstandings and disagree- ments, and recognize that families can take time to make decisions. Finally, in the third stage, during implementation of the intervention, the researchers suggest that professionals listen to the opinions of the family regarding the efficacy of the intervention strategies, respond to the family’s questions and concerns, help the family establish goals, and recognize that “develop- ment of cultural reciprocity requires time and persistence” (p. 48). Results of their study in which cross-cultural competence was utilized found that the young lady’s behavior improved and was maintained over time.

Source: Information from Wang, M., McCart, A., & Turnbull, A.P. (2007). Implementing positive behav- ior support with Chinese American families: Enhancing cultural competence. Journal of Positive Behavior Interventions, 9(1), 38–51.

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Teachers can improve the intensity of services through classroom structure, student grouping procedures, and incidental teaching procedures.

When setting up classrooms, teachers should structure the daily schedule so that each student has the opportunity for one-to-one instruction as much as possible each day. The instructional day should include little or no down time. Students with autism are more likely to engage in stereotypical behaviors (e.g., non-learning behaviors) during down time. Teachers should arrange classroom schedules with minimal transitions. Transitions are often difficult for students with autism. Moreover, tantrums are most often associated with transition activ- ities. As such, decreasing the number of transitions will result in fewer challenging behaviors and increased time for student learning. Finally, teachers should develop lesson plans that result in as many learning trials as possible each day. Learning trials should be comprised of a variety of types of learning, including 1:1, small group, large-group choral responding, and natural environment training.

Teachers can utilize effective grouping to increase 1:1 instructional opportunities. One- to-one instruction with a student can take place while the other students are being taught in small groups or working on independent activities. Students with similar Individualized Edu- cation Program objectives can be grouped together in groups of two or three at the same table using the same or similar materials. In this situation, the teacher delivers DTT to one student while the others are working on an independent task or engaged with a reinforcing activity. At the end of the trial, the teacher then moves to the next student until each student has received 1:1 instructional trials.

Finally, teachers may use incidental teaching strategies, as discussed previously, to pro- vide increased opportunities for 1:1 instruction. Incidental teaching trials can be delivered in the lunch line, in the restroom, on the playground, during hallway transitions, and during centers or free-play activities. Incidental teaching trials should be delivered in different ways as opposed to identical instructional delivery. Students may predict the instructional situation rather than learn how to exhibit the behavior under different contexts.

duratIon oF InterventIon The total duration of intervention (i.e., in years, months) required to produce optimal gains for students with autism is also commonly debated. How- ever, several research studies suggest that intensive intervention for 2 or more years is likely needed to produce optimal results. Howard, Sparkman, Cohen, Green, and Stanislaw (2005) compared 14 months of intensive ABA therapy to eclectic therapy of the same duration for young children with autism. Results showed that the ABA group made statistically signifi- cant gains when compared to the control group. However, the gains were less than those in studies that evaluated intensive ABA for 2 or more years (e.g., Cohen et al., 2006; Lovaas, 1987; Sallows & Graupner, 2005). Similarly, Eikeseth, Smith, Jahr, and Eldevik (2002) evaluated the effects of intensive ABA therapy for 1 year and found significant results, but still lower than those in studies evaluating longer-term ABA therapy. Reed, Osborne, and Corness (2006) found that 9 months of intensive ABA produced significant gains but lesser gains than studies evaluating long-term ABA. Finally, Sheinkopf and Siegel (1998) evalu- ated ABA therapy that was both lower in intensity (approximately 20 hours per week) and shorter in duration (approximately 15 months) and found that children again achieved sta- tistically significant gains in IQ when compared to controls, but that the gains were smaller than those found in studies that implemented ABA for 2 or more years. These four studies, particularly when contrasted with the existing studies on longer-term ABA therapy, provide evidence that ABA therapy for children with autism should be provided for 2 or more years, if optimal outcomes are desired. Given that most students with autism enter school settings at ages 3 through 5 and remain there until at least age 18, teachers should be able to provide long-term intervention for their students on the autism spectrum.

Given the significant volume of research on the outcome of intensive ABA inter- vention for students with autism, it seems clear that ABA is the methodology of choice for teaching students from this population. Additionally, all research cited above was pub- lished in peer-reviewed scientific journals, thus meeting the requirement under IDEA of

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2004. Furthermore, it should be noted that there is not a single controlled study published in a peer-reviewed journal that demonstrates robust intervention effects in students with autism without the use of ABA therapy. Finally, studies that have evaluated ABA therapy of short duration and/or of low intensity indicate that optimal outcomes are not produced. In order for students with autism to achieve maximal intervention effects, multiple studies have demonstrated that ABA should be provided for more than 25 hours per week and for a minimum duration of 2 years.

summary

Many peer-reviewed research studies have concluded that an intervention approach using the principles of ABA yield sig- nificant results for students with autism. Given the fact that both the No Child Left Behind Act (2001) and the Individ- uals with Disabilities Education Improvement Act (2004) require that teachers use research-based practices, the use of

ABA strategies in teaching students with autism is an essen- tial component of any comprehensive program for these stu- dents. Teachers are encouraged to seek advanced training in the use of ABA strategies and to remain current on the research in the field in order to best serve their students on the autism spectrum.

Chapter revIew questIons

1. Describe and give an example of discrete trial training for a student with autism. (Objective 1)

2. Describe and give an example of errorless teaching for a student with autism. (Objective 2)

3. Describe and give an example of error correction for a student with autism. (Objective 3)

4. Describe and give an example of both generalization and maintenance for a student with autism. (Objective 4)

5. Describe and give an example of incidental teaching for a student with autism. (Objective 5)

key terms

Applied behavior analysis (ABA) 80 Chaining 88 Discrete trial training (DTT) 82 Discriminative stimulus 82 Error correction 86 Generalization 85

Incidental teaching 90 Instructional control 83 Intraverbal 91 Maintenance 85 Mand 91 Milieu teaching 90

Modeling 88 Principles of Behavior 80 Shaping 87 Tact 91 Verbal Behavior 90

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96

Case of audrey Audrey is a 4-year-old girl with autism. She does not use verbal language to have her needs met. Audrey utilizes a picture exchange communication system to request a preferred item or activity. She will not walk across a room to request an item, instead she will climb, reach, or open compart- ments to get what she desires. Audrey spends most of her day actively avoiding social-communication interactions. She prefers to engage in individual activities like jumping, spinning, swinging, and looking at books. Audrey’s assessment of social-communication skills indicates that she rarely engages in joint attention experiences, uses little eye contact, and primarily uses communication to have wants or needs met. Audrey engages in few parallel play interactions with her peers. She is beginning to follow one-step directions and indicate an understanding of the back- and-forth nature of communication during structured activities.

Case of Tyler Tyler is a 35-year-old man with autism. He works at the local library as part of a work program with his independent living community. Tyler rides the bus to work and home. His job is to repair damaged items, place scanning stickers on new books, and to shelve returned items. Tyler often stops patrons and tells them about the book he is shelving, the author’s last name, and the genre (mystery, etc.). He has difficulty changing topic within a conversation, and often, interactions are ended by the other party abruptly. The most recent assessment of Tyler’s social- communication skills indicates that he needs instruction in several areas of communication. Although Tyler uses verbal communication, he often uses the wrong tense and/or incorrect word order in sentences. He clearly demonstrates an understanding of the back-and-forth of communication, but does not appear to be aware of or read other’s body language. Tyler is a very literal thinker.

Case of Graham Graham is a 9-year-old boy with autism. As a third grader, he spends most of his day in the general education classroom. With adult support, he uses an augmentative device to engage in classroom interactions.

Case sTudy Examples

After reading this chapter, learners should be able to: 1. Describe typical early

language development. 2. Discuss the communication

differences of children with autism.

3. List and describe the verbal operants.

4. Discuss the major research contributions to the understanding of communication intervention for students with autism.

5. List and describe some of the research-based interventions for communication intervention for students with autism.

Chapter Objectives

Christina Carnahan, Ph.d. University of Cincinnati

Clare Chung Lake Travis Independent School District

amy harbison Vanderbilt University

amarie Carnett Victoria University of Wellington

teaching students with Autism to communicate

ChaPTer 6

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Graham uses his “talker” to answer questions in class, ask questions to his teacher and peers, and to comment on class activities. He usually plays by himself at recess and occa- sionally plays games with other peers during small group time. Graham sometimes com- ments inappropriately within the classroom, saying things like “big nose” to a girl at his table. Graham’s assessment of social-communication skills indicates that he understands the reciprocal nature of communication and is beginning to engage in interactive play activities. Graham does not use spoken language. He often uses incorrect word order and word endings when using his augmentative device. Graham does not follow eye gaze of peers in communication exchanges and does not appear to utilize context cues to assist in topic maintenance.

IntroduCtIon

Autism Spectrum Disorders (ASDs) are neurological disorders characterized by differences in social communication. Verbal and nonverbal social communication patterns represent key features of autism (Attwood, 1998; Chiang, Soong, Lin, & Rogers, 2008; Noens & van Berckelaer-Onnes, 2005; Tager-Flusberg, 1999). At the base of the variations in nonverbal and verbal social communication are differences in communicative intent and joint attention (Baranek, 1999; Baron-Cohen et al., 1996; Leekam & Moore, 2001; Lord, 1995; McArthur & Adamson, 1996; Mundy & Burnette, 2005; Mundy, Sigman, & Kasari, 1990; Noens & van Berckelaer-Onnes, 2004; Quill, 2000; Robins, Fein, Barton, & Green, 2001; Sigman & Ruskin, 1999; Stone, Ousley, Yodar, Hogan, & Hepburn, 1997; Werner & Dawson, 2005; Wetherby, Watt, Morgan, & Shunway, 2007). From a very early age, students with autism exhibit differences in their interactions with others (Charman, 2004; Dawson et al., 2004; DiLavore & Lord, 2005; Leekam & Ramsden, 2006; Leekam, Lopez, & Moore, 2000; Naber et al., 2008; Osterling, Dawson, & Munson, 2002; Rutherford & Rogers, 2003; Sullivan et al., 2007; Toth, Munson, Meltzoff, & Dawson, 2006). These differences influence the development of important communicative behaviors needed at home, school, and in the community. For a comprehensive discussion of communication development in typically developing children, please visit the American Speech and Hearing Association at http://www.asha.org/public/ speech/development/chart.htm.

What Is soCIal CommunICatIon and Why Is It Important?

The essence of communication is the ability to use symbols (i.e., spoken words, nonverbal ges- tures) and to convey to or receive a feeling or idea from another person (Paul, 2005). Messages are conveyed in countless ways, such as speech, sign language, written words, facial expres- sions, gestures, Braille, signs or symbols, and body movement. Hulit and Howard (2006) note that “communication is so much a part of the human experience that we are constantly sending and receiving messages” (p. 3). Prizant and Wetherby (2005) describe social communication as the use of “conventional and socially appropriate verbal and nonverbal means to communicate for a variety of purposes across social settings and partners” (p. 925). Social communication requires some level of understanding of social settings and events and the ability to continu- ally monitor and engage in exchanges with others. Communication consists of several compo- nents, making it a complex skill to learn. These components include joint attention, symbol use and communicative intent, and language (see Figure 6.1).

Below are a few important points related to social communication and autism:

1. Social-communication impairments often lead to a variety of challenging behaviors. Addressing the social-communication needs of students with ASD is an important com- ponent of promoting positive behavior (Lord et al., 2005).

2. Even if an individual with ASD has verbal language, he will continue to need instruc- tion in the pragmatic aspects of communication.

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Joint attention

Language Symbol use and intention

FIgure 6.1 Components of Communication

Box 6.1 dIversIty note

Communication norms differ across cultures. We must attend to differences between cultures and of the cultures in which the students in our classroom are involved. Communication norms vary in several ways: direct versus indirect language, formal versus informal communication, expressive versus neutral, low context versus high context, and contact versus no contact. For more information or specific examples on variances across cultures, see Communicating with Diverse Cultures, a workshop sponsored by the Diversity Committee of the Michigan College Personnel Association.

Students with high-functioning autism are known to have social-communication issues and issues with generalization. These students must receive explicit instruction in appropriate interactions including how to interact in accordance to cultural norms. For example, if a child with Asperger’s Syndrome were placed in a classroom with a teacher from outside the stu- dent’s cultural experience, both the student and the teacher would need explicit instruction in how to interact. The student will likely be unable to differentiate the cultural difference between himself and the teacher, therefore resulting in an increased need for specific and explicit instruction in the differing rules of communicative exchange. The modification of an already taught system of appropriate communication with the dominant culture is required in order for the student to respond to the norms of differing cultures.

3. Social-communication skills are imperative for community participation, increased independence, relationship development, and so on. Thus, intensive instruction related to social-communication skills is crucial for students with autism. The sections below highlight key differences in the language development of children with ASD. These differences provide a foundation for ongoing assessment and instruction.

Joint attention

Joint attention is an important component of communication. The term joint attention refers to not only the ability to engage in an experience with someone else but also the knowledge of and active participation in the experience. Quill (2000) defines joint attention as the “coor- dination of attention among oneself, social partners, and an object” (p. 8). Joint attention implies active, shared experience.

Babies develop joint attention in the first year of life. Caregivers help babies move from self-centered attention to engage in interactions with others. Through these interactions that occur during the first few months, babies come to recognize objects and people separate from themselves; they begin to understand the very social nature of interacting. Joint attention development is the foundation of the many social-communication skills that will develop

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through childhood. Joint attention interactions not only teach children specific skills (i.e., communication involves two people engaging in reciprocal interactions) but also make the child available for learning other important social-communication concepts (Charman, 2004; Dawson et al., 2004; Happe, 1998; McDuffie, Yoder, & Stone, 2005; Sigman & Ruskin, 1999; Smith, Mirenda, & Zaidman-Zait, 2007; Toth et al., 2006).

Owens (2005, pp. 173–174) describes four phases in the development of joint atten- tion. These phases occur between birth and 12 months for children with normal language development. In phase one (4 weeks to 6 months), babies learn to look toward objects and recognize when their attention is being called to another object (other than the child him- self). During phase two, around 7 to 8 months, children begin to make efforts to communi- cate independently. These initial communicative bids involve the child reaching with an open hand to indicate an object of interest. Over time, the reaching becomes a point and eventually the child begins moving toward and reaching for the objects. Between 8 and 12 months, chil- dren enter phase three of joint attention development. They now use all available resources to obtain objects of interest or the attention of a parent by combining gestures and vocalizations. By the time a child is around one year, he begins to pair single words with eye gaze and/or a gesture to draw attention to objects or to obtain an object/action of interest.

Hulit and Howard (2006) suggest the construction of conversation as one additional type of joint attention. Through the give and take of conversation, children learn the back- and-forth routines and dialogues that exist in everyday communication. They begin to under- stand nuances of conversation such as the type of communication dialogue appropriate for different settings. Similar to the first three phases of joint attention, this advanced skill clearly influences the child’s involvement and skill development in other areas during early social-communication exchanges.

Adamson, Bakeman, Deckner, and Romski (2008) made an important distinction between two different joint attention (or joint engagement) experiences. They categorized joint attention into supported and coordinated joint attention. The distinction between the two is the ability of the child to not only attend to the shared topic (supported joint attention) but also attend to the partner (coordinated joint attention). In their study of joint attention, they found that “children with autism rarely coordinated attention to a shared object and a partner, a defi- cit that was no less marked in children who had acquired relatively large vocabularies” (p. 91).

To illustrate the development of joint attention, let us consider Philip, a child with typical language development. As a young child, his parents buy him a new stuffed giraffe. As they play with him, Philip’s parents hold the giraffe where he can see it saying, “Look, giraffe” while looking at him and back to the giraffe. By the time he is 6 months old, Philip recognizes the change in pitch of his parents’ voice indicates a shift in attention; his parents are drawing his attention to an object. Philip responds to the change in pitch by looking at the giraffe and smiling back at his mother or father. As he gets a little older, Philip reaches toward his giraffe and looks toward his mother or father in the hopes of playing. He eventually adds a vocaliza- tion to his point and eye gaze. “Uh-uh-ooh,” he says. As his first birthday approaches, Philip begins using word approximation to indicate his interest in an object other than himself. He no longer says, “uh-uh-ooh” as he reaches for the giraffe. Instead, as he points to the stuffed giraffe, he says “Raffe” while glancing repeatedly between his mother and the toy. When his mother picks up the toy while teasing Philip, he falls to the floor in a heap of giggles.

Two types of joint attention support the development of verbal and nonverbal commu- nication skills. The first, response to joint attention (RJA), involves an individual’s ability to respond to initiations from others. Philip demonstrated RJA as he responded with a smile and a glance to the giraffe and his mom as she engaged him with the toy giraffe. The second, initiating joint attention (IJA) interactions, involves initiating joint attention interactions with a communication partner (Bruinsma, Koegel, & Koegel, 2004; Jones & Carr, 2004). In our example above, Philip demonstrates IJA as he points to the giraffe, comments, “Raffe,” and looks between his mother and the toy. Children use protodeclarative initiations to share or engage in social interactions. Protoimperative initiations allow children to direct the behavior (i.e., to obtain an object) of others.

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Active engagement in joint attention experiences contributes to and is crucial for social-cognitive development (Mundy & Newell, 2007). The importance of the progression is multifaceted. Joint attention is crucial for language development. It signals a child’s under- standing of the social nature of communication. Through joint attention, the child is begin- ning to understand communication as a back and forth process between two individuals. As a child engages in joint attention interactions, he learns his role in directing the attention of others. Over time, he comes to understand that he not only can direct the attention of others but others can also direct his attention. Thus, the child begins to understand communicative intent in others (Bruinsma et al., 2004).

symbol use and Communicative Intent

Through experience, a child comes to understand that the intent of others is different from his own. The term communicative intent refers to the notion that a speaker has an intended outcome in sharing a message with others (Adams, 2002). Symbols are the means by which we convey our communicative messages. Symbols include spoken words, pictures, and nonverbal gestures such as pointing. The power of a symbol is not in the symbol itself but rather in the ability of the speaker to use the symbol to convey a message to another person. Augmentative communication tools make it possible for children with limited functional communication to convey their message and engage in social interactions with others. An important point is that augmentative communication devices are not only for students who do not use verbal com- munication. These systems support any individual who does not yet have a functional means by which to communicate with others. For more information on this topic, see Chapter 11 on assistive technology.

In the previous sections, we discussed the stages and importance of joint attention in communication development. Around the first year, young children begin to use important symbols to demonstrate communicative intent. These symbols include pointing, eye gaze, and verbal approximations. Symbol use and communicative intent are intertwined in that the emergence of symbol use for social purposes indicates a developing understanding of commu- nicative intent.

Bates, Camaioni, and Volterra (1975), building on the work of Austin (1962) and Searle (1969), discussed the stages of communication intention in children. Communicative intent is described as a three-stage process. The development of communicative intent takes a child from using reflexive cries to complex communication to get his wants and needs met and engaging in a social exchange regarding a topic of interest. As we saw in an earlier illustration, the development of joint attention interplays with the development of communicative intent between birth and 12 months. As a child’s experiences grow and social awareness develops, he learns that communication occurs for a multitude of purposes. Through joint attention, a child engages with others who model the many different purposes of communication.

Bates et al. (1983) described the first stage of intention development, the perlocutionary stage, as a time during which a child moves from the use of reflexive cries to an increased understanding of the function of common objects. Without an understanding of the function of common objects, it is difficult to request those objects (Bates, Bretherton, Shore, & McNew, 1983). In the second stage of intention development, the illocutionary stage, a child begins to use gestures to signal intentionality. Children begin using gestures both to engage other individuals in an activity of interest (protodeclarative intent) and to have needs and wants met (protoimperative intent). The final stage, the locutionary stage, takes a child from the point of gesture use to the initial use of single words to communicate intent.

It is generally accepted that communicative function is seen in children before the use of verbal words (Bruner, 1981; Halliday, 1975). The number of functions identified by each researcher and every language development book differs, although common among most are the abilities to control the behavior of others, expression of emotions, satisfactions of needs or wants, sharing knowledge, and gaining attention.

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Let us once again consider Philip. Development of communicative intent starts with Philip’s use of reflexive cries when he is hungry. Eventually, Philip understands that the func- tion of the bottle is to give him milk. As Philip continues to develop, he reaches out to indi- cate hunger and request the bottle. Eventually, Philip’s reach becomes a point paired with a single word or approximation, “ba-ba,” indicating his desire for the bottle. Similar to request- ing, Philip develops the ability to demonstrate refusal. As a very young infant, he may cry when in distress or when presented with something he does not enjoy. Eventually, Philip turns his face and pushes the item away with his hands. By the third stage of development, Philip says “no” while vigorously shaking his head from left to right to indicate refusal.

Though it will be addressed in detail later in the chapter, at this point it is important to note the dissonance in the development of joint attention and communicative intent in children with ASD. Children with ASD demonstrate a difference in the function of their inter- actions with others. Specifically, research suggests that individuals with ASD are more likely to engage in protoimperative than protodeclarative interactions. These differences correlate with the differences in development in joint attention. Disordered joint attention impedes the understanding of the social nature of communication (Adamson et al., 2008). If a child does not understand the social function of communication (i.e., communication to share an inter- est), his communicative interactions will continue to focus on personal needs/desires. Table 6.1 provides an overview of communication development in young children.

taBle 6.1 language development

aGe CommuniCaTive skill

birth to 3 months • demonstrates recognition of familiar voices by turning head, quieting, or smiling (sharp & hillenbrand, 2008; vukelich, christie, & enz, 2008)

• Attends to faces (centers for disease control and prevention [cdc], 2013) • produces cooing sounds (sharp & hillenbrand, 2008)

4 months to 6 months

• Observes and imitates caregivers’ mouth movements and facial expressions (cdc, 2013; sharp & hillenbrand, 2008; vukelich, christie, & enz, 2008)

• cries in different ways to express different needs (cdc, 2013; sharp & hillenbrand, 2008) • begins producing vowel sounds (sharp & hillenbrand, 2008) • makes babbling sounds, using alternation of consonant and vowel sounds (e.g.,

mamamamama) and uses expression when babbling (cdc, 2013; sharp & hillenbrand, 2008)

6 months to 12 months

• points at things using fingers (cdc, 2013) • responds to own name (cdc, 2013; vukelich, christie, & enz, 2008) • takes turns with adults in making sounds (cdc, 2013) • makes sounds that express happiness and sadness (cdc, 2013) • demonstrates understanding of “no” (cdc, 2013)

12 months to 18 months

• uses some gestures, such as waving goodbye (cdc, 2013) • responds to joint attention: shows ability to follow a point and the object of an adult’s gaze

(behne, Liszkowski, carpenter, & tomasello, 2012; carnahan, 2011; Locke, 1996) • speaks first word (conti-ramsden & durkin, 2012) • has some echolalic speech (vukelich, christie, & enz, 2008) • makes sounds other than crying to obtain and maintain attention (sharp & hillenbrand, 2008)

18 months to 24 months

• Follows simple commands (sharp & hillenbrand, 2008; vukelich, christie, & enz, 2008) • uses a minimum of 10 words, mostly nouns, in expressive vocabulary (sharp & hillenbrand,

2008; vukelich, christie, & enz, 2008) • makes a variety of consonant sounds to begin words (sharp & hillenbrand, 2008) • demonstrates a steady increase in vocabulary (sharp & hillenbrand, 2008) • mean length of utterance (mLu) of 2 morphemes (schachter, shore, hodapp, chalfin, &

bundy, 1978)

(Continued)

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language

Communication is often confused or used synonymously with language. Language, one com- ponent of communication, is a rule-governed system of abstract symbols. The components of language include syntax, semantics, and pragmatics.

Syntax refers to the structure of language. Children begin to develop syntax when they combine two or more words together in utterances. When one-word utterances are used, there are structural rules to follow. It is when words are combined that rules apply. For example, in the English language, the subject precedes the action (e.g., I run). The knowledge of semantics requires the use of the parts of language and words that influence meaning. While vocabulary is the basis of meaning, in order to move beyond the use of one-word utterances, a child must start to understand the additional components of words and language. Bound morphemes occur at the beginning and end of words to influence meaning. For example, the addition of an “s” to the end of a word changes the meaning from singular to plural (e.g., “cat” and “cats”). Complex language skills require an under- standing of syntactical rules such as the influence of bound morphemes. The semantics of language include the ways in which words change to incorporate quantity (plural vs. singular), temporal information (verb tense), and state (prefixes such as “un,” “non”) as well as other properties.

taBle 6.1 (Continued)

aGe CommuniCaTive skill

2 years • demonstrates receptive identification of a few body parts (sharp & hillenbrand, 2008; vukelich, christie, & enz, 2008)

• Follows instructions with two steps (cdc, 2013) • uses at least 50 words in expressive vocabulary (sharp & hillenbrand, 2008) • combines two words to make phrases (sharp & hillenbrand, 2008) • begins to talk about the future (Atance & O’neill, 2005) • uses a few pronouns (vukelich, christie, & enz, 2008) • uses two or more prepositions (vukelich, christie, & enz, 2008) • speaks in a way caregivers can usually understand (sharp & hillenbrand, 2008) • mLu of 3.2 morphemes (rice et al., 2010)

3 years • speaks in a way unfamiliar listeners can usually understand (sharp & hillenbrand, 2008) • Forms longer sentences with four words or more (sharp & hillenbrand, 2008) • names most objects in the environment (cdc, 2013; sharp & hillenbrand, 2008) • expresses own first name, gender, and age (cdc, 2013) • uses some plural words (e.g., cars, dogs) (cdc, 2013) • holds a conversation with two to three sentences (cdc, 2013) • mLu of 4 morphemes (rice et al., 2010)

4 years • uses a clear-sounding voice (sharp & hillenbrand, 2008) • demonstrates understanding of metaphors (vosniadou, 1987) • tells stories that stay on a topic (cdc, 2013; sharp & hillenbrand, 2008) • says first and last name when asked (cdc, 2013) • Follows basic grammar rules used by family (cdc, 2013; sharp & hillenbrand, 2008) • mLu of 4.7 morphemes (rice et al., 2010)

5 years • tells stories using full sentences (cdc, 2013) • can say own full name and address (cdc, 2013) • uses future tense and simple units of time (e.g., tomorrow, yesterday, night, morning) (cdc,

2013; vukelich, christie, & enz, 2008) • identifies common opposite words (e.g., hard/soft, big/little) (vukelich, christie, & enz, 2008) • mLu of 4.9 morphemes (rice et al., 2010)

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CommunICatIon CharaCterIstICs oF learners WIth autIsm

When discussing learners with autism, it is often cited that communication delays are the largest obstacle they must overcome in order to be successful in their everyday lives. The American Psychiatric Association (2000) defines Autism Spectrum Disorder as delayed or abnormal functioning in at least one or more of the following areas: social interactions, language, and/or play. These delays are present before age 3. So while it is known that children with autism have delays in communication, it is difficult to actually describe the characteristics of their language because each child is so unique. What can be discussed, though, are the parts of the brain responsible for language production that are typically damaged in children with autism and how that can affect their communication. There are specific communication deficits that can be observed in many individuals with ASD.

Research has found that children with autism often have enlarged areas of the brain and unusual brain activity (Whitman, 2004). Two areas of the brain often found to be enlarged are the frontal and temporal lobes. These areas are largely responsible for the development and production of language. The Broca’s area, which is located in the frontal lobe of the brain, is responsible for putting together words syntactically and grammatically to create expressive language (Sprenger, 2008). People who experience damage in the Broca’s area can typically understand language, but are unable to express it effectively (Sylwester, 2005). The Wernicke’s area is the part of the brain where receptive language is processed (Allman, 2000). People with damage in this area often have comprehension and word-finding difficulties (Sylwester, 2005). While the Broca and Wernicke areas are in two separate parts of the brain, they are constantly working together as language is being processed in a typically developing brain (Allman, 2000). In a child with autism though, the Broca and Wernicke areas often do not work together for reasons not fully understood yet.

There are communication deficits tied to other parts of the brain that are typically affected in a child with autism. The first is executive functioning. Whitman (2004) described executive functioning as the ability for the brain to plan, solve problem, regulate impulses, and recall information from the working memory. Executive functioning is thought to be carried out in the frontal lobe of the brain, although many other areas might contribute (Whitman, 2004). When a child with autism has deficits in executive functioning, they might experience impulsivity, lack of spontaneity, and limited pretend play (Whitman, 2004). Another area often affected in learners with autism is the concept called theory of mind. In short, theory of mind is the abil- ity to understand that other people have thoughts, feelings, and beliefs that are different from one’s own (Whitman, 2004). It is often said that children with autism have “mind blindness.” This is the inability to perceive other people’s thoughts and feelings (Whitman, 2004). Due to this, children who have a deficient theory of mind often lack empathy, the ability to understand others, and the ability to read or interpret other people’s feelings (Whitman, 2004). This makes social-communication difficult for a child with autism.

While the degree to which a specific person with autism is affected can vary dramatically, several deficits in language are commonly observed in individuals with ASD. Up to 50% of people who have autism do not ever acquire functional speech (Noens & van Berckelaer- Onnes, 2005). In the group of people with autism who do use speech in a functional manner, other atypical characteristics are often apparent. A person who has ASD may have echolalic speech (Boutot & Tincani, 2009). A person with ASD may perseverate on a specific topic of conversation (Arora, 2012) or may demonstrate deficits in other conversational skills, such as initiating conversation, asking questions, sharing information, or elaborating on a topic. Often, a person with ASD will largely utilize and comprehend only concrete or literal language; others’ use of abstract language, humor, metaphor, or sarcasm can lead to misunderstanding for an individual who has ASD (Melogno, D’Ardia, Pinto, & Levi, 2012). An individual’s language may tend to be pedantic, with atypical prosody or other unusual vocal qualities (Brown & Poulson, 2009). Some individuals with ASD demonstrate excellent use of syntax and grammar, while others may struggle with grammar, including the reversal of pronouns (Boutot & Tincani, 2009).

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Though some children with ASD demonstrate relatively intact understanding of the grammatical rules of language, there are differences in some areas. Two examples include the acquisition of certain vocabulary forms and the use of morphemes to indicate temporal rela- tionships. First, students with ASD often demonstrate a greater capacity for learning nouns (i.e., runner) over verbs (i.e., running). Additionally, individuals with ASD appear to have difficulty using bound morphemes (i.e., play vs. played, work vs. worked) to mark past tense.

In addition to knowledge of syntax and semantics, pragmatics plays a critical role in expressive and receptive language. Pragmatics is the ability to integrate meaningful infor- mation from a context or setting to inform language comprehension and use. Components of pragmatics include communicative intent, responsiveness and initiation, repairs and turn taking, cohesion, topic, and coherence (Adams, 2002).

For young children, understanding an object’s real-world function influences compre- hension. However, as children develop, they utilize context clues to inform comprehension rather than relying on knowledge of object use (Loukusa et al., 2007; Tager-Flusberg, Paul, & Lord, 2005; Volden, Coolican, Garon, White, & Bryson, 2009). For example, if a child hears the statement, “the baby gives daddy a bottle,” an understanding of how these objects work in the real world would influence his interpretation. He may presume that the speaker intended to say, “daddy gives the baby a bottle.” However, as the child matures, she is more inclined to integrate contextually relevant information to inform his interpretation.

While children with typically developing language learn the syntax, semantics, and pragmatics of a language by overhearing and engaging in communication exchanges, the devel- opment of the different aspects of language is often impaired in individuals with ASD. While syntax and semantics may be relative strengths in the face of pragmatics for some individuals with ASD, these are still areas of concern and need attention (Bara, Bosco, & Bucciarelli, 1999; Eigsti, Bennetto, & Dadlani, 2007; Geurts & Embrechts, 2008; Kjelgaard & Tager-Flusberg, 2001; Lord & Paul, 1997; Rapin & Dunn, 2003).

Children with global language delays experience differences in all three areas of language. Pragmatics often becomes the focus of intervention since it is often more clearly identified and appears to have the largest social impact on a child’s interaction. It is important to understand that impaired semantic and/or syntactic understanding can also cause social isolation for individuals with ASD, especially those on the higher functioning end of the spectrum. Incorrect use of syntax or semantics can make communication less f luent and distracting to the communication partner, and significantly impair the ability to gain information. If a child does not understand the use of some morphemes, his ability to gain or understand information presented by a communication partner will be impaired, resulting in a communication breakdown. Volden et al. (2009) note that both structural language and pragmatics play a role in everyday communicative functioning but do not indicate how well a child will navigate social interactions. It is important then to consider the addition of targets in all areas of language for children with ASD rather than to focus on only the pragmatic aspects of language development.

Further discussion of social-Communication skills in Children with asd

Approximately 33% to 50% of children with autism do not develop functional speech (Noens & van Berckelaer-Onnes, 2005). While the others do develop speech, both groups demonstrate impairments with the pragmatic aspects of language (Mundy & Markus, 1997; Rapin & Dunn, 2003). Research suggests that these differences correlate with the cognitive processing style and joint attention deficits described earlier (Hale & Tager-Flusberg, 2005; Mundy, 2003; Quill, 2000). For example, people with autism may attend to specific words or phrases without regard for the situation or context that influences meaning (Noens & van Berckelaer- Onnes, 2004). As a result, their verbal skills often overshadow their comprehension abilities. A person with autism may have a large vocabulary, but not understand simple comments or directions from others (Lord & Rhea, 1997). Similarly, a person may also have strong word

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decoding skills, but struggle with reading comprehension (Attwood, 1998). Other challenges include a propensity toward literal/factual thinking (Noens & van Berckelaer-Onnes, 2004). For example, a student with ASD, when told to put his eyes on the speaker, may actually walk to the teacher, leaning in an attempt to place his eye on the other person. The following paragraphs provide an overview of common social-communication features in ASD.

Engagement and experience are the basis for learning and development (Twachtman- Cullen, 2008) Young children with autism demonstrate qualitative differences in engagement and interactions with both the individuals in their environment and the environment itself. For these children, there is somewhat of a viscous cycle in that the behavioral manifestations (i.e., lacking motivation to engage in joint attention interactions) of the disorder decrease availability for engagement. Differences in quantity and quality of interactions lead to decreases in social experiences, thereby influencing social-cognitive development (Mundy & Burnette, 2005). That is, it is not that individuals with ASD never engage in joint attention interactions (Franco & Wishart, 1995; Kasari, Freeman, Mundy, & Sigman, 1995; Legerstee & Weintraub, 1997; Sigman & Ruskin, 1999), but that the form (i.e., style) and function (i.e., purpose) of the interactions are different (Adamson et al., 2008).

Children with ASD tend to experience the most difficulty initiating joint attention (Jones & Carr, 2004). When children with ASD do initiate joint attention interactions, they are more likely to engage in protoimperative initiations (i.e., make a request) than proto- declarative initiations (Murray et al., 2008; Chawarska & Volkmar, 2005). They may not point to objects or use eye gaze to engage others for social purposes. Instead, individuals with ASD may use interactions such as hand pulling to indicate a desire. The form (i.e., symbol used to convey the message) of the interaction differs in that the child is using a hand pull rather than a point. The function (i.e., message) is different in that the child uses the interaction to make a request or indicate a desire, rather than to share a social experience (Calloway, Smith-Myles, & Earles, 1999; Carter, Davis, Klin, & Volkmar, 2005; Toth et al., 2006).

Joint attention interactions provide children with opportunities to develop a variety of lan- guage and social skills (Toth et al., 2006). Examples of such skills include vocabulary building, receptive language development, pragmatic skills, emotional regulation, and pretend play (Jones & Carr, 2004; Morales, Mundy, Crowson, Neal, & Delgado, 2005; Markus, Mundy, Morales, Delgado, & Yale, 2000). Given the importance of joint attention for typically developing young children, the differences exhibited by children with ASD most certainly influence the develop- ment of social-communication behaviors including communicative intent and pragmatic lan- guage use (Bruinsma et al., 2004; Charman, 2004; Dawson et al., 2004; Happe, 1998; McDuffie et al., 2005; Murray et al., 2008; Sigman & Ruskin, 1999; Smith et al., 2007; Toth et al., 2006).

It is difficult to separate the effects of differences in joint attention, symbol use, and communicative intent on the communicative behavior of young children. These characteris- tics manifest in the number and type of interactions exhibited by children on the spectrum. Namely, differences in eye gaze or eye contact, types of symbols used, and the purpose (i.e., social vs. directive) of communicative interactions are defining features of symbol use and communicative intent in individuals with ASD (Bruinsma et al., 2004).

CommunICatIon assessment and InterventIon

Our primary role as interventionists is to support the development of social communication for meaningful, functional purposes in the children we serve (Adams, 2002; Ogletree, Oren, & Fischer, 2007; Prizant & Wetherby, 2005). Though it is important to understand the characteristics or defining features of ASD, understanding the unique interests, strengths, and behavioral manifestations of our students is also important. Boxes 6.2–6.4 provide an overview of areas for social-communication assessment in ASD. These differences warrant assessment and, based on data analysis, intervention for individuals on the spectrum. In the following sections, we will discuss some foundational principles to guide the assessment process and then provide a brief overview of possible interventions.

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Communication assessment

The purpose of this section is to provide interventionists with resources to conduct meaning- ful assessment in authentic settings. It is beyond the scope of this chapter to detail all of the formal communication assessments available. Rather, we offer an overview of areas for consid- eration and specific suggestions to support the assessment process. As a guide, we focus on the skills suggested by the National Research Council (NRC, 2001) as important for social-com- munication development. These include:

Social skills to enhance participation in family, school, and community

Expressive verbal language, receptive language, and nonverbal communication skills

Increased engagement and flexibility in developmentally appropriate tasks and play

Cognitive skills, including symbolic play and basic concepts

Replacement of problem behaviors with more conventional and appropriate behaviors

Paul (2005) suggests that the role of assessment is to develop a communication profile detailing the “functions an individual is currently expressing and the means by which he or she attempts to do so” (p. 802). Based on the assessment, practitioners develop intervention plans for increasing the function for which an individual communicates and the conventional forms through which those functions are communicated. It is important to recognize that different assessments approach the process in many different ways (i.e., different formats, data collection strategies). Quill (2000), for example, uses an extended checklist to assess four broad areas of social-communication skills. These include social-communication behaviors, core skills, social skills, and communication skills.

Box 6.2 offers three general considerations related to social-communication assessment. The considerations include communication frequency, or how often the child interacts; form, or the mode the child uses to engage in social-communication interactions; and function, or the purpose of the child’s interaction.

In addition to the general frequency, form, and function of social-communication inter- actions, attention to specific communication behaviors is important. The child’s strengths, needs, and interests must guide the intervention process. For children with advanced verbal language skills, additional considerations are necessary. Twachtman-Cullen (2008) suggests that assessment and interventions for these individuals focus on “pragmatics comprehension” or the influence of context and social information on language (p. 104).

Box 6.2 general poInts related to soCIal-CommunICatIon assessment

Consider the frequency, form, and function of communicative interactions

1. How often does the child initiate and respond to social-communication interactions with others? a. Track and compare the number of incidences in which the child responds to and

initiates interactions with others.

2. How does the child initiate these interactions? a. Examples include pointing versus reaching with an open hand toward items, and

grabbing someone’s hand.

3. What are the functions of the social-communication interaction (for what purposes)? a. Request (object, action, or interaction) b. Protest c. Social engagement (i.e., share experience)

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Box 6.3 addItIonal assessment ConsIderatIons

The following questions and consideration serve only as a guide. For extensive assessment guidelines see the resources in Box 6.4.

Interests and strengths 1. What activities, topics, or themes does the child enjoy or find interesting?

a. Consider activities that hold the child’s interests and attention. b. When does the child demonstrate independent, active engagement?

2. Describe the child’s strengths.

3. What is the child’s preferred learning style?

Joint attention 1. Does the child engage in joint attention experiences? Specifically, does the child use

eye gaze to actively engage in a shared triad experience (i.e., the child, another individ- ual, and an object)?

Symbol use and intention 1. Consider the nonverbal symbols the child uses. What are these symbols (i.e. eye gaze,

gestures, facial expression)?

2. Consider how the child responds to the nonverbal symbols others use. Does the child follow an eye gaze? Does the child recognize and respond to the facial expressions of others?

3. Consider the child’s play. a. Does the child engage in parallel play or initiate play interactions with others? b. How does the child respond to bids from adults and peers? c. Does the child demonstrate pretend play?

Language 1. Describe the child’s verbal communication skills. Consider word use.

2. Does the child use morphemes to mark temporal relationships?

3. Consider the child’s pragmatic language skills.

a. Consider the conversational skills of the child. Does the child use context to inform his understanding?

b. Does the child understand the basic rules of conversation (i.e., turn taking, topic maintenance, maintaining a reciprocal conversation)?

c. How does the child’s cognitive style influence his social-communication skills? Is the child a literal thinker?

d. Does the child recognize the thoughts, feelings, or emotions of others?

Box 6.4 offers additional resources for building a social-communication assessment. These resources include references that practitioners may find helpful.

As previously mentioned, the focus of assessment should be the development of a com- munication profile that leads to interventions that support functional social-communication skills. Thus, assessment strategies that occur in natural settings and provide a true picture of the child’s skills are important (Twachtman-Cullen, 2008). Below is a list of strategies that support such assessment based on the work of Mesibov, Shea, and Schopler (2005), Paul and Sutherland (2005), and Twachtman-Cullen (2008).

1. Whenever possible, work with the individual in his natural environment and give con- sideration to home, school, and other community settings. Pay special attention to set- tings where parents or other professionals report challenges.

2. Provide structure and visual supports as needed to ensure that the child understands the task expectations. For example, use a schedule (i.e., picture or written) to indicate the number of activities the child must complete before a break.

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3. Use high rates of reinforcement. Reinforcers include edible items, other tangible items such as stickers, social activities, games, and computer activities, and the list goes on.

4. Create enticing situations or scenarios. Examples of strategies for enticement include hiding objects, using physical play interactions, showing the child an unopened bag of his favorite snack, playing a repetitive game and suddenly stopping the interaction, using dolls or puppets and dressing them in unlikely outfits, and placing items of inter- est out of reach, but in the child’s sight.

5. Embed assessment in shared reading or other literacy experiences. 6. Using engaging learning materials, specifically topics, items, or themes of interest. Ask

the child, parent, siblings, past teachers or other therapists, and so on, for items or activ- ities that the child finds interesting.

7. Use prompts or repeat/revisit a task or skill to increase understanding. For example, if assessing receptive vocabulary comprehension, use a prompt to demonstrate how you want the child to identify the item of object. This ensures that the assessment truly tar- gets the child’s vocabulary rather than his understanding of the direction.

Intervention

The work of designing and implementing interventions for individuals with ASD is crucial to future success and must be considered as such by all team members. The most important skills are those that promote an individual’s ability to independently engage in meaningful social-communication interaction in a variety of settings (NRC, 2001; Ogletree et al., 2007; Prizant & Wetherby, 2005). To achieve these social-communication skills, the NRC makes several recommendations. We have summarized a few of these recommendations below:

Interventions should target functional, spontaneous communication.

Interventions should provide social-skills instruction across settings, namely in the setting in which the child will most likely apply the skill.

Active engagement in intensive intervention with many learning opportunities is critical.

At this point, it is important to note the critical nature of ongoing assessment and data- based decision making. The NRC (2001) suggests 3 months as the mark for evaluating the effectiveness of an intervention and making any necessary adjustments. Given this timeline, continuous assessment and data collection is critical (see Box 6.5, “Research Note”).

Box 6.4 assessment reFerenCes

Preschool Language Scale (Zimmerman, Steinek, & Pond, 2002).

Clinical Evaluation of Language Fundamentals—Preschool (Semel, Wiig, & Secord, 2003).

Clinical Evaluation of Language Fundamentals—Fourth Edition (Semel, Wiig, & Secord (1992)).

Peabody Picture Vocabulary Test (Dunn, Dunn, Robertson, & Eisenberg, 1981).

Comprehensive Assessment of Spoken Language (Carrow-Woolfolk, 1999).

Oral and Written Language Scales (Carrow-Woolfolk, 1995).

Goldman-Fristoe Test of Articulation (Goldman & Fristoe, 2000).

Social Communication Questionnaire (Rutter, Bailey, & Lord, 2003).

Do, Watch, Listen, Say: Social and Communication Intervention for Children with Autism (Quill, 2000). The references in this box include a sample of assessment references. These resources serve as guides as educational teams work to understand each student’s specific strengths, interests, and needs.

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Box 6.5 ReseaRch Note

Current research findings suggest two forms of video modeling as effective intervention strat- egies for increasing the social-communication skills in students with ASD (Ayers & Langone, 2005; Bellini & Akullian, 2007). These interventions include video modeling (VM) and video self-monitoring (VSM). VM and VSM refer to the use of a videotaped demonstration to teach children specific, targeted behaviors.

Through video modeling, students receive repeated exposure to skills they need to learn. After watching the videotaped demonstration, students have opportunities to imitate or practice in real world situations. The distinction between VM and VSM is the subject (i.e., actor) of the demonstration model. If the student is videotaped, it is considered a VSM.

Between the years of 1980 and 2005, 29 studies were published on VM and VSM (Bellini & Akullian, 2007). Bellini and Akullian found nine studies utilizing VM/VSM spe- cifically targeting social-communication skills and play behaviors. Three other studies spe- cifically addressed conversation skills. Targeted behaviors varied across studies with most or all students involved demonstrating improvement. Below is a list of communications skills addressed through VM and VSM:

• Spontaneous verbal requests (Wert & Neisworth, 2003) • Play-related verbal responses (Buggey, Toombs, Gardener, & Cervetti, 1999; D’Ateno,

Mangiapanello, & Taylor, 2003) • Social initiations and reciprocal play behaviors (Nikopoulos & Keenan, 2003, 2004) • Engagement in extended pretend play sequences (MacDonald, Clark, Garrigan, &

Vangala, 2005) • Increasing play-related statements (Taylor, Levin, & Jasper, 1999) • Compliment-giving responses and initiations (Apple, Billingsley, & Schwartz, 2005) • Social skills (Simpson, Langone, & Ayers, 2004) • Conversation skills (Charlop & Milstein, 1989; Charlop-Christy, Le, & Freeman, 2000;

Sherer et al., 2001)

The effectiveness of video modeling may be due to the matching of learner preference to intervention modality in that a student’s desire to watch themselves or others on video may increase interest (Bellini & Akullian, 2007; Sherer et al., 2001; Wert & Neisworth, 2003). This relates directly to the argument presented in this chapter for assessing and addressing the joint attention deficits in children with ASD. Without adequate joint attention, a child is unable to attend to the model being presented.

There is a variety of intervention techniques available to support the social-communication development of individuals with ASD (see Figure 6.2). These interventions exist along a con- tinuum from behavioral to pragmatic developmental (Ogletree et al., 2007; Paul & Sutherland, 2005). As with assessment, it is beyond the scope of this chapter to provide a full review of all available interventions. However, we will highlight a few common interventions and offer sug- gestions for designing comprehensive programming.

The work of Ivar Lovaas conducted in the 1970s and 1980s serves as the basis for much of the literature behavioral interventions for individuals with ASD (1987, 1989). Examples of behavioral interventions include discrete trial instruction and verbal behavior. Traditional discrete trial instruction often occurs in a one-on-one setting involving the presentation of multiple, systematic learning opportunities (Smith, 2001). Each learning trial begins with a cue or teacher directive designed to elicit a specific student response. If the student has not learned to demonstrate the correct response, the instructor pairs the cue with a prompt (e.g., gesture, physical prompt). The student then responds. If the student responds correctly, the instructor provides reinforcement. If the response is incorrect, the instructor implements spe- cific error correction procedures.

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inTervenTion TyPe/CiTaTion review desCriPTion findinGs and ConClusions

augmentative and alternative Communication (aaC)

Ganz et al. (2012) Meta-analysis of 24 single-subject research studies to determine the effectiveness of aided AAC systems most commonly used with individuals on the autism spectrum.

Findings suggested that aided AAC does have positive effects on behavioral targets (i.e., challenging behavior, social skills, and academic skills) and increasing communication with individuals who have autism.

Ganz et al. (2011) Meta-analysis of 24 single-subject research studies on aided AAC systems with individuals with ASD; utilized systematic search and coding procedures; calculated ES using IRD.

All ES were rated as moderate or better; largest ES were associated with people with ASD and no other comorbid disorder and preschool age participant.

Ganz, Rispoli, Mason, and Hong (2014)

Meta-analysis of 35 single-subject research studies on aided AAC systems with individuals with ASD; utilized systematic search and coding procedures; calculated ES using IRD.

Largest ES were associated with general education classrooms; PECS and SGD were associated with larger ES than other picture AAC systems; SGD had larger ES than PECS for challenging behavior treatment.

Schlosser and Wendt (2008)

Systematic review of nine single-subject and two group studies involving AAC interventions on speech production in children with autism or PDD-NOS.

The majority of the studies showed that AAC interventions increased speech production. Authors noted that gains in speech production varied based on characteristics of the participants.

Van der Meer and Rispoli (2010)

Systematic review of 23 studies involving the use of speech-generating devices (SGDs) for children with autism.

Results showed that interventions using SGD have promising results for increasing communication for children with autism. Specifically, requesting (i.e., manding) appeared to be the most common skill targeted among the studies.

PeCs

Hart and Banda (2010)

Systematic review of 13 single-subject studies that examined PECS interventions for effects on speech and problem behaviors, generalization, and social validity for individuals with autism and developmental disabilities.

Results indicated that all participants but one had an increase in functional communication. In addition, problem behaviors decreased while speech increased in a number of participants.

Ganz, Davis, Lund, Goodwyn, and Simpson (2012)

Meta-analysis of 13 single-subject research studies involving PECS and individuals with ASD; utilized systematic search and coding procedures; calculated ES using IRD.

PECS is a promising intervention; ES was greatest when used as part of FCT and with preschool children with autism; people who advanced through the most PECS phases had the best communication outcomes.

Preston and Carter (2009)

A review of 27 studies that implemented the PECS protocol as prescribed by Frost and Bondy (1994) with individuals diagnosed with autism or other disabilities.

Results showed PECS to be a promising intervention for increasing functional communication in people diagnosed with autism. Effects on speech development remain unclear, but several studies showed participants gained speech after PECS intervention.

Tincani and Devis (2010)

Meta-analysis of 16 single-subject studies examining the efficacy of PECS in establishing functional communication and speech in individuals with autism and other disabilities.

Results indicated that PECS has favorable results as a communication intervention for individuals with little to no functional communication. More research is needed on the facilitation of speech production in individual participants.

FIgure 6.2 Summary of Reviews on Interventions for Communication with Children with Autism Spectrum Disorders

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inTervenTion TyPe/CiTaTion review desCriPTion findinGs and ConClusions

Computer/video

Ramdoss et al. (2011)

Systematic review of 10 studies using computer-based interventions (CBI) to teach communication skills to children with autism.

All studies reported improvement across multiple communication skills, including receptive language, vocal imitation, and social/communicative initiations when CBI was used with participants.

Parent Training

Lang et al. (2009) A systematic review of 11 studies that examined the effectiveness of procedures used to train parents to implement communication interventions with children on the autism spectrum.

Improvements in the parent’s ability to implement communication interventions and subsequent gains in their child’s communication were found in the majority of studies reviewed. Several methods of training parents were used in studies, but more research will be needed on which strategies yielded the most results.

Meadan, Ostrosky, Zaghlawan, and Yu (2009)

A review of 12 studies using parent- implemented interventions in natural environments to increase the social and communicative behavior of children with autism.

All studies reported positive results in both parent training and communication for the children.

Another teacher-directed behavioral-based approach is verbal behavior. Based on Skinner’s analysis of verbal behavior, there are five broad classes of verbal behavior, including echoes; mands; tacts; reception by feature, function, and class; and intraverbals. Verbal behavior uses teaching principles similar to those in other behavioral programs to systematically move students through language acquisition. Once children learn to echo or repeat specific words, they learn to use words for a variety for a variety of purposes or functions (i.e., label, request, respond to verbal communication of others) (Sundberg & Michael, 2001).

In the middle of the continuum are naturalistic intervention strategies, including pivotal response training (PRT). These interventions apply behavioral principles in more naturalistic settings across the child’s day (Ogletree et al., 2007). PRT is an intervention strategy that applies behavioral principles in naturalistic settings (Koegel, Carter, & Koegel, 2003; Koegel, Koegel, & McNerney, 2001). PRT is designed to target a small set of keystone or pivotal behaviors that will lead to development of skills in other important areas (e.g., social-communication skills). Pivotal behaviors for individuals with autism include increased motivation, the ability to respond to multiple cues, the ability to self- regulate, and increased incidence of self-initiation. PRT addresses concerns of traditional behavioral interventions related to the generalization and utility of skills learned in one-on- one teaching settings to new environments and the maintenance of these skills over time (Koegel, Koegel, & Carter, 1999). For example, students with autism may learn to follow the direction, “sit down” while working with one adult, but cannot follow the direction in the presence of several other children or in environments that are more chaotic. Another concern relates to teacher efficiency, especially in classroom settings (Taubman et al., 2001). For example, in a classroom with six students, it is difficult for a teacher to provide one to one instruction for each student throughout the school day. This is not to say that discrete trial teaching strategies no longer apply. Rather, the principles of discrete trial instruction are effective in contexts that are more natural. For more information on PRT, visit http:// education.ucsb.edu/autism/.

FIgure 6.2 (Continued)

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Finally, on the other end of the continuum are social-pragmatic interventions, includ- ing programs such as Social Communication, Emotional Regulation, and Transactional Support (SCERTS) (Prizant, Wetherby, Rubin, & Laurent, 2003). Prizant and colleagues describe the SCERTS model as “a comprehensive, multidisciplinary approach to enhancing communication and socioemotional abilities of children from early intervention to the early school years” (p. 289). The model is embedded throughout the individual’s day and empha- sizes three different priorities. The priorities include social communication (joint attention and symbol use), emotional regulation to promote self-control and active engagement, and transactional supports to promote generalization across all aspects of the child’s life. The SCERTS model does not prescribe specific strategies, but instead offers a framework for designing an intervention plan. For additional information on SCERTS, visit http://www .scerts.com/.

To guide the intervention planning process we offer a few big ideas and several support- ing strategies. The big ideas:

1. Use assessment data to guide intervention planning. Rather than focusing on buying or selling one specific intervention, comprehensive, person-centered planning aligns the needs of the individual with specific intervention strategies.

2. Comprehensive interventions promote functional, authentic outcomes. Functional, authentic outcomes are determined by the ecological factors such as the individual’s interests and goals, his support system, and culturally responsive practices (Ogletree, 2007).

3. Comprehensive interventions occur within meaningful context (i.e., a setting that as closely as possible mimics the environment that the skill will be used).

4. Comprehensive interventions include plans for generalizing learned skills across environments.

5. Most importantly, comprehensive interventions include collaboration between families, school professionals, community professionals, and other community agencies. Ongoing problem solving promotes an environment with high standards and tenacity toward goals. The team work approach allows for increased social validity and shared strategies across settings. Concurrently, collaboration supports generalization of new skills across environments.

Below are several suggestions to support the big ideas.

1. Increase active engagement by allowing the child to initiate or lead the interaction and using motivating learning materials (e.g., special interests, strengths, tangible reinforcers).

2. Structure the learning setting to promote understanding. Structures include physical boundaries (i.e., furniture arrangements), visual supports, and clear task organization (Mesibov et al., 2005). Students demonstrate increased engagement when the environ- ment is well structured.

3. Recognize symbolic sequences. If a child does not yet use words, try pictures (i.e., pho- tographs, colored line drawings, black and white line drawings, writing) or even objects (real objects and miniature objects) (Paul, 2005).

4. Plan for data collection. Develop a systematic strategy for tracking and analyzing stu- dent progress over time.

5. Communicate, communicate, communicate. Share your intervention data with all team members. Ask for anecdotal reports of the individual’s success in other settings. Engage all team members in problem solving.

When designing interventions, it is important to consider the mode of communication the individual will use. The following section contains information on the various alternative and augmentative forms of communication, when a child is nonverbal.

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Augmentative and Alternative Communication Systems

Individuals with ASD often need an alternative mode of communication to effectively communicate their wants and needs when spoken language skills have not been developed or are underdeveloped (Ganz et al., 2011). Augmentative and alternative communication (AAC) systems were created to provide communication tools, such as the use of a speech-generating device (SGD) or Picture Exchange Communication System (PECS), for individuals with little to no speech (Shane et al., 2011). SGDs, formerly referred to as a voice output communication aids (VOCAs), are electronic devices that translate digitalized verbal messages for students with limited or no verbal speech (Lancioni et al., 2007; Thunberg, Sandberg, & Ahlsen, 2013). PECS is a communication system that involves the use of picture or symbol cards that are exchanged with another person to take the place of spoken communication (Lancioni, 2007). As technological advancements have been made, there has been a shift toward utilizing portable high-tech devices to teach functional communication skills (Shane et al., 2011).

There are two major categories for classifying AAC devices: unaided AAC and aided AAC (Sigafoos & Drasgow, 2001). Sigafoos & Drasgow (2001) define unaided AAC as com- munication systems that exclude the use of any external device or materials. Examples of unaided AAC include gestures or pointing, shaking one’s head “yes” or “no,” or using manual signs (e.g., sign language) (Mirenda, 2001). In contrast, aided AAC systems involve the use of a device, equipment, or other external aid to assist an individual. Examples of aided AAC include electronic communication aids such as SGDs, photographic cards, symbols, and real objects (Sigafoos & Drasgow, 2001).

Unaided aided

Gestures; shaking head “yes” or “no”; pointing

PECS; picture exchange; real objects used for communication exchange

Manual sign language SGD: iPad with communication app (i.e., “Proloquo2Go,” “Table-Talk”); Go Talk; Big Mack; Hip Talk; Dynavox

MAnuAl Sign Manual sign is a type of unaided AAC that in the past has been utilized as a communication mode for individuals who would benefit from a form of AAC (Bondy & Frost, 2002) Results for teaching functional communication using manual signs have been mixed; the amount of training required to teach signs can be time consuming, and learners are not always successful in spontaneous use of the signs taught (Mirenda, 2003; Lancioni et al., 2007). A limited number of studies within the last 10 years focused on teaching functional communication skills by utilizing unaided AAC systems like manual signs. For example, Valentino & Shillingsburg (2011) taught an individual with ASD to use manual sign across verbal operants (mands, tacts, and intraverbals) by exposure to the signs. Additionally, Carbone, Sweeney-Kerwin, Attanasio, and Kasper (2010) taught three participants to request, using manual sign and vocal approximations, by reinforcing successive approximations.

Manual sign may be an effective type of alternative communication system for some individuals with ASD; however, consideration should be given to the prerequisite skills that are essential for successfully teaching manual sign through assessment (Sigafoos, Didden, & O’Reilly, 2003). For example, a student’s fine motor ability should be assessed, since many signs require fine motor movements (Mirenda, 2001). Manual sign requires an individual to have imitation skills; if an individual does not possess such skills, manual sign may be a less desirable communication option than others. If a student lacks these prerequisite skills, other types of AAC systems should be reviewed due to these constraints (Sigafoos, Didden, & O’Reilly, 2003). As a result of the limitations of manual sign language, aided AAC systems should be considered as an alternative.

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pICture exChange CommunICatIon system PECS is an AAC system used to teach individuals with ASD “a rapidly acquired, self-initiated functional communication system” (Bondy & Frost, 2001, p. 727). PECS involves teaching an individual to utilize a communication exchange by handing a picture card representing a message to a communication partner; communication skills that can be taught using PECS range from requesting items to answering questions (Bondy & Frost, 2002). The system follows initial language development in that it begins by targeting initiation, a pivotal skill acquired by very young children. PECS involves six different phases of instruction that incorporate behavioral teaching principles such as systematic prompting and reinforcement. During phase one, individuals learn to initiate interactions by exchanging pictures for highly desired items. Initially, individuals exchange one picture for one object. In the later phases, the individual acquires other skills, such as phrase development, commenting, answering questions, and verbal communication.

Many studies have shown PECS to be an effective communication option for individuals with ASD (Ganz, Davis, Lund, Goodwyn, & Simpson, 2012). For example, Ganz et al. (2012) conducted a meta-analysis of 13 PECS studies and found that PECS was a promising interven- tion for targeted outcomes of functional communication skills.

speeCh-generatIng devICes There are numerous types of SGDs (formerly known as VOCAs) that can be utilized to teach functional communication to an individual with ASD. SGDs can range from single-button switches (i.e., Big Mack) to high-tech devices with computer interfaces that generate voice output (i.e., Go Talk, Dynavox, iPad with communication application). Much of the current research that is focused on SGDs reports positive outcomes for teaching functional communication. For example, in a systematic review conducted by van der Meer and Rispoli (2010) on communication interventions involving SGDs and children with ASD, positive outcomes were found for 86% of the studies reviewed. Studies have also found that utilizing SGDs can increase the number of communication opportunities by increasing the number of communication partners who are able to understand an individual’s communication (Lancioni et al., 2007). As stated in the research, SGDs can effectively be employed to teach functional communication skills to many individuals with ASD.

ConsIderatIons For seleCtIng the type oF aaC system or devICe Several factors should be evaluated when determining the best mode of AAC for an individual with ASD. The most important considerations should be (a) assessing the needs of the learner, (b) determining the communication goals for learner, and (c) considering individual preferences of communication modes (Mirenda, 2001; van der Meer & Rispoli, 2010; van der Meer, Sigafoos, O’Reilly, & Lancioni, 2011).

First, the functionality of the communication mode should match the needs of the learner, and assessment of the individual’s abilities and deficits should be the guide to deter- mine which AAC option meets her needs (van der Meer et al., 2011). This requires that com- munication goals are based on the communication needs of the individual (Mirenda, 2001; van der Meer & Rispoli, 2010). For example, manual sign may be a difficult system for some learners because of the many varied physical movements required for sign versus the few phys- ical movements required with PECS (i.e., handing a picture card to a communication partner) (Tincani, 2004; van der Meer et al., 2012).

Another consideration that is outlined in the literature is the importance of individual preference. Accounting for individual preference in choosing a device can contribute to positive results of targeted communication skills as well as the maintenance of these skills (Ganz et al., 2011; Lancioni et al., 2007; van der Meer et al., 2012). It is also important to evaluate whether the individual’s preference changes across situations (i.e., people and environments) (van der Meer et al., 2011). Determining which type of AAC is best for an individual involves several variables, and as reflected in the literature, there is not necessarily one best mode (Sigafoos & Drasgow, 2001). As such, multimodality should be a considered option for an individual with ASD (Sigafoos & Drasgow, 2001; van der Meer et al., 2012).

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teaching the verbal operants

Frequently children with autism have some verbal abilities, and thus, instructional goals include expanding and increasing their speech. As discussed in Chapter 5 of this text, the- verbal operants are language-based behavioral units described by Skinner. Skinner broke down traditional components of language and communication into four essential types, calling them verbal operants: mands, tacts, echoics, and intraverbals (see Chapter 5 for definitions and examples of these operants). In this section we will discuss how to teach the verbal operants.

teaChIng mandIng Sundberg (2007) described manding as being one of the most integral parts of language development for a child. Mands are often the first verbal operant acquired and serve as an interactive tool between children and adults. Skinner has said that manding is the only type of verbal behavior that directly benefits a learner (Sundberg, 2007). This is due in part to the strong ties to reinforcement a mand provides. For example, if a child is hungry, they can mand for “cookie” and immediately receive a cookie. This has satisfied their current deprivation state of hunger and in turn reinforced the mand “cookie” for the future when that motivational operant (MO) is present.

Teaching manding to a child with autism provides them control over the delivery of reinforcers, which should enhance the probability of future communication (Murphy & Barnes-Holmes, 2009). Manding though requires motivation on the student’s part (Barbera, 2007). Many times our learners find other methods for expressing their wants that get the same if not better results (e.g., challenging behavior). Barbera (2007) discusses the importance of discerning if a child is ready to be taught manding. First, a student should be able to reach for and take items she wants. Providing ample opportunities for the student to make choices in their daily activities can assist with giving incentives to reach and take items. This also brings us back to motivation. Motivating items must be at the center of a program to ensure the student will actually want to mand. Determining what these motivating items are can easily be done using preference assessments or simply observing what the student interacts with most in his environment. Finally, when determining if a student is ready for a manding program, a communication system should be in place or be in development to ensure there is a reliable method in which the student can communicate.

Once it is determined that manding is appropriate to teach to a student, it is best to start by teaching for items in sight. This is called a mand-tact. It is best to start with a mand- tact because students at this phase of a program will be most successful when they request for

eChoiC mand TaCT inTraverbal

antecedent: Someone’s verbal behavior

antecedent: Student’s desire or motivation

antecedent: Nonverbal stimulus present in the environment

antecedent: Someone’s verbal behavior

behavior: Verbal behavior (student imitates)

behavior: Verbal behavior (student requests)

behavior: Verbal behavior (student labels)

behavior: Verbal behavior (student fills in a  blank or answers a question)

Consequence: Social (e.g., praise)

Consequence: Student receives access to item or activity requested

Consequence: Social

Consequence: Social

FIgure 6.3 Overview of the Verbal Operants

Source: sundberg, 2007.

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items that are in their immediate environment (Barbera, 2007). Items out of sight could be too difficult at this initial teaching stage because it might still be an abstract concept to our students that they can request for items not present in the environment. Once a larger vocabu- lary is obtained by the learner (about 50+ words) you can transition to manding for items out of sight, or what is called a pure mand.

Both Sundberg (2007) and Barbera (2007) caution the addition of words like please or more to a manding program. The reasons being that these words are not always functional to a student with autism. Also, the student is not learning the mand for something when they are taught more or please instead of the actual name of an item. As a consequence, please or more could become words for everything. Take, for example, the student who has been taught “more” to request juice when it is in sight. As soon as the juice is out of sight and the student mands “more,” we may not know it is for juice since “more” could mean many things in this instance.

When beginning a manding program, remember that a typically developing student can learn a mand after a few short trials. For our students with autism though, learning a sin- gular mand could take hundreds of trials (Barbera, 2007). In the following sections we discuss specific strategies for teaching manding to students who are both nonverbal and verbal. Also, we want students to eventually mand spontaneously and in the presence of naturally occurring stimuli. Guiding students towards this goal is also discussed in further sections.

strategIes For teaChIng mandIng to students Who are nonverBal When teaching manding to students who are nonverbal, you should begin by placing several pre- ferred items within reach of the learner. Make notes of what items are grabbed by the student. Take those items out of reach of the student once it is determined which ones are going to be motivating. When the student reaches for an item again, block and prompt them to use their selected communication system. Immediately reinforce the student by providing access to the item once they have successfully manded.

It is important to have several reinforcers available at this stage of teaching so you can offer new choices once the student grows tired of one. It is also important to have a variety of reinforc- ers available to avoid satiation on any one item (Barbera, 2007). All too often we hear teachers say, “But they don’t seem to be motivated by anything.” Sundberg (2007) discussed that there are many children with autism that for unknown reasons appear to show low levels of motiva- tion. In these cases, it is important that creativity be used to determine a small repertoire of rein- forcers and contrive ways to get new mands from this sampling. For example, Sundberg (2007) described putting edibles in clear containers the child cannot open to get a new mand for the word open. This is also called incidental teaching and is discussed in more detail in a later section.

As training progresses, the teacher should fade prompts until the student will mand on her own. Also, once a student is reliably manding for at least five items independently, add distance and persistence to the training (Bondy & Frost, 2002). This will teach the student to seek out people when he wants something, not just when that person is in front of them.

mandIng WIth verBal students Teaching manding to students who are already verbal has many similarities to teaching students who are nonverbal. Just like with students who are nonverbal, it is important to notice items that interest the student in order to determine the strongest reinforcers. We have mentioned several times that a student’s environment needs to be motivating and rich with reinforcers to increase the likelihood that mands will occur. Barbera (2007) elaborated that in addition to a stimulating environment, a teacher needs to be careful not to place too many demands on the student during a manding session so as not to signal that rein- forcement has stopped and work has begun. The following is an example of an all too common occurrence. A student is jumping on a trampoline when the teacher stops him to try and elicit the mand “jump.” The student does not immediately mand, which prompts the teacher to say, “If you want trampoline you have to say jump.” This is a huge demand for the student! It could sig- nal that the reinforcement received from the trampoline is finished and work has begun. For our work avoidant learners this could also signal the start of challenging behaviors. In short, Barbera (2007) suggested that a manding session should look very much like an advanced pairing session.

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Once reinforcing items are determined, have them readily available in the environment. When the student reaches for an item, block and give the model for which to mand for it. The model can either be an echoic, a sign, or a prompt to use their communication system. If the child is successful, immediately reinforce by providing access to that item. If incorrect, give the model again along with a prompt. Time delay prompts may be best in these situations in order to give the student a chance to respond.

Other strategies for teaching manding with students who are verbal include incidental teaching. Three common forms of incidental teaching are sabotage, missing items, and block- ing (Kaiser, Ostrosky, & Alpert, 1993). In sabotage, the teacher would provide an item to a student, but leave out a key component or prevent complete access to it. For example, giving the student access to a clear container with her favorite toy in it but leaving the lid tightly screwed on. With the missing item strategy, a student is provided an activity but an item key to participation is missing. For example, giving the student a preferred coloring book but not the crayons. You may give the SD “what do you need” during the missing item and sabotage scenarios to signal to the learner he needs something. Finally, blocking is another way to pro- mote manding through incidental teaching. Simply prevent the student from independently accessing the reinforcing item in order for the student to mand. An example of this is placing a highly preferred toy on a high shelf.

Finally, frequent correspondence checks should occur with any manding program. A cor- respondence check occurs when the teacher ensures the student is manding for what she truly wants. Having the student reach for an item after manding can provide a quick correspondence check. If the student reaches for an item that was not requested, block access and redirect to request for the item reached for. This becomes especially important when the student is using a communication system. We will often see mistaken exchanges using communication systems due to a variety of factors.

progressIon oF mands A common barrier to the development of mands is when the mand is actually under the control of a prompt (i.e., echoic, imitative, intraverbal) (Sundberg, 2007). In this case, the mand is not considered functional because it was the SD (e.g., “what do you want?”) that evoked a response, not a student’s MO. We know from previous sections that it is important not to move too quickly from a mand-tact (in-sight) to a pure mand (out of sight) until a student’s vocabulary has expanded to about 50 words. The same principle goes for introducing the intraverbal mand. When we start a manding program using the SD “what do you want,” the student may become dependent on that cue to communicate. If the student becomes dependent on this cue, you will eventually need to transfer stimulus control from the SD, to the item (mand-tact), and finally to the pure mand. This will add extra unnecessary steps and time to the training process. Also, we do not want the student to only mand for items when a person asks.

Another question often asked is, “when can we start expecting the student to use a full sentence for a mand instead of just one word?” Barbera (2007) cautioned against expecting a student to use a full sentence too soon. She added that improvement should not be measured on the length of utterances but rather how many different needs and wants a child is able to get met through mands. When a student is ready to add more words to an utterance, the words should add meaning to the phrase. For example, if the student mands for a piece of candy by saying, “candy,” you could add the color to the utterance so it becomes “green candy.” You have now increased the length of utterance and the meaning for both you and the learner.

teaChIng taCtIng Barbera and Kubina (2005) described tacting as the foundation for language development. They explained that without knowledge of tacts children will be unable to engage in simple acts like manding or more complex skills like inferring meaning. Tacting is defined as the part of language where the speaker names or labels things for which they’ve had direct contact with in their environment (Sundberg, 2007). It can also be known as expressive labeling. For example, a student sees a car and says “car” in response. Tacting is different from manding in that it does not require much initiation on the student’s part and, as seen from Figure 6.3, the reinforcing consequence is different. With manding, the student’s

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reinforcement is access to the desired item. With tacting, reinforcement is usually a social consequence like verbal praise.

Determining whether a student needs tacting as part of a verbal behavior program is quite straightforward. Simply present the student with a nonverbal stimulus and see if they can name it (Sundberg, 2007). Once you begin to teach tacting, Barbera (2007) suggested using DTT because it is easier to prompt the student and reinforce successes. This also allows for multiple trials with new vocabulary. Begin with the intraverbal-tact “what is it” as you either show the student a stimulus or point to things in the natural environment. As the stu- dent obtains a larger vocabulary, you can transfer stimulus control to the pure tact by fading the intraverbal cue.

When choosing vocabulary to teach as part of a tacting program start with items (nouns) found in the student’s natural environment. Follow it by adding a few familiar/ everyday actions. This will make the vocabulary more meaningful to the student. You can also use vocabulary from a student’s mastered mand repertoire. Since those items have proven to be motivating before, it could help elicit language in the instance of a tact. There are cau- tions though to using vocabulary that has been mastered first as a mand. Those reasons are discussed below.

As mentioned before, using vocabulary from a student’s manding program can be a means by which to motivate tacting. It can also lead to confusion for the student if not planned accordingly. The confusion comes from the different reinforcement a student receives. For example, the student says “ball” while tacting and only receives verbal praise from the teacher. Earlier when they manded “ball” they received a ball to play with. The student may now be confused by what consequence they will receive after saying, “ball.” This could lead to frustration and an interruption to learning. To reduce confusion, the teacher could pair the social consequence usually received after a tact with another activity the student finds rein- forcing (Barbera, 2007). So the student tacts “ball” again, but this time the teacher verbally praises him and blows bubbles.

Once a student begins to progress in their tacting, it is tempting to start adding vocab- ulary beyond just nouns and simple actions. It is important thought not to add any tacts beyond nouns (and a few actions) until the student has at least 50+ concrete words in their vocabulary. Barbera (2007) recommended tacting what a student sees first followed by what is heard. Tacting the remaining senses (taste, touch, smell) and other abstracts like colors, shapes, and prepositions should not be done until a solid lexicon of nouns (about 100+) is obtained. Finally, avoid having a student tact two words (e.g., big dog) until again they have a larger concrete vocabulary.

teaChIng eChoICs Sundberg (2007) suggested that the ability to echo a word might be one of the most important measures for potential language development. He further stated that transferring echoics to other verbal operants is quite easy to do within a verbal behavior program. This makes teaching echoics important as it has ability to further language development. An echoic is simply an imitation of someone else’s verbal behavior. A true echoic will have no stimuli present when the SD is given (Barbera, 2007). One example of using echoics with young typically developing children can be seen in play. The caregiver says, “that’s a doll, can you say doll.” When the child echoes, “doll,” the caregiver praises and will probably give more echoics as they continue to play. This is just one way young children add new vocabulary to their expanding language.

When we determine if a student needs to be taught echoics, it is important to assess without the actual item or picture (Barbera, 2007). If the item or picture is present, you might end up getting a mand or tact instead of the verbal imitation. If the child does not have the ability to imitate your verbal stimulus, you will need to teach it. Often when we begin teach- ing echoics an intraverbal cue will be necessary to elicit the verbal imitation from the student. The intraverbal cue is simply adding, “say” before the targeted word (e.g., “say, ball”). Once the student has acquired several reliable echoics with the cue, transfer stimulus control to the

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pure echoic, which is, imitating what is said without the intraverbal cue. The goal for teach- ing echoics is to eventually have the student independently echoing without the intraverbal cue or item present.

If the student is echolalic, teaching echoics may not be a necessary part of their program. A student with echolalia already has the skills to echo a model provided and therefore does not need to be taught those skills. We might see echoics being used with a student who has echolalia in the case of transferring the echo to other verbal operants. If this is the case, it is important to avoid using intraverbal cues so there is not confusion on the student’s part as to what word is being taught. For example, if teaching the word dog to a learner with echolalia, don’t use the intraverbal cue, “say, dog.” The student might then think the word for dog is always “say dog” instead of just “dog.”

teaChIng IntraverBals An intraverbal is the verbal response needed to fill in a blank or answer a question (Barbera, 2007). Just like echoics, an intraverbal is a response to a verbal stimulus. The difference though is that while an echoic is an exact imitation of another person’s verbal behavior, an intraverbal requires a whole other set of words for which to respond (Barbera, 2007). While this makes teaching intraverbals more difficult than echoics, they are essential for conversational skill development and therefore should be taught.

There are two types of intraverbals. The first type is the fill-in intraverbal, which is typically taught using familiar songs or rhymes. An example of this is singing a nursery rhyme with a student and pausing to let them fill in a word. To make teaching this type of intraverbal easier, choose songs and rhymes already familiar and motivating to the student. Barbera (2007) recommended choosing about two to three words per song that are repetitive so as to allow multiple opportunities for response. If the student is successful filling in the blank, offer praise and continue. Only allow about a 2-second pause for which the student should attempt to fill in the blank. If they are unsuccessful you have a couple of options. Barbera (2007) suggested overemphasizing the fill-in as you continue to sing while offer- ing another opportunity to complete the blank when the word occurs again in the song. Another suggestion is pairing the pause with a visual cue of the missing word. For example, the teacher sings, “Twinkle, twinkle, little,        ,” then holds up a picture of a star to cue the word. This strategy is called a tact to intraverbal transfer and is discussed more in the transfer trials section (Barbera, 2007).

This type of intraverbal can also become more advanced by having the learner fill in other phrases not part of songs or rhymes. For instance, the teacher says, “you brush your        ,” which the student would respond with a targeted response such as teeth or hair. Referencing a student’s mastered tacting vocabulary will assist in choosing words and phrases for which to teach. This ensures you are using words the student is already fluent with and have meaning to him.

The second type of intraverbal is answering questions. The most common type is the “wh”-question (who, what, where, and when). Remember, typically developing students do not begin answering wh-questions until about age 3 to 4 and with a vocabulary of about 600+ words (Barbera, 2007Bar). This is important to keep in mind when deciding if this is an appropriate skill for a learner. When teaching a student to answer wh-questions, it is best to start with what and where. The best method for formulating a question for a student is to pull from already mastered fill-in-the-blank statements. For example, if the student can respond to You sleep in a         with the word “bed,” simply turn it into the question, “where do you sleep.” By teach- ing a student to answer questions, you begin to lay the foundation for more complex conver- sational skills.

We have now discussed teaching strategies for all the verbal operants. Figure 6.4 pro- vides a reference for the most effective scope and sequence to use when teaching each verbal operant. As your teaching progresses, you will probably observe that a student will develop quickly in some areas, while others will continue to need work. In our next section we will discuss how to use these strengths in order to develop other areas.

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transfer trials

A transfer trial is a strategy used to build upon the strengths of a student and in turn improve their areas of weakness (Barbera, 2007). Arantes and Berg (2009) further explained that for a transfer to occur, one skill must already be under the control of some stimulus. The transfer then occurs by shifting the control to another set of stimuli that does not currently control the behav- ior. For example, if a student has strong receptive skills but lacks expressive skills, you can use a transfer trial to transfer stimulus control from one operant (receptive) to another (expressive).

Barbera (2007) described two types of transfer trials. The first type is a transfer trial within a verbal operant. This could be described as the gradual fading of prompts within one verbal operant until the child is independent with the skill. The best example of this is using most to least prompting with a learner. The second type is a transfer trial across verbal oper- ants. Typically when transferring across verbal operants you will pick one operant the student has been successful with, then use those skills to transfer to a new or weaker operant. Examples of transferring across verbal operants are described in detail below.

• Echoic to tact transfer: Teacher: “Say, ball”(no stimulus present) Student: Echoes “ball” Teacher: Holds up picture of a ball (offer partial echoic prompt if needed) Student: Tacts, “ball”

• Tact to intraverbal (Fill-in) transfer: Teacher: “What is it?” while holding up an item Student: Tacts, “Crayon” Teacher: (Stimuli is taken away) “You color with a        ” Student: “Crayon” (intraverbal fill-in)

• Tact to intraverbal (answer) transfer: Teacher: “What number?” while holding a 9 Student: Tacts, “Nine” Teacher: (Stimuli is taken away) “How old are you?” Student: “Nine”

FIgure 6.4 Scope and Sequence: Teaching the Verbal Operants

eChoiC mand TaCT inTraverbal

To begin: Intraverbal cue, “Say,        ”

To begin: In-sight items (mand-tact)

To begin: – Intraverbal cue, “what is it” – Nouns and a few actions

from the student’s everyday environment

To begin: Fill-ins with familiar songs and rhymes

after 50+ words: Fade intraverbal cue to the pure echoic

after 50+ words: – Out-of-sight items

(pure mand) – Intraverbal cue, “what

do you want”

after 50+ words: Continue to add nouns, actions, and things the student hears from the environment

after 50+ words: Fill-ins with phrases/ statements not part of songs

after 100+ words: – Add more abstracts such as

things the student tastes, touches, or smells. Can also start adding colors, shapes, and prepositions

– Add two-word combinations (e.g., big dog)

after 600+ words (and at least age 3): Answering questions (start with what and where)

Source: sundberg, 2007.

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• Echoic to intraverbal transfer: Teacher: “Say, purple” Student: “Purple” Teacher: “What color is your shirt?” Student: “Purple” (intraverbal answer)

The following are examples of transfer trials using visual and auditory discrimination and expressive labeling.

• Visual discrimination to auditory discrimination Teacher: “Match, green” (gives student a green card) Student: Matches green card from teacher to the green card in array Teacher: “Point to green” Student: Points to green

• Receptive to expressive Teacher: “Point to the dog” Student: Points to picture of a dog Teacher: “What is it?” Student: “Dog”

• Visual discrimination to expressive Teacher: “Match, car” (gives student a picture of a car) Student: Matches to another picture of a car in an array Teacher: “What is it?” Student: “Car”

After reading through the different examples of transfer trials across verbal operants, you might have noticed that the first skill always flows directly to the next skill. Meaning, the teacher does not stop to offer a consequence (i.e., reinforcement) after success with the first skill. Instead, a consequence is only offered after the completion of the transfer. By doing this, the student will view the transfer as one continuous trial. This makes a student’s response more likely to occur because there will not be a pause for a new antecedent. Finally, a transfer trial is essentially giving the student a prompt in order to be successful with the new skill. As with any prompt, you must have a plan in place for fading to ensure the student is eventually responding to the naturally occurring stimuli for that verbal operant.

summary

Social communication is at the center of the human experi- ence. Children with autism differ in their development of social-communication skills. Throughout this chapter, we discussed typical social-communication development and how social communication differs for children with autism spectrum disorders. Joint attention, communication intent, and symbol use are critical components of development.

Data-based decision making and interventions guided by thorough assessments are crucial to increasing a student’s social-communication repertoire. A collection of strategies to assist with this assessment and intervention planning was presented, along with specific information in the instruction of the verbal operants.

Chapter revIeW QuestIons

1. What are the typical stages of joint attention and communication development? (Objective 1)

2. What are some common deficits in social communication for students with autism? (Objective 2)

3. What are the verbal operants? List and describe. (Objective 3)

4. What are some methods of instruction of the verbal operants? (Objective 4)

5. What are some other evidence-based intervention strat- egies or models for use in teaching communication to students with autism? (Objective 5)

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Key terms

Augmentative and alternative communication (AAC) 113

Broca’s area 103 Communication 97 Communication assessment 106 Communicative intent 100 Discrete trial instruction 109 Echoics 118 Expressive verbal language 106 Illocutionary stage 100 Initiation of joint attention (IJA) 99

Intraverbals 119 Joint attention 98 Language 97 Locutionary stage 100 Mands 115 Nonverbal communication skills 99 Perlocutionary stage 100 Picture Exchange Communication

System (PECS) 113 Pivotal response training (PRT) 111 Pragmatics 102

Receptive language 104 Reciprocal interactions 99 Response to joint attention (RJA) 99 Semantics 102 Symbol use 100 Syntax 102 Tacts 117 Verbal operants 113 Video modeling 109 Wernicke’s area 103

Internet resourCes

Online modules detailing a variety of interventions http://www.autisminternetmodules.org/mod_list.php

UCSB Koegel Autism Center (PRT) http://education.ucsb.edu/autism/

The SCERTS model http://www.scerts.com/

Picture Exchange Communication System http://www.pecs.com/

Center for Autism and Related Disabilities (incidental teaching, etc.) http://www.coe.fau.edu/card/Free%20Resource%20Materials.htm

Treatment and Education of Autistic and related Communication Handicapped Children http://www.teacch.com/communication.html

Augmentative and Alternate Communication Connecting Young Kids http://aac.unl.edu/yaack/index.html

Route 66: Literacy for Adolescent and Adults Beginning Readers http://www.route66literacy.org/?gclid= CMe4wt_wxpgCFQu-GgodkzDC1w

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Social Challenges of Children and Youth with Autism Spectrum Disorders

Chapter 7

Scott Bellini, ph.D. and anna Merrill Indiana University, Bloomington

CaSe of Kelly Kelly is a kindergartner with autism and significant expressive commu- nication deficits. She is primarily echolalic and seldom uses her language spontaneously with classmates and teachers. Kelly is extremely fearful of social situations and often avoids social interactions. Consequently, Kelly spends the vast majority of her playground time by herself, with little peer interaction. A social skills assessment concluded that she had signif- icant skill deficits in initiating interactions and maintaining interactions with peers. A peer-mediated intervention (PMI) was implemented that taught Kelly’s peers how to initiate and respond to her initiations.

CaSe of Khalil Khalil is a 28-year-old man with autism. Khalil said that he had a best friend once, but that the two of them had stopped spending time together. He currently has no friend and spends the majority of his time alone. He stated that he did have a girlfriend for a brief time but the relation- ship ended, according to Khalil, because he grew tired of spending time with her. He stated that he becomes anxious in crowded environments and often avoids social settings. Khalil received an associate’s of science degree in information technology from a local community college. Khalil has worked in primarily menial labor jobs (e.g., custodial work); how- ever, he is currently unemployed. Khalil stated that his difficulties with social interactions and hypersensitivity to crowded environments may be impacting his ability to find and keep a job. Vocational rehabilitation ser- vices were implemented that targeted social skills essential for finding and keeping a job. Khalil was also taught coping strategies to help him regulate his response to sensory stimuli.

CaSe of Car Carlos is a 9-year-old boy with autism who engages in a number of problem behaviors, such as touching and pushing other children. Carlos also makes inappropriate comments in class, such as calling the teacher ugly and telling his classmates that they are stupid. A functional behavior assessment was conducted to assist with the development of an intervention plan. During the playground observation, Carlos ran into the girls’ bathroom. As he ran in, about a dozen girls ran out screaming and giggling, followed by Carlos who was doing the same. Carlos was

CaSe StuDy Examples

Chapter ObjeCtiveS After reading this chapter, learners should be able to: 1. Increase knowledge of

common social skills deficits. 2. Increase awareness of the

relationship between social skills deficits and deleterious outcomes.

3. Increase awareness of skill acquisition versus performance deficits.

4. Increase knowledge of meta- analytical research regarding social skills training.

5. Increase knowledge of social skills assessment techniques.

6. Increase awareness of available social skills training strategies.

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immediately taken to the principal’s office. At the conclusion of the observation and teacher interview, it was determined that the function of the problem behavior was peer attention. That is, Carlos was engaging in inappropriate social behaviors to gain peer attention. As a result, an intervention was developed that focused on providing Carlos with ample opportunities to gain peer attention during the course of the day through the use of structured playgroups. Each day, Carlos had the opportunity to invite two friends to play games with him for 10 to 15 minutes. The thought was that if Carlos had ample opportunity to satisfy his craving for peer attention, he would not have any need to engage in inappropriate behaviors to gain their attention. The intervention also focused on providing frequent reinforcement for appropriate behavior. Unfortunately, the intervention failed miserably. In the structured playgroup, Carlos engaged in all the inappropriate behaviors (e.g., touching, name calling) that he had engaged in prior to the intervention. The primary reason for the failure was that the intervention did not teach replacement behaviors. That is, Carlos still did not have the skills necessary to effectively and appropriately gain peer attention.

IntroduCtIon

Social skills have been defined as “socially acceptable learned behaviors that enable a person to interact with others in ways that elicit positive responses and assist in avoiding negative responses” (Gresham & Elliot, 1990). Effective social skills allow children to elicit positive reactions and evaluations from peers as they perform socially approved behaviors (Ladd & Mize, 1983). Social skills are distinguished from social competence in that social skills rep- resent behaviors that must be learned and performed and social competence represents judg- ments of those behaviors by others (Gresham, 2002).

Although some individuals with Autism Spectrum Disorders (ASDs) experience excel- lent outcomes, a majority of individuals will have persistent social impairment (Szatmari, Bartolucci, Bremner, Bond, & Rich, 1989). This impairment could be attributed to the fact that few children receive adequate social skills programming (Hume, Bellini, & Pratt, 2005). This dearth of services is an unfortunate reality, especially considering that social skills defi- cits have been linked to other deleterious outcomes, such as poor academic performance, peer rejection, isolation, social anxiety, depression, and other forms of psychopathology (Estes, Rivera, Bryan, Cali, & Dawson, 2011; Bellini, 2006a; Tantam, 2000; Welsh, Park, Widaman, & O’Neil, 2001). Furthermore, based on a meta-analytical study (Bellini, Peters, Benner, & Hopf, 2007b), those few children who are receiving social skills programming may not be receiving effective social skills programming. Social skills training should be an integral part of a child’s overall programming, and an emphasis should be placed on implementing effective, empirically tested interventions.

The chapter will provide an overview of common social skills deficits in individuals with ASD and discuss methods for assessing social skills and social competence. The chapter will also provide a summary of the results and recommendations produced by meta-analytical research studies on social skills programming. The chapter will conclude with a description of social skills strategies that have been empirically examined via research. The chapter is sep- arated into three broad sections: (a) common social skills deficits, (b) social skills assessment, and (c) social skills training.

Common SoCIal SkIllS defICItS

Impairment in social functioning is a fundamental characteristic of ASD and is well docu- mented in the literature (Attwood, 1998; Baron-Cohen, 1989; Brown & Whiten, 2000; Dawson & Fernald, 1987; Rogers, 2000). According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (4th ed., text rev.; DSMV-IV-TR; American Psychiatric Association, 2000), essential diagnostic criteria in the social domain include the

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following: “(a) marked impairment in the use of multiple nonverbal behaviors such as eye-to- eye gaze, facial expression, body postures, and gestures to regulate social interaction; (b) failure to develop peer relationships appropriate to developmental level; (c) a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people; and (d) lack of social and emotional reciprocity” (p. 75). In addition, social avoidance and withdrawal is a hallmark feature of many individuals with ASD. This feature was noted more than a half-century ago by Leo Kanner (1943), who described autism as a disorder with two primary clinical features: extreme aloneness and insistence on preserving sameness.

Some professionals have interpreted social withdrawal as an indication that individuals with ASD lack motivation and interest in interacting with others and in establishing relation- ships. This assumption has been challenged by others (Attwood, 1998; Bellini, 2006b) who emphasize that many individuals with ASD do have an interest and desire to establish and maintain meaningful relationships. However, significant social skills deficits, history of peer failure and rejection, and intense social anxiety make it very difficult for these individuals to achieve or even attempt social success. The result is sometimes a life absorbed in solitary hob- bies and interests. For others it leads to a pattern of inappropriate behavior that is intended to gain peer attention and affiliation, but instead it often leads to peer failure and rejection.

It is also important to discern between behaviors that are effective with peers and behav- iors that are effective with adults. One need only consider the behaviors of popular children to realize that effective social behavior does not always represent “appropriate” social behavior. Sometimes the behaviors that are targeted for reduction by adults are the behaviors that are quite effective when interacting with peers (talking loudly, vulgar language, etc.). As such, it is imperative to view social skills from a developmental perspective.

The following is a description of common social skills deficits in individuals with ASD. Social skills deficits are separated into four broad categories of social functioning: (a) nonverbal communication, (b) social initiation, (c) social reciprocity, and (d) social cognition.

nonverbal Communication

Successful social skills require the ability to read and understand the nonverbal cues of others and to clearly express thoughts, feelings, and intentions through facial expressions, gestures, and body language. In many ways, our nonverbal communication is more meaningful than our verbal communication. Difficulty in reading body language or nonverbal cues of others is a common problem for individuals with ASD. Some fail to look for nonverbal cues and are virtually oblivious to the nonverbal communication of others. Others may look for nonverbal cues, but interpret them incorrectly or fail to understand their message. Understanding non- verbal communication requires that we recognize the body language of others and infer the meaning of the nonverbal communication. This occurs by integrating all the available non- verbal and contextual cues in the environment. For instance, imagine yourself arriving home from school and finding your mother standing in the doorway, arms folded, and with a scowl on her face . . . and holding your report card! You would probably be able to (a) recognize your mother is upset and (b) infer based on the contextual cues (i.e., holding the report card and scowling) that her consternation has something to do with the report card in her hand.

Social Initiation

Difficulties with initiating interactions are common among individuals with ASD (Hauck, Fein, Waterhouse, & Feinstein, 1995). Many children fall into one of two initiation categories: those who rarely initiate interactions with others and those who initiate frequently, but inap- propriately. Children in the first category often demonstrate fear, anxiety, or apathy regarding social interactions. It was once believed that the vast majority of children on the autism spec- trum fit into this category. In fact, many social skills interventions have been designed with the express goal of increasing social initiations. However, in recent years an increasing num- ber of children fit within the latter category. These children initiate interactions frequently,

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but their initiations are often ill-timed and ill-conceived. For example, they may interrupt or talk over someone. They may ask repetitive questions or questions that pertain only to their own interests. They may talk with others in settings that require silence, such as a library or church. For these children, the goal of social skills training is not to get them to initiate more frequently but to get them to initiate more appropriately.

Social reciprocity

Social reciprocity refers to the give-and-take of social interactions. Successful social interactions involve a mutual, back-and-forth exchange between two or more individuals. If you have ever been on a date where your date would not stop talking about himself or perhaps you had to do all the talking because your date had little to say, you will understand how problems with social reciprocity can hinder social interactions. Many individuals with ASD engage in one-sided interactions in which they are either doing all the talking or fail to respond to the social initia- tions of others and to build on conversations with others. Individuals with ASD may continually derail conversations by changing the subject to fit their own self-interests. Joint attention is also a key component of social reciprocity. Joint attention refers to the ability to attend in unison to an object with another person. Travis, Sigman, and Ruskin (2001) demonstrated that initiating joint attention was significantly related to social competence in individuals with ASD.

Social Cognition

Several social skills difficulties exhibited by children and adolescents with ASD may be attributed to the manner in which they process social information, or social cognition (Baron- Cohen, 1989). Social cognition directly impacts the success of social functioning. Social cognition involves understanding the thoughts, intentions, motives, and behaviors of ourselves and others (Flavell, Miller, & Miller, 1993). Knowing and understanding social norms, customs, and values is essential to healthy social interactions and is influenced by our social cognition (Resnick, Levine, & Teasley, 1991). Within the social-cognitive domain, three processes are particularly important in social functioning: knowledge (know-how), perspective-taking, and self-awareness. Individuals with ASD often experience difficulties in all three of these areas.

Knowledge is an essential component of successful social interactions. Cognitive the- orists describe two types of knowledge: declarative and procedural (Pressley & McCormick, 1995). Declarative knowledge is responsible for understanding the often unwritten social rules and customs of society. Declarative knowledge also helps us interpret “figures of speech” or idi- oms, most of which make no literal sense. It tells us that “raining cats and dogs” means “rain- ing hard.” Children with ASD also have difficulties understanding idioms and the unwritten rules of social relationships. For example, an individual with ASD might tell a stranger that he is overweight or that his breath stinks. Or, she might try to find the location of her thinking cap when her teacher says “It is time to put your thinking cap on.”

The ability to understand the internal psychological processes of others and to take another person’s point of view is critical to social cognition and to successful social interac- tion (Frith, 1991). In children and adults who have an inadequate theory, or knowledge of mind, such as those with ASD, social functioning is significantly impaired (Baron-Cohen, 1989). Specifically, Baron-Cohen has found that individuals with autism demonstrate signifi- cant deficits in the ability to attribute mental states to others and correctly predict the beliefs of others. The results of such mindblindness (Attwood, 1998) are usually social interactions that lack social and emotional reciprocity.

Successful social interaction requires that we continually monitor and regulate our behaviors, thoughts, and feelings during social interactions. Self-awareness encompasses the ability to monitor, regulate, and evaluate our thoughts and actions. By doing this, we are able to modify our actions to ensure that our interactions will be enjoyable and successful. Self-awareness is also inextricably linked to the ability to read nonverbal cues and perspective- taking. Self-awareness allows us to monitor how our actions or behaviors impact others. Without proper self-awareness we would engage in one-sided interactions, and perhaps seemingly inappropriate or embarrassing behaviors.

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types of Skill deficits: performance deficits versus Skill acquisition deficits

Social skills deficits are often conceptualized from a skill acquisition–performance deficit dichotomy. A skill acquisition deficit refers to the absence of a particular skill or behavior. For example, a young child with ASD may not know how to effectively join in activities with peers; therefore, she will often fail to participate. If we want this child to join in activ- ities with peers, we need to teach her the necessary skills to do so. A performance deficit refers to a skill or behavior that is present, but not demonstrated or performed. To use the same example, a child may have the skill (or ability) to join in an activity, but for some reason fails to do so. In this case, if we want the child to participate, we would not need to teach the child to do so (since she already has the skill); instead, we would need to address the factor that is impeding performance of the skill, such as lack of motivation, anxiety, or sensory sensitivities.

The benefit of using a skill acquisition–performance deficit model is that it guides the selection of intervention strategies. Most intervention strategies are better suited for either skill acquisition or performance deficits. The selected intervention should match the type of deficit present (Gresham, Sugai, & Horner, 2001). That is, you would not want to deliver a performance enhancement strategy if the child was mainly experiencing a skill acquisition deficit. Examples of skill acquisition strategies include the following: Social Stories™, video modeling, pivotal response training, social scripting, and social problem-solving strategies. (See Box 7.1 for more information on the use of video modeling.) Performance enhancement strategies include the following: reinforcement strategies, environmental modifications, prompting strategies, peer-mediated interventions, and social priming. It is important to note that these two categories are not mutually exclusive. Some strategies are capable of both teach- ing a new skill and enhancing the performance of existing skills (e.g., video modeling, Social Stories™, prompting, and self-monitoring). In addition, performance enhancement strategies are often used to supplement skill acquisition strategies. That is, when a skill is being taught via a skill acquisition strategy, it is necessary to implement performance enhancement strate- gies to facilitate the performance of the newly learned skill.

Box 7.1 trendS and ISSueS noteS

The Use of Technology in Instruction In recent years, the use of technology has played a prominent role in the implementation of social skills programming. Technological tools have been integrated with existing treat- ment modalities, such as Social Stories™ and modeling, to create promising new practices. Storymovie (see The Gray Center for information) is a video application of Social Stories™ that allows the child watch videos of children demonstrating the behavior or situation por- trayed in the story. Video modeling (see “Video Modeling and Video Self-Modeling” in this chapter for more information) is a technique that incorporates video technology to teach chil- dren new skills. In addition, several computer programs have also been developed to address both emotions and perspective-taking abilities in individuals with ASD. Perhaps the most popular of these computer programs is Mind Reading: An Interactive Guide to Emotions devel- oped by Simon Baron-Cohen (2004). The program contains three areas to teach children how to recognize the thoughts and emotions of others: “emotions library,” “learning center,” and “game zone.” The emotions library contains an extensive collection of video clips depicting actors (children and adults) displaying a variety of emotions organized into a helpful collec- tion of “emotion groups.” The learning center teaches the child about the various emotion groups by providing a pictorial and video example depicting an actor displaying the emotion in a social setting. This area also provides lessons and quizzes that can be tailored to match the child’s individual needs and skill level. The third part of the program, “game zone,” provides a collection of five emotions-related games.

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SoCIal SkIllS aSSeSSment

The first step in social skills training programs should consist of conducting a thorough eval- uation of the child’s current level of social functioning (Bellini, 2006a). The purpose of the social skills assessment is to identify skills that will be the direct target of the intervention and to monitor the outcomes of the social skills program. The evaluation details both the strengths and weaknesses of the individual related to social functioning. The identification of personal strengths is an important element of a social skills program because it allows the intervention- ist to leverage the individual’s strengths in a manner that facilitates social relationships. For instance, if the adolescent with ASD has an encyclopedic knowledge of baseball statistics, or is a math whiz, then the interventionist can connect the child with other children with similar interests. The identification of weaknesses allows the interventionist to identify skills that will be the direct target of the intervention.

The assessment often involves a combination of observation (both naturalistic and structured), interview (e.g., parents, teachers, playground supervisors), and social skills rating forms (parent, teacher, and self-reports). Social skills assessment involves the direct assessment of social skills (via systematic observation) and the evaluation of social competence (via inter- view and rating scales).

evaluation of Social Competence

Evaluations of social competence are typically conducted through the use of interviews or rat- ing scales. Interviews are a valuable method for obtaining information regarding social func- tioning in a relatively short time by allowing us to collect and synthesize information from a variety of respondents representing a wide range of settings. That is, they allow the evaluator to make decisions regarding the direction and focus of the program. The interviews also allow the evaluator (who may be a professional unfamiliar with the child) to learn about the child’s strengths and weaknesses related to social functioning. Interviews can be broad and encom- passing or a more focused problem identification and analysis interview that breaks social skills into component parts.

Rating scales are indirect assessment tools that provide a wealth of information on the child across a variety of functioning areas. These measures range from informal checklists to standardized rating scales and may be administered to parents, teachers, and the child. Rat- ing scales can measure social functioning, anxiety, self-concept and self-esteem, and behav- ioral functioning. A major advantage of behavior rating scales is their ability to quickly and efficiently obtain large quantities of information regarding social behavior from a variety of sources and across a variety of settings (Elliott, Malecki, & Demaray, 2001). The use of rat- ing scales can also increase the social validity of the social skills program when information gleaned from the assessment is linked directly to the development of treatment goals and objectives (Gresham et al., 2001).

evaluation of Social Skills

Observation of social behaviors should follow the interviews and administration of rating scales. Two traditional methods of observation may be used to assess the social functioning of children with ASD, naturalistic and structured. The purpose of both methods is to observe the child’s social performance across settings, persons, and social contexts. Naturalistic observation involves observing and recording the child’s behavior in real-life social settings, such as the school playground and cafeteria, or in various social settings at or near the child’s home. Natu- ralistic observation is the ideal method of observing social behavior because it involves behav- ior that is authentic and spontaneous, allowing us to record behavior in settings that the child typically encounters in the course of his daily life. It also allows us to observe behavior across settings and across persons. This is particularly important in cases where the child might be interacting well in structured settings (i.e., the classroom) but not in unstructured settings (i.e., the playground) or interacting well with certain peers, or with adults, but not with other

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children or unfamiliar adults. Structured observations involve observing the child in an envi- ronment that has been artificially established to facilitate social interactions between the tar- get child and preselected peers. Structured observations involve observing social behavior in a structured playgroup or structured social group. The child with ASD is grouped with one or two nondisabled peers in a setting that is rich in social opportunities (games, toys, and other age-appropriate play objects). Nondisabled peers may also be coached prior to the observation to make sure that they include the child with ASD in their activities.

Social Validity

Social validity refers to the social significance of the treatment objectives, the social signif- icance of the intervention strategies, and the social importance of the intervention results (Gresham & Lambros, 1998). It involves ensuring that the consumers believe that the selected treatment objectives are indeed important for the child to achieve. If consumers do not believe that the objectives are important, they will be less likely to exert the effort necessary to achieve those objectives. This aspect of social validity is established during the initial social skills assessment, specifically during the interview process.

Gresham (2002) provides a classification system that separates social skills assess- ment methods into three categories that represent different levels of social validity. Type I measures include rating scales and interviews designed to measure social competence. Type I measures are the most socially valid assessment measures because they directly measure the impressions of key stakeholders. That is, the results of Type I measures represent the judg- ments of parents and teachers. As such, treatment objectives developed from these measures are likely to be accepted and viewed as socially acceptable by these key stakeholders. A major advantage of Type I measures is their ability to efficiently obtain information regarding social behavior from a variety of sources and across a variety of settings. A major disadvantage of Type I measures is the fact that they are often not sensitive to short-term changes in behavior. For instance, the child might be demonstrating an increase in the target behaviors without key stakeholders noticing these changes. Type II measures involve the direct assessment of the child’s social skills. As such, these measures are valuable to progress monitoring and are used extensively in applied research studies involving single-subject methodology. Type II measures are sensitive to small changes in behavior because they are linked directly to the treatment objects. For instance, if the interventionist identifies “joining in activities with peers” as a treatment objective, the intervention would then observe the child to measure whether “join- ing-in” behavior has increased over the course of the intervention. Type III measures are the least socially valid assessment measures. Type III measures involve conducting role-play sce- narios or asking questions of the individual related to social cognition (e.g., social problem solving or perspective-taking scenarios). Although these are important areas to address via intervention, research has demonstrated that these measures are not related to measures of social competence (Type I measures) or measures of social skills (Type II measures).

The social acceptability of intervention strategies is also critical to the success of the social skills training. If consumers do not think that an intervention strategy will be effective or if they think it may be harmful to the child, they will be less likely to implement it. The social importance of intervention results represents the consumer’s perceptions of the inter- vention results. If the consumer does not believe that the intervention resulted in positive and meaningful change for the child, then the consumer is likely to disengage, or discontinue, the social skills program.

functional Behavior assessment and Social Skills

Functional behavior assessment (FBA) refers to a process of determining what is maintain- ing the problem behavior (see Chapter 4 for more information on FBA). FBA integrates a variety of data, including interviews, observations, and rating forms. An FBA might deter- mine that a child engages in inappropriate touching behavior to gain peer attention. The function of this behavior would be peer attention. Another purpose of the FBA is to determine

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what antecedent stimulus (also referred to as a discriminative stimulus) might be trigger- ing, or occasioning, the problem behavior. For instance, the FBA might reveal that the child engages in aggressive behaviors toward individuals with loud voices. In this case, the loud voices would be serving as a trigger for the aggressive behavior. Yet another purpose of the FBA is to identify potential establishing operations (EOs) for the problem behavior. EO is a condition that increases (or decreases) the probability that a problem behavior will occur. In this way, social skills deficits, isolation, and social anxiety serve as EOs for many problem behaviors. For instance, a child with social skills deficits who is socially isolated may be more likely to engage in inappropriate behavior to gain peer attention than a child with effective social skills who receives copious amount of peer attention throughout the day. Or, a child with severe social anxiety may be more likely to engage in appropriate behavior to avoid or escape interactions, and thereby reduce her anxiety level, than would a child without anxiety.

A fundamental purpose of the FBA is to develop a behavior intervention plan. The intervention is linked directly to the data gathered via the FBA process and addresses the function, the antecedent stimulus, and/or the EO. A key feature of the intervention plan is to teach replacement behaviors. A replacement behavior is an appropriate behavior that serves the same function as the problem behavior. As such, social skills are considered replacement behaviors, and social skills training often takes on a level of importance in the development of intervention plans. For instance, the child who engages in inappropriate touching to gain peer attention can be taught replacement behaviors (i.e., social skills) to effectively initiate inter- actions with peers. Performance of these newly learned skills would allow her to gain the peer attention she desires, and thus diminish the need to engage in inappropriate touching.

SoCIal SkIllS traInIng

Social skills training refers to instruction or support designed to improve or facilitate the acquisition and/or performance of social skills. Social skills training programs address three primary objectives: promote skill acquisition, enhance the performance of existing skills, and facilitate the generalization of skills across settings and persons. For most children, social skills are acquired through learning that involves observation, modeling, coaching, social problem solving, behavior rehearsal, feedback, and reinforcement-based strategies (Gresham & Elliot, 1990). Two underlying assumptions of all social skills training programs are that individuals can be taught to behave differently, and they will elicit more positive reactions and evaluations from peers as they acquire and perform more socially approved behaviors (Ladd & Mize, 1983). Elliot and Gresham (1991) discuss five factors that contribute to social skills deficits: (a) lack of knowledge, (b) lack of practice or feedback, (c) lack of cues or opportunities, (d) lack of rein- forcement, and (e) the presence of interfering problem behaviors. Social skills training programs should identify the factors that are contributing to the social skills deficits of the target child and attempt to ameliorate these deficits through programming. The following section provides a summary of meta-analytic research and literature reviews that have been conducted on social skills training for children with and without ASD. These research studies provide a valuable synthesis on the existing knowledge base regarding social skills training and also provide help- ful recommendations for effective programming. The section concludes with a description of specific social skills training strategies commonly used with individuals with ASD.

results of meta-analytical research: Ingredients of effective Social Skills

programS A number of qualitative reviews have examined the effectiveness of social skills interventions for children with ASD and have provided suggestions for increasing the effec- tiveness of social skills programming (Hwang & Hughes, 2000; McConnell, 2002; Rogers, 2000). Hwang and Hughes (2000) reviewed 16 studies involving social skills programming for children with ASD between the ages of 2 and 12. The researchers concluded that social

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skills programming shows “considerable promise for increasing social and communicative skills” of children with ASD (p. 340), pointing to positive changes in social behaviors across the studies in the literature review. Rogers (2000) provided a comprehensive narrative of social skills strategies for children with ASD. Rogers concluded that children with ASD are respon- sive to a wide variety of social skills intervention strategies to facilitate both adult–child and child–child interactions. These strategies include pivotal response training, adult prompt- ing, environmental modifications, social skills groups, Social Stories™, video modeling, and peer-mediated instruction.

McConnell (2002) conducted a literature review of 55 studies examining social skills interventions for young children with ASD. McConnell divided social skills interventions into five categories: (a) environmental modifications, (b) child-specific interventions, (c) collateral skills interventions, (d) PMIs, and (e) comprehensive interventions. According to McConnell, environmental modifications involve modifications to the physical and social environment that promote social interactions between children with ASD and their peers. Child-specific interventions involve the direct instruction of social behaviors, such as initiating and responding. Collateral skill interventions involve strategies that promote social interactions by delivering training in related skills, such as play behaviors and language, rather than training-specific social behaviors. PMIs involve training nondisabled peers to direct and respond to the social behaviors of children with ASD. Finally, comprehensive interventions involve social skills interventions that combine two or more of the aforementioned intervention categories. McConnell concluded that young children with ASD can benefit from arranged environments that include structured, preferred activities and opportunities for positive interactions with more socially competent peers coupled with targeted, direct intervention to enhance his or her own individual skills.

A number of quantitative meta-analyses have been performed on social skills inter- vention studies involving children and adolescents with and without ASD. Although these studies have failed to support the effectiveness of social skills training in general, they do provide helpful guidance in determining the ingredients of effective social skills interventions. In general, studies have demonstrated that traditional social skills training programs are only minimally effective in teaching social skills to children and adolescents (Bellini et al., 2007b; Gresham et al., 2001; Quinn, Kavale, Mathur, Rutherford, & Forness, 1999). Quinn et al. (1999) found small effect sizes in their meta-analysis of 35 studies examining social skills interventions in children and adolescents with emotional and behavioral disorders. In addi- tion, no significant differences in outcomes were observed for the duration of the intervention, quality of the research design, age of the participant, and the specific construct used to mea- sure social skills. The researchers concluded that social skills programs must be designed to fit the individual needs of the child as opposed to forcing the child to fit into the chosen social skills strategy or strategies. Finally, the researchers concluded that the type of skill deficit (i.e., performance deficit vs. skill acquisition deficit) must also be considered when developing a social skills intervention plan. Results were consistent with the low treatment effects observed in the meta-analysis performed by Mathur, Kavale, Quinn, Forness, and Rutherford (1998).

After reviewing numerous studies, Gresham et al. (2001) concluded that meta-analytic reviews of social skills training have yielded a wide variety of results, ranging from ineffec- tual to highly effective interventions. The authors provided a number of recommendations for promoting effective social skills interventions. First, the researchers recommended that social skills training should be implemented more frequently and more intensely than what is typi- cally implemented. They concluded that “thirty hours of instruction, spread over 10–12 weeks is not enough” (p. 341). Second, they concluded that a major weakness of social skills interven- tions is due to the fact that social skills training often takes place in “contrived, restricted, and decontextualized” (p. 340) settings, such as resource rooms or other “pull-out” settings. Third, the researchers posited that the ineffectiveness of many social skills programs is a result of the interventionists’ failure to match the social skills strategy to the type of skill deficit presented. For instance, if the child is experiencing skill acquisition deficits, then intervention strategies

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designed to teach new skills should be selected. Finally, Gresham et al. concluded that the traditionally weak treatment effects of many social skills programs might be the result of out- come measures that do not match the skills that are being taught.

Bellini et al. (2007b) conducted a meta-analysis of school-based social skills interven- tions for children and adolescents with ASD. Results of this meta-analysis suggest that school- based social skills interventions are only minimally effective for children with ASD. A major finding of the study was that students receiving social skills programming in their typical classroom setting had substantially more favorable treatment outcomes than did students who received services in a pull-out setting. Environmental modifications, child-specific interven- tions, collateral skills interventions, PMIs, and comprehensive interventions produced similar treatment results, and there were no differences observed between individual and group inter- vention formats. The results support the recommendations offered by Gresham et al. (2001), which include (a) increasing the dosage of social skills interventions, (b) providing instruction within the child’s natural setting, (c) matching the intervention strategy with the type of skill deficit, and (d) ensuring intervention fidelity.

Specific Social Skills training Strategies

Social skills training can be delivered across a variety of settings (e.g., home, community, classroom, resource room, playground, and therapeutic clinic) and with multiple persons (e.g., family members, teachers, counselors, speech and language pathologists, social workers, occupational and physical therapists, psychologists, physicians, and case managers). In addition, social skills can be taught in an individual, group, or class-wide format. Successful social skills training programs promote cooperation between both parents (and other family members and caregivers) and professionals and should take into consideration the child and family’s culture (see Box 7.2). There are a number of important questions to consider when selecting social skills strategies. For instance, does the strategy target the skill deficits identified in the social assessment? Does the strategy enhance performance? Does the strategy promote skills acquisition? Does the strategy facilitate generalization? If not, what is the plan to facilitate generalization? Is there research to support its use? If not, what is your plan to evaluate its effectiveness with the child? Is it developmentally appropriate for the child? (See Figure 7.1 for more on a developmental perspective of social skills training.) The following section summarizes a number of social skills strategies that have been systematically tested via research. This section is separated into three categories: promoting skill acquisition,

Box 7.2 dIVerSIty noteS

In social skills training, it is critical to understand the role of culture in the interaction and communication patterns of our students or clients. What may be viewed as a social skills deficit by the dominant culture may in fact be an extremely functional and effective social behavior when viewed within the context of the person’s culture. For instance, some persons from Latino cultures may view direct eye contact as disrespectful, especially when communi- cating with an elder (LaFrance & Mayo, 1976). It would be insensitive to instruct this child to maintain eye contact during interactions, and even worse, it would undermine the values instilled in him by his family. In addition to eye contact, culture may influence a number of social behaviors such as personal space, conversational turn-taking, voice volume, and emo- tional expression. It is also extremely important to recognize that there is great variation within cultures regarding interaction patterns. That is, we cannot accurately predict a per- son’s interaction or communication style simply by knowing her cultural affiliation. Social behavior should be evaluated on a person-by-person basis and always viewed within the context of the person’s culture.

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An examination of social skills requires a developmental perspective. That is, social skills change during the course of the child’s development, and as such the focus of social skills training should also change. The following captures the typical development of social skills across three developmental levels: early childhood, middle childhood, and adolescence (adapted from Bierman & Montminy, 1993). These developmental issues are important to consider in both teaching social skills to the individual with ASD and in the implementation of PMIs.

early Childhood

• Engage in shared-play activities • Require interactive play skills • Interactions are brief in duration • Engage in frequent squabbles with peers • Concrete social perceptions • View themselves and others in physicalistic terms (skin color, hair length, size, etc.) • Sociometric status (popularity among peers) more variable • Grudges and preferences for peers tend to be modified continually

Middle Childhood

• Peer-approved social behavior becomes more complex and demanding • Play becomes more organized and rule-bound • Acquire skills related to sustained interpersonal relationships • Acquire self-regulation skills • Compare abilities and characteristics of self and others across time and context • Focus more on relationship aspects of friendship • Become more norm-based in their evaluations of self and peers • Underestimate the competencies of disliked peers (intelligence, physical stature,

athletic abilities, etc.)

adolescence

• Social activities become more diverse • Expectations of friendship develop to include intimacy, self-disclosure, and loyalty • Social withdrawal and isolation increases, especially following peer rejection • Able to anticipate social encounters and consider multiple perspective or viewpoints • Social reasoning develops beyond rigid, rule-based expectations • Perceptions of peers become more rigid and difficult to change • Extremely susceptible to peer influences • More likely to view peer rejection as an indication of personal unworthiness • More vulnerable to social anxiety

fIgure 7.1 Social Skills from a Developmental Perspective

enhancing performance, and facilitating generalization. It is important to note that these strategies do not represent an all-inclusive list of available social skills training strategies. The field of autism is dynamic with new strategies being developed and evaluated on a frequent basis. The strategies selected for this chapter represent a sampling of strategies with documented effectiveness with individuals with ASD.

Skill acquisition Strategies

SoCIal StorIeS Social Stories™ (Gray, 2000) is a frequently used strategy to teach social skills to children with ASD. Sansosti, Powell-Smith, and Kincaid (2004) conducted a research synthesis of eight Social Stories™ intervention studies. The researchers concluded that

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Social Stories™ is an effective intervention strategy in addressing the social, communication, and behavioral functioning of children and adolescents with ASD. Social Stories™ presents social concepts and rules to children in the form of a brief story, which may be used to teach a number of social and behavioral concepts, such as initiating interactions, making transi- tions, playing a game, and going on a field trip. Gray (2000) emphasizes that the story should be written in response to the child’s personal need and that the story should be something the child wants to read on her own (depending upon ability level). She also stresses that the story should be commensurate with the child’s ability and comprehension level. Perhaps, most important, Gray recommends that the story should use less directive terms such as can or could, instead of will or must.

VIdeo modelIng and VIdeo Self-modelIng Video modeling is a technique that involves demonstration of desired behaviors through active video representation of the behav- ior. A video modeling intervention typically involves an individual watching a video demon- stration and then imitating the behavior of the model. Video self-modeling (VSM) is a specific application of video modeling wherein the individual learns by watching her own behavior. Results of a recent meta-analysis suggest that video modeling and VSM are highly effective intervention strategies for addressing social-communication skills, behavioral functioning, and functional skills in children and adolescents with ASD (Bellini & Akullian, 2007a). Results demonstrate that video modeling and VSM effectively promote skill acquisition and that skills acquired via video modeling and VSM are maintained over time and transferred across persons and settings.

The effectiveness of video modeling and VSM for individuals with ASD can be attributed in part to the fact that video modeling and VSM integrate an effective learning modality for children with ASD (visually cued instruction) with a well-studied intervention technique (modeling). In addition to capitalizing on the effectiveness of visual instruction, there are a number of other factors that make video modeling and VSM effective interven- tions for children with ASD. As Bandura (1977) theorized, attention is a necessary com- ponent of modeling. That is, a person cannot imitate the behavior of a model if the person does not attend to the model’s behavior. Some individuals with ASD exhibit overselective attention or attend to irrelevant details of the environment. The use of video modeling allows interventionists to remove irrelevant elements of the modeled skill or behavior through video editing. The removal of irrelevant stimuli allows the individual with ASD to better focus on essential aspects of the targeted skill or behavior. In addition, video modeling and VSM can be implemented with minimal human interaction, thereby reducing much of the distress and anxiety related to social interactions. (See Box 7.3 for more on anxiety issues in individuals with ASD.) Motivation could be another factor contributing to the success of video model- ing and VSM interventions. Watching videos is a highly desired activity for many children with and without ASD, leading to increased motivation and attention to the modeled task. In VSM, motivation to watch oneself on the video may be enhanced by the portrayal of pre- dominantly positive and successful behaviors, which may also increase attention and enhance self-efficacy.

SoCIal proBlem SolVIng Many children with ASD have difficulties interpreting and analyzing social situations. This is due to a number of factors, including lack of self-awareness, failure to read nonverbal and contextual cues, difficulties with perspective-taking, and fail- ure to understand social rules. It is also due to the fact that they lack the necessary skills and strategies to analyze social situations. Research has demonstrated that social problem solving (SPS) can be taught to children with ASD. A meta-analysis conducted by Beelman, Pfingsten, and Losel (1994) found that SPS strategies were effective in increasing performance on social problem tasks. However, a major limitation noted by the researchers was that these increases in social problem-solving ability had no carryover effect to other areas of social functioning, such as specific social behaviors or skills. That is, SPS strategies may increase social problem solving, but their impact on social skills and social competence is questionable.

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Box 7.3 reSearCh noteS

The Relationship between Socials Skill Functioning and Social Anxiety Recent research suggests that individuals with Autism Spectrum Disorders may exhibit signifi- cantly higher levels of anxiety than the general population (Bellini, 2004; Gillott, Furniss, & Walter, 2001; Green, Gilchrist, Burton, & Cox, 2000; Kim, Szatmari, Bryson, Streiner, & Wilson, 2000). These studies suggest that individuals with ASD exhibit a broad range of anxious symptoms, including physiological arousal, panic, separation anxiety, and social anx- iety. Anxiety can be a debilitating disorder, often associated with excessive worry and fear, and isolation. Social anxiety is particularly salient to a discussion of social skills, given the impact that it has on social functioning. The essential feature of social anxiety is an intense fear of social situations or performances. Bellini (2006a) presents a developmental pathway that describes both the development of social skills deficits and social anxiety in adolescents with ASD. The research indicates that the path to social skills deficits and social anxiety for individuals with ASD begins with an early temperament that is marked by a high degree of physiological arousal. This physiological arousal makes it more likely that the young child with ASD will become overwhelmed by interactions with others and avoids subsequent social interactions. Social withdrawal then limits the opportunity for the child to develop effective social skills by limiting her ability to interact with peers. Impairment in social skills func- tioning significantly increases the chances for negative peer interactions and social failure. To complete the pathway, the presence of physiological hyperarousal makes it more likely that the individual will be conditioned by these negative social experiences, leading to increased social anxiety. The model provides valuable treatment implications for practitioners working with individuals with ASD and comorbid social anxiety. As a result of this research, Bellini offers the following recommendations for practitioners addressing the social-emotional func- tioning in children with ASD:

1. It is imperative that we assess anxiety in children with ASD to examine how it may be influencing their social performance.

2. Social skills programs should include teaching the child how to regulate her physio- logical responses to stressful events.

3. Early intervention to decrease social withdrawal is critical to the development of social skills.

4. Social skills training should be an integral component of a child’s individual education program (IEP) throughout her education career.

5. Peer intervention strategies should be used to facilitate an atmosphere of acceptance and caring to minimize the possibility of negative peer interactions.

Many different methods and techniques have been used to facilitate the development of social reasoning in children with and without ASD (Elias, Butler, Bruno, Papke, & Shapiro, 2005). SPS strategies can be used in individual and group social skills programs or they can be incorporated into a classroom curriculum. The following represents an example of SPS strategy that incorporates many of the basic elements of social problem solving. The first step of the SPS process may be to describe the social scenario, setting, behavior, or problem (what’s happening or what has happened?). The next step may be to predict the consequences (what do you think will happen next? what will be the consequences of this behavior?), and then select an alternative behavior (what could he/she/you have done differently?). Finally the child may be asked to predict a consequence for the alternative behaviors.

pIVotal reSponSe traInIng Pivotal response training (PRT) (Koegel & Koegel, 2006) is an intervention program based on the principles of applied behavioral analysis that is utilized in natural environments and capitalizes on the availability of naturally occur- ring reinforcers. PRT targets so-called pivotal behaviours (behaviors that lead to widespread changes in other behaviors), which facilitates transfer of skills to multiple settings and

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collateral improvements in nontargeted behaviors. PRT directly targets behaviors related to initiation and responding to environmental cues. PRT targets four pivotal areas: responsivity to multiple cues, initiation, motivation, and self-management. PRT teaches children to attend and respond to multiple cues in the environment. Intervention in this area teaches the child to select cues that are relevant in a given context or situation. Intervention in the initi- ation area teaches the child to effectively initiate interactions with others. Intervention in the motivation area addresses the child’s lack of motivation related to social situations. Interven- tion includes giving the child a choice in activity, using natural reinforcers, and reinforcing reasonable attempts at interacting. Interventions in self-management teach the child to be more independent and less reliant on prompts from others in their environment. Humphries (2003) conducted a research synthesis of 13 studies that investigated the effectiveness of PRT. Humphries concluded that PRT is an effective strategy for addressing the behavior, communi- cation, and social functioning of children with ASD.

SoCIal SCrIptIng and SCrIpt fadIng Scripting involves the presentation of a struc- tured script to the child that provides an explicit description regarding what the child will say or do during a social interaction (Mayo & Waldo, 1994). The script may provide a narrative of what to say during a conversation or what to do during an activity. The script may contain the entire sequence of the interaction or only the initiation. For instance, the child might be taught a script for initiating an interaction with a peer who is also taught to respond in a scripted fashion. The benefits of scripting for individuals with ASD have been demonstrated in research involving both conversational scripts (Loveland & Tunali, 1991) and play scripts (MacDonald, Clark, & Garrigan, 2005). A major limitation of scripting is that the child may become reliant on the script and be unable to engage in spontaneous, unscripted interac- tions. Script fading is a research-based practice designed to address this limitation (Krantz & McClannahan, 1998). Script-fading involves the introduction of script to facilitate an increase in social interactions and then a systematic fading of the script over time to promote mainte- nance, generalization, and elaboration of the interaction.

additional Strategies to promote Skill acquisition

There are a number of additional strategies that have been used extensively to teach social skills in other populations. This section will summarize two of those skill acquisition strate- gies: behavioral rehearsal and coaching. Behavioral rehearsal, or role-playing, is used primarily to teach basic social interaction skills. It is an effective approach to teaching social skills that allows for the positive practice of skills (Gresham, 2002). Behavioral rehearsal involves acting out situations or activities in a structured environment to practice newly acquired skills and strategies or previously learned skills that the child is having difficulties performing. Coach- ing utilizes verbal and visual instruction to facilitate the development and performance of social skills. Coaching is a flexible teaching strategy that may take many shapes and forms, but typically contains the following three basic steps: (a) introduce the social rule to the child, (b) provide opportunities to practice or rehearse the skill with a coach, and (c) provide imme- diate feedback to the child regarding her performance.

Strategies to enhance performance of existing Skills

prImIng Priming refers to the “incidental activation of knowledge structures” (Bargh, Chen, & Burrows, 1996), which facilitates memory recall or behavioral performance. The positive effects of priming to facilitate social behavior is supported by other researchers, who used priming to increase the social initiations of preschool children with ASD (Zanolli, Daggett, & Adams, 1996) and to decrease problem behaviors in the classroom (Koegel, Koegel, Frea, & Green-Hopkins, 2003). Video priming has been used to reduce problem behaviors during transitions for children with ASD (Schreibman, Whalen, & Stahmer, 2000).

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The researchers selected transitions in settings deemed most problematic by the children’s parents. The researchers then videotaped the settings to show the environment just as the child would see it (moving through the store, getting ready in the morning, etc.). The children were not depicted in the video.

The usefulness of priming procedures to activate knowledge structures and to facilitate social cognition and social behaviors makes it a valuable intervention component in social skills programming. Social cognitions and social behaviors can be primed by presenting cog- nitive or behavioral primes just prior to performance of the skill or behavior in the natural environment.

Cognitive priming strategies can be either visual (e.g., pictures, videos, modeling, or visual prompts) or verbal instruction (e.g., verbal description of the behavior, discussion of the behavior, or verbal prompts). Behavioral priming strategies involve behavioral rehearsal or prac- ticing the skill or behavior just prior to performing it in the natural environment. Priming does not teach new skills or behaviors; however, it is a powerful strategy for activating skills and behaviors already in our behavioral repertoire.

promptIng Prompts are highly effective in facilitating child–adult and child–child inter- actions in children with ASD (McConnell, 2002; Rogers, 2000). Prompts are supports and assistance provided to the child to help her acquire skills and successfully perform behaviors. Prompts can be used to teach new social skills (in the case of physical and modeling prompts) and to enhance performance of previously acquired skills. In addition, they may be used with novice or advanced performers, in individual sessions or in group sessions, with verbal chil- dren or with nonverbal children, and with preschoolers or with adults. Prompts may be deliv- ered by adults or by other children. A limitation of prompting strategies is that the child with ASD may limit social interactions to only instances in which prompting is provided. As such, a prompt-fading plan is implemented to systematically fade prompts from most to least supportive.

There are five primary types of prompts that may be used to facilitate social behavior. They are discussed from most to least supportive. The most supportive prompts require the greatest amount of adult support and the least amount of independence on the part of the child, whereas least supportive prompts require more independence on the part of the child and less adult assistance. The goal is to use the prompt that provides just enough support—or the least supportive prompt necessary for the child to successfully complete a task. Physical prompts consist of physically guiding a child’s performance of a target skill or behavior and are the most supportive type. Physical prompts range from hand-over-hand guidance (most supportive) to a simple physical touch to facilitate a specific movement (least restrictive). Modeling prompts consist of demonstrating or performing all (most supportive) or part (least supportive) of the desired skill or behavior to the child who imitates the skill or behavior immediately. Verbal prompts include specific verbal directives (most supportive) or instruc- tions or single words and phrases designed to trigger, or jog, a child’s memory of how to perform a task (least supportive). This type of prompt can be used to teach new skills or behaviors and also to enhance performance of existing skills or behaviors. Gestural prompts involve providing a nonverbal gesture that visually directs or reminds an individual to per- form a task. Gestural prompts typically not only include various hand signals but may also include visual cues and supports (pictures, cards, etc.). They range from elaborate (pointing to a location and pantomiming an activity) to simple (pointing to another student to facil- itate a social initiation). Natural prompts are the least supportive type of prompt. These are stimuli that naturally occur in the child’s environment that direct a behavior to occur. This may include a bell ringing or kids lining up to go outside. There are many natural prompts for social interactions. A common natural (and direct) prompt occurs when a person initiates an interaction with us (i.e., asks us a question). This prompt naturally directs our behavior to respond to the person.

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Self-monItorIng Self-monitoring strategies have demonstrated considerable effective- ness for teaching children with and without disabilities to both monitor and regulate their own behavior (Carter, 1993). Self-monitoring can be considered a skill acquisition strategy because it teaches the child to monitor her own behavior, but it may also be considered a performance-enhancing technique because through self-monitoring the child is able to enhance the performance of an existing skill. The self-recording of behavior can be used during the behavioral performance or after the performance (or both). Strategies can target a number of externalizing behaviors, such as time on task, work completion, and disruptive behaviors, as well as internal processes, such as thoughts (self-talk) and feelings (both pos- itive and negative). Self-monitoring strategies may involve having the child record occur- rences, duration, and frequencies of behaviors (whether the behavior was performed, for how long, how frequently it was performed) and the quality of the behavioral performance (how well the behavior was performed). Self-monitoring strategies have also been used effec- tively to address the social and behavioral functioning of children with ASD (Coyle & Cole, 2004; Shearer, Kohler, Buchan, & McCullough, 1996). Shearer et al. used self-monitoring to increase the social interactions of preschool children with ASD. Coyle and Cole used self-monitoring in combination with video self-modeling (positive self-review) to decrease off-task behavior in school-aged children with ASD. Finally, self-monitoring strategies sup- port generalization of skills because they teach children to independently monitor their own behavior.

peer-medIated InterVentIon Peer-mediated intervention (PMI) is an effective strategy for facilitating social interactions between young children with ASD (and other disabilities) and their nondisabled peers (Laushey, & Heflin, 2000; Odom, McConnell, & McEvoy, 1992; Sasso, Mundschenk, Melloy, & Casey, 1998; Strain & Odom, 1986). In PMI programs, nondisabled children in the class are selected and trained to be peer buddies for a child with ASD. As such, the nondisabled peers participate in the intervention by making social initiations or responding promptly and appropriately to the initiations of children with ASD during the course of their school day. PMI allows children with ASD to perform social behaviors through direct social contact and by modeling the social behaviors of peers.

PMI allows us to structure the physical and social environment so as to promote suc- cessful social interactions. PMI can be used in naturalistic settings (classroom and playground) and also in structured settings (structured playgroups). For maximum effectiveness, it is rec- ommended that PMI programs be used in both settings. The use of peer mentors allows the teacher and other adults to act as facilitators rather than participate as active playmates. The use of trained peer mentors also facilitates generalization of skills by ensuring that newly acquired skills are performed and practiced with peers in the natural environment.

poSItIVe reInforCement Social interactions can be stressful and excruciatingly dif- ficult for children with ASD, at least until they acquire sufficient skills and confidence. Therefore, reinforcement is often integrated into most social skills programs. Positive rein- forcement is a powerful motivator of human behavior. Individuals are driven to perform behaviors to obtain a positive reinforcer. A child who receives a reinforcer for initiating an interaction with another child is likely to initiate interactions again in the future. The oppo- site is also true: a child who does not receive a reinforcer for initiating an interaction (e.g., the other child rejects his initiation attempt) will be less likely to initiate interactions in the future. Specific types of reinforcers include attention (from peers or adults), social praise, sen- sory items, tangible items (toys, stickers, food, etc.), and preferred activities (playing a video game or extra recess time).

In addition to increasing wanted behavior, the delivery of positive reinforcement com- municates to the child that adults are monitoring his behavior. This is a very important con- cept for reducing problematic behaviors. Reinforcement also provides feedback to the child

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about his behavioral performance. And since it is the delivery of positive reinforcement, it will involve feedback regarding positive behaviors rather than the negative ones.

facilitating generalization

A critical aspect of all social skills programs is to develop a plan for generalization, or transfer of skills across settings, persons, situations, and time. The ultimate goal of social skills train- ing is to teach the child to interact successfully with multiple persons and in multiple natural environments. From a behavioral perspective, the inability to generalize a skill or behavior is a result of too much stimulus control. That is, the child performs the skill or behavior only in the presence of a specific stimulus (person, prompt, directives, etc.). For instance, the child may respond to the social initiations of other children, but only if his mother is there to prompt him. If mom is not there, he does not respond. Generalization is particularly import- ant for children with ASD who often have pronounced difficulties transferring skills across persons and settings. A number of strategies may be used to facilitate generalization of social skills across settings, persons, situations, and time, including: (a) reinforce the performance of social skills in the natural environment, (b) train with multiple persons and in multiple set- tings, (c) ensure the presence and delivery of natural reinforcers for the performance of social skills, (d) practice the skill in the natural environment, (e) fade prompts as quickly as feasible, (f) provide multiple exemplars for social rules and concepts, (g) train skills loosely (i.e., vary the instruction, directives, strategies, and prompts used during skill instruction), (h) teach self-monitoring strategies, and (i) provide booster sessions (i.e., provide follow-up training after initial instruction has been discontinued).

Summary

Impairment in social functioning is a central feature of ASD. Individuals with ASD experience difficulties related to social initiation, social reciprocity, nonverbal communication, and social cognition. These skill deficits can be separated into either skill acquisition or performance deficits. A skill acquisition deficit refers to the absence of a particular skill or behavior. A performance deficit refers to a skill or behav- ior that is present, but not demonstrated or performed. It is critical to select strategies that match the type of skill defi- cit. Skill acquisition strategies involve techniques to teach new skills. They involve the introduction and demonstration of behaviors that are not presently in the child’s behavioral repertoire. Performance enhancement strategies are designed to facilitate or enhance the performance of existing or newly

learned skills. These strategies enhance performance by either addressing the factor diminishing performance (e.g., lack of motivation, sensory sensitivities) or by providing opportuni- ties to perform newly learned skills. An essential first step of social skills training is to identify the skills that will be tar- geted during intervention. This is done through social skills assessment. The assessment often involves a combination of observation (both naturalistic and structured), interview (e.g., parents, teachers, playground supervisors), and social skills rating forms (parent, teacher, and self-reports). The types of social skills training strategies that should be selected are supported by research and match the type of skill deficit, and social skills training programs should be intensive and imple- mented in natural settings.

Chapter reVIew QueStIonS

1. Describe common social skills deficits in individuals with ASD. (Objective 1)

2. Why is it important to teach social skills to individuals with ASD? (Objective 2)

3. How are social skills and social competence evaluated? (Objective 3)

4. Distinguish between a skill acquisition deficit and performance deficits. How is this dichotomy important to intervention? (Objective 4)

5. What does meta-analytical research tells us about the effectiveness of social skills training for individuals with ASD? (Objective 5)

6. What social skills training strategies are available to teach social skills to individuals with ASD? (Objective 6)

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key termS

Child-specific interventions 131 Cognitive priming strategies 137 Collateral skill interventions 131 Establishing operations (EOs) 130 Functional behavior assessment

(FBA) 129 Generalization 130 Initiation 136 Meta-analysis 131 Motivation 136

Peer-mediated intervention (PMI) 138 Performance deficit 127 Pivotal response training (PRT) 135 Priming 136 Prompts 137 Reciprocity 126 Responsivity to multiple cues 136 Scripting 136 Self-management 136 Self-monitoring 138

Skill acquisition deficit 127 Social acceptability 129 Social anxiety 124 Social cognition 126 Social competence 124 Social skills 124 Social problem solving (SPS) 134 Social Stories™ 133 Social validity 129 Video modeling 134

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Daily Living Skills Chapter 8

Jennifer r. hamrick, M.S. BCaBa University of Texas at Austin

Gena Barnhill, ph.D. BCBa Lynchburg College

CaSe 1 Luis was 4 years old when diagnosed with autism and an intellectual dis- ability. His parents brought him into a private, center-based program for children with autism in order to begin applied behavior analysis therapy. During the assessment, a series of questions were asked to determine his functional skills in terms of daily living.

Developmentally, at 4 years of age, he should have been able to feed himself, attempt teeth brushing, change in and out of clothes, toilet, and so on. But Luis was unable to complete any of these activities inde- pendently, and it was noted during conversations with his parents and in observations that his parents completed all of these activities for him. In order to have his needs met or have his parents complete routines for him, Luis had developed a repertoire of behaviors that would quickly get him access to activities through maladaptive behaviors. In order to get snacks, Luis would point toward food items and cry until Mom or Dad handed him food items.

CaSe 2 Vocational programs that are typically offered as part of a high school degree program provide opportunities for students to go to actual job sites to generalize job skills they may have learned within the classroom setting. While at these job sites, educational assistants or job coaches pro- vide oversight and supervision to students with minimal prompting in order to foster independence.

Cody was a 17-year-old male with autism who was participating in a vocational program as part of his education at a public school. Cody has recently been assigned to a work site at location in order to work on skills within an office setting. During his time at the office, an instructional assis- tant would supervise Cody from a distance in order to allow him to work independently. While working, Cody continually looks to the assistant for approval and asks what the next step is to each activity. The instructional assistant continually verbally prompts Cody to stay focused and keep work- ing. Eventually, Cody brings the materials over to the assistant and continues to question next steps.

CaSe StuDy Examples

Chapter ObjectiveS After reading this chapter, learners should be able to: 1. Identify core characteristics of

ASD that impact a student’s ability to learn daily living skills.

2. Describe the prerequisite skills necessary for daily living skills that should be addressed when working with individuals with ASD.

3. Identify the tools and assessments commonly used to assess and measure daily living skills.

4. Explain how to utilize effective teaching strategies when teaching daily living skills.

5. Discuss the processes involved when making data-based decisions for program development and curriculum for daily living skills.

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CaSe 3 To better meet the needs of the children who are part of a self-contained classroom at a pub- lic junior high school, a special education teacher makes significant changes to the morning arrival routines. Miss Wagner asks the parents to no longer park and walk their children into the classroom but to pull up in the car line and drop their students off just as all of the other parents and students at the school do. Miss Wagner ensured the parents that staff would be assisting and teaching the students their new routines and shadowing them as long as neces- sary in order to build independence with this new routine. Her goal in doing so is to teach her students to be able to get out of their car on their own, get their own materials, and eventually walk to the classroom independently.

After one week of implementing this new protocol for morning arrival routines, all par- ents have been working with Miss Wagner in implementing this new routine, except for Logan’s mom, Mrs. Hall. When the teacher stopped Mrs. Hall one day to ask her if she had any con- cerns about the new routines they were trying to implement for Logan, Mrs. Hall said there was absolutely no way Logan would ever be able to walk down the hall by himself. When ques- tioned about this and why she felt Logan would not be able to complete this routine, Mrs. Hall’s response was, “because he has autism.” Miss Wagner then asked Logan’s mom what the arrival routine was for her other children, all of whom were typically developing. Mrs. Hall informed her that she just pulls up and dropped them off, but again reiterated that Logan was not capable of doing this.

Mrs. Hall and Miss Wagner then began to discuss the long-term goals and ultimate out- comes for Logan and his plans once he is an adult and no longer in school. Logan and his parents ultimately would like for him to live somewhat independently in a group home. Miss Wagner then discussed the importance of this very simple routine and how important it was to focus on this now in order to continue to work toward Logan’s long-term goals.

Mrs. Hall then said she would try this new routine for Logan’s sake for two weeks. Within four days of the new arrival routine, Logan was able to get out of his mom’s car, grab his bags, and walk to class with very little supervision by classroom staff.

IntroduCtIon

Daily living skills are those skills that many of us take for granted as they are a part of our everyday lives and daily routines. Daily routines such as showering and getting dressed for the day, loading the dishwasher, or preparing a meal or snack are routines that take little or no training for an individual who is typically developing. In 1991, Dunlap and Robbins (as cited in Iovannone, Dunlap, Huber, & Kincaid, 2003) reported that these skills should be those that (a) are most likely to have utility in the individual’s life so that he can con- trol the environment, (b) will increase the individual’s independence and quality of life, and (c) increase the individual’s capable performance. A good test of the functionality of a skill is to ask whether the result of not learning a specific skill will necessitate another person to carry out the task. Individuals with autism and other developmental disabilities do not tend to learn these and other valuable daily living or functional skills naturally. Throughout a person’s lifetime, many developmental milestones are crossed, and at each step, new skills and routines are typically learned. Depending on the severity of an individual’s disability, the ability to learn, or acquire, these skills at a level of full independence will play a large factor into how long it might take for a person to learn a specific skill. That being said, educators and behavior analysts who are working with individuals to teach and build daily living skills must use the same practices used to determine what skills will be assessed, targeted, and taught as they use for making determinations for academic skills. When developing an educational plan for daily living skills and functional routines thorough assessments, evidence-based practices, consistent

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methodologies and instructional strategies, and data collected to show progress should drive the decision-making progress when determining which daily living skills should be the target of focus.

Core CharaCterIstICs that ImpaCt daIly lIvIng skIll defICIts

By definition, a diagnosis such as autism or other developmental disabilities means there is a potential for deficits in core areas of functioning. According to the DSM-V (2013), an Autism Spectrum Disorder (ASD) diagnosis means there are deficits in the areas of social and commu- nicative as well as restricted, repetitive behaviors that include sensory abnormalities. When looking specifically at the areas of social and communicative deficits, there are several defi- cits that would directly impact an individual with autism’s ability to independently complete daily living skills and functional routines.

When looking at each component of an ASD diagnosis, each can impact a student’s ability to learn daily living skills in some way. To begin with, social reciprocity is key for con- versations in many daily living skills. If an individual is working on a daily living skill in a community setting that requires asking for help for a sales clerk in order to make a purchase, then this skill would be impossible to master if the individual with autism does not have the ability to have a conversation.

Inability to read social cues as well as adjusting behaviors to fit certain social situations can also hinder a person’s ability to make progress in areas of daily living skills and functional routines when considering functional routines and daily living skills that occur while access- ing the community or that would occur in a vocational setting.

Restricted and repetitive behaviors can also cause problems in learning daily living skills and functional routines. Research has shown the repetitive, or stereotypic, behaviors hinder skill acquisition (Ahearn et al., 2007). Focus on reduction of stereotypic behaviors will be necessary to help build daily living skills.

ultimate outcomes and goals

When determining functioning level for an individual, it’s important to remember that when selecting a functional skill to target, the ultimate goal and outcome for everyone, no matter the skill, would be the ability to complete the skill or routine as independently as they possi- bly can. For some individuals this might mean true independence. In order to be fully inde- pendent, a student must be able to complete a daily living skill or functional routine free of support or prompting from outside sources such as educators, teaching assistants, or caregiv- ers. Considerations should be taken for those to whom full independence might not be a realis- tic goal due to physical limitations related to their disabilities. It will be important to discuss with a student’s support team what level of independence should be reasonably expected from an individual when teaching daily living skills. The guiding factor when making this deter- mination should be based on the least restrictive environment and procedures that are most likely to be successful in allowing the student in question to complete their daily living skills and functional routines with the least amount of support necessary.

social significance

Other considerations to keep in mind when developing goals and objectives for daily living skills and functional routines are the social significance of each goal that is developed. Any time behavior change procedures are being considered, no matter what the behavior, ethical guidelines and considerations should be taken into account to ensure the daily living skills and behaviors of which we are assessing and determining to be a focus are socially significant

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and important. Daily living skills and functional routines should be chosen only for their significance for their importance and not out of convenience for others (Baer, Wolf, & Risley, 1968). While this information seems common sense to most, there are many times I have seen goals written for students that had absolutely no real meaning to the child’s life. Take for example a case I was involved in as a consultant in a public school. I had been called in to help the teacher develop a functional behavior assessment and behavior intervention plan. The student was nonverbal and had very significant challenging behaviors. The student’s behavior, self-injurious head banging had warranted the occupational therapist providing a helmet for him to wear all day. Upon observing the student, it was noted that he had no functional communication to facilitate even completing any daily living skills. As part of the records reviewed prior to any portion of the FBA, I looked at his speech goals that were developed by the speech and language pathologist for this campus. The student had one speech goal: to learn how to wave his hands during a song. A couple of questions came to mind when reading this as it was obvious he did not have any functional language. First, what daily living skill was this speech goal a prerequisite for? What lifelong goal will the goal of hand waving eventually lead to? How is this goal socially significant? When trying to answer each of these questions, it became very clear that this goal was not appropriate for this student and we needed to revisit his goals based solely on the criteria of socially significance. That being said, when developing goals for students keep the following questions in mind:

• What are the student’s lifelong goals? • What prerequisite skills should be addressed in order to build daily living skills or

functional routines? • How will this goal lead to the student’s lifelong goals? • Is this goal socially significant?

Ensuring that each goal is socially important will ensure that goals are being written with the student’s best interest in mind and that they are not just being written at the conve- nience of the educator (Box 8.1 addresses need for fidelity as well as social validity). Table 8.1 lists specific daily living skills that may be goals for some students.

Box 8.1 trends and Issues

Issues that can arise in teaching students in the public school setting with ASD and signifi- cant developmental disabilities deal primarily with treatment fidelity. When looking at what components make an effective educational program for an individual student, the amount of training necessary for the staff members and direct caregivers is key in assuring that interven- tions and instructional techniques are utilized effectively with a high level of quality when teaching new skills, both academic and functional in nature. In a quantitative study that was conducted with universities across the United States, the overall consensus was that pro- fessors teaching special education coursework did not feel they were adequately preparing teachers to work with LID populations. The purpose of this survey was to determine the prevalence of programs training teachers across the United States. Each university was asked about their specific coursework and, on average, how much time was spent teaching about specific instructional strategies, most of which were, and still are, considered evidence-based practices. One hundred and eighty-four instructors at higher education institutes across 43 states responded. When looking specifically at the instructional strategies that are specific to a self-contained setting, an overwhelming majority of universities spent 3 hours or less addressing specific instructional strategies with university students preparing to be teachers in a self-contained setting (Barnhill, Polloway, & Sumutka, 2011). Additional training in undergraduate programs as well as ongoing trainings and continuing education for educators and behavior analysts will continually need to be reviewed while finding ways to strengthen and maintain treatment fidelity when teaching academic and daily living skills to students with ASD and other developmental disabilities.

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IndependenCe

There cannot be enough emphasis placed upon the topic of independence. The ability to inde- pendently complete daily living skills and functional routines is truly the ultimate goal for all when developing plans and educational programs for individuals with autism and other devel- opmental disabilities. So often, I met parents and teachers who have a completely different set of expectations for their children with autism, or any other developmental disability, than they do for their typically developing children who do not have a diagnosis of any kind. I can still remember the first (and only) mother I met years ago who had a daughter in middle school with a diagnosis of autism. She had spent years teaching her daughter daily living skills at home. She could cook, clean, do laundry, and so on, and basically ran the entire house because the ultimate goal and outcome for her daughter was to live in a group home once she finished high school. Her neurotypical daughters who were around the same age had very few of these same skills, but Mom knew she could potentially teach her typically developing daughters these skills in a summer before going off to college as opposed to a lifetime of work it took for her daughter who had autism.

ConCerns when skIlls are not developed

Daily living skills or functional skills are those that are for the most part not taught to us directly, and it is the assumption that many of these skills are just known or picked up through interactions with others (Myles & Simpson, 2001).

When trying to discern the reasons why an individual has not developed certain skills, there are many factors to consider. Have they had the opportunity to learn a specific skill? What, or whom, is preventing the individual from learning new skills? Are there prerequisite skills that must be mastered prior to introducing a new skill?

BarrIers to learnIng and dependenCe on others

Barriers to learning are typically the main reason why individuals are able to make progress on current skills or learn a new skill set. As part of the Verbal Behavior Milestones Assessment and Program Placement, Mark Sundberg (2008) has identified a list of 24 barriers that typi- cally impede and individuals process in the development of verbal behavior. When reviewing this list, as well as the literature discussing each of the barriers, it’s evident that not only will these behaviors prevent development of language or prerequisite skills for daily living skills but it could also prevent skill acquisition of basic daily living skills and functional routines.

taBle 8.1 What are Daily Living Skills?

preSChooL aGe eLeMentary SeConDary aDuLt

play skills playing in groups Uses telephone plans social outings

eating with utensils cleaning up after mealtime preparing meal buying groceries for meal prep

toileting brushes hair Shaves packs clothing for travel

teeth brushing bathes self during bath/shower routine

regulate water temperature for bath water

Schedule doctor appointment

transitions Working in groups Safely crosses streets and roadways

return/exchange items in a store

** While this is not a comprehensive list of daily living and functional skills, these are examples of skills that would be age appropriate for each of these developmental milestones.

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One of the key components to the prevention of developing new skills that could be easily prevented or changed is prompt dependency. An individual becoming prompt dependent is always a concern when teaching any skill, whether it be academic or functional in nature. Many of the instructional strategies that are used to teach students with significant devel- opmental delays are what sometimes leads to students becoming prompt dependent. Acqui- sition of new skills typically happens in a one-to-one setting and necessitates educators and caregivers giving frequent verbal instructions and social praise. Without proper prompt fad- ing, individuals with autism and other developmental disabilities can begin to rely on this frequent reinforcement, making it difficult to build independence (Hume, Loftin, & Lantz, 2009). Table 8.2 lists prompt hierarchies and fading levels to be considered when developing programming in daily living skills.

taBle 8.2 hierarchy of prompting and Considerations When prompt Fading

LeveL oF proMptinG DeFinition exaMpLe

independent the individual is able to complete a daily living skill independent of any help or guidance from a caregiver.

the individual is able to complete the steps of washing his hands completely independent with no need for assistance from anyone.

verbal prompt the individual requires verbal prompts and reminders from a caregiver in order to complete a daily living skill or functional routine successfully.

the caregiver uses a verbal prompt such as “turn on the water” when assisting an individual during a hand-washing routine.

visual prompt the individual requires some sort of visual cue, such as pictures of the steps of the process, or a visual reminder to complete a certain step within the daily living skill or functional routine.

a picture schedule posted above sink shows each step of completing the hand-washing routine.

Model the individual requires some type of modeling of all or a portion of the daily living skill or functional routine in order to complete the skill successfully. Modeling may mean the caregiver is completing the step or routine first, then the individual replicates what she saw.

the caregiver turns on the water faucet, then turns it off in order to demonstrate the next step of the hand-washing routine for the individual to complete the entire daily living skill.

gesture the caregiver might need to make gestures in order to prompt the individual who is unable to complete the next step of the routine.

an example of a gesture might mean the caregiver points to or taps the handle on a faucet to prompt the individual to turn on the water to wash her hands.

partial physical a partial prompt may mean the caregiver must physically touch or guide the individual to complete all or a portion of a routine in order for her to successfully complete the daily living skill or functional routine.

the caregiver nudges the individual’s arm or hand in the general direction of the handle on the water faucet.

Full physical a full physical prompt may mean the caregiver using full, hand over hand, guidance to help an individual complete all or portions of a daily living skill or functional routine.

the caregiver, hand over hand, helps the individual by placing her hand on the handle of the water faucet to turn it on.

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ChallengIng BehavIors

Other barriers that may hinder the ability of students to complete daily living and functional skills are challenging behaviors. Challenging behaviors can be defined as behaviors that inter- fere with instruction or life in general for an individual and are not only challenging to the person who is displaying said behaviors but also challenging to parents, teachers, and other caregivers who are a part of their environment (O’Reilly et al., 2010). As with any behavior that is impeding the learning of an individual with a developmental disability, a thorough assessment of what is causing the behavior, or the function of this behavior, should be con- ducted in order to find ways to decrease these behaviors while finding functionally equivalent replacement behaviors. If it’s found that challenging behaviors are one of the main reasons an individual with autism or other developmental disabilities is not making adequate progress toward their daily living skills and functional routines, then a functional behavior assessment is warranted.

prerequisite skills

Lastly, of the potential barriers that could be inhibiting an individual from learning daily living skills and functional routines are prerequisite skills. Many functional skills are learned in the natural environment through imitation for individuals who are typically developing. A deficit for children with autism is the ability to imitate; therefore, lacking the prerequisite skill of imitation hinders the ability to learn new skills that are being modeled by caregivers, whether it be in the natural environment or by direct instruction (Cardon and Wilcox, 2010). This goes back to the ultimate outcomes and goals we set for our students. No matter the age of the student, when working with students and families to determine an education plan, the long-term goal should be plans for adulthood. Once the type of living and vocational goals the family has for their child are clear, it is essential to ensure that the goals we are working on will eventually lead to the life-long goals.

Prerequisite skills are not limited to just imitation. Functional communication is key for students to have as well when learning daily living skills. As discussed previously in terms of barriers to learning daily living skills, language development will be imperative. Additional skills of learning how to attend to specific tasks; how to attend in a group; how to work inde- pendently and complete tasks; how to follow rules, timetables, and work schedules; and how to avoid irrelevant stimuli and attend to relevant stimuli when possible will be necessary and specifically taught to individuals with ASD.Once basic skills are functional and fluent, then additional communicative skills related to specific functional routines can be taught as part of the daily living skills and functional routines.

daIly lIvIng skIlls—developmental mIlestones

toddler/preschool age

When children with autism and other developmental disabilities are diagnosed, a number of skills are assessed. Based on the deficits found through assessments, a treatment, or educational, plan is developed to focus on the skills that are imperative for student growth. As part of the educational programming for very young individuals who are newly diagnosed, daily living skills and functional routines should be a focus of a child’s program from the very beginning. Developmentally, there are skills that could be considered daily living and functional for each age level. When working specifically with individuals who are preschool age, it’s important to first focus on the development of daily living skills that will help integrate them into the least restrictive environment for their age level. Part of these basic skills to help preschool- age children integrate into an environment with children in a least restrictive environment is language development as a prerequisite. Along with language, an additional prerequisite

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would be motor imitative skills. Receptive language and motor imitation will be key to teach the basic functional skills that are appropriate for preschool-age children. Examples of some of the first skills many parents and caretakers teach when teaching daily living and functional skills that incorporate many of the prerequisite skills discussed can be jumping, hopping, and playing ball with a peer or adult, which can incorporate not only motor actions of catching and throwing but language as well. Daily skills at the preschool level should be centered around age-appropriate play skills as well as functional skills such as basic dressing skills like putting on sock and shoes, opening food containers, and turning lights on and off. Skills also taught in preschool programs help children to function within the classroom setting and prepare them for classroom routines and learning in future grades. The following skills are considered by as cited in Dawson et al. (1997, p. 319), as a beginning list of survival skills that are taught in preschool programs to children to help them to function independently in a general education classroom:

• Complying with adult requests • Taking turns • Listening to directions from afar or near • Sitting quietly during activities • Volunteering • Raising one’s hand to solicit attention • Walking in line • Using toilets in classroom versus in the hallway • Picking toys up after use • Communicating about basic needs

elementary

Transition into kindergarten from a preschool program should be relatively smooth if an individual with autism or other developmental disabilities have had extensive training in daily living skills. During elementary school, there are many daily and functional routines that are imperative for students to learn in both the home and school setting. Developmentally, students are ready for basic classroom routines. If students entering kindergarten and other elementary grades have yet to master the prerequisite skills discussed previously as well as functional and classroom skills from the preschool classroom, they should still be considered a priority for learning. No matter the age of the individual in which an educational plan is being developed, it’s important to consider what Dunlap and Robbins (1991) stated as considerations for what can be called functional independence. Skills that create functional independence will: (a) allow individuals with ASD and other developmental disabilities the utility so that they can control the environment, (b) increase the individual’s independence and quality of life, and (c) increase the individual’s capable performance.

Utilizing assessments specifically to assess skill deficits in individuals with ASD and devel- opmental disabilities will ensure that the necessary skills will be addressed and will build upon prerequisite skills in order to increase functional levels. Use of assessments such as the ABLLS-R, AFLS, and the VB-MAPP will help educators and behavior analysts to make data-based decisions and drive instruction.

secondary/adult

As secondary students, individuals with autism or other developmental disabilities not only work on daily and functional routines to help them be successful and independent within their home and school settings but there should also be a large focus on vocational and community routines. At this point in an individual’s education, classroom routines and instruction will begin to shift toward teaching the necessary skills for life after graduation. If we refer back to the previous section on elementary and look at what constitutes functional independence, it

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is much different for a high school student aging out of the school system and moving into adulthood. Think about the skills that you or I complete on a daily basis and each of these should be skills educators and behavior analysts are including in academic and individualized instructional plans for students with ASD and developmental disabilities.

transition training and planning

The Individuals with Disabilities Education Act (IDEA) states that part of the educational programming for a student with disabilities is a focus on preparing and transitioning a stu- dent into post-secondary life, whether that be continued education, independent living, or community participation (IDEA, 2004). Transition plans vary per school district, but the ulti- mate goals and outcomes for each transition plan should be to determine community, living, social, and vocational goals for a student while they are still in the school setting that will prepare her for life as an adult after high school. While schools are only mandated to start transition plans at 14 years of age, it’s imperative the educators keep a student’s lifelong goals in mind when developing IEP goal and objectives. A question that ever teacher should ask parents of children with autism and other developmental disabilities is, “Where do you see your child when he or she is 25 years old? 35 years old?” What kind of job do you think he will have? Where will he live? What do you think he will do for fun? The answers to these questions when asked of a parent of a 4-year-old may differ 5 years later, but keeping the plans for students as young as four in the forefront of an educator’s mind as they plan that child’s individual education plan.

The most important part of transition planning is the inclusion of the student in mak- ing decisions about his future as an adult. Educators who are assessing preferences for living, vocational, and social activities after high school will only get accurate answers for each area by directly asking the student. If the student is unable to answer these questions themselves, then information from caregivers as well as information from previous assessments, IEP goals, and progress reports can help garner information that can be used for transition. Goals developed for transition into adulthood should be no different than other academic and daily living goals and objectives in that they should be easily assessable and measureable. Data will be collected and analysis of the data occurs for transition visual goals just as it does for academic goals.

InstruCtIonal strategIes

Behavior analytic principles

According to No Child Left Behind (NCLB) and IDEA, when teaching students with devel- opmental disabilities, educators and school districts should use instructional strategies that are based on scientific research. Simpson (2005) pointed out that No Child Left Behind (NCLB) mentioned the use of scientifically based research more than 100 times. Scientifically based research is defined as “research that involves the application of rigorous, systematic, and objec- tive procedures to obtain reliable and valid knowledge relevant to education activities and pro- grams” (NCLB, 2002). Furthermore, Simpson (2005, p. 142) reported that NCLB considers the “gold standard” of scientifically based practices to include resources and materials that were validated by means of research designs that used random samples and control and experimen- tal groups. However, for several sound and ethical reasons, randomized control group designs are not often used in research with individuals with ASD. Simpson (2005) concluded that the scientifically based research requirement of NCLB seems to be restricting and imped- ing the identification of effective practices involving students with ASD. He also pointed out that the National Research Council (2001) recognized that there were times when ran- domization was not feasible. It is critical for educators and families to be informed about the research literature regarding effective treatments for autism so that harm is not done in pro- moting unproven treatments and time and money is not wasted when another more effective method could have been implemented (Herbert, Sharp, & Gaudiano, 2002).

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Evidence-based practices and types of instructional strategies used when teaching children with autism and other developmental disabilities can mean many things. For the purposes of this text book, evidence-based instructional strategies are based on the methodologies of applied behavior analysis. While IDEA and NCLB do not have defin- itive measures as to what evidence based specifically means, The National Professional Development Center on Autism Spectrum Disorders (NPDCASD) has defined this to mean single-case design studies that have had at least five high-quality investigations conducted by at least three different investigators (NPDCASD, 2013). With decades of research to substantiate the use of applied behavior analysis to teach new skills, this is not only recom- mended for other subject areas discussed within this textbook but should be utilized when teaching daily living skills and functional routines as well. Further, student cultural diver- sity may also be a consideration (see Box 8.2).

There are a variety of behavior analytic principles that can be utilized when teaching daily living skills and functional routines. First and foremost, task analysis is one of many behavior analytic principles to use. Cooper, Heron, and Heward (2007) define task analysis as “breaking a complex skill into smaller, teachable units, the product of which is a series of sequentially ordered steps or tasks.” Think back to your days in junior high and your science teacher making you write down the steps of making a peanut butter and jelly sandwich. Once you wrote out all of the directions, you were then to tell him step by step what to do. If, at any point, you had left out a step or forgotten to write something out as a step, the process stopped and the PB&J was never fully completed. This is a task analysis. If I think back to the way Coach Lucas wanted me to task analyze making a PB&J, there are essentially 27 steps to a PB&J from the time I gather my supplies until I take a bite of my sandwich.

When task analyzing daily living skills and functional routines for individuals with autism and other developmental disabilities, we would take the same step-by step process to each routine that we will be teaching. How much you have to break down the routines is solely based on the individual learner. For example, let’s say you have two students who need to learn to independently wash their hands. Joe requires extensive training for skill acquisition of all of his skills while Kim may only need a few prompts. Joe’s task analysis may have nine steps that break down what to do when washing his hands and it will be the teacher’s responsibility to help him become independent with each step of the process. Kim may only need to know: (a) get soap, (b) wash your hands, and (c) dry your hands.

Task analyzing the skills and routines lets the educator and caregivers know where to step in and help with certain tasks or behaviors while allowing the individual to be as inde- pendent and successful as possible throughout daily routines.

generalization of skills

prompt fadIng While prompt dependency is something educators and caretakers should actively try to prevent, the use of prompts are necessary when teaching brand new skills. Skill acquisition typically requires the educator to use errorless learning techniques to ensure the learner contacts reinforcement and learns each step of any given task anal- ysis or skill being presented. Careful consideration for the types of prompts used as well as how to fade the prompts as quickly as possible should be considered in order to avoid prompt dependency. Choosing the lowest level of prompting necessary and trying to fade that prompt out quickly can prevent antecedent control from inadvertently being shifted to the prompt.

assessments of daily living skills

As with any skill being taught, it’s important to make decisions as to what or how these skills will be mastered based on data and thorough assessments of skill sets, or lack thereof. Until recent years, having a thorough assessment that educators or behavior analysts could use to

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determine an individual’s skill set was somewhat limited. With increased work on daily living skills and functional skills, some assessments have been developed to gather data and infor- mation in order to make a data-based decision about what type of programming to use when teaching these important skills.

While there are norm-referenced tests that look specifically at adaptive behavior, many of these assessments require extensive training and an understanding of how to score them based on the norm-reference scales associated with them. These are typically not something that classroom teachers or behavior analysts will have specialized training in to use when developing treatment programs to focus on daily living scales.

While assessments such as the Verbal Behavior Milestone Assessment and Placement Program (VB-MAPP; Sundberg, 2008) and Assessment of Basic Language and Learning Skills-Revised (ABLLS-R; Partington, 2008) look at very basic functional skills for children, they are limited to focus on skills that early learners and young children would need to access their environments. Two assessments that specifically address daily living skills for older stu- dents and adults have been developed in recent years that are relatively easy to use not only for teachers and behavior analysts, but could also potentially be used by other caregivers when determining the level of independence for basic skills for individuals with autism and other developmental disabilities.

faCter The Functional Assessment & Curriculum for Teaching Everyday Routines, or FACTER, is an assessment that can not only be used to assess the baseline skills of a student with developmental disabilities but also allows for the student booklet that is used for assess- ment to be used as an instructional and curriculum guide when developing IEP goals and instructional plans for daily living. Also, it’s possible to use this booklet and the data and information gained through evaluation to monitor progress for students as part of the IEP team meetings.

FACTER is divided up developmentally by age-appropriate skills that a student should be completing independently in both elementary and secondary levels of public school. While both elementary and secondary student booklets address the same domains in terms of func- tional skills, the secondary student booklet addresses more areas for accessing the community and career routines in order to begin developing levels of independence in preparation for transition into adulthood.

Students in both elementary and secondary schools can have a student booklet used to assess their daily and functional routines by scoring their level of independence when completing the steps of a task analysis for each routine assessed through FACTER. Ideally, every step of the routine should be scored as independent. When assessing baseline scores for each task analysis, the assessor must calculate the total score based on the “Independence Measurement Scale” levels of independence and divide this by the total number of tasks in that specific routine. The “Independence Measurement Scale” is a Likert scale that measures from 0 to 4 the ability to complete a routine independently; 0 = not able to complete at all with 1 = requires a full physical prompt continuing through the hierarchy of prompting to 4 = independent.

An example of a daily routine measured with FACTER would be a basic skill such as going to the bathroom. If you take into consideration all of the steps of using the restroom such as walking into a bathroom, turning the light on, and so on, you could potentially have up to twenty steps of a task analysis and each step should be completed independently.

Example of FACTER score for a routine:

Combined total of scores on Independence Measurement Scale/Total number of steps = 45/20 = 2.25

Based on this score, the overall routine would indicate the individual requires, on aver- age, some level of physical assistance and is not completely independent at completing this routine. Looking at each step of the task analysis, the teacher, or whomever is teaching this

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skill, can annotate what type of instructional strategies can be used to teach the steps that are not being completed independently as well as how to fade the prompts that are being used during these steps.

afls The Assessment of Functional Living Skills, or AFLS, is a relatively new assessment that addresses a comprehensive list of skills across several areas of an individual’s life. There are several, separate modules that address multiple areas such as basic living, home, community, school, vocational, and independent living skills. Once completed, each assessment module can then function as a curriculum guide to help educators, behavior analysts, and caregivers throughout the process of teaching these critical skills. Each module contains a skills tracking chart that will be recognizable to educators and behavior analyst who are familiar with com- pleting an ABLLS-R assessment. While this assessment is not broken down developmentally into levels and milestones as FACTER, it does provide a continuum of skills from the very basics of functional skill. For example, when assessing meal time behaviors, the skills are as simple as knowing which foods to use utensils with while eating to completely cleaning the dining area and kitchen once a meal is complete.

development of goals and oBjeCtIves for daIly lIvIng skIlls

No matter what setting an individual is in when learning daily living skills, developing goals and objectives is no different than when developing academic goals. Once the assessment of choice has been completed, next steps would be to carefully look through the assessment to determine the strengths and deficits of each individual and utilize this information to choose goals for each learner. Each of the assessments discussed within this chapter have a visual anal- ysis tool, or a main way to summarize the information found while conducting the assessment. Once this information is collected, the educator or teacher can then look at each skill or task that did not meet mastery criteria. These skills or task would be the basis for each goal devel- oped within the IEP; therefore, allowing development of the IEP for functional, daily living goals to be solely based on data.

measurement of goals and progress

As noted earlier in this chapter, when teaching daily living skills, similar approaches would be utilized as would with teaching academics and other areas of focus for children with autism and other developmental disabilities. Evidence-based practices such as behavior analytic meth- odologies should be utilized when teaching daily living skills. As such, when measuring the goals and objectives that were previously determined to be of focus of an individual’s daily liv- ing program, dimensions of the behaviors must be defined in such a way that behavior analytic measures can be utilized to quantify progress so that data-based decisions can continually be made on program development and progress.

As part of the process of developing goals and objectives for daily living skills, educa- tors and behavior analysts should determine at the time of goal and objective development what type of data collection procedures will be used to measure progress. For example, when writing an IEP goal that addresses daily living skills, if mastery criteria are looking at level of prompt dependency and prompt fading, then data may actually be taken on the level of prompting necessary to complete the routine. Let’s say an individual is capable of completing a tooth brushing routine but takes an extraordinary long time to do so and the goal states reducing the amount of time needed to complete the routine, then we would ultimately make the determination to take data on duration of the routine. Table 8.3 lists some appropriate daily living goals.

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Data ColleCtion ProCeDures

Once the fundamental type of measurement is determined, the procedure in which data will be collected will need to be selected as well. As a consultant within a public school setting for many years, my advice to educators was to create or choose the data sheet at the same time the goals and objectives are being developed. Also, make the decision at this time how often data will be taken, who will be taking the data, and how specifically it will be graphed. In doing so, there is a clear expectation of the educators and caregivers to continually use this informa- tion to guide teaching daily living skills and functional routines.

Types of data collection for daily living skills may vary. We’ve discussed using task analysis to help develop a way to teach the different steps of each functional routine. Let’s assume when teaching a skill such as hand washing, the educator is utilizing errorless teach- ing strategies so that the learner is able to complete the routine of washing his hands with no mistakes. In order to take data on the steps of the task analysis, the person can take data on the level of prompting required to complete each step. This information can help to guide steps in prompt fading as well as see how quickly the student is making progress toward independence.

When measuring levels of independence, taking self-graphing data is a simple choice. When marking the data, it allows you to skip graphing because it does if for you. An example is provided in Table 8.4.

table 8.3 Examples of Measureable Goals and Objectives in Each Content Area

FunCtiOnAl Skill tArGEt BEhAviOr GOAl

toileting Student will be able to independently complete the steps and process of a toileting routine in order to successfully void in the toilet.

Student will be able to independently pull down/off clothing in order orient him/ herself to sit on the toilet 80% of the time as measured by correct occurrences/total opportunities.

Mastery criteria are met when student is able to complete this task four/five opportunities across a minimum of two settings.

Student will be able to urinate in the toilet with no more than one accident per week as measured by correct occurrences/total opportunities.

eating Student will be able to independently eat meals/snacks on his own in a cafeteria setting.

Student will independently open lunchbox four/five opportunities in order to get items out for meal time.

vocational Student will be able to independently follow through with the steps and process for arriving to work.

Student will independently clock in and clock out of work using his employee’s system 9/10 times as measured by permanent product.

Student will be able to take a break for lunch independently.

Student will independently take a break for lunch on time and return to work at the correct time four/five times as measured by permanent product of time card.

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When using a data collection system that tracks the level of prompting necessary, you can then connect the data points to create the graph that shows decrease in the amount of prompting, which, in essence, allows you to see how independent the individual is becoming when completing the routine.

Additional data collection systems should be considered as well. As discussed earlier, it is best to choose the method of data collection as soon as the IEP goals are chosen. As a future educator, you know that when developing IEP goals and objectives, they must be measurable, (IDEA, 2004). While measurability was not operationally defined by IDEA, finding a way to quantify each skill will help to guide the process of goal development. Ideally, IEP goals should be written with the type of measurement in being used. An example of this would be: “Student will be able to use functional communication to request help from staff when need- ing assistance 4 out of 5 opportunities as measured by frequency.”

Once the IEP goal is developed and the type of measurement is determined, in this case frequency, the data collection procedures should be determined. Considerations for this not only have the type of measurement, but there will also be a time limit to when data is col- lected as well as whether correct and incorrect responses be recorded?

Data collection should be taken daily for goals that are in skill acquisition and being taught daily. Once collected, visual analysis will need to occur in order to see if the skill is improving to the point of mastery, and if not, what instructional strategies or level of prompt- ing need to change in order to ensure the skills are being taught effectively.

vIsual analysIs of progress

Once the data is collected, visual analysis should be conducted in order to see if the behav- iors or skills targeted changed, and if so, it can it be directly related to the interventions and instructional strategies employed by the educators and caregivers (Cooper, Heron, & Heward, 2007). Graphing the data that has been collected can be done many ways. When measuring data and analyzing this information, the first thing to consider is the level of mastery that has been determined when writing each individual goal. In looking at the goal previously used in this chapter, “Student will be able to use functional communication to request help from staff when needing assistance 4 out of 5 opportunities as measured by frequency,” we can calculate that mastery of this goal would be 80%. When interpreting the data from each day’s data col- lection procedures, it will be educators and behavior analysts who will look into the data and the mastery criteria are set in order to see if the skill has been mastered and what steps will then be necessary to maintain the goal at mastery level.

taBle 8.4 Self-Graphing Data Sheet

i i i i i i i i i i

verb verb verb verb verb verb verb verb verb verb

vis vis vis vis vis vis vis vis vis vis

g/M g/M g/M g/M g/M g/M g/M g/M g/M g/M

pp pp pp pp pp pp pp pp pp pp

Fp Fp Fp Fp Fp Fp Fp Fp Fp Fp

goal: washing hands. i = independent; verb = verbal prompt; vis = visual cue or picture; g/M = gesture or model; pp = partial physical prompt; Fp = full physical prompt.

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summary

Daily living skills and functional routines are essential skills that should be a primary focus of education and an import- ant part of an individual’s IEP when in the school setting. Considerations for teaching daily living skills should focus on independence, and keep in mind that any specific skill that requires assistance from another person hinders an individ- ual with ASD or other developmental disabilities from being completely independent and successful on their own. These skills can be taught at any age level, and determination of what skills should be taught should be based on age appropri- ateness and functioning level of the individual.

Core characteristics of ASD, such as social skill and communicative deficits, have a profound impact on an individual learning daily living skills. Focusing on the deficits that are directly related to these characteristics and teaching prerequisite skills will help to determine skills that are of social significance to the individual and their success at being as independent as they possibly can be. If daily living skills and functional routines have not been mastered by an individual with ASD or other develop- mental disabilities, it will be important for the educator or behavior analyst to take into consideration barriers to learning that might be impeding progress with specific skills. Challenging behaviors, prompt dependence, and lack of functional communication are just a few of the

barriers to learning that can prevent growth and develop- ment in daily living skills as well as many other goals that are more academic in nature.

Daily living skills and functional routines look very different across the age levels. Many people assume these are skills solely focused on secondary schools or transitioning to adulthood, but toddler and preschool-age children can learn daily routines and skills that are age appropriate for them and will help to prepare them for the classroom setting once in public school. From then on, daily living skills will not only continue to grow and become age and developmentally appro- priate and begin to shift from being academic in nature for preschool- and elementary-age students but will also begin to focus on functional skills and daily living routines for individ- uals as they become teenagers and begin the transition process into adulthood.

Once daily living skills have been established, instruc- tional strategies to be used to teach these skills should be determined while keeping in mind that evidence-based prac- tices such as applied behavior analysis should be utilized to ensure the most effective teaching strategies are being used to teach new skills.

A range of assessments have been developed in recent years that address many of the daily living skills and func- tional routines that individuals, no matter the age, should

Box 8.2 dIversIty

Traditional intervention and instructional techniques have focused on the acquisition of aca- demic learning, adaptive and functional skills, communication, and the reduction of problem behaviors for students with autism to develop independence and self-responsibility (Wilder, Dyches, Obiakor, & Algozzine, 2004). However, multicultural students with autism have “triple layered problems—they are culturally different, they may be linguistically different, and they have an exceptionality that is loaded with behavioral repertoires” (Wilder et al., 2004, p. 105). Evidence seems to support the idea that multicultural students have more challenges with the academic and behavioral customs of the school culture than do students from the dominant culture. Given the relative paucity of research specific to the challenges multicultural students with autism face, it is not clear if the traditional focus of interventions will be effective for multicultural students with autism and their families. Research in this area is in its infancy (Wilder et al., 2004). Therefore, educators are strongly encouraged to learn about their students’ cultures and infuse the curriculum with materials that reflect their students’ cultures. Furthermore, given the research support for parents’ involvement in the educational planning of their children with ASD, it is important for educators to understand the multicultural family’s customs and the importance they place on teaching academic skills. Not all cultures view independence and community-based competence—which are compo- nents of middle- to upper-class European American cultural values in the United States—as valuable (Wilder et al., 2004). This is important information to consider when developing IEP goals for multicultural students with autism.

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Internet resourCes

AFLS assessment: https://www.partingtonbehavioranalysts.com/page/afls-74.html

FACTER: www.proedinc.com

The National Professional Development Center on Autism Spectrum Disorders: http://autismpdc.fpg.unc.edu/

National Autism Center’s National Standards Project: www.nationalautismcenter.org/nsp/

acquire in order to be an independent adult. These assess- ments (ABLLS-R, AFLS, VB-MAPP, FACTER) look at a vari- ety of daily living skills for both young and adult learners and provide quantifiable information and data for the educator to use in order to make an informed decision when developing daily living goals.

Data collection procedures as well as visual analysis of the data on skills being taught will help drive instruction and allow educators and behavior analysts to make changes to the program in order to ensure effective instruction is occurring and each learner is working toward their highest level of inde- pendence possible.

Chapter revIew QuestIons

1. Name three core characteristics of ASD that may impact a student’s ability to learn daily living skills. (Objective 1)

2. What prerequisite skills should be a primary focus of instruction prior to teaching daily living skills and func- tional routines? (Objective 2)

3. Name two assessments that have been developed in recent years that specifically assess daily living skills for individ- uals with developmental disabilities. (Objective 3)

4. What are some specific instruction strategies that are evi- dence based that can be used to teach daily living skills? (Objective 4)

5. Once skills are assessed, what should then occur with the findings in order to make an informed decision with instruction and data collection? (Objective 5)

key terms

Prompt dependence 155 Task analysis 150 Skill acquisition 150

Functional skills 145 Functional independence 148 National Research Council 149

Scientifically based research 149

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Effective Practices for Teaching Academic Skills to Students with Autism Spectrum Disorders

Chapter 9

Stephen Ciullo, ph.D. Texas State University—San Marcos Research Fellow—The Meadows Center for Preventing Educational Risk

This chapter describes effective strategies, techniques, and resources to enhance the academic outcomes of students with Autism Spectrum Disorders (ASDs). Other chapters in this book describe in detail vari- ous techniques to improve challenging behaviors, social skills, and other aspects related to the school and life outcomes of students with ASD. However, in recent years, there has been an emphasis on the need for edu- cators to understand which instructional practices are based on research, and how they can be implemented to improve another critical compo- nent contributing to the development of students with ASD: long-term academic success.

This chapter was written to accomplish the following goals. First, since academic standards are changing across the United States, an explanation of these changes and how they impact students is provided. Next, descriptions of learning needs that are specific to students with ASD are described to provide context to the challenges facing educators. Then, a description of research related to improving the academic outcomes of students with ASD is included along with suggestions for teaching practices in reading, writing, and mathematics. The chapter concludes with considerations for differentiat- ing and modifying the curriculum and provides helpful resources for future learning and professional development.

Chapter ObjEcTivES After reading this chapter, learners will be able to: 1. Describe the current academic

expectations that will influence the education of students with ASD and educators in the next several years.

2. Discuss the learning needs that are unique to students with ASD that must be considered by educators to promote academic success.

3. Summarize key research findings on effective instruction and intervention for students with ASD in reading, writing, and mathematics, and explain how these strategies can be implemented.

4. Describe how educators can incorporate principles of Universal Design for Learning (UDL) to modify or adapt instruction to meet the academic needs of students.

5. Identify additional resources to access evidence-based instructional programs to enhance the educational outcomes of students with ASD.

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Looking ahead: aCademiC expeCtations that impaCt students with asd

Educators of students with disabilities, including the professionals who teach students who have ASD, must consider how national reform and accountability movements impact the edu- cation of their students. In 2001, the No Child Left Behind Act resulted in increased educator and student accountability as measured though standardized testing in Grades 3–12. This meant that educators were encouraged to use evidence-based practices (EBPs) to teach stu- dents and that ongoing progress monitoring was needed to inform intervention for students that struggled (Yell, Drasgow, & Lowrey, 2005). Now, a new movement will be influencing education in at least 45 U.S. states: The Common Core State Standards (CCSS).

the Common Core standards

The CCSS were developed by the National Governor’s Association in 2010 and subsequently adopted by almost all U.S. states for several reasons. First, by providing consistency in expec- tations across states, educators will have more confidence that students are learning similar content. Additionally, this movement was designed to raise standards in order to improve col- lege and career readiness, and prepare U.S. students for the global workforce. The standards, which can be accessed for online (http://www.corestandards.org/), include K–12 standards for mathematics, and English Language Arts (ELA), which include reading for literature, infor- mational texts, social studies, and science and technical subjects. Writing standards are also included within the ELA standards. The CCSS for each subject includes specific grade-level expectations and “Anchor Standards,” which direct the long-term outcomes that students should attain for high school graduation.

By reading the standards online, teachers gain a comprehensive picture of the detailed expectations. However, for this chapter there are a few important strands of the CCSS in different subject areas that will be briefly summarized because they may be especially chal- lenging for students with disabilities. Beginning with reading, there are two notable stan- dards that special educators should be aware of. First, is the expectation that students will be able to independently read complex literary and informational texts with grade-level proficiency and demonstrate comprehension with those texts (Common Core Standards, 2010). Across grades, this standard will influence not only instruction in ELA classes but also reading in content classes, such as science and social studies. A second challenging standard is the Integration of Knowledge and Ideas. This reading comprehension standard suggests that students must read and evaluate the central ideas and themes from variety of texts, analyze arguments and claims in the text, and compare and contrast the themes and relevant information. For students with disabilities, including some with ASD, these standards will pose difficulties.

The writing standards also contain challenging expectations that will influence teach- ing (Graham & Harris, 2013). Students are expected to write for a variety of purposes such as persuasive essays and informational writing and, most importantly, to use writing to con- vey the knowledge learned and extend comprehension following reading (Common Core State Standards Initiative, 2010). The four key strands of the CCSS for writing in K–12 are to write for a variety of purposes, master the production process (planning, revising, rewriting, etc.), produce a product in a single setting on paper or the computer, use research or text to present knowledge and extend learning, and integrate writing daily to expand content learning and comprehension. While these skills are critical to success in high school and college, they pres- ent challenges for students with writing difficulties and disabilities who already have trouble with written expression and the cognitive demands needed to write for a variety of purposes and points of view (Graham & Harris, 2013). Success on these standards will depend on quality teaching and using strategies grounded in successful research.

In recent years, leading educators have called for mathematics instruction in schools to de-emphasize basic memorization and algorithm practice, and instead, engage students

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Box 9.1 trends and issues

Academic Outcomes Statistics from the National Longitudinal Transition Study 2 (NLTS2) pertaining to the long- term outcomes of students with ASD demonstrates the need to improve instruction. Over 50% of students with ASD who left high school in recent years reported that they had not enrolled in college or had been hired for a job (Shattuck et al., 2012). Furthermore, compared to students in other disability categories, students with ASD have experienced some of the lowest rates of postsecondary success (Shattuck et al., 2012). Students with ASD from low-in- come neighborhoods and with more serious functional impairments are at an elevated level of risk for grim postsecondary outcomes.

Reading and mathematics difficulties contribute to these poor outcomes. Research- ers found that when rates of literacy growth were compared and graphed for students with different disabilities, students with autism demonstrated slower reading growth curves com- pared to students with learning disabilities (LDs). Students with autism typically improve in word identification and comprehension between age 7 and 17. However, at 17, word read- ing ability resembles that of “typically achieving” 10-year-olds and comprehension ability is slightly below a W-score of 500, which is an age equivalence of 10 (Wei, Blackorby, & Schiller, 2011). Mathematics growth statistics are also undesirable. Compared to students with LD, students with autism demonstrated slower growth in math calculation (Wei, Lenz, & Blackorby, 2013). While these unfavorable outcomes do not impact all students with ASD, it is important for educators to be aware of potential academic deficits to provide remediation of academic risk in school and strive to improve the chances for long-term success.

in complex tasks such as deep conceptual learning, problem solving, reasoning, and explain- ing mathematical thinking to demonstrate problem solving (Jitendra, 2013). Educators and school district personnel can access the complete CCSS for mathematics online (http://www. corestandards.org/Math), but there are several elements that special educators should understand. First, in the K–12 standards, Geometry is emphasized across all grades. Second, Algebraic thinking and measurement concepts are emphasized heavily beginning in kindergarten to provide students with the early skills and understanding of concepts that will be used in the future, such as elapsed- time problems. It is also important to note that by the time students leave fifth grade, they are expected to be able to divide and multiply fractions (Powell, Fuchs, & Fuchs, 2013). Finally, the overarching theme of the standards is that students must not only understand how to solve prob- lems and equations but also be able to think and reason mathematically and express understanding. Students with pervasive math difficulties have historically had problems with telling time (Burny, Valcke, & Desoete, 2012), which will impact elapsed time problem solving which is integral in upper elementary grades. Additionally, some students with math difficulties have trouble solving math problems in general due to language comprehension deficits that interrupt understanding of the question or a path to a solution (Compton, Fuchs, Fuchs, Lambert, & Hamlett, 2012). Finally, reading difficulties can negatively impact word problem solving and these reading difficulties can translate to poor performance (Powell et al., 2013). In summary, to help students with ASD and mathematics difficulty succeed, careful planning, differentiation, and evidence-based instruction will be critical.

aCademiC outComes

Before specific strategies and educational frameworks are described for improving the perfor- mance of students with ASD, it is important to discuss the literature pertaining to the learning outcomes that are common to this population of students and understand their needs. Box 9.1 presents statistics that provide some context to the academic achievement of students with ASD. Then, an explanation of learning considerations based on social and behavioral charac- teristics will be provided to help educators enhance learning for this diverse group of students.

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educating a diverse group of students

Although students with ASD represent a diverse or heterogeneous group of learners, there are learning and behavioral characteristics that some students with high-functioning autism (HFA) and Asperger’s Syndrome (AS) share according to research (Rourke & Tsatsanis, 2000). For example, many students were observed to have delays in social functioning, including using interpersonal skills to communicate their needs, uncharacteristic body lan- guage, and difficulty with interpreting abstract language and verbal directions (Donaldson & Zager, 2010). These traits should be considered when planning lessons, organizing class activities, and communicating with students.

There are two other learning-related elements pertaining to students with ASD that can help educators teach content. First, some students can demonstrate extensive knowledge in a specific academic domain or area of interest, but not in others, causing educators to make false assumptions pertaining to the scope or reach of their knowledge (Barrett, 2006). For example, a student with ASD named Michael may enjoy reading books about geography and the biomes on the planet Earth, but demonstrate delayed comprehension ability when read- ing fictional or literary stories due to the more abstract story structure or a lack of interest. This is related to the theory of weak central coherence. This means that some students with ASD may be successful at attending to small details but have difficulty with understanding the broad implications or main idea of certain topics or concepts (Constable, Grossi, Moniz, & Ryan, 2013). Awareness of this issue can inform instructional planning and should be considered by teachers.

A second factor to consider is that some students with ASD interpret language in a lit- eral manner (Donaldson & Zager, 2010). Case Example—This could mean that Amy, a seventh grader with AS, does not understand certain humor, such as idioms used by her teacher such as “You really went to town on that magazine.” This awareness should be considered because it will influence activities such as selecting student partners during collaborative learning, careful thought to how directions are administered, and a realization that although some stu- dents with ASD may appear to be noncompliant, they may be having difficulty understanding directions or a social situation.

It is also important to make one suggestion about the role of assumptions relating to instructional planning. Educators should not make broad assumptions about the academic needs of students with ASD because ability levels are often diverse, or heterogeneous. Despite the academic statistics previously discussed, such as low reading and math abilities on average, educators of students with ASD realize that this population of learners can be unpredictable in their performance. For example, in a study that analyzed the reading abilities of students with pervasive developmental and Asperger’s Syndrome, results indicated that some children scored extremely high across all components of reading (e.g., fluency, phonics, comprehen- sion), while others had difficulty with basic reading tasks such as phonics and reading fluency (Nation, Clarke, Wright, & Williams, 2006). This suggests that educators of students with ASD should not overgeneralize performance trends and be sure to provide instructional strate- gies that are differentiated and based on research (Whalon, Al Otaiba, & Delano, 2009). This chapter will now explore the research pertaining to effective teaching practices for students with ASD and explain how these techniques can be implemented.

ConneCting researCh and praCtiCe

Accountability movements in the United States, the requirement that students pass standard- ized tests in content classes to graduate from high school, and the new Common Core State Standards have contributed to the need for educators to use practices based on research. Edu- cators should have confidence that when teaching a new strategy, the technique must have been investigated via quality research designs and replicated with different students (Cook, Tankersley, & Landrum, 2009). However, some educators might be asking, “Where can we actually locate these research-based practices for improving academic and behavioral outcomes

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for students with disabilities, and specifically, for students with ASD”? This is a valid ques- tion because although research is frequently explained in research-oriented journals, many educators do not have the time or training to read and interpret complex research studies. Fortunately, there are teacher-friendly “research to practice” resources that make research and teaching strategies accessible. To provide access to these resources, an Internet Resources table that explains reliable resources and includes a link for each is included at the end of this chapter. Following the summary of teaching practices provided in this chapter, readers are encouraged to explore the resources and learn more, and engage in ongoing investigation of instructional practices for students with ASD.

The subsequent section of this chapter is organized according to the following frame- work. First, for each academic area, a summary of key research is provided. Next, for each com- ponent, lesson ideas for improving academic outcomes are described. Due to space limitations, a more comprehensive summary of strategies was not possible. However, the ideas presented are based on promising research, and additional resources are included for educators interested in locating more information

reading

The National Reading Panel (2000) identified five critical components of instruction. The first component, which is relevant to educators in Grades K–1, is phonemic awareness (PA). PA is the ability to hear, identify, and manipulate individual sounds in words. For example, you may ask a student, “tell me the three different sounds you hear in the word bat”. Or, “what happens if we change the ending sound in bat to the d sound”? There are many games and les- sons that teachers can engage students in to improve their PA skills (see Box 9.2 for ideas and resources). The second reading component is phonics. Phonics is the ability to understand that different sounds correspond with letters of the alphabet (or combinations of letters), and these can be manipulated and blended to read and write words. For example, Mrs. King may have just finished teaching her students that putting c and h together is an example of a digraph sound, and makes the sound common in words like chip, chop, or chomp. Mrs. King could teach her students to use the ch sound to read new or unfamiliar words like chat, or cheat. This can also be done through fun games and lesson activities and reinforced by reading books with students that correspond to the specific phonics rule or concept that was taught, such as a book called “ Charlie chomps on a crunchy bag of chips” (see Box 9.2 for PA and phonics tips and resources).

The remaining three components may be more familiar to many educators. Fluency, the next component, means to read a text accurately with speed and expression. There are several strategies that teachers can use to help build fluency, beginning in second or third grade. Case Example for Fluency—Mr. Jones, a third-grade teacher wants to improve fluency for his students, so he uses three research-based practices (Vaughn & Thompson, 2004). First, to improve comfort and expression, Mr. Jones leads the class in echo reading. This means that he reads a sentence from a passage, and students repeat the sentence modeling his speed and expression. Next, Mr. Jones tries choral reading of a poem. This means that the class reads the poem together to promote active engagement and practice. Finally, using books at the stu- dent’s reading levels based on assessments, he asks students to use the repeated reading strategy. This means that students read the same passage or book several times in a row to increase proficiency. Each time, the teacher emphasizes increasing the speed and improving expression. Mr. Jones occasionally times the students on successive attempts and then shares the time to demonstrate that students improved their speed and accuracy.

Vocabulary, the fourth component, is the ability to understand the meanings of words to help students read for understanding. Teachers can provide vocabulary instruction before, during, and after reading to assist with understanding, especially with challenging content area texts. The fifth and final component is reading comprehension. Reading comprehension means to understand the material being read, and apply this meaning to novel situations such as discussion, writing, or other activities. To illustrate these ideas in action, a case example is included after a brief review of research.

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Box 9.2 researCh to praCtiCe

phonemiC awareneSS phoniCS

http://www.readingrockets.org/article/ 377/#pairs1 Free lesson activities for pre-K and kin- dergarten, including breaking up words into segments (e.g., b/a/d/) and phoneme substitution (e.g., “Say bad without the d, or change the d sound to a t for me”).

Sequence of phonics skills http://www .phonictalk.com/phonics_steps.php This teacher-friendly website provides a framework for the sequential order that phonics skills should be taught so that students master foundational ele- ments before more complex skills are introduced.

Rhyming The ability to create rhyming words is a key skill. Teachers should first model rhymes (sit, bit, fit) and then ask students to create additional rhyming words, with corrective feedback. Follow- ing this activity, books that reinforce each rhyming pattern can be used.

Onset and rime cards Teachers create cards for students to learn word families. The onset cards are the beginning of the word (e.g., bl) and the rime cards contain word endings (e.g., ast, ack, oat, ip).

Students move the rime cards to match with the onset to practice new words (bloat, black, etc.). Teachers model and then practice together with feedback, followed by independent practice. This can be done for the various phonics patterns and skills (http://www.readingrockets.org/strategies/ onset_rime/).

Phoneme segmentation The ability to distinguish or segment different sounds that make up words. First, teachers should assess a student’s ability to do this via free early reading assessments like DIBELS (e.g., http://dibels.org/next. html), and then analyze what types of mistakes were made to target instruction.

Matching pictures and words An example of this activity would be to first teach the long vowel i in words like bike, hike, or fight.

Then, provide a list of pictures and ask students to circle the pictures that represent a word with the long i sound, while ignoring the pictures that do not portray a word with that sound pattern.

Elkonin boxes (Vaughn & Linan- Thompson, 2004). Using a 3 or 4 square chart and small play chips, students identify the distinct sounds in words. Each time the student hears a phoneme in a word spoken by the teacher, the student moves a chip into a separate box. For example, the student would move four chips into boxes for the word “stag, s/t/a/g”.

Literature connection Connect phonics rules to books that reinforce skills taught.

For example, after teaching consonant digraphs like sh or ch, the teacher reads a book for reinforce- ment such as “The Chocolate Chip Ship.” During reading, students could put their thumb up when a digraph is identified (http://www.funphonics.com/)

a review of the researCh Compared to students with learning disabilities, less research has been conducted for students with ASD in reading (e.g., Gajria, Jitendra, Sood, & Sacks, 2007; Solis et al., 2011). However, in recent years, more research has been conducted for students with ASD and the results are encouraging. Whalon et al. (2009) conducted a review of the literature that analyzed all five components of reading for students with ASD. They found that in 11 studies, students demonstrated improved outcomes when provided intervention. It was discovered that phonics instruction resulted in improved reading skills for students with ASD, and explicit and systematic instruction (e.g., clear procedures, modeling, guided practice) should accompany instruction (Whalon et al., 2009). Another key finding was that providing time for students to practice reading fluency using research-based practices (see Case Example for Fluency above) resulted in fluency gains. At the time (2009), there was less published research for comprehension. However, recent research has expanded on compre- hension interventions such as using compare/contrast interventions, graphic organizers, and question generation routines for improving comprehension of narrative and expository text.

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In summary, although the research is emerging, when interventions have been conducted in reading for students with ASD, the ability of these students to read effectively improved. Next, a framework based on this research will be provided for vocabulary and comprehension. The subsequent section describes a sample lesson framework based on research that can be used in Grades 4–12 to help students to learn vocabulary and to read for comprehension.

a Lesson framework for reading instruCtion The following framework is a case example of how teachers can facilitate reading achievement for a group of 4 seventh grad- ers with ASD who experience reading difficulties.

Case exampLe – voCaBuLary and Comprehension

Before Reading Strategies Before reading, Ms. Jordan engages students in activities to learn vocabulary and build back- ground knowledge.

• The passage students will read is an expository passage about important inventions from the Industrial Revolution period.

• To engage students, Ms. Jordan asks students to identify several of their favorite items (computers, IPADS, sneakers). For 5 minutes, students discuss ways that the items might have been developed to improve people’s lives.

• Next, a 3-minute video about the growth of factories during the Industrial Revolution is shown.

• Vocabulary is taught next—the teacher provides words, definitions (e.g., manufactur- ing), and a picture related to each word. The students read each word and definition chorally, and then turn to a partner to discuss a prompt related to the word. For exam- ple, “turn to your partner and explain what manufacturing means. Then explain one product that your family uses that is built through a manufacturing process.”

• Finally, the teacher and students preview the text and the teacher draws attention to the difficult proper nouns. This is done so that the words are familiar during reading. Pic- tures, subheadings, and graphs are also reviewed and discussed (Hairrell et al., 2011).

• Students then make predictions based on their preview and background knowledge pertaining to what they might discover.

During Reading Strategies • Students are paired with a partner, and asked to read the two-page text on the Indus-

trial Revolution. Students alternate paragraphs to maximize engagement and provide feedback for word reading errors. The teacher also visits with groups to facilitate and check for engagement.

• Pre-made cards that contain prompts for questions the students can ask after reading every two paragraphs can be created by teachers (Whalon & Hanline, 2008). This pro- motes active engagement and main idea identification. For example, the cards might ask “What the main idea of the paragraph was?”, “What the most interesting fact they learned was?”, and “Which details support the main ideas?”

After Reading Strategies • After the students finish reading, Ms. Jordan asks literal and inferential questions of

students to probe for understanding, such as “What are the names of two inventors that you read about? What did they create?” Or “Which invention do you think helped make people live more comfortable? Explain why.”

• Next, to teach Ms. Jordan leads students in the Get the Gist strategy (Klingner, Vaughn, & Schumm, 1998). For three sections of text identified by the teacher, the students must iden- tify the most important who or what from that section, then three important details about the who or what, and then write a sentence using these ideas that captures the main idea.

• Ms. Jordan first models the process and then provides guided support as the students use Get the Gist. In several weeks, the students will be able to accomplish this task independently.

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writing

The research for enhancing writing outcomes in students with ASD is limited compared to research with students in other disability categories. Research to support writing skills in students with ASD, such as sentence and paragraph composition, grammar and punctuation, and other genres like persuasive writing, is necessary to help students meet standards (e.g., Graham & Harris, 2013). Teachers are encouraged to teach foundational writing skills to fos- ter grade-level writing expectations and meet the writing expectations of the CCSS (Graham & Harris, 2013). To facilitate success, an instructional framework that includes modeling, guided practice, and independent student practice is recommended.

Writing Case Example—Ms. Hanson wants to teach 2 fourth-grade students with high functioning autism to compose a complete paragraph since they have recently mastered sen- tence writing proficiency. First, Ms. Hanson displays examples of paragraphs to demonstrate the different elements (topic sentence, three supporting details, and a conclusion). Next, she shows students how she integrates a graphic organizer for planning. Ms. Hanson and her stu- dents will now use a graphic organizer to plan and compose a paragraph about a field trip to a science museum (see Figure 9.1). After working collaboratively on planning and practicing paragraph writing with teacher assistance for 2 weeks, the students begin independent prac- tice using the graphic organizer to plan and subsequently write paragraphs related to prompts, and recent books they have read. Visual supports in the form of a graphic organizer are import- ant for students with ASD (Constable et al., 2013). Ongoing feedback and support to facilitate independent writing proficiency and generalization of acquired skills will also be important for Ms. Hanson’s students.

ideas and resourCes for effeCtive writing instruCtion A recent literature review demonstrated that writing interventions for students with disabilities other than LD are associated with increased written expression (Taft & Mason, 2011). One strategy with encouraging research for students with ASD is self-regulated strategy development (SRSD) (Asaro & Saddler, 2010; Delano, 2007). SRSD research suggests that persuasive writing in middle school students improved with SRSD (Delano, 2007). Furthermore, narrative writing skills with elementary students with ASD improved after explicit instruction in the SRSD frame- work (Asaro & Saddler, 2009).

Detailed procedures for SRSD can be accessed via the web links provided in Box 9.3. SRSD consists of six stages of instruction. The stages are developing background knowledge, dis- cussion, modeling the strategy, memorizing the strategy, providing support, and independent practice (Asaro & Saddler, 2010). The following resources should be accessed for teachers who are seeking to learn about SRSD to improve essay writing for students with ASD and writing difficulties.

figure 9.1 Pre-Writing Graphic Organizer

Science Museum Field Trip

Last week, our class took a trip to the new Science Museum to view the Space exhibits.

• Scientists have more advanced pictures now of the planets in our Solar System. • Scientists are also helping NASA discover a way to help astronauts land on an asteroid or Mars. • In the next 20 years, new technology will help the United States accomplish the goal of more advanced space exploration.

Our field trip to the museum was fun, and we look forward to learning more about space exploration in the future!

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reSourCe DeSCription SrSD reSourCe

The National Center on Accelerating Student Learning provides detailed information on SRSD that includes a comprehensive descrip- tion, lesson plans, and the materials (graphic organizers and mnemonic charts) that accom- pany the lessons.

http://kc.vanderbilt.edu/casl/srsd.html

The IRIS Center from Vanderbilt University contains professional development modules and resources for teachers for writing, reading, and mathematics. The SRSD module includes step-by-step instructions for teachers and real- istic examples of implementation.

http://iris.peabody.vanderbilt.edu/srs/chal- cycle.htm

Box 9.3 seLf-reguLated strategy deveLopment

mathematics

In the introduction of this chapter, the CCSS expectations in relation to mathematics were summarized. Essentially, mathematical reasoning, conceptual learning, and problem solving are emphasized by contemporary standards (Jitendra, 2013). The emphasis on higher-level thinking skills, however, does not suggest that mastery of foundational skills (e.g., subtrac- tion, subtraction with regrouping, and multiplication) should be overlooked. After basic skills are established, students can apply their knowledge to more advanced tasks. Teachers should employ strategies that can introduce students to abstract concepts, while still focusing on foundational skills such as algorithms and fact fluency (Donaldson & Zager, 2010). Explicit and strategic instruction with multiple opportunities to practice should be integrated. Recent research (e.g., Donaldson & Zager, 2010; Rockwell, Griffin, & Jones, 2011) provides insight into techniques that educators can integrate to improve mathematical skills. Several examples are explained in the subsequent section.

ideas for effeCtive mathematiCs instruCtion Direct and explicit instruction is an effective technique for teaching concepts and skills to students with difficulties or disabilities (Donaldson & Zager, 2010). This means that educators use assessment and progress monitor- ing results to identify the specific deficits that students have. After targeting skills requiring instructional support, teachers employ multiple demonstrations for performing an operation (e.g., subtraction with regrouping). After repeated examples, students practice the skill or operation with feedback. This means that correct responses are rewarded, and when incorrect responses occur, the teacher redirects students and provides assistance. This has been effective for students with disabilities for computation and problem solving (Houten & Rolider, 1990; Wilson & Sindelar, 1991). Direct instruction principles can be used for introducing all new skills such as telling time, elapsed time, and fractions.

Another strategy recommended for students with high-functioning autism and Asperger’s Syndrome is concrete-representational abstract (CRA) for teaching fractions (Donaldson & Zager, 2010). An example of CRA would be to show students a concrete example of a concept, such as two halves of a pie. Next, a mathematical representation such as two halves of a rectangle is demonstrated. Finally, the teacher introduces the abstract representation of the concept, such as the fraction ½. This can be used with easier to more complex concepts through the same three-step process. CRA has been successful for teaching other mathematical concepts such as algebra (Witzel, 2005).

Connecting literacy experiences to mathematical concepts is another option that edu- cators can consider to support mathematical understanding. In the primary grades, teachers can select books to read to the class as a shared story experience that is associated with

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a mathematical concept that the class is currently working on (Courtade, Lingo, Karp, & Whitney, 2013). For example, a children’s picture book that describes two children counting money to buy ice cream could reinforce the concept of identification of denominations and basic addition. Another example is the book How Big is a Foot (Myller, 1990)? This story supports measurement of inches and feet and basic fractions. In summary, using books to teach mathematics can support mathematical vocabulary of concepts, depict concrete exam- ples of the topics taught in math lessons, and serve as a springboard for a subsequent math activity (Courtade et al., 2013).

differentiating and modifying instruction

A theoretical framework called Universal Design for Learning (UDL) has inf luenced numerous educators and students. UDL is a broad framework intended to improve academic outcomes and student engagement in learning that entails several key principles designed to guide instruction and planning. The National Center on UDL delineated key elements for educators to factor into their instructional planning to facilitate improved student learning (http://www.udlcenter.org/aboutudl/udlcurriculum). The first component is goal setting, to help students become active learners and achieve learning outcomes for a specific academic purpose, such as to improve problem-solving ability or higher-level thinking. Differentiation of methods is the second principle designed to help students attain goals. Differentiation of methods can include technological integration, environmental adaptions, or other processes that make the lesson comprehensible. The third component is the integration of tools to facilitate learning, such as content enhancement tools to provide background information, integration of media and technology, and other mechanisms to present content to students clearly (Rose & Meyer, 2000). Assessment is the final component defined by the National Center on UDL. Teachers can implement various assessments to collect information to inform instruction. Additionally, educators are encouraged to offer flexibility of assessments based on student’s need, such as allowing an oral examination for a student who frequently demonstrates externalizing behavioral problems when writing. Teachers of students with ASD can use the theoretical framework of UDL to differentiate teaching and deliver intervention.

differentiated instruCtion Differentiation of instruction and materials can enhance the achievement of students with disabilities and promote meaningful learning (Landrum & McDuffie, 2010). If properly implemented, differentiation via principles of UDL can foster grade-level curriculum access and momentum toward the attainment of goals on Individ- ualized Education Plans (IEP). A case example is used to demonstrate how principles of UDL and differentiated instruction can be implemented in middle school for a student with autism.

Case Example—Appropriate Differentiation: Marco, a ninth grader with autism, has a fifth- grade reading level according to benchmark assessments administered to all students at the beginning of the year. Marco enjoys learning on the computer, completing written assign- ments on the computer, but becomes easily frustrated and sometimes refuses to complete class assignments if extensive writing is involved. Marco’s IEP goals are to write a multiparagraph essay and identify main ideas and compose a summary following reading with above 80% accuracy.

Marco’s teacher, Mrs. Huerta, carefully considers his academic goals as well as his learn- ing and behavioral characteristics to effectively teach Marko. For example, to help Marco achieve his IEP goals, while accessing grade-level content for the upcoming science unit on “Heat”, Mrs. Huerta does the following: first, to introduce Marco to a crucial term, convection, she provides the definition and they proceed to read from a fifth-grade science book to foster background knowledge, because she knows that providing alternate texts on a related topic can improve comprehension (Fenty & Barnett, 2013). As they read, Mrs. Huerta and Marco work together to apply the main idea strategy called Get the Gist to identify main ideas and a

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graphic organizer to highlight the main ideas used to generate a summary sentence (Klingner et al., 1998). Mrs. Huerta also shows Marco a 5-minute video that depicts thermal energy and the movement of gases in the environment. The following week, when Marco’s class learns about convection in his inclusive science class, Marco feels comfortable because he has back- ground information on this topic. The class reads a grade-level passage, but considering his reading difficulties, Marco is paired with a student that has eighth-grade reading skills. They engage in a process where the stronger reader reads the passage initially as Marco follows along, followed by Marco reading the passage the second time with corrective feedback pro- vided (Fuchs, Fuchs, & Burish, 2000). After reading, the class answers questions. The teachers allow students, including Marco, to use an iPad or computer to answer the questions to offer flexibility during the assessment process. In summary, while the case example of Marco cer- tainly does not provide the entire scope of possible differentiation and UDL ideas, it integrates several concrete examples of how teachers can differentiate learning and use pre-teaching to promote access of grade-level content.

Quality resources and professional development

This chapter concludes with the final topic pertaining to effective academic instruction: ongo- ing professional development and resources for educators.

researCh to praCtiCe opportunities Frequently reading research to practice articles is a proactive method for remaining current about new teaching and intervention practices for students with ASD. Although school districts and universities are other sources for informa- tion, educators can obtain new strategies by reading several peer-reviewed journals that are written for educators. Although the following suggestions are not a comprehensive list, the following journals frequently contain strategies for teaching students with ASD: Intervention in School and Clinic, Teaching Exceptional Children, and Focus on Autism and Other Developmental Disabilities.

Attending professional conferences that describe instructional practices for students with ASD is another method for learning new information about teaching and intervention. Becoming a member of professional educational organizations such as the Council for Excep- tional Children or the Division on Autism and Other Developmental Disabilities is another way to gain access to trends, issues, and current research. In summary, staying informed and receiving ongoing professional development can be beneficial for becoming a more capable educator, and improving academic instruction for students with autism.

summary

In this chapter, the following main ideas were discussed. First, academic expectations such as the Common Core State Stan- dards were described in relation to the impact on students with ASD and educators. Second, a description of several learning characteristics of students with ASD and perti- nent statistics about their academic outcomes were outlined. Third, research findings pertaining to effective instruction for students with ASD were summarized along with strategies for reading, writing, and mathematics. The fourth topic covered was differentiation and considerations for using UDL to make content accessible. Finally, ongoing professional development and sources for new and reliable information were presented. Peer-reviewed journals, conferences, and membership in pro- fessional organizations can enhance the understanding of research-based interventions and instructional techniques for educators who work with students who have autism.

In summary, three important concepts are empha- sized at the conclusion of this chapter. First, the Internet resources provided earlier will be useful sources of information for teaching resources. Educators need reliable resources to understand strategies based on evidence. The links provided are reliable resources for linking research to practice. Second, it is important to reiterate an idea mentioned previously: stu- dents with ASD represent a heterogeneous group of learners. Although some students with ASD may possess some simi- lar learning characteristics, it is important to remember that each student has individual academic, social, and behavioral needs. To improve the long-term outcomes of students with ASD, educators are encouraged to stay up-to-date with evi- dence-based practices, carefully consider learning needs of the individual, and differentiate instruction to promote meaning- ful academic engagement.

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Chapter review Questions

1. What are some of the current academic expectations that may be challenging for students with ASD who experience learning difficulties in literacy or mathematics? (Objective 1)

2. Explain a unique characteristic of students with ASD and describe why educators should be aware of this trait. (Objective 2)

3. Describe two key research findings pertaining to academic outcomes for students with ASD, and describe two strate- gies that can be used to promote improved academic perfor- mance in reading, writing, or mathematics. (Objective 3)

4. Describe three techniques on how you can modify a fifth-grade reading lesson about Explorers of the Southwest, for students with ASD that have below– grade level reading and writing skills. How would you ensure meaningful access to the content, while differentiating the assignment to meet student's learning needs? (Objective 4)

5. Using the Internet, identify, summarize, and explain why you intend to use one of the Internet resources described in this chapter to facilitate ongoing professional development. (Objective 5)

key terms

Common Core State Standards 158 Differentiation 166 Evidence-based practices 158

Fluency 161 Phonemic awareness 161 Phonics 161

Universal Design for Learning (UDL) 166

Weak central coherence 160

internet resourCes

Reading Rockets: http://www.readingrockets.org/

Reading Rockets contains lesson ideas for improving the instruction of reading and writing for students with difficulties in literacy. The site and associated resources are free.

National Center on Intensive Intervention: http://www.intensiveintervention.org/

A national center designed to increase the access of educators to interventions in mathematics, writing, reading, and behavior based on evidence. The free resources include reviews of research practices, considerations for multicultural special education, progress-monitoring tools, and expert advice.

What Works Clearinghouse: http://ies.ed.gov/ncee/wwc/

The Institute of Education Sciences sponsors this site. It reviews the evidence pertaining to the effectiveness of instructional teaching practices. The “practice guides,” available for free, can assist educators with classroom challenges for behavior and education.

Center on Instruction: http://www.centeroninstruction.org/

A center for providing free resources to educators of students with learning difficulties and disabilities. This includes examples from classrooms, professional development modules, and academic and behavioral tools and strategies for current effective practices.

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169

Play-Focused Interventions for Young Children with Autism

Chapter 10

Kara hume, ph.D. and Lauren turner-Brown, ph.D. University of North Carolina, Charlotte

e. amanda Boutot, ph.D. BCBa-D and amber paige Texas State University

Case of Cooper Cooper is a 2-year, 4-month-old boy who was diagnosed with autism at 22 months. In the last 6 months, Cooper has been in a home-based inten- sive early behavioral intervention program through a local provider of applied behavior analysis (ABA) services. The owner of the company was trained in the classic “Lovaas” method of ABA and primarily uses discrete trial training (DTT) for instruction. Further, because of the classic train- ing, the owner insists that all therapies, including Cooper’s, take place at a table separate from the rest of the family and any distractions. Ini- tially, Cooper resisted sitting at the table for more than 10 seconds, and the therapists had to hold him in place, providing rewards for when he stopped crying and became still. After 6 months, Cooper is able to sit still at the table, without crying, for 25 minutes at a time, working on various skills, including receptive identification of familiar people (e.g., pointing to pictures of his family members); matching to sample (e.g., matching 3D objects such as his Little People™ farm animals with photographs of real farm animals), sorting big and little items into cups, and vocal and motor imitation. Cooper’s mother and father are pleased that he is no lon- ger screaming through each 2-hour session, but they have concerns that Cooper seems to be learning skills that he doesn’t really use in his every- day life. They are particularly concerned that he still does respond to his name, play with his older sister or other children, and requires constant supervision.

Case of rajeev Rajeev, a 3-year-old boy with autism, is verbal (though much of his vocal- izations are echolalic) and has self-help skills that are nearly typical (e.g., he can go to the restroom and wash his hands afterward, dress and undress himself; he is learning to brush his teeth). Rajeev attends a university-based inclusive preschool, which includes 25% children with disabilities. Rajeev has been receiving private ABA services since his autism diagnosis at age 2, and his family credits a lot of his independence and communication on this intensive programming. His private ABA provider is particularly proud that they have now taught Rajeev to read, which he seems to enjoy and has helped with some behavioral issues as well (e.g., they are using social narratives to prepare him for trips to the zoo, and to doctor, thus reducing behavioral challenges in those environments). However, even

Case stuDy Examples

Chapter ObjeCtIves After reading this chapter, readers will be able to 1. Describe the characteristics of

play in young children with autism.

2. List and define the types of play.

3. Discuss pros and cons of various methods used to teach children with autism to play.

4. Describe how play materials can be adapted to increase engagement and functional use.

5. Discuss why adapted play materials are beneficial for individuals with ASD.

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with the good progress that he has made, Rajeev’s mother has consulted with another ABA provider to discuss social and play skill development for him. Specifically, Rajeev’s mother is concerned that he doesn’t play with the other children during centers or recess at the preschool and prefers to wander by himself from center to center or to sit on a swing all of recess. Last Wednesday, Rajeev’s private ABA provider and the consulting ABA provider met with Rajeev’s mother at the preschool to observe his center time behavior. As they observed, the teacher dis- missed the children to their various centers, directing Rajeev to the “kitchen” center with two other children. However, rather than play at the center, Rajeev traced his hands over the plastic oven/stove, spun a toy pan, and flicked a toy spatula in front of his eyes. “See,” said Rajeev’s mother, “he doesn’t play with them; he’s just stimming!” “So,” responded the private ABA provider, “he can read!!” To which the consulting ABA provider said, “Yes, but none of these other children can read … they can play, that is what we need to focus on teaching Rajeev!” Rajeev’s mother agreed and a play program was put into place for him for the following week, and within a month, Rajeev was engaging in play activities with his peers at three of the five preschool centers as well as with his parents at home.

Case of Casey Casey was diagnosed with autism on her second birthday. Her mother was devastated, but not surprised. She noticed that Casey did not do many of the same things as her 5-year-old sister, particularly in the areas of language, socialization, and play. Immediately following the diagnosis, Casey’s mother sought ABA services for her daughter. Because their state did not have an insurance mandate that covered ABA services for children with autism, the family could only pay for 4.5 hours per week of services. They were able to find a Board Certified Behavior Analyst (BCBA) who would work on a sliding scale and provide ABA services in their home for Casey three times a week for 1.5 hours each. The ABA program- ming centered on the three areas of most concern to the family (i.e., language, socialization, and play), and was done in a naturalistic environment (the play room at Casey’s home), using play-based ABA. Within 2 months, Casey was speaking and making eye contact with her family and service providers. Within 4 months, Casey was engaging in unprompted social play with other children of her own age, as well as with her sister. Further, she was not only playing with toys appropriately, but she had also begun to engage in symbolic play. In fact, one Friday evening her mother called her BCBA with exciting news, Casey had just observed her sister playing in the new toy kitchen she’d gotten for her birthday. Because it was a new toy, Casey hadn’t been taught how to play on it yet nor had she had the opportunity to observe anyone else doing so. On that evening, however, she watched her sister for a few moments, and then went to the kitchen and pretended to stir in a pot and put something in the stove. Her mother was so excited to see the progress Casey had made. Her BCBA was thrilled with the generalization of play skills, noting that even with only 4.5 hours per week, Casey was making excellent progress.

Overview Of play CharaCteristiCs and issues fOr yOung Children with autism

Play is important for growth in social skills and the cognitive development of children. Engag- ing in play gives children the opportunity to learn about the world around them and how to interact with it, and it is linked to features of language development (Baranek et al., 2005, p. 20). Play develops in stages, beginning with object manipulation, which develops into func- tional play, and then symbolic play. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V; American Psychiatric Association [APA], 2013) diagnostic criteria for autism in the area of play include “(a) difficulties in sharing imaginative play and in making friends; (b) stereotyped or repetitive speech, motor movements, or use of objects;

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(c) highly restricted, fixated interests that are abnormal in intensity or focus” (DSM-V Autism Spectrum Disorder). The following is a description of the stages of play. Each stage of play will be broken up into two categories: (a) common characteristics and (b) the issues children diagnosed with autism face.

Object manipulation

Children begin to manipulate objects by licking, feeling, banging, shaking, and turning them around. Object manipulation gives children an opportunity to learn about different objects and the environment around them. At this stage of exploratory play, there is no functional relation between the child’s actions and the objects he is playing with.

CharaCteristiCs Of ObjeCt manipulatiOn in Children with autism Children diagnosed with autism show differences in exploratory play and object manipulation. They tend to have atypical interests as they show interest in a limited number of objects, or just one part of the object. The objects they show interest in are often played with in a repetitive manner. For instance, when an infant with autism is given a rattle to play with the infant may repeatedly spin the rattle in circles. A typically developing infant may show a variety of play behaviors when given a rattle, by first spinning the rattle and then shaking the rattle. Individ- uals with Autism Spectrum Disorder (ASD) have play skills that lacks novelty and flexibility (Baranek et al., 2005, pp. 21–22). Object-focused interactions in children with autism refers to the concept that all of the child’s attention is given to the object he is playing with; it is not likely that the child will engage with another object or that there will be engagement with another person to join in on his play.

issues fOr Children with autism According to McDuffie, Lieberman, and Yoder (2012) “play with objects often serves as a context for language learning” (p. 399). Individ- uals diagnosed with ASD show difficulties disengaging their focus of attention from their objects of interest. This issue makes it less likely that the individual will engage with a variety of objects. When a typically developing child is playing with his caregivers, the caregivers tend to verbally state everything that the infant does and then imitate his actions. Through this process, language begins to develop in the child. The inability to disengage attention from an object makes it less likely that a child with autism will play with a vari- ety of objects. McDuffie et al. (2010) states “this characteristic may make it less likely that children with ASD will attend to and engage with a variety of objects, notice attention- directing social cues, or direct communication acts toward social partners” (p. 399). When a child with autism shows limited interests in multiple stimuli, he may be less likely to benefit from the adult’s verbal input therefore missing out on social and language learning opportunities.

functional play

Functional play has been defined as “the appropriate use of an object or the conventional asso- ciation of two or more objects such as using a spoon to feed a doll or placing a teacup on a saucer” (Williams, Reddy, & Costall, 2001, p. 68). Functional play appears in children at approximately 12 months of age. At this time, functional play is simple and self-directed; children are beginning to associate actions to various objects while playing. For example, a child may in sequence brush his hair, put a toy phone up to his ear, and put a toy cup up to his mouth. This function association develops into a more elaborated type of play; children begin to play with multiple objects at a time. Children now engage other people while playing, they may tilt the toy cup up to their mouth and then their stuffed animal’s mouth, and then they may hand the cup to their mother to drink. Play continues to develop to a higher level where the child is less dependent on the object being present to play.

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Williams et al. (2001) describe two types of functional play: simple functional play and elaborated functional play. Simple functional play occurs when a child combines two objects that are functionally related, such as placing a teacup on a saucer or when a child uses the object in a way that shows the appropriate function, such as bringing the teacup to his mouth. Elaborated functional play occurs when the child begins using multiple objects appropriately together, showing their appropriate functions, accompanied by a gesture or vocalization; for instance, when a child uses a spoon to stir “soup” in the pot and then making slurping noises while tasting the “soup” (Williams et al., 2001, p. 71).

CharaCteristiCs Of funCtiOnal play in Children with autism As typically developing children around 12 months of age develop functional play skills, they begin to assign functions to the objects they manipulate. While playing, caregivers teach children the appropriate use of toys through language and imitation. Joint attention and imitation are important facets in developing functional play skills. Joint attention occurs when children share attention between the object and the person playing with them.

Children with ASD show repetitive and predictable functional play behaviors. Little time is spent engaging in acts of functional play. When they do engage in functional play, their time is spent engaging in the simple play acts with a single object, such as pushing a car on the ground. When compared to typically developing children, they spend less time engaging in novel functional acts while playing (Williams et al., 2001, p. 73). For instance, while playing with cars, a child with autism may line the cars up in a row or stack them on top of one another. She may sit on the carpet with one car and spin the wheels repeatedly. Or, the child may play with the cars in an appropriate manner, such as driving the car around on the carpet, but his play often looks the same in each new play routine. The child may always choose the same car, drive in the same pattern, and if he is communicating, his speech is often repetitive while playing with the cars.

issues fOr Children with autism Imitation and joint attention are areas of diffi- culty for children with ASD. While playing, children with autism often give all of their attention to the object they are playing with. It is difficult for the individual to maintain attention to the object while also trying to coordinate social engagement. This is a chal- lenge when a caregiver is teaching them a novel play act. Williams et al. (2001) states “to the extent that children with autism fail to engage other people in their use of objects, or use them to guide their own dealings with objects, they are excluded from a great deal of information about how to use them in a functionally appropriate way” (p. 69). Children with autism are often in the early stages of play; without interventions, they may show dif- ficulties in elaborating on their play to transition from self-directed play to engaging with others while playing.

symbolic play

Symbolic play appears between 18 and 24 months of age and continues to develop as the child grows. There are three forms of symbolic play that children engage in: substituting one object for another, such as using a banana as a telephone; attribution of false properties, like holding a bottle in a doll’s hand as if the doll was holding it; and attribution of presence to imaginary objects, for instance serving invisible food on a plate (Williams et al., 2001, p. 68). Symbolic play develops into pretend play and then into social play as the child first begins to create imaginary events for objects, and finally begins to engage other individuals in his acts of play. The following is a description of (a) pretend play and (b) social play.

pretend play Pretend play is defined as “the ability to create imaginary events, to estab- lish alternate identities for objects, environments, and persons, including the self” (Rutherford

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& Rogers, 2003, p. 289). The child begins to engage in pretense, and use his imagination to assign a role to an inanimate object. Pretend play accompanies language development and often requires both verbal and nonverbal communication. It begins to emerge in typically developing infants between the ages of 9 and 24 months. It emerges as the child starts produc- ing functional acts, such as putting a spoon into her mouth, in a play setting. The process of a child bringing a spoon to his lips overtime is elaborated, so the child now brings a spoon to his lips and makes a slurping noise. Eventually his play will grow to the point where he begins substituting in other objects in for the spoon. Rutherford and Rogers (2003) states “pretend play often involves the construction of verbal narratives, an activity that involves complex planning, sequencing, and organization, as well as well-developed language skills” (p. 289). Pretend play begins as solitary acts of play. As the child develops, he begins to engage others in his pretend play, making a shift to social play.

sOCial play Symbolic play shifts to social play when individuals begin to acknowledge others and engage in social interactions. Social skills develop in children as they grow from playing alone to engaging other individuals in their play (Naber et al., 2007, p. 857). Any play where children interact with each other is social play. It is structured and often includes pretend play and the use of child’s imagination. Social play requires an ongoing interaction between the children playing together. Explicit communication occurs when the children engage with each other about their ongoing interactions.

CharaCteristiCs Of symbOliC play in Children with autism Individuals with ASD show a limited interest in others, and they often prefer to play alone. They do not play with groups of children; instead, they engage in parallel play next to other children (DSM-V, 2013). Children with autism show limited spontaneous symbolic play and they do not often substitute one object for another. Play is often repetitive or imitated from other individuals. They do not often spontaneously engage in pretend play. Pretend play activities often require modeling and explicit instruction (Hobson, Lee, & Hobson, 2008, p. 12). When it does occur, children with ASD often engage in pretend play for shorter amounts of time than their typ- ically developing peers. Children with ASD have poor social imitation skills and they often lack the ability to produce normal back and forth conversation (DSM-V, 2013). They do not often like to share objects or interests, two characteristics which are important to engage in social play.

issues fOr Children with autism Children with ASD show impairments in sym- bolic and pretend play (DSM-V, 2013). Even after explicit instruction of pretend play, it is difficult for children with ASD to generalize the skills to novel pretend play scenarios (Hobson et al., 2008, p. 12). They show difficulties in the areas of joint attention, social imitation, and social-emotional reciprocity. Difficulties engaging in joint attention become particularly challenging for children with ASD when it comes to symbolic play. Symbolic play requires that children not only know the function of an object but that they also need the awareness of the pretend identity of that same object. Dykstra, Boyd, Watson, Crais, and Baranek (2012) state “the level of symbolic play exhibited by young children is frequently shown to predict later language skills” (p. 5). Impairments in joint attention, social imita- tion, and social-emotional reciprocity make it challenging for children with ASD to engage in social play. Individuals with ASD show limitations in both receptive and expressive lan- guage, which negatively impacts their ability to engage others in and sustain social play (Douglas & Stirling, 2012, p. 36). To engage in pretend or social play with individuals, a child has to first signal that he wants to play pretend, articulate his ideas to his peers, and then continue with a back and forth dialogue while playing. This is a challenge to children with ASD who show language impairments, social deficits, and lack imitation and joint attention skills (see Table 10.1).

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teaChing Children with autism tO play

As the opening cases in this chapter demonstrate, it is possible to teach children with autism to play. However, it has not always been a focus of intervention programs. The cases of Cooper and Rajeev illustrate that failure to focus on play can lead to frustration on the part of family members, as well as nonfunctional skill instruction for children. The case of Casey demon- strates that naturalistic instruction may be more appropriate at teaching play skills than more traditional ABA methods, particularly discrete trial training at a table (e.g., “table time”; see Boutot & Hume, 2012, for a review). The literature on play instruction is relatively scant compared to other, more heavily researched skill areas (e.g., communication and social skills); however, consensus in recent years has essentially been that (a) teaching play to children with autism is an essential part of their programming, particularly for younger children, and (b) evidence-based strategies can be used to teach this important skill. This section will briefly summarize the literature on teaching play to children with autism.

Traditional discrete trial training frequently utilizes “table time” for instruction on a variety of discrete skills for which a single behavioral response is required (e.g., “point to car” or “show me your nose”). As pointed out by Boutot and Hume (2012), however, this tradi- tional method may not be appropriate or effective for every skill, particularly play skills or skills being taught to very young children. Young children require frequent breaks and more opportunities for play in their daily routine than older children. Further, as evidenced by the case scenario of Cooper at the opening of this chapter, requiring a very young child to sit for extended period of times and working on drill and practice may not be functional for her. The case of Cooper, though it may seem exaggerated, is actually based on numerous youngsters

table 10.1 play Characteristics in typically Developing Children

ages pretenD pLay soCiaL pLay

1 year • Children do not yet engage in pretend play or it is random

• Children do not yet engage in social play

2 years • Children begin to substitute objects, that is, using a banana as a telephone

• Children begin to imitate pretend play actions of others

• Prefer to play alone

• Children prefer to play alone • Parallel play • Children are dependent on adult guidance

3 years • Children begin make-believe play • they begin assigning roles in play • Children begin to engage in extended pretend play,

using abstract items to represent something else, that is, they use a pile of sand to make a cake

• Parallel play • Children enjoy playing short group games that

do not require rules

4 years • tells stories • games begin to include places that the child has

never visited before

• Children enjoy playing with other kids • Plays simple organized games such as tag • Plays simple table games requiring turn taking

5 years • Children begin to narrate their pretend play • Play is organized • Children begin to play and negotiate with others

Source: johnson, s. (2013, july 8). life stages Inc. retrieved from http://www.lifestagesinc.com/#/blog/4557419691/developmental- Progression-of-Pretend-Play/6090627. Foundation: symbolic Play. (n.d.). retrieved April 13, 2015, from http://www.cde.ca.gov/sp/cd/re/ itf09cogdevfdsym.asp. the development of Play Age by Age. (2015, january 1). retrieved April 13, 2015, from http://www.scholastic. com/content/collateral_resources/pdf/eCtonline/developmentofPlay_AgebyAge_1112_00.pdf

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known personally to one of the authors. While it appear obvious to some, the use of more naturalistic strategies with very young children may be more appropriate.

According to a meta-analysis conducted by Lang et al. (2009), the most commonly used intervention for teaching both functional and symbolic play is modeling. Modeling involves demonstrating to the child what behaviors or behavioral chains to do and assisting the child in replicating this model. For children who are able to attend to and imitate a model, modeling can be an effective strategy for a variety of skills (Charlop & Milstein, 1989). Further, modeling can be used during naturally occurring play opportunities. Systematic prompting paired with contingent reinforcement of a target behavior was the second most commonly used intervention according to a review by Lang et al. (2009) to teach both functional and symbolic play skills. Though frequently criticized for lack of generalization, the use of contingent reinforcement, for play skills in particular, has been shown to produce long-term positive effects, including the development of intrinsic reinforcement following initial use (Nuzzolo-Gomez et al., 2002, as cited in Lang et al., 2009). Milieu teaching is another commonly used teaching strategy for functional and symbolic play skills (Lang et al., 2009). Milieu teaching is a naturalistic strategy that focuses on instruction in the natural environment, with naturally occurring reinforcers and materials, and follows the child’s lead. Milieu teaching combined with modeling, prompting, and contingent reinforcement was used by Kasari, Freeman, and Paparella (2006) to teach play skills to children aged 3 to 4 years, compared to a control group and a group with a different targeted skill (joint attention). Results suggest that the package of milieu teaching, modeling, prompting, and reinforcement produced significant increases in play skills over the other groups. The results of this study, combined with other research in the last decade, suggest that a naturalistic method of teaching, combined with systematic instruction of specific skills, may be effective for improving play skills of young children with autism.

adapting play materials

The difficulties individuals with ASD have in demonstrating play skills, as described pre- viously, can be influenced by the play environment, as well as the play materials. Research indicates that adaptations to the physical space in which children with ASD play, as well as to the materials used during play experiences, can support increased engagement with play materials (Hume & Odom, 2007), increased social interaction during play activities (Murdock & Hobbs, 2011), improved affect (Baker, Koegel, & Koegel, 1998), and reduction of stereo- typic behavior (Bennett, Reichow, & Wolery, 2011). Modifications to the play space, includ- ing limiting play materials and environmental distractions, are recommended to support the play skills of individuals with ASD and will be discussed below. In addition, modifications to the play materials, including the incorporation of high-interest items and the use of visual instructions and visual organization are highlighted as strategies proven to improve the play skills and play-related outcomes for individuals with ASD.

adapting play environment

The use of an organized intervention setting when working and playing with individuals with disabilities, including those with ASD, is a widely recommended and long-studied practice (Bailey & Wolrey, 1984; Norquist & Twardoz, 1990; Sandall, Hemmeter, Smith, & McLean, 2005). An environment that provides functional cues about the activities that will occur in each space as well as the behavioral expectations for those activities is more likely to promote and sustain student engagement (Norquist & Twardoz, 1990). The literature suggests that an organized environment is key for individuals with ASD, as several learning characteristics of individuals with ASD, including distractibility and difficulty in processing environmen- tal stimuli (Siegel, 1999), can be supported through a carefully arranged intervention space. A number of interventions designed for individuals with ASD provide recommendations for

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organizing the environment when teaching play skills. Project ImPACT, a parent training program for families with young children on the autism spectrum, recommends setting up a defined play space with physical and visual boundaries to limit distractions and to keep the individual with ASD close during play activities (Ingersoll & Dvortcsak, 2010, 2011). In school, clinic, and home settings, consider furniture placement to make smaller, more inti- mate spaces that are more manageable and understandable for individuals on the spectrum, which can assist in helping individuals with ASD become more organized, calm, and engaged during play activities (Hume, Turner-Brown, & Boyd, 2013; Ingersoll & Dvortcsak, 2010; Mesibov, Shea, & Schopler, 2005). Supporting research indicates that when school staff rear- ranged low furniture and materials, which served as physical and visual boundaries for an adolescent with ASD, there was a marked increase in appropriate classroom behavior (Hirasaw, Fujiwara, & Yamane, 2009).

Project ImPACT also recommends limiting distractions when teaching playing skills, encouraging the individual with ASD to increase attention to the other person/people and play materials, rather than attending to other sights and sounds in the environment, such as the television (Ingersoll & Dvortcsak, 2010). Similarly, Family Implemented TEACCH for Toddlers (FITT), an application of structured teaching strategies with very young chil- dren, recommends limiting the number of toys visible/available to individuals with ASD when playing together, as providing fewer options will allow for greater attention and focus (Hume et al., 2013). In homes, clinics, or school settings, this may include covering or put- ting away play materials when not in use, using a screen or divider to limit visibility when teaching or practicing play skills, rotating play materials, and/or minimizing the number of play materials in the setting. Early Start Denver Model, a proven intervention designed to teach a broad range of skills to young children with ASD, recommends having just one toy in front of the individual with ASD to help the child focus on the skill being taught (Rogers, Dawson, & Vismara, 2012). Research indicates that providing these visual bound- aries for students (i.e., covering materials with sheets that are not being accessed or attended to during instructional periods) can reduce self-stimulatory behavior and increase on-task behavior (Duker & Rasing, 1989), thus supporting the development and demonstration of play skills.

adapting play materials

Beyond adapting the environment in which individuals with ASD learn and practice play skills, adaptations to the play materials have proven to impact the duration of engagement during play activities (Bennett et al., 2011; Hume & Odom, 2007), the complexity of play sequences (Murdock & Hobbs, 2011), affect during play activities (Baker et al., 1998), and appropriate use of play materials (Blum-Dimaya, Reeve, Reeve, & Hoch, 2010). Several adap- tations have been examined in the literature and described in intervention manuals, including: (a) adapting play activities to reflect the interests of individual with ASD, (b) adding visual instructions such as photos to play activities, and (c) visually organizing play materials. Each of these will be described and reviewed below.

inCOrpOrating interests Play skills of individuals with ASD may be skewed by restricted interests that can limit opportunities to interact with a wide variety of play materials and with various play partners who may not share the same interest (Jung & Sainato, 2013). Individuals with ASD may be most motivated by idiosyncratic objects, topics, or themes, such as maps, trains, letters/numbers, or specific television shows or characters (Baker, 2000), which often do not lend themselves to typical play activities. Research and practice indicate that incorporating idiosyncratic interests into more traditional play materials and activities can be a successful strategy to encourage individuals with ASD to engage with a broader array of play materials and to engage in interactive play activities (Baker 2010; Baker et al., 1998; Hume

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et al., 2013). For example, Baker (2000) adapted three Bingo games for individuals with ASD to incorporate their special interests (e.g., using numbers from a number line, using scenes from a favorite movie) in an effort to increase engagement during play activities and social interaction with siblings. Results indicate that the adaptation resulted in increased engagement, social interaction, and positive affect, and a number of the results maintained when games that did not include special interests were introduced (Baker, 2000). Similarly, Baker et al. (1998) incorporated the special interests of three individuals with ASD into gross motor play activities at recess. Games of “follow-the-leader”, tag, and “Simon-Says” were adapted to include idiosyncratic interests related to maps, Disney characters, and movie themes, and the adaptations again resulted in increased time engaged in play activities and increased reciprocity during play (Baker et al., 1998).

Adapting play materials to incorporate individual interests can be an important first step in encouraging individuals with ASD to engage with a variety of materials—materials that may not typically appeal to the indi- vidual or may be beyond their current repertoire of play skills (e.g., con- struction toys, books, toys used in functional and symbolic play such as dolls, open-ended play activities such as play dough) (Hume et al., 2013). For example, if an individual with ASD does not typically engage with Duplos/Legos, but is highly interested in characters from Sesame Street, adding pictures of favorite characters to the blocks can increase interest and motivation, and can encourage individuals to interact with novel play materials and use play materials in a functional manner (see Figure 10.1). This con- cept can be used across play materials and activities (e.g., gross motor activities as described above, functional and symbolic play activities) and can be used to facilitate interaction with peers or siblings who may not share the special interest, but may be drawn to the play material or activity (Baker, 1998, 2000). Additionally, some students may benefit from available apps on mobile devices or computers, with which they may already have an interest (see Box 10.1).

Visual instructions Visual instructions help an individual with ASD to know what he is supposed to do (Mesibov, Shea, & Schopler, 2005). Visual instructions explain or depict how a play material can be used and/or the behavioral expectations for the individ- ual using pictures, objects, or written words. They are provided before and/or during play activities to support individuals in successfully engaging in or completing activities. Visual instructions may be particularly important during play activities, as play materials require more generativity, creativity, and flexibility than other domains (e.g., academic, self-help), all noted areas of deficits for individuals with ASD (Hobson, Lee, & Hobson, 2009). Visual instructions have been used in a number of studies with individual with ASD and have proven to increase functional use of toys (Mavropoulou, Papadopoulou, & Kakana, 2011), enhance social interaction during play (Murdock & Hobbs, 2011), and support indepen- dent completion of play activities (Hume & Odom, 2007; MacDuff, Krantz, & McClanna- han, 1993).

A commonly used and well-supported adaptation for play materials is the use of photos to depict of a series of steps or actions to complete during a play activity or with a specific play material (termed activity systems, MacDuff et al., 1993; termed work systems, Hume & Odom, 2007; Mesibov et al., 2005; termed storyboard, Rogers & Dawson, 2012). Visual instructions, such as a photo sequence, may be used to direct an individual with ASD to specific play mate- rials in an effort to broaden the play repertoire and reduce restricted play routines, or a series of photos may be used to teach a sequenced play activity (Murdock & Hobbs, 2011; Rogers & Dawson, 2012). For example, when preparing an individual with ASD for a more complex play scene with a baby doll, staff or caregivers may take a series of photos of activities one may do with a doll (e.g., put baby in tub, wash baby, dry baby). Single photos may also be used

Figure 10.1 Incorporating Interests Into Play Activities

vlad_g/Fotolia

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to provide support for individuals as they are learning functional and symbolic play routines and actions (e.g., a farm animal completes an action, such as “the pig jumps” and “the horse sleeps”). Research indicates that though play may be taught in a more rote fashion using these visual instructions, individuals with ASD are able to generalize both functional and symbolic play skills to novel materials and activities when the visual instructions are faded (Murdock & Hobbs, 2011).

Several additional types of visual instructions were provided to two elementary aged boys with ASD to increase independent activity completion during play time and were applied to play materials such as puzzles, picture matching cards, and Legos (Mavropoulou et al., 2011). These included a picture dictionary, a jig (two- or three-dimensional visual cues outlining how an activity is assembled), product sample (sample of what the task or activity will look like when completed, see Figure 10.2), and color coding, and when in use the visual instructions supported on-task behavior and a reduction in adult prompting for one student. Similarly, Bennett et al. (2011) provided visual instructions with play materials, including a photo cue to assist in puzzle completion, in their examination of engagement, task comple- tion, and stereotypic behavior during play activities. The use of visual instructions resulted in immediate increases in engagement and dramatic decreases in stereotypic behavior Bennett et al. (2011).

Visual organization Providing additional organization to the play material or activity can prove a beneficial adaptation as well. Along with creating an organized play environment, as described above, providing organized play materials and activities can increase engagement with a broad range of play activities (Bennett et al., 2011; Hume & Odom, 2007; Mavropou- lou et al., 2011). Visually organizing the activities can include stabilizing them on a tray, providing containers for extra parts and pieces, reducing the number of parts and pieces, and/ or providing cues or highlighting within a play activity to emphasize its most important parts and pieces. Research indicates that minimizing extra stimulation in activities, ensuring that all needed materials for an activity are included, and providing organizational supports such as trays, containers, and necessary highlighting (i.e., outlining the shape of puzzle pieces on the puzzle board, per Bennett et al., 2011) can support the development of play skills across the developmental levels (Hume & Odom, 2007; Mavropoulou et al., 2011). In addi- tion, intervention manuals propose visual organization when introducing play materials to individuals with ASD.

Figure 10.2 A Product Sample Provides an Example of How the Play Material Can Be Used/ Constructed

Nenov Brothers Images/Shutterstock

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Early Start Denver Model recommends limiting the number of pieces within an activity or toy to avoid confusion and distractibility (Rogers et al., 2012). Rogers et al. recommend starting an activity with just one or two pieces when introducing play materials to help mini- mize confusion and distractibility. Several examples of different types of visual organization for play activities are included in Figure 10.3.

The adaptations to play environments, materials, and activities described in this chapter, though not an exhaustive review, represent some of the most frequently used intervention strategies in both research and practice (National Standards Project, 2009; Stahmer, Collings, & Palinkas, 2005). The adaptations inf luence motivation, a key contributor to the development and use of play skills, by incorporating individual interests and adding visual supports. These adaptations also pair a relative strength in individuals with ASD, visual detail processing (Kaldy, Kraper, Carter, & Blaser, 2011), with the noted weaknesses play skills often tax, such as creativity and flexibility, thus allowing greater participation and success during play activities.

Figure 10.3 An Art Activity Is Visually Organized (The Activity Is Stabilized, Containers Are Used for Materials, and the Materials Are Minimized)

Box 10.1 trends and issues

Play in the age of “apps” As technology continues to become more accessible to educators and families, it is likely that more individuals with ASD will have regular access to portable devices such as the iPad and iTouch. These devices can be incredibly useful for individuals on the spectrum, as a recent publication titled Apps for Autism (Brady, 2011) identifies over 200 technology-based appli- cations for download that directly relate to the needs of individuals with ASD. There are con- cerns, however, about the use of these technology-based tools in teaching play skills to those with ASD. Current thought indicates that while technology use has measureable benefits in teaching play, it can stimulate repetitive and isolated play for those on the spectrum (Rogers et al., 2012). When working on expanding play skills, focusing on simple toys, household objects, and pretend play toys are recommended (Rogers et al., 2012) rather than screens (e.g., TVs, movies, computers). As the field continues to evolve, researchers, families, and practitioners will need to collaborate to navigate through and respond to these concerns.

Mikhail Rulkov/Shutterstock

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Chapter review QuestiOns

1. What are the characteristics of play in young children with autism? (Objective 1)

2. What are the types of play and what are examples of each? (Objective 2)

3. What are the pros and cons of various methods used to teach children with autism to play? (Objective 3)

4. How can play materials be adapted to increase engagement and functional use? (Objective 4)

5. Why are adapted play materials beneficial for individuals with ASD? (Objective 5)

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181

Assistive Technology for Learners with Autism Spectrum Disorders

Chapter 11

elizabeth a. West University of Washington

tal Slemrod University of Washington

CaSe #1: teChnology and literaCy development Gabriel is a student who has autism and is learning to read. When Gabriel was in preschool, he used a computer with preschool computer software to learn cause-and-effect skills. He accessed programs on the computer by using a modified mouse and a touch screen. Gabriel is getting older and needs access to literacy and communication skills, both written and expressive. Gabriel now uses a standard mouse and he benefits from hear- ing information on the computer with voice output software. Gabriel is highly motivated by certain cartoon characters. Consequently, these char- acters were used as the foundation for many of the activities created for him. Gabriel’s teacher took digital photographs of the cartoon characters and loaded them into computer programs to personalize the activities and increase Gabriel’s motivation to learn literacy skills and improve commu- nication. The programs allowed for individualization, visual cues, voice output, and options for scaffolding emergent skill development. Gabriel is provided with custom files that contain motivating graphics that are relevant to his understanding of language, provide for repetition and practice, and allow him to integrate new concepts in a way that supports his learning style.

CaSe #2: aCtivity SCheduleS Grace is a teenager who benefits from the use of activity schedules to assist her with transitions across her school day. Grace was diagnosed with autism at an early age and is primarily nonverbal. Grace had difficulty with transi- tions and it was determined that Grace required more information to assist her with transitions. Grace learned how to use activity schedules at school that contained photographs of the various tasks and activities that she does throughout her school day. The photographs were sequenced in a portable, age-appropriate photo album. Initially, Grace was provided with prompts to access the schedule and initiate transitions. Gradually, the prompts were systematically faded and now Grace independently opens her book, turns to the appropriate page, and does the activity. Use of activity schedules has progressed from providing Grace with more information about her daily schedule to providing her with visual information about specific steps of activities. Use of this mid-tech solution, activity schedules, has assisted Grace in becoming more independent across her school day.

CaSe Study Examples

Chapter ObjecTiveS After reading this chapter, you should be able to: 1. Describe the potential benefits

of assistive technology for individuals with Autism Spectrum Disorders.

2. Explain how categories of assistive technology are identified based upon the seven areas of human function.

3. Discuss the framework and rationale for considering the student, the environment, and the tasks required for active participation first before selecting the tools needed to address the tasks.

4. Outline the service delivery system and describe each step in the process.

5. Summarize the core components of collaboration and who should be involved to provide appropriate assistive technology supports and services.

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IntroduCtIon

Technology plays a pivotal role in the education of learners diagnosed with an Autism Spec- trum Disorder (ASD). Technology can take many forms and serve many functions. Integral to many programs developed for learners with an ASD is the use of technology to assist in the attainment of critical skills necessary to lead a productive life.

Assistive technology (AT) is a generic term that includes assistive, adaptive, and reha- bilitative devices and the process used in selecting, locating, and using them. AT promotes greater independence for students with disabilities and can be an equalizing force as these students gain access to inclusive environments. AT provides enhancements to or changed methods of interacting with the technology needed to accomplish tasks that promote pos- itive educational outcomes. A formal, legal definition of AT was first published in the Technology-Related Assistance for Individuals with Disabilities Act of 1988 (The Tech Act). This act was amended in 1994, and in 1998 it was replaced with the Assistive Tech- nology Act of 1998 (AT Act). Throughout this history, the original definition of AT has remained consistent. The Tech Act of 1998 defines Assistive or Adaptive Technology as “products, devices or equipment, whether acquired commercially, modified or customized, that are used to maintain, increase or improve the functional capabilities of individuals with disabilities.”

The consideration of assistive technology devices and services is required during the development of every individualized educational program (IEP) and every individual family service plan (IFSP) for children birth to school age. The Individuals with Disabilities Educa- tion Act (IDEA) of 1997 requires that each IEP/IFSP team considers and documents any AT devices and/or services that a child may need. Important to the IDEA mandate, upheld in the 2004 re-authorization, is the focus on both “device” and “service.” It is not sufficient to merely provide access to a device with no “service.” Services extend to students with disabilities or their caregivers to help them select, acquire, or use adaptive devices. Such services can include functional evaluations, training on devices, product demonstration, and equipment purchas- ing or leasing.

Students with ASD can benefit from technology in many arenas of their lives: edu- cation, recreation, employment, and social. AT can assist students with ASD by increas- ing their independence, developing communication and literacy skills, and building social competence. Influences in these areas serve to improve student’s overall quality of life and equalizes educational opportunities by promoting access to the general education setting (see Box 11.1).

Use of technology, specifically technology that relies heavily on visual input, may be of particular benefit for learners with ASD. One of the general trends that has been noted in children with autism is that they are visual learners and thinkers (Dettmer, Simpson, Myles, & Ganz, 2000; Edelson, 1998; Grandin, 1995; Mesibov, 1998; Prizant & Rubin, 1999; Quill, 1997; Wheeler & Carter, 1998). Use of visual supports and strategies is of benefit for many individuals with autism that aligns well with the visual nature of technology.

Recommended competencies in the area of AT have been identified by the Council for Exceptional Children. A subcommittee appointed by the National Association of State Direc- tors of Special Education, called Partnership of States, developed a statement of competencies for school district staff members working in the area of assistive technology. See Table 11.1 for a complete listing of the competencies. These competencies serve as a useful guide for technol- ogy, which advances at such a rapid pace that it may be difficult for the practitioner to keep up with current trends and recommendations in the field. This chapter serves to provide an overview of technology and its potential for applied use in the everyday lives of those students who are diagnosed with ASD.

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Box 11.1 trends and Issues notes #1

Access to the general education curriculum is emphasized by IDEA and includes the ability to obtain materials as well as the ability to understand and use them. Internet communica- tions, multimedia, and universal design are providing new learning tools. Internet communi- cations can transport students beyond their physical environments, allowing them to interact with people far away and engage in interactive learning experiences. Students can also access electronic multimedia encyclopedias, library references, and online publications. Multimedia tools are another way in which information can be made accessible to students. Multimedia use of text, speech, graphics, pictures, audio, and video in reference-based software is espe- cially effective. While a picture can be worth a thousand words to one student, audio- or text-based descriptive video or graphic supports may help another student focus on the most important features of the materials. Used in conjunction with assistive technology, e-books can use the power of multimedia to motivate students to read. They include high-interest stories: The computer reads each page of the story aloud, highlighting the words as they are read. Fonts and colors can be changed to reduce distraction. Additional clicks of the mouse result in pronunciation of syllables and a definition of the word. When the student clicks on a picture, a label appears. A verbal pronunciation of the label is offered when the student clicks the mouse again. Word definitions can be added by electronic dictionaries and thesaurus. These books are available in multiple languages, including English and Spanish, so students can read in their native language while being exposed to a second language. The Center for Applied Special Technology (CAST) promotes the concept of universal design (Rose & Meyer, 2002), which asserts that alternatives integrated in the general curriculum can provide access to all students, including a range of backgrounds, learning styles, or abilities. Providing material in digital form, which can easily be translated, modified, or presented in different ways, can often attain the goal of universal design.

areas of human funCtIon

Categories

When decisions are being made about the provision of AT services for individuals with ASD, it is important to base them on factors related to human function rather than on diagnosis. The real issue is the difficulties the student has in functioning within his environment and how to provide adequate supports.

taBle 11.1 examples of technology Solutions

teChnology to inCreaSe aCCeSS teChnology aS inStruCtional tool

no Tech physical, speech, or occupational therapy Systematic teaching procedures

Low Tech pencil with rubber grip velcro fastener raised desk to accommodate wheelchairs

flash cards Overhead projector chalkboard

medium Tech wheelchair hearing aid

calculators instructional video tape

high Tech Adaptive keyboards Speech synthesizer virtual reality devices

instructional computer software interactive multimedia systems computer text with hypermedia links

Source: Adapted from blackhurst, e. (1997). perspectives on technology in special education. Teaching Exceptional Children, 63(4), 1997, 41–48.

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The term function can be defined as an action that a person takes in response to a demand to meet some need. Human functions can be grouped into several categories and the National Assistive Technology Research Institute (see Internet Resources) staff have categorized AT according to seven areas of human function. This conceptualization is adapted from Melichar’s (1978) work to categorize and locate assistive and adaptive devices according to their functional applications. These seven categories are highlighted below.

exIstenCe The first and most basic category, existence, refers to those functions that are needed to sustain life. These functions include feeding, elimination, bathing, dressing, groom- ing, and sleeping. Services for students with ASD may focus on teaching them how to perform such functions. Numerous devices exist to assist students in performing these functions.

CommunICatIon Numerous communicative functions exist, specifically, oral and written expression, visual and auditory reception, internal processing of information, and social inter- action. Use of technology, specifically use of augmentative and alternative communication (AAC), is of great benefit given that communication difficulties are a core deficit for learners with ASD. An AAC system is an “integrated group of components, including the symbols, aids, strategies, and techniques used by individuals to enhance communication” (American Speech-Language-Hearing Association, 1991, p. 10). Qualities of visual systems for commu- nication appear to match the cognitive strengths of students with autism (Quill, 1995). Given the communicative needs of students with ASD, practitioners have relied upon AAC to assist students to become functional communicators both in the present and with a vision toward the future (Beukelman & Mirenda, 1998).

AAC systems can range from relatively low-tech systems (i.e., simple adaptations with no batteries or electronics, such as communication boards and conversation books) to high- tech devices (i.e., complex electronic or computer driven technologies). AAC systems may be roughly classified into one of two categories: unaided communication systems and aided com- munication systems (Beukelman & Mirenda, 1998; Romski & Sevcik, 1988). Unaided AAC systems do not require any sort of external communication device for production of expressive communications and may include sign language, facial expressions, gestures, and nonsymbolic vocalizations. Aided AAC systems require an external communication device for production and include the use of picture communication boards and voice output devices (Beukelman & Mirenda, 1998; Miller & Allaire, 1987).

The primary emphasis of communication intervention has shifted to the acquisition of functional communication skills within natural environments. Although structured approaches are still utilized, best practices today emphasize functional language skills within natural daily routines and natural environments (Beukelman & Mirenda, 1998; Calculator & Jorgensen, 1991). Functional communication is “the actual use of language to achieve predetermined purposes. In order to be functional, language must influence others’ behaviors and bring about effects that are appropriate and natural in a given social context” (Calculator & Jorgensen, 1991, p. 204). Functional communication may promote literacy learning given the visual nature of reading and writing and the strong visual-spatial strengths of learners with ASD.

One example of a contemporary and frequently used approach to functional commu- nication is the Picture Exchange Communication System (PECS) (Bondy & Frost, 1994). Practitioners utilizing the PECS program emphasize communicative exchanges as students are taught to request and comment by giving picture cards to a communication partner. The results of systematic review and meta-analysis reveal promising effects of PECS on enhancing functional communication of learners with ASD (Flippin, Reszka, & Watson, 2010; Ostryn, Wolfe, & Rusch, 2008; Preston & Carter, 2009; Tien, 2008; Tincani & Devis, 2011).

Numerous AAC devices exist, focusing on output and input methods. Voice output communication aids (VOCAs), also referred to as speech-generating devices (SGDs), are portable AAC devices that produce synthesized or digitized speech. Van Der Meer and Rispoli (2010) performed a review of communication interventions involving SGDs for children with autism and identified that they are a viable communication option for children with

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autism. In addition to using output methods for communication, AAC interventions have also been used to communicate input from others. Several case studies demonstrate the effectiveness of using visual symbols to augment communication (Hodgdon, 1995; Peterson, Bondy, Vincent, & Finnegan, 1995; Quill, 1997). Several “input” methods exist, specifically the use of visual schedules, where children with ASD access a visual representation to assist with comprehension of activity sequences. Visual schedules have been used in many ways to facilitate the attainment of numerous skills. See Box 11.2, Research Notes, for examples of innovative uses of multimedia supports with activity schedules.

A recent increase in accessible handheld media devices with applications have promoted opportunities for access to visual content and appropriate instructional materials (Shane et al., 2012). These types of technology (e.g., Apple iPad and Proloquo2Go) can enhance language and communication in learners with ASD. At times, a technology can serve both as an instruc- tional technology and as an assistive technology and both types can serve as supports for learn- ers with ASD within the educational context. Everyday technologies (smart phones, iPod touches, tablets) may be more cost effective for learners with ASD and may be more motivat- ing than traditional AT devices. Bouck, Flanagan, Miller, and Bassette (2012) encourage prac- titioners to rethink everyday technology as AT to meet students’ goals. These authors suggest that commercial technologies primarily seen in out-of-school contexts can influence student learning when selected and aligned to IEP goals.

Closely aligned with the category of communication is the need for behavioral support. Strong empirical support exists for the use of functional communication training to replace challenging behaviors. Individuals with ASD are able to learn to use AAC to replace chal- lenging behavior (Mirenda, 1997). The AAC form must serve as a functional equivalent to the challenging behavior (Horner et al., 1990) and a systematic approach has been designed to assist practitioners in this endeavor.

Body support, proteCtIon, and posItIonIng Some students need assistance to maintain a stable position to support portions of their body. Students with ASD who have fine- and/or gross-motor difficulties as well as sensory difficulties may require the support of devices in this functional category. An array of materials may be used to meet the student’s need for support and input. Examples include the use of weighted vests, stability balls, tactile toys, vibrating pens, and platform swings.

travel and moBIlIty Functions in this category include crawling, walking, using stairs, lateral and vertical transfers, and navigation of the environment. Wheelchairs, special lifts, canes, walkers, specially adapted tricycles, and crutches can be used to support these functions.

Box 11.2 researCh notes

Kagohara, D. M., van der Meer, L., Ramdoss, R., O’Reilly, M. F., Lancioni, G. E., Davis, T. N., Rispoli, M., Lang, R., Marschik, P. B., Sutherland, D., Green, V. A., & Sigafoos, J. (2013). Using iPods and iPads in teaching programs for individuals with developmental dis- abilities: A systematic review. Research in Developmental Disabilities, 34, 147–156.

The authors of this review examined 15 studies across several domains, specifically academic, communication, employment, leisure, and transitioning across school settings. Outcomes were reported for 47 participants who ranged in age from 4 to 27 years and had a diagnosis of ASD and/or intellectual disability (ID). Results of a systematic review of these 15 studies indicate that iPods, iPod Touch, iPads, and related devices have potential value and that individuals with ASD and/or ID can be taught to operate them. These authors acknowledge a limitation of the research base as published literature contains a small number of participants (<50) with a broad age range and varying diagnoses or degrees of intellectual disabilities.

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envIronmental InteraCtIon The environment can be adapted or the student can adapt to the environment. Environmental interaction includes functions associated with these adaptations as seen in the performance of many of the activities of daily living, both indoors and outdoors. Examples include food preparation, operation of appliances, accessing facilities, and alteration of the living space. It may be necessary to make a number of modifications to school facilities to accommodate functions in this category.

eduCatIon and transItIon Functions in this category include those associated with school activities and various types of therapies. Numerous technologies may be used within the context of schools and can include computer-assisted instruction, audio instructional tapes, print magnifiers, book holders, and other materials and equipment that can facilitate education.

Computer-assisted instruction (CAI) may include the use of computer-delivered prompts, systematic learning programs, vocabulary development, technology-based curricu- lar adaptations, writing programs with word predication and virtual reality. Computer soft- ware programs, such as Boardmaker, allows for the creation of environmentally specific visual language tools for language boards or VOCA displays. CAI has been relied upon to teach learners with ASD academic skills (Pennington, 2010); social communication, including lan- guage, emotion recognition, and social skills (Wainer & Ingersoll, 2011); and goal setting and self-determination (Mazzotti, Wood, Test, & Fowler, 2012). In addition, use of an iPad to deliver instruction has been shown to reduce escape-maintained behavior and increase engage- ment for some children with an Autism Spectrum Disorder (Neely, Rispoli, Camargo, Davis, & Boles, 2013). Collaborative virtual environments have also been used to facilitate the attain- ment of specific skills (see Box 11.3, Trends and Issues Notes #2).

sports, fItness, and reCreatIon Functions associated with group and individual play, sports, games, hobbies, and leisure time are included in this functional category. An array of equipment and devices exist that can facilitate functions in this category to promote active participation.

Box 11.3 trends and Issues notes #2

A virtual environment can be defined as a computer-generated three-dimensional simulation of a real or imaginary environment (Cobb, Kerr, & Glover, 2001). One emerging area for children with autism is the use of collaborative virtual environments (CVEs; Moore, Cheng, McGrath, & Powell, 2005). CVEs have begun to be used as an assistive technology, as an edu- cational technology, and as a means of helping address potential theory-of-mind impairments. Central to the use of CVE is the notion of an on-screen avatar. The user can interact within this environment using a self-selected avatar, defined as a representation of the user’s identity within the computer environment (Gerhard, 2003). In a CVE, there can be more than one user, and the users can communicate with each other using their self-selected avatars. Moore et al. (2005) define a CVE as a “distributed computer-based virtual space (or set of sp case) in which people can meet and interact with others via their avatars” (p. 232). Avatars can poten- tially provide presence and social facilitation for those involved in a CVE. Given the impair- ments that individuals with autism exhibit, use of CVE may have potential benefit. CVE may promote communication among users and facilitate social skills as a range of scenarios to practice are provided. Use of this technology is in its infancy, however, as technology advances research will be needed to demonstrate its efficacy.

Source: Moore, D., Cheng, Y., McGrath, P., & Powell, N. J. (2005). Collaborative virtual environment tech- nology for people with autism. Focus on Autism and Other Developmental Disabilities, 20(4), 231–243.

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Technology can take many forms to serve the above functions; from the low-tech pic- ture drawing to the high-tech voice output system. Blackhurst (1997) provides a continuum of technology-based solutions ranging from no-tech, low-tech, medium-tech, and high-tech tools (see Table 11.2). As illustrated in the table, AT can be used for different objectives with different children with disabilities.

Handleman and Harris (2000) describe several areas that are important in comprehen- sive early education programs for children with ASD. These areas are as follows: social and cognitive development, verbal and nonverbal communication, adaptive skills, increased com- petence in motor activities, and amelioration of behavioral difficulties. These areas are not

taBle 11.2 overview of education tech points

• education Tech point #1—consideration and referral

when a child has an identified educational difficulty, assistive technology questions at the referral stage center around the specific problem that the student is experiencing and whether simple, readily available assistive technology utilized in the classroom might provide enough support that referral to special education would not be necessary.

• education Tech point #2—evaluation

Questions for the evaluation team included whether the student can be evaluated accurately without assistive technology and what types of assistive technology might enhance the student’s performance. The implications for school districts here are that evaluation center staff must have the same awareness level training recommended for student service teams, in addition they need specific training on the requirements of iDeA and Section 504 for accommodations and modifications. They also need access to an array of assistive technology devices to use for evaluation purposes and to colleagues with expertise about assistive technology for various difficulties, including positioning, hand use, augmentative communication, computer access, and print access.

• education Tech point #3—Trial periods

The questions to be addressed at the point of extended assessment of assistive technology needs are related to what specific tasks the student needs to be able to do and what, if any, assistive technology could possibly help.

• education Tech point #4—plan Development

After the evaluation and assessment data have been assembled, an appropriate educational program must be developed. The school district must determine if assistive technology is needed for the child to receive a free appropriate public education. implications for the school district include insuring that staff members are trained in writing assistive technology into the iep and that they include appropriate periodic review to identify and deal with unanticipated problems.

• education Tech point #5—implementation

implementation questions focus on responsibility for day-to-day operation. This area includes questions such as who will make sure the equipment is up and running, what will happen when it needs repair, and what the district will provide in the interim if they are going to seek outside funding to purchase a device.

• education Tech point #6—periodic review

iDeA requires the periodic review of each student’s iep. This review should include evaluation of the effectiveness of the assistive technology solutions in the child’s plan. Questions at the point of periodic review center around whether the assistive technology devices and services that were planned and provided have actually had the intended effect.

• education Tech point #7—Transition for Students who use AT

provides steps to consider for students who are transitioning to ensure that what is working well for the student continues. in addition, a reevaluation of what is not working well must occur to revise plans for improvement.

Source: bowser, g., & reed, p. (2012). Education tech points: A framework for assistive technology. winchester, Or: coalition for Assistive Technology. retrieved from www.educationtechpoints.org/manualsmaterials/education-tech-points

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specific to early education programs as each domain is critical to the lives of individuals with ASD at every age. As noted, AT can take many forms and serve many functions as it is used in interventions to assist students to meet specific goals in comprehensive educational programs.

assIstIve teChnology servICe delIvery systems

the process

A typical AT delivery system consists of assessment, acquisition, application, and an evaluation (refer to WATI [Wisconsin Assistive Technology Initiative] Internet Resources for detail on delivery systems). Service delivery should include a detailed, systematic process for examining a student’s abilities and difficulties and the demands of the environments and tasks. When considering AT, the environment and the tasks must be considered before tools are selected. To support this belief, the SETT Framework (see Internet Resources, Joy Zabala) has been devel- oped to aid in gathering and organizing data that can be used to make appropriate decisions. The SETT Framework considers, first, the Student, the Environment(s) and the Tasks required for active participation in the activities of the environment, and, finally, the Tools needed for the student to address the tasks. Information about the Student, the Environments, and the Tasks must be gathered and thoughtfully considered before an appropriate system of Tools can be pro- posed and acted upon. The outline of questions to consider in each area of the SETT Framework was developed as a guideline and a place to start. Teams gathering and acting upon this data may wish to seek answers to numerous additional questions. In virtually every situation, how- ever, any questions that arise will relate to one of the areas of the SETT Framework.

assessment The first step in the process involves assessing the technology-related needs of students with disabilities to determine if any equipment may be needed. Consideration of AT should occur during the very earliest stages of evaluating a student’s eligibility for special education services. The successful use of any educational tool or strategy begins with an effec- tive assessment of a student’s individual needs. In order for AT to be effective, its selection and use must be grounded in a solid understanding of (a) a child’s needs, strengths, and suitability for different assistive technologies and (b) the technology’s features, characteristics, demands, and suitability for the child (Office of Special Education Programs [OSEP], 2000). The cul- tural context of learners should be examined as a key aspect when considering AT. Researchers (e.g., Hetzroni & Harris, 1996; Huer, 1999, 2000; Parette, 1999) have identified culture as a critical consideration in the successful implementation of AAC systems (see Box 11.4).

Box 11.4 dIversIty notes

Generally thought to be helpful to any student whose needs seem to require them, assis- tive devices or services are useful only if the student’s family wants them. In establishing AT goals, IEP teams need to consider certain factors relating to the family’s perception of their child’s disability and also their ability to understand and implement the devices. Some families, for instance, prefer that their children remain dependent on family and community resources rather than have them gain independence by means of the AT device or service. Some families may want their children to be included with their peers, but others may be afraid that the device will mark their child as out of the ordinary, and still others may feel doubly stigmatized by the AT, already having to cope with the stigma of their minority sta- tus. The key to successful implementation of AT in the IEP is to consider the appropriateness of the device or service for a particular child, within the context of the family. Parette and McMahan (2002) formulated a detailed list of family goals and expectations regarding assis- tive technology, potential positive and negative outcomes, and possibly IEP responses in light of those outcomes. These researchers also provide a helpful set of questions team members can pose to families regarding acceptance of the device within the family and community, expec- tations of results to be gained from its use, and the resources available.

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Many barriers exist related to assessment, namely, lack of current and thorough informa- tion, lack of understanding of a child’s environment, supplementary supports, changing needs of children, and costs of assessments (OSEP, 2000). Education Tech Points is a system that was developed to assist in consideration of AT (Bowser & Reed, 2012). Each Education Tech Point identifies the specific times within the planning and provision of specially designed instruction that the need for AT (both devices and services) should be considered. Education Tech Points offer a way to integrate AT into IEP/IFSP team planning and into the management system that each school district uses to ensure provision of appropriate services to children with disabilities. The 2012 edition of Education Tech Points contains text, resources, and a CD with tools and forms to help practitioners develop an assistive technology process for an individual child or for an entire school district. Key points to assist in making decisions regarding utilization of assis- tive technology services and resources are identified and incorporated into the regular educational planning system. Initial Education Tech Point questions guide the IEP/IFSP team through the necessary steps to determine if a child may need an assistive technology device or service.

aCquIsItIon Once a determination is made, the AT team sets out to acquire the device. A large barrier to acquisition is funding of services and supports.

applICatIon Once a device has been acquired, the next step is to use the device with the student. During implementation, the Education Tech Point questions at points 5 and 6 can assist the education staff to monitor the program in order to ensure that needed changes are addressed in a timely and efficient manner. Training of consumers is critical during the ser- vice delivery process. Determining exactly what to teach and how to teach it must be highly individualized not only to meet the needs of the child, but to fit into the beliefs and lifestyle of the family as well as teachers, therapists, and other persons who are involved. Whatever the family is counted upon to do must fit into their lifestyle and routines, and not be burdensome. To ensure that this occurs, everyone involved, and the family in particular, must have funda- mentally agreed with both the choice of technology and its accompanying teaching program.

During the application stage, it is critical for the trainer to identify and use those “teachable moments.” Ideally, formal instruction should occur frequently and for short peri- ods of time. This is easier to do when teaching is integrated into daily activities and routines, including play time (i.e., naturalist teaching methods are useful). Children should be taught in natural settings, places in which the child is familiar and feels at ease. The essential philosophy of service provision has evolved from a focus on isolated skills taught during pullout therapy to an inclusive model, one in which functional skills are taught within natural environments.

evaluatIon The success of the AT solution must be periodically evaluated and necessary adaptations must be made to the devices. The Quality Indicators for Assistive Technology (QIAT) Consortium has focused its efforts on defining a set of descriptors that could serve as over-arching guidelines for quality AT services (for more information visit the QIAT Web site at http://www.qiat.org). Descriptors developed by the Consortium can assist practitioners to develop and provide quality AT services. The current version provides intent statements and identifies errors that are often committed when attempting to implement various AT services.

CollaBoratIon

Effective collaboration is essential during the service delivery process. In addition to the family and student, several people should be involved in the service delivery process, namely, a person knowledgeable about the student, a person knowledgeable in the area of curriculum, a person knowledgeable in the area of language, a person knowledgeable in the area of motor, and a per- son who can commit the district’s resources. During an AT assessment, team members must work together to discover the most promising solutions for a student. The collaborative pro- cess should not stop after assessment is complete but should continue to ensure sustainability of programs. Assessment and intervention should form a continuous and dynamic process that is directly influenced by collaboration.

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190 Chapter 11 • assistive teChnology for learners with autism speCtrum DisorDers

Internet resources

The TAM (Technology and Media) Division of the Council for Exceptional Children offers a variety of information about assistive technology and special education instructional technology. http://www.tamcec.org

Trace Research and Design Center includes software toolkits and many disability-related articles and papers. http://trace.wisc.edu//world/computer_access/multi/ sharewar.htm

The Family Village is a Web site designed to provide information for families with children with disabilities. This site offers extensive resources on AT. http://www. familyvillage.wisc.edu/

Closing the Gap offers a variety of articles, resources, and interactive activities related to assistive technology. http://www.closingthegap.com/index.lasso

Augmentative and alternative communication resource guide for young children. http://aac.unl.edu/yaack/toc.html

Contains information on creating literacy-based communication boards and an excellent resource list on AAC. http://www.aacintervention.com

The Wisconsin Assistive Technology Initiative (WATI) is recognized as a leader in the provision of statewide support for assistive technology services, and their site offers a wealth of practitioner friendly resources. http://www.wati.org

summary

Assistive technology can serve as a powerful equalizer in the lives of students with ASD and can facilitate access to a range of meaningful opportunities. Culturally relevant and responsive assistive technology services and supports must be provided during each step of the decision-making, implementation, and evaluation process. AT can either be a blessing or a barrier. A collaborative process must be established where partnerships

are forged to adequately reflect needs and desires. One of the greatest potentials for the use of technology is in the education of learners with ASD. Technology has the potential for dramat- ically improving the quality of education and the quality of life for youth with ASD. Effective use of technology can foster independence, can promote the development of communica- tion and literacy skills, and can build social competence.

Key terms

Activity schedules 184 Aided AAC systems 184 Areas of human function 184 Augmentative and alternative

communication (AAC) 184 Computer-assisted instruction 186 Device 182 Education Tech Points 189

Functional communication 184 High-tech 184 Low-tech 184 Medium-tech 187 Multimedia supports 185 Picture Exchange Communication

System (PECS) 184

Quality Indicators for Assistive Technology (QIAT) 189

Service 182 SETT Framework 188 Unaided AAC systems 184 Voice output communication aids

(VOCAs) 184

chapter revIew QuestIons

1. Interview a student who uses AT, a family member of a student who uses AT, or school personnel who support a student who uses AT and identify the reported benefits of assistive technology. (Objective 1)

2. Create a diagram or visual representation of the categories of assistive technology and seven areas of human function. (Objective 2)

3. You have been asked to lead an IEP meeting where team members are considering the use of AT for a particular student. Identify and discuss the framework and rationale

for considering the student, the environment and the tasks required for active participation first before select- ing the tools needed to address the tasks. (Objective 3)

4. Create a Venn diagram or another type of visual aid that outlines the service delivery system and depicts each step in the process. (Objective 4)

5. You have just received a new student who you feel needs AT supports and services. Identify the core components of collaboration and who you think should be involved in the process. (Objective 5)

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The National Assistive Technology Research Institute conducts assistive technology (AT) research, translates theory and research into AT practice, and provides resources for improving the delivery of AT services. http://natri.uky.edu

The Quality Indicators for Assistive Technology (QIAT) Web site includes the work done to date to develop a comprehensive set of quality indicators for effective assistive technology services. Managed by Dr. Joy Zabala. http://www.qiat.org

CAST researches and develops ways to support all learners according to their individual strengths and needs through Universal Design for Learning (UDL). http:// www.cast.org/

This project provides information and consultation to AT programs. Locate the AT program in your state and read articles relating to legislation and AT. http://www. resna.org/

This is a general site with information and resources for a range of assistive technology. http://www.abilityhub.com/

ABLEDATA provides objective information about assistive technology products and rehabilitation equipment available from domestic and international sources. http://www.abledata.com/

Matrices are provided to serve as resources that match technology tools with supporting literature on promising practices for the instruction of K-8 mathematics and reading for students with disabilities. http://www.techmatrix.org/

Selected links on ASD including articles and sites with practical strategies. http://www.lburkhart.com/index.html

This site contains information and resources as well as free printable picture symbols and charts to use for visual schedules and steps within tasks. http://www.dotolearn.com/

This is a weekly newspaper for AAC users as well as emergent readers. Communication symbols are used along with the text. http://news-2-you.com/

This site is maintained by Dr. Joy Zabala Director of Technical Assistance at CAST (http://cast.org) where she also directs the technical assistance efforts of the National Center on Accessible Instructional Materials (http://aim.cast.org). This site primarily serves as a location for providing information and supports related to the SETT Framework but also includes links to other areas of interest, particularly QIAT, UDL, and AIM. http://www.joyzabala.com/Home.php

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192

Case of Madeline Madeline is a 26-month-old child recently diagnosed with autism. Made- line’s parents noticed something wasn’t quite right with her development from around 6 months. Whereas Madeline’s older sister Michelle had been quick to roll over, pull up, crawl, and walk, Madeline showed no signs of wanting to explore her environment, no interest in pulling up to gain access to table tops or furniture, and was slow to complete most major milestones. Her parents asked her pediatrician about this at each well- baby visit, but were assured that all children develop at different rates and that Madeline would eventually catch up. Two months later, she was diagnosed with autism.

Case of logan Logan is an 8-year-old girl with high-functioning autism who attends her neighborhood public elementary school and receives special education pull-out services for 1.5 hours per day. Logan receives special education services for social skills, pragmatic language, reading, and writing. She has a great many difficulties with fine motor skills. In particular, Logan has difficulty with handwriting and has begun to display challenging behaviors when required to write. Her teachers have asked that she be allowed to type her lessons instead of handwrite them, but her family believes this will unnecessarily single her out from her peers and believes it is important for her to be able to write.

Case of ali Ali is a 14-year-old girl who is excited about starting high school in the fall. In elementary middle school, she reflects as if she felt out of place and awkward not just socially, but in other ways as well. In particular, Ali reports that she “hated” PE class, because, as she says, “I couldn’t do any of the things the other kids could do. Other kids have all of this ath- letic ability, and I just could never figure out how to make my body DO some of that stuff!” Ali’s parents have talked to the school about finding an alternative to the state requirement of PE for high schoolers and are considering the color guard or rowing. Ali just hopes that the other kids won’t make fun of her if she has trouble with those activities, too.

Chapter 12

Chapter Objectives At the end of this chapter, the reader will be able to: 1. Describe the difference between

gross and fine motor skills. 2. Explain the importance of

examining motor difficulties for individuals with autism.

3. List and describe some of the common motor difficulties for individuals with autism.

4. List some of the assessment methods that can detect motor difficulties for individuals with autism.

5. Describe the research on motor issues for people with autism.

Mark guadagnoli and B. Justin aylsworth University of Nevada, Las Vegas

Christie aylsworth, Ms/CCC-slp, shana gilbert, otr Pediatric Rehabilitation and Behavioral Services, Schertz, TX

Motor consideration for individuals with Autism spectrum Disorder

Case study Examples

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IntroduCtIon

To the casual observer, autism is a condition that results in a struggle with social skills and communication. Parents of children with autism will tell you that it is much more. Many children with autism also have great difficulty with motor skills, such as running, throwing a ball, and handwriting. In fact, even those who appear to have adequate or age-appropriate motor skills, often demonstrate difficulty in motor function and quality. Current research suggests that up to 83% of children with autism have motor deficits (Hilton, Zhang, White, Klohr, & Constantino, 2012). Yet, despite the high prevalence of such deficits, they are not included in the diagnosis of autism and often neglected in the treatment. In general, this chapter is written to provide a foundation for understanding the relationship between autism and motor abilities. More specifically, we will describe the motor deficits of children with autism and how these deficits are important early indicators of autism. Finally, intervention strategies as they relate to motor function will also be discussed.

the ImportanCe of movement

Although we rarely give it a second thought, the learning and control of movement is critically important to our existence as humans. At the very basic end of the movement spectrum, movement is necessary for survival of an organism and the propagation of its species. Eating, locomotion, and procreating all require movements. Think for a moment what life would be like if we were unable to move; locomotion would be impossible, as would reaching out to grasp objects, communicating with others, and our ability to see. Even briefly considering the prospect of being paralyzed is horrifying to an average person. Such examples make one realize the importance of movement at a basic level, but movement is also important in a less basic way. On the elaborate end of the movement spectrum, movement is a wonderfully elegant form of expression, as anyone who has watched Mikhail Baryshnikov dance or Michael Jordan play basketball can attest. And yet, there is something else to know about movement.

Movement is more than movement

Movement is our way of expressing ourselves and our way of interacting with our envi- ronment as well as with each other. Movement can occur in response to another person or an environmental stimulus. Movement results from a complex set of operations that require us to decide what to do and then how to plan and execute the necessary act. As such, movement is an important window into the inner working of our brain and body.

movement taxonomIes

Motor learning and behavior specialists have created a taxonomy to describe movement. This taxonomy is described below and the language will be used as we move through the chapter focusing on children with autism.

fundamental motor skills

According to Gabbard (Gabbard, 2011), fundamental motor skills are the “building blocks” or foundation movements for more complex and specialized skills. Locomotion, stability, and manual manipulation of objects are the three main areas of fundamental motor skills. Locomotion includes walking, running, skipping, and hopping. For the most part, locomo- tion is how we get from here to there. Stability is balance-related movements and coordi- nation of movements in general. Finally, manipulation includes all types of manual control. Reaching, grasping, and releasing are considered examples of fundamental manual control.

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These skills are more complex than meets the eye. Under normal situations, reaching and grasping an object is learned within the first 10 months of life. However, to be able to release an object accurately can take another 5 months to learn. For example, a child may be able to reach and grasp a bottle, but to put it back on the table when they are finished drinking is a hit or miss proposition until the child is 18 to 20 months of age. As a result, it’s probably not a good idea to give your baby your expensive Ming vase to put on the table for you.

At the simplest level, fundamental movements are required for children to navigate their world and communicate with each other. As the children become more competent, fundamental movements are required for children to competently and confidently play games, sports, and recreational activities offered at school and in the community. Further- more, fundamental movements are utilized throughout the life span. Although adult move- ment patterns may appear more complex, many of these patterns are still built from base fundamental skills. For this reason, developing fundamental skills is not only important for a child to successfully interact with the world but also for creating more complex move- ments later in life.

Movements, fundamental or otherwise, can be additionally categorized by the control required for the movement. In this regard, movements are put into two general categories: gross and fine.

• Gross movements are typically the large movements, such as running and jumping. These movements require the use of the large muscle groups in the arms, legs, and torso. Examples of gross movements include running, kicking, and throwing. You may recognize that these are some of the earliest movements learned. One reason for this is that gross movement typically requires less precise control than fine movement and, therefore, can be initiated with some degree of success within the first few years of life.

• Fine movements are typically small movements that require precise control. These movements use the small muscles of the fingers, toes, wrists, lips, and tongue. Examples of fine movements include speaking, keyboarding, and releasing an object with precision. As you can imagine, fine movements typically develop later than gross movements since they require a greater degree of central nervous system sophistication.

These basic taxonomies of movement are present for all children, including those with Autism Spectrum Disorders (ASDs). According to the National Institute of Mental Health, the group of brain disorders associated with autism is collectively referred to as Autism Spectrum Disorder.

Why Is the InvestIgatIon of motor defICIts an Important QuestIon?

At the most basic level, the investigation of motor deficits in children with autism is important as motor deficits have a negative effect on a child’s outcomes and quality of life. Understanding the prevalence of these deficits, and how to treat them, can at the least lead to improving a child’s happiness on a case-by-case basis. In the cases of children with Asperger’s Syndrome or very high–functioning ASD, if a child looks at his peers and notices he himself is moving awkwardly in comparison, he may become self-conscious and more withdrawn, further increasing the negative social impairment associated with autism. Unfortunately, with the tactless and unrelenting honesty of children, awkward movements may even be ridiculed by peers. Creating a strong, confident psyche, allowing a child with the aforementioned conditions to confidently move and partake in physical activities may improve willingness to interact. Children burdened by core weaknesses may also benefit from increased strength, allowing them for focus and sit still in classes. Physical therapy

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will also have a direct and obvious benefit for children who suffer from muscle deficits, such as those caused by toe-walking.

The less obvious reason for investigating motor deficits is less focused on the individ- ual child, but on the disorder as a whole. Currently, the vast majority of research on autism is focused on the cognitive domains, especially social interactions. However, the potential for research into motor deficits is beneficial as the parts of the brain involved in motor skills are more understood and easily researched than those responsible for language and social interactions. The regions associated with motor skills are well defined and can more easily be studied with brain scans (Mostofsky et al., 2009). Because of this, if one can definitively associate motor deficits with autism disorders, not only can disorders be used as a tool for diagnosis but also brain scans can be used as a diagnostic tool and cast an eye toward fur- ther understanding the complex disease. One of the difficulties with this suggestion is the difficulty in differentiating between ASD and other motor-based disorder such as apraxia/ dyspraxia or other comorbid disorders. Indeed, many core characteristics of autism are shared by other diagnoses in the global category of Pervasive Developmental Disorders. However, in spite of these difficulties, researchers are growing in their belief that motor functioning in children with ASD will be important in diagnosis (Teitelbaum et al., 2004) and intervention (Baranek, 2002).

This suggestion brings up important work from Stewart Mostofsky, a pediatric neurol- ogist at the Kennedy Krieger Institute in Baltimore. Dr. Mostofsky suggested that studies of motor skills and autism offer two advantages to researchers. First, motor skills are easier than social and communicative skills to observe, measure, and assess. Second, by assessing motor skills, one can use brain-imaging techniques to examine the condition. An advantage to imaging the brain’s motor cortex, rather than more cognitive areas, is that the motor cortex is a well-defined region. As such, researchers can be more efficient in looking at specific regions and processes. This becomes even more interesting when looking at children with autism because it has been documented that young children with autism have a greater volume of white matter in their brains than do typically developing children (Herbert et al., 2004). Interestingly, this difference is largely extinguished by adolescence.

Increased brain volume is the most consistent neuroimaging finding in children with autism (Carper et al., 2002; Courchesne et al., 2001). This increase in volume seems to be specific to the brain’s white matter. White matter serves a critically important role in brain function. It is brain tissue that carries information between the nerve cells in the brain and spinal cord. In cases where white matter does not develop the way it should, the result is often developmental disabilities. To investigate the relationship between white matter, autism, and motor skills, researchers generally use the Physical and Neurological Examination for Subtle Signs (PANESS). The PANESS is a standardized test to measure a child’s gross and fine movements. To measure the volume of white matter in the brain’s motor regions, the researchers use anatomic magnetic resonance imaging (aMRI). aMRI is typically designed to optimize discrimination between gray matter, white matter, and cerebrospinal f luid as these three tissue types are used to define the boundaries of many brain structures. Drawing a correlation between these two assessment methods has yielded some very interesting findings.

In the case of children with autism, it has been demonstrated that the white matter volume in the motor cortex is greater for children with autism than control children. More specifically, the white matter in question is the localized or radiate white matter. The radiate white matter forms connections within the motor cortex or to regions nearby. This means that it is different than other white matter, which carries signals to more distant brain regions. According to Dr. Mostofsky, “One prevailing hypothesis [about autism] is that there is an overgrowth of localized connectivity and a relative undergrowth of more distant connectivity.” Mostofsky and others have demonstrated that the larger their white matter volume, the worse children performed on motor skills.

Related to the issue of white matter, recent evidence has suggested that individuals with ASD may have issues of functional underconnectivity. This means that the communication

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between brain regions is less efficient in individuals with ASD when compared with indi- viduals without ASD. The underconnectivity theory was originally proposed in 2004 (Just, Cherkassky, Keller, and Minshew). Since then, the hypothesis has been tested in many studies (e.g., Hazlett et al., 2011).

More specifically, it has been found that a brain region in the temporal lobe, which is important for several functions known to be impaired in autism (biological motion percep- tion, language, auditory processing, auditory–visual integration), is more widely connected with other parts of the brain in children and adolescents with autism than in typically devel- oping children (Shih et al., 2011).

Interestingly, because of the work of Shih and others, the notion of underconnectivity has taken a different turn. Specifically, the most recent data suggest that it is not simply that brain areas are less well connected, but these area functional networks in the brain connect with too many other areas of the brain and therefore do not specialize well. It is not well under- stood why this happens but it seems to be related to a lack of appropriate synaptic pruning. This pruning increases the efficiency of connections between neurons by pruning inefficient connec- tions. Importantly, it has been demonstrated that differences in the brain of children with ASD and others arise in the first 6 months after birth. This creates exciting possibility of developing markers of ASD in advance of symptom onset and perhaps even interventions.

What Is the evIdenCe for motor defICIts In ChIldren WIth asd?

Historically, research related to children with ASD has focused primarily on social interaction and communication aspects of the children. By comparison, research on motor skills for chil- dren with ASD has been less comprehensive. However, in the past 10 years in particular scien- tists and practitioners alike have realized the importance of understanding the full spectrum of autism, including its impact on motor functions (e.g., Baranek, 2002; Provost, Heimerl, & Lopez, 2007; Staples & Reid, 2010).

When researchers investigate gross and fine motor skills in school-aged children with ASD, they typically use one of three methods. These methods include comparing children with autism to a standard score from control-group children (normative sample comparisons), analyzing home videos of the child, or group comparisons. In this case, group comparisons are when children with autisms are tested with children without autism and compared based on their abilities on a particular measure. It is different than normative sample comparisons (NSCs) in that NSC use baseline data from normal children rather than testing the children with and without ASD at the same time under the same testing conditions. The majority of evidence suggesting individuals with ASD have motor delays has centered on findings from normative sample comparisons.

Several recent studies have found consistent motor delays in children with ASD. For example, Provost, Lopez, and Heimerl (2007) compared motor scores in children with ASD to those of children without ASD and found that all children with ASD had delays in gross motor skills, fine motor skills, or both. A few of these normative sample comparisons are sum- marized in the chart below.

Green et al. (2009) found that all of the children in their study with AsD scored below the 15th percentile on the Movement Assessment battery for children test

berkeley, Zittel, pitney, and nichols (2001)

50–73% of children with AsD had overall motor development, including locomotor and object control

Miyahara et al. (1997) found poor motor coordination in children with AsD

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Consistent with these findings are those of video analyses of young children with ASD. For example, video analysis had confirmed that children with ASD demonstrate hypotonia and hypoactivity (Adrien et al., 1993; Baranek, 1999).

In addition to pure motor issues, several studies, including group comparison studies, have indicated children with ASD have sensory and motor performance differences that affect their participation in socialization and daily activities. The majority of children with ASDs reach early developmental motor milestones within normal ranges. However, many experience difficulties with motor functions. As defined in Table 12.1, these may include a variety of motor deficits. These include the capacity to execute unpracticed motor skills. This ultimately affects motor sequencing, motor imitation of actions/postures, formation of oral-motor patterns, changing movements in response to sensory cues, timing of actions, inhibiting actions, and using sensory feedback to guide motor actions. As a result, adaptive tasks and social-communicative functions such as speech, articulation, gesturing, and eye-gaze coordination are impacted. These deficits significantly affect early development of intersubjectivity, relating to others, and communicative intent. Simultaneous interpersonal actions, facial expressions, coordinated eye movements, voice, and body movements are all necessary for adequate emotional expression and social exchanges.

Children with ASD also tend to present with deficits in core strength and proximal stability. This results in difficulty with distal control and maintaining postural positions for daily tasks, such as circle time and putting shoes and/or clothing on. The child with autism that also exhibits deficits in core strength and proximal stability often appears “fidgety”

table 12.1 definitions and examples of Motor issues in individuals with asd

title definition/exaMples

praxis the capacity to execute unpracticed motor skills. for example, a child playing with a new toy. praxis is composed of three parts: (a) ideation, (b) motor planning, and (c) execution.

ideation the capacity to develop a specific goal for an action. that is, understanding there are multiple ways to interact with a single object or one’s own body and deciding on which goal to plan for. for example, a child may decide between throwing a toy ball, kicking it, or rolling it, among other possible interactions.

Motor planning the ability to plan the movements of one’s own body to complete the desired goal. for example, if the child decided he wishes to kick the ball, he would form a plan on how he would get to the ball and how he intended to kick it.

Motor sequencing related to motor planning, motor sequencing is organizing the movements so that they may be completed consecutively and with the intention of being fluid. that is, the child must know the order in which to complete movements and when to make them. Kicking too early will result in missing the ball.

(Continued)

vilensky, Damasio, and Maurer (1981) Differences in stride lengths and increased stance times in children with autism compared to normal children

Manjiviona and prior (1995) issues with manual dexterity, ball skills, and balance

Mari, castiello, Marks, Marraffa, and prior (2003)

problems with movement execution and planning

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title definition/exaMples

Motor execution the final step in praxis; carrying out the desired action. for example, the child physically kicking (or attempting to kick) the ball.

Motor imitation the ability to replicate an observed motor skill. for example, if you were to show the child how to kick the ball with the side of the foot as is done in soccer, his potential for motor imitation would be reflected in how accurately he replicated the kick that was demonstrated.

Oral-motor patterns the motor skills involved in moving the mouth. these can be simple skills such as opening the mouth, or complex skills such as mastering speech. in more complex skills, motor sequencing plays a significant role.

eye-gaze coordination the interaction between the gazes of two or more individuals involved in a task or conversation. Gazes between individuals consist of certain patterns (what they look at and when they choose to look at it), the alignment of gaze patterns is termed eye-gaze coordination. for example, a regularly functioning children should focus on the same areas when completing a task. (note: this can also include triadic attention between a desired object, object of interest or motivating event, and another person; gaze monitoring— following the eye gaze of another person to an item/event). Often in children with AsD, who also have a comorbid motor disorder, it is challenging for them to coordinate the triadic attention and following another person’s eye gaze.

social exchanges based on the social exchange theory, which states that within social interactions, a person’s choices are made with the intent of maximizing self-interested outcomes. that is, we make social exchanges to benefit ourselves. for example, a child may do something she is told to do, to look good, or in expectation of praise or reward. the praise and/or reward is reinforcing to the child, resulting in a learned social behavior.

social-communicative functions

Any means by which an individual communicates. for infants, or those unable to speak, these functions may include crying, cooing, smiling, reaching, pointing, and gesturing. for those capable of speech and articulation, language is used. in this case social implies another level of communication. social communication is based on engaging with another person, reading body language, reading environmental cues, and utilizing nonverbal as well as verbal/alternative communication skills.

core strength the muscular control required to stabilize the spine and to maintain posture and stability. for example, a child with core strength deficits may have trouble sitting still, as the core muscles easily tire.

proximal stability the ability of muscles within the arms and legs (proximal), or the muscles within the hands, or to a less extent feet (distal), to maintain stability and limit unintended variation within movement. for example, a child with proximal stability deficits may have difficulty lifting his arms for extended periods.

Distal control the ability to accurately control the hands and feet to interact with the world, or one’s own body. Distal control cannot be successfully developed without addressing deficits in proximal stability. for example, a child cannot accurately choose where to put down a toy if her arm is too weak to smoothly move to where the child intends to release the toy.

perceptual-motor integration

the ability to adjust movements in response to changing sensory cues (internal and external), utilizing sensory information to guide motor skills. for example, internal cues such as how balance shifts on an uneven surface will guide a child to correct his stance, while external cues such as seeing how they move in relation to the surface will also guide movements.

or “antsy” because she is unable to maintain a postural position for more extended peri- ods of time. This presents a problem, especially to high-functioning autistic children who attend regular school. To the unfamiliar educator, the postural difficulties and movements may be interpreted as inattentiveness (and the deficits may impair children to the point

table 12.1 (Continued)

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Chapter 12 • Motor Consideration for individuals with autisM speCtruM disorder 199

of distraction within the learning environment). Physical therapy may then be utilized to strengthen the child’s core and stabilizing muscles. Such therapy may help the child to avoid fatigue and the subsequent fidgeting and distraction. Additionally, the child with these difficulties tends to run through motor activities very quickly because a slower pace would require more strength, stability, and control. These requirements may be too diffi- cult for the child with a compromised motor system. Fast movements paired with already weakened system will often lead to an awkwardness in movements akin to the awkwardness children with autism demonstrate in social interactions. This combination can be very trou- bling for children. Indeed, for children with autism who are socially aware, the disorder can, and often does, result in lowered self-esteems (Hilton et al., 2012).

Awkward movements may further increase these feelings of anxiety leading to a reduced feeling of self-worth into adulthood. Therapy based upon strengthening and teaching the child with autism to move at an appropriate pace may improve self-esteem leading to a higher quality of life and perhaps less social aversion.

“From our results, it looks like motor impairments may be part of the autism diagnosis, rather than a trait genetically carried in the family,” says lead author Claudia List Hilton, Ph.D., assistant professor in occupational therapy and an instructor in psychiatry. “That suggests that motor impairments are a core characteristic of the diagnosis.”

Source: Newsroom, Washington University in St. Louis.

In conjunction with motor planning deficits, functioning on dynamic surfaces is quite challenging. This point brings up an interesting chicken and egg scenario. Is it that children with ASD have core deficits due to a lack of experience with activities that would develop good motor functioning or do they avoid activities that would enhance motor ability because these activities are difficult? The answer probably lies somewhere between the two alterna- tives. At this point the answer is unknown. However, we do know that children who are appropriately challenged tend to increase their abilities (Guadagnoli & Lee, 2004). Therefore, it is precisely this difficulty that makes activities requiring motor planning and functioning on dynamic surfaces so valuable. Indeed, we believe that many therapeutic activities for chil- dren with autism/Autism Spectrum Disorder (AU/ASD) should include motor planning and functioning on dynamic surface, not only to enhance these skills but also to enhance skill sets in general.

When thinking about these areas of impairment in children with AU/ASD, it is again vitally important that a full evaluation assessing all areas of development is performed. Unfortunately, to date, there are no specific motor tests designed for accessing motor functions in children with autism. This means care must be taken in effectively evaluating the motor skills of those within the autism spectrum of disorders. Due to the large variation in severity of cognitive impairments, the use of standardized motor tests should be determined on an individual basis (Texas Statewide Leadership for Autism Training, 2009). This will be discussed in further detail within the chapter. Looking at all areas of development, as well as the individual child, will help determine whether there are concerns regarding attention and hyperactivity, concerns regarding sensory processing abilities, or whether core strength and proximal stability deficits are mimicking some of the characteristics of Attention Deficit Hyperactivity Disorder (ADHD). Although the presence of core strength and proximal stability impairments is frequently seen in children with autism within the clinical setting, more research should be performed.

There are numerous studies regarding motor deficits, initiation and planning, in chil- dren with AU/ASD (e.g., Ming et al., 2007). In general, these studies have documented hypo- tonia, motor apraxia, reduced ankle mobility, history of gross motor delay, and toe-walking

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in individuals with ADS. For example, Hilton et al. (2012) compared healthy children to their autistic siblings (brothers, sisters, and fraternal twins) and found that 83% of autistics demonstrated below average motor skills, while only 6% of the healthy siblings scored below average. This evidence suggests that motor deficits demonstrated by children with autism are not separate inherited deficits (as has been previously thought), but are indeed associated with autism itself. Furthermore, within this study, a link was demonstrated between the severity of motor deficits and the degree of social impairment as well as the severity of autism. As further evidence of this, a study on children aged 6 to 8 years determined that 73% of autistics tested exhibited poor to very poor TGMD (Test of Gross Motor Development) performance skills (Berkeley et al., 2001).

Ming et al. (2007) found hypotonia (51%), apraxia (34%), toe-walking (19%), and gross motor delays (9%) in children with autism. Importantly they also found a reduced prevalence of these motor deficits in older children. This suggests improvement over time, whether through natural progression, results of interventional therapy, or the com- bination of the two, which peaks to the potential importance of intervention for motor deficits.

Findings from neuroscience may provide insight into the observed deficits. For exam- ple, there is evidence to suggest that children with autism utilize their cerebellum less during movements (Mostofsky et al., 2009). The cerebellum is the structure in the brain that (among other functions) is responsible for automatic movements. This means that chil- dren with autism may in turn rely more on conscious movement, having to deliberately plan their actions as opposed to habits. This strategy is common in early stage learning for non-autistic individuals, but is generally grown out of with maturity and experience. How- ever, this is not the case with children with autism. If indeed children with autism utilize their cerebellum less during movements than do controls, it would be a potential cause of clumsy movements, and slower reaction times, as commonly observed. Due to the preva- lence of deficits demonstrated, all of these studies indicate that it is important to assess both gross and fine motor skills and to include the aforementioned areas, when evaluating a child for AU/ASD. The results of the studies support the need for both occupational and physical therapy services.

Motor skills are not considered primary diagnostic categories for ASD. However, recent evidence is overwhelming that some degree of motor dysfunction is present in most if not all of the young children with ASD (Provost, Heimerl, & Lopez, 2007). This includes dysfunction in gross motor skills, fine motor skills, or both. Provost suggested, and we concur, that the “clinical implications of these findings strongly suggest that all young children with ASD should receive complete developmental evaluations that include assessment of their motor functioning.” Unfortunately, such an evaluation is generally not done during the evaluation but not used as diagnostic criteria.

Can motor ImpaIrments be part of early deteCtIon?

Motor deficits associated with autism may begin as early as the first months of life (Karmel et al., 2010). This begs the question, “Could these motor deficits perhaps be more than a complication of autism?” This is, again, a case of the chicken or the egg. Currently, there is little research on the topic, although it certainly warrants further investigation. Trends have been determined in infants, as babies within the NICU (neonatal intensive care unit) who later develop autism move their arms less than those who develop normally (Karmel et al., 2010) despite being of the same birth weight, gender, and gestation. Jana Iverson, associate profes- sor of psychology at the University of Pittsburgh, is one of the few researchers beginning to shed light on the subject. It is believed that motor impairments could make it more difficult for infants to interact with the world around them, as well as limiting their ability to focus on relevant stimuli. This unfortunately creates a downward spiral, where the infant becomes

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more withdrawn from the outside world, trying less to interact, further increasing the deficits. Potentially, physical therapy can alter this disconnect.

Landa, director of the Center for Autism and Related Disorders at the Kennedy Krieger Institute in Baltimore, states that although deficits in infants do not guarantee autism, they are signs that make a difference in designing early intervention programs. The signs include things such as head lag (when a baby aged 4 months head flops back rather than staying in line with the torso, while lifted), weak arms, and core deficits. These signs can potentially be used for early diagnosis. Furthermore, if these are contributing factors to the development of autism, when motor deficits are addressed early in infants, they may decrease the severity of the disorder.

diagnostic perspective: Christie a.

Under 3 years of age, children suspected of autism are typically diagnosed with ASD until they have received intensive therapeutic services and turn 3 years old. Once they have turned 3, they are completely reevaluated and it is determined whether or not they will formally receive a diagnosis. AU evaluations should always test at least seven areas of development. These areas are receptive language skills, expressive language skills, nonver- bal problem-solving skills, social-emotional skills, fine motor skills, and gross motor skills. Typically, it is a dip in language and social skills that determines whether or not AU/ASD is present with the motor skills not necessarily age appropriate but higher than the language and social skills. If all skills were low, or the levels appeared relatively flat across a develop- mental age level, then that would be considered more global developmental delay, with possible AU/ASD characteristics. The level of cognitive functioning is also an important area when determining if AU/ASD is present. Cognitive function may be an indicator of severity (if AU/ASD is determined to be present) and possibly an indicator of how the child may respond to therapeutic services. However, for a child who presents as very limited in his engagement/joint attention skills, receptive language and nonverbal problem solving may be difficult to truly assess.

The bottom line is that of the more than 1,200 Autism Diagnostic Evaluations I have performed with a clinical team, very few of the children displayed intact, flexible, and chronologically on target gross and/or fine motor skills. This is regardless of age.

What Is the ImportanCe of physICal therapy?

It has been established in several studies that there are motor deficits associated with ASD. If not corrected, these musculoskeletal deficits, such as tightness of the hamstrings and hip- flexors due to toe-walking, can cause secondary problems. Hamstring tightness develops from having to try and maintain balance while walking on the toes. If not corrected, this can lead to lower back problems and issues with the knee and hip joints. Additionally, toe-walking can exacerbate the postural and stability problems that already exist.

Further, the secondary issues associated with poor motor skills can become more pronounced if not attended to. Early in the chapter we stated that movement is more than movement. Movement is our way of expressing ourselves and our way of interacting with our environment and with each other. Movement can be the result of our responding to others or to an environmental stimulus. Therefore, if our movement is compromised so too might be the way we interact with the world and it interacts with us. Understanding movement in general and then extending to children diagnosed with AU/ASD may be helpful in this case.

Behavioral challenges for children with autism limit motor experiences and can create difficulty from a therapy perspective. Not long ago it was difficult to convince the medical community and insurances that children with AU/ASD would benefit from physical therapy services. The good news is that the field is largely past that hurdle. The bad news is that it

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is challenging to find physical therapists who are willing to see children with autism, both because of the thought progress that their progress was slow and because of the often impeding behavioral challenges.

We can also look at some general cognitive and learning theories in support of pro- viding a comprehensive intervention program for children diagnosed with AU/ASD. These theories are relevant in considering how a child with AU/ASD may have motor deficits as a result to decreased engagement with others and her environment.

• R.A. Schmidt—Schema theory: In order to refine motor movements, one must be able to recall learned motor patterns and evaluate motor patterns carried out in order to determine if the movement was adequate and successful. This refining of motor patterns leads to a f lexible/functional motor movement that may be generalized to various environments and tasks.

• Esther Thelen—Dynamic motor action theory: Internal and external components work together to form flexible and efficient motor patterns.

• Jon Kaas—Brain plasticity: External tactile and sensory information affects the development of motor patterns and may allow for reorganization of new neural pathways.

• L.S. Vygotsky—Social cognition and language: Discussed “transactional learning”: Children learn skills through play with others.

• Jean Piaget—Assimilation and accommodation: Children learn and adapt through trial and error that leads to new schemas and thus new knowledge.

• Bates and MacWhinney—Resource allocation: Perceptual cues, presented frequently and used consistently, allow for an action to grow in flexibility and strength. Perceptual cues that are differing or inconsistent require the child to increase the use of extra pro- cessing resources.

• Amy Wetherby—Communicative functions: Whetherby focuses on the need for intent with regard to a child’s verbal, nonverbal, visual, and gestural communication. Inten- tion and purpose are necessary for functional movements.

• Katherine Nelson—Event knowledge: A child’s knowledge of everyday experiences as well as his cognitive representations of everyday experiences are the foundation for cog- nition, language, and motor actions.

• L. Bloom—Language Development and Emotional Expression: single resource model. Based in language, language is acquired through a tension between the effort that is needed and a child’s level of engagement. A child’s actions and/or movements are a result of the child’s interest in the event and the attention/effort required. A mismatch between the child’s intent and the other person’s understanding pushes the child to become more detailed with regards to her motor movements. This is necessary for devel- oping increasingly detailed motor movements and adequate generalizing them into functional everyday activities.

Many of these theories suggest that in order for a child to learn new, flexible (Abbs, Gracco, & Blair, 1984), and functional motor skills, he needs to be able to adequately engage with the environment as well as the people in the environment. The child must also be able to determine how successful the movement has been and regulate how to adapt insufficient motor movements. Children with autism have significant difficulties that impact both their appropri- ate engagement and self-regulation. As a result, they have difficulty making motor patterns, initiating motor patterns, and refining motor patterns for better generalization and flexibility.

standard motor skIll assessments

“Because it appears that motor problems are inherent in autism (cf., Aspy & Grossman, 2007; Nayate, Bradshaw, & Rinehart, 2005; Ozonoff et al., 2008), a motor assessment is important to understanding the complex needs of an individual on the spectrum.” This statement, which is common in the field of autism, is ironic considering that currently there are no specific motor

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skill assessments designed for autistics (Texas Statewide Leadership for Autism Training, 2009). Paired with a lack of normative data, this presents a challenge in understanding the true severity of motor deficits within the autistic population. For example, the School Function Assessment (SFA; Coster, Deeney, Haltiwanger, & Haley, 1998) and the Pediatric Evaluation of Disabilities Inventory (PEDI; Haley, Coster, Ludlow, Haltiwanger, & Andrellos, 1992) are criterion-based assessments that measure the functional performance of a variety of motor activities.

According to Coster et al. (1998), the “SFA was developed to meet a need for an assessment tool that could help guide program planning for students with disabilities who are attending ele- mentary school.” More specifically, the SFA was designed to measure students’ performance of functional tasks that supports their participation in the academic and social aspects of an elemen- tary school program. Therefore, the assessment has several goals, which include:

• Assists in the initial assessment of student needs • Identifies areas of limitation that affect effective participation • Identifies strengths that might help a student overcome these limitations • Supports effective communication between team members • Evaluates the outcomes of services provided • Facilitates collaborative program planning

The PEDI is a comprehensive measure of functional performance. Scores from the PEDI result from a battery of 197 functional skill assessment. Higher scores on the PEDI suggest greater deficit. The PEDI is biased toward the lower end of the functional skills for children and seems to be most appropriate for children with significant physical disabilities. It is prob- ably not appropriate for children with mild physical disabilities. For all these reasons, it is probably not the most appropriate assessment for children with autism.

Obviously these assessments are steps in the right direction. However, there are some issues. The SFA was designed for all disability groups and all developmental levels. Such a comprehensive assessment is a good start, but because it is so general, it may be difficult for it to capture the uniqueness of autism. The PEDI, as mentioned, is best at assessing children with significant physical disabilities. Additionally, the nature of autism would make it diffi- cult to complete a 197 functional skill assessment. Therefore, most would argue that such a targeted assessment is not best to assess children with autism.

The lack of specific motor skill assessments for autistics creates a lack of normative data for children with autism. This presents a challenge in understanding the true severity of motor deficits within the autistic population. Unfortunately, this also increases the difficulty of formu- lating therapies. In place of motor skill assessments designed for autistics, motor assessments originally designed for a control population may be utilized. As you can imagine, there are a number of concerns that arise when using such tests on autistics. The first of which is the result of cognitive and social impairments within the autistic spectrum. Autistics commonly have dif- ficulties in focusing, and following directions. In the case that an autistic does not focus on the task, or does not completely understand the directions, they may exhibit poorer functioning or yield the testing as inconclusive. Unfortunately, such a problem can further fuels the debate as to whether or not motor deficits should be included in the autism diagnosis. Additionally, there is the issue of variance of such communication difficulties within the spectrum. For some higher functioning autistics, a standardized motor test will be sufficient. However, for others who may not be as high functioning, standard tests may be very difficult to definitively implement.

Summary

The current chapter is designed to examine the literature related to the relationship between motor abilities and children with ASD. It is out hope that such information will provide a basic understanding of the relationship and explain why using motor ability assessment may be used for early intervention

is important for overall development. Further, we hope that the chapter will also help the clinician/student to think about the child as a whole, and how everything works together, as opposed to individual deficits or disorders.

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key terms

Eye-gaze coordination 198 Social exchanges 198

Distal control 198 Proximal stability 198

Chapter revIeW QuestIons

1. What are the differences between gross and fine motor skills? (Objective 1)

2. Why is it important to examine motor functioning for individuals with autism? (Objective 2)

3. What are some of the common motor difficulties of individuals with autism? (Objective 3)

4. What assessments can be used to assess motor difficulties for individuals with autism? (Objective 4)

5. What does the research say about the motor issues for people with autism? (Objective 5)

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Sexuality Education for Students with ASD

Chapter 13

peggy J. Schaefer Whitby University of Arkansas

ratIONaLe aND OBJeCtIVeS Learning how to build social relationships, beginning with friendships and leading to intimate relationships, is a key developmental stage for young adults. Adolescents benefit from training in sexual development and rela- tionships. For children with Autism Spectrum Disorder (ASD), sexuality education is even more critical as social interaction and communication are core deficits. Further affecting development in the area of sexuality education is that young people with ASD have fewer opportunities to learn from their peer groups. And let’s face it: Much of the information we learn about sexuality comes from our peers. Unfortunately, children with ASD are less likely to be invited to social activities with their peers (Gerhardt, 2006). Without being taught specific skills related to developing appro- priate relationships, children with ASD may approach others in an inap- propriate physical or verbal manner and misread subtle social cues or body language in others. Sexual development and curiosity is normal. Children with ASD deserve to understand intimate relationships and develop the skills necessary to engage in such relationships so they can become fully self-determined (Travers, Tincani, Whitby, & Boutot, 2014).

Even if children with ASD participate in mainstream sexuality edu- cation, they may misinterpret information. Therefore, children with ASD might not receive all the information they need from mainstream sex educa- tion. Sexuality education for children with ASD needs to be explicit and be taught using a model that emphasizes their strengths and teaches concepts across contexts. The focus of this chapter is to build a rationale for the need to individualize sexuality education, discuss collaboration within Individ- ual Education Plan (IEP) teams to meet the needs of children with ASD in terms of sexuality education, and present easy-to-use strategies to teach sexuality.

Chapter ObjEctivES After reading this chapter, learners should be able to: 1. Understand the research in

sexuality education for people with ASD.

2. Understand the need for sexuality education across the life span.

3. Develop collaboration strategies to use when working with the IEP teams.

4. Identify appropriate curricula for teaching sexuality.

5. Understand interventions for teaching sexuality.

CaSe StuDy 1: uNDerStaNDINg the NeeD fOr SexuaLIty eDuCatION Angelo is a 13-year-old student with high-functioning autism. He is served in the general education setting and is currently receiving no spe- cial education support. His parents have been working with the school to increase his level of support in mathematics and social development. The school is hesitant to provide special education services because they do not believe he meets criteria for services under the autism category. Angelo begins to struggle with social development as his interest in having a

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girlfriend increases. He chooses a girl—the most popular girl in class—who he decides will be his girlfriend. He chooses her because, “She has lots of friends and if she is my girlfriend her friends will be my friends. Then I do not have to worry about making friends.” He tells her, “You are going to be my girlfriend.” His situation at school spirals down from that point. First, the girl is frightened and tells her friends. His peers label him a stalker. The girl reports Angelo to the counselor because she is scared. Angelo is called into the office for questioning. He answers “yes” to every question he is asked and is suspended. The school and the family meet. The school agrees to provide Angelo with counseling for social-skills development. The counselor has no knowledge in the area of high-functioning autism. Angelo’s teachers are not provided with any strategies to support him in the classroom. He becomes a target of bully- ing. Other boys ask him sexual questions. Angelo thinks these kids are his friends and he tells them his most intimate thoughts. The boys tell everyone what he says. This happens several times. Again, the girl he has a crush on is frightened by what he is telling others. One day she wears an angora sweater. As she walks past Angelo in the hall, he reaches out and touches the back of the sweater. Her fear increases and she reports the incident to the counselor. Angelo is suspended for inappropriate touching. Angelo’s parents request autism-specific training. They are told, “This is not autism. This is sexual-predator behavior.”

SexuaLIty eDuCatION Sexuality education is critical for people on the autism spectrum. However, there are myths related to sexuality that minimize the need for educating people in this population that place the person at great risk due to their lack of understanding. First, some may believe that peo- ple with ASD have no sexual interest or desires (Ailey, Marks, Crisp, & Hahn, 2003). Others believe that people with ASD have hypersexual behaviors. The truth is people with ASD have the same desires and fantasies as people in the general population; their desires are not reduced or deviant, and they want intimate relationships (Stokes & Kaur, 2005). However, the abil- ity to develop appropriate intimate relationships is hindered by social communication, social interaction, and theory of mind deficits. People with ASD vary greatly on their ability to establish meaningful sexual relationships.

Even though people with ASD have the same sexual feelings and desires as others, their ability to act upon and understand their feelings may be affected by their autism (Stokes & Kaur, 2005). The sociosexual development of people with ASD may be out of sync with their physical sexual development. This discrepancy between physical maturity and social maturity may cause the person with ASD to exhibit seemingly inappropriate behavior. As children with ASD approach adolescence, the discrepancy is more striking. It is important to understand that the social expec- tations for the community will be based upon the child’s age and not their development.

People with ASD are at risk for making inappropriate sexual attempts, at risk for abuse and exploitation, and at risk for sexual-related health issues. Stokes, Newton, and Kaur (2007) found that people with ASD reported more inappropriate courtship behaviors and less use of appropriate social-communication behaviors to initiate relationships. People with ASD were more likely to touch the person of interest, believe that the person had feelings for them, show obsessive interest in a person, make inappropriate comments, monitor the other person’s activi- ties or follow them, threaten the other person, or threaten to harm themselves. Not only is this behavior problematic, but when people with ASD show their naiveté or inappropriateness to the wrong person, they become at increased risk for exploitation and abuse.

Overall, people with developmental disabilities, including those with ASD, have an increased risk of sexual abuse (Ailey et al., 2003). Some evidence suggests that people with ASD are especially prone to sexual abuse because (a) predators may view them as vulnerable due to the lack of communication skills (Edelson, 2010); (b) they have a desire for social acceptance but lack the understanding of appropriate relationships (Gerhardt, 2006); (c) they do not or are unable to report abuse (Ailey et al., 2003); and (d) they may not know that what is being done is wrong (Newport & Newport, 2002). Caregivers wish to protect people with ASD, and in order to do so, sexuality is often discouraged or punished (Travers et al., in press). This type of protection may force people with ASD to act outside of conventional norms to have their needs met.

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When a person must engage in sexual activities outside conventional norms, or does not have the knowledge he needs to engage in sexual relations, he is at increased risk for high-risk sexual behaviors. People with ASD may be placed in living situations that are not supportive of acting on their own sexuality. For example, a person with ASD who is gay may not be able to act on his sexual orientation because his parents do not condone homosexuality, or an adult with ASD may live in a group home with a roommate and therefore with no privacy for mas- turbation. If there are no opportunities to engage in appropriate sexual activities, people are forced to engage in semi-deviant behaviors to have their needs met. For example, if a person cannot masturbate in his bedroom, he may attempt to masturbate in a public bathroom. If a couple can’t engage in petting behaviors because parents are supervising a date, the couple may be forced to engage in petting behaviors in semi-public places, such as on the school bus or at school.

When people are unable to gain access to the knowledge or materials needed to make healthy decisions about sexuality, they may make poor decisions regarding sexual-health issues. While little data is available on sexually transmitted disease (STD) for people with ASD, it has been suggested that people with disabilities are at greater risk for STDs because they have not been taught how to protect themselves (Gougeon, 2009). People with ASD need access to sexuality education, but sexuality education for this population is usually reactive versus proactive (Gerhardt, 2006). In other words, people with ASD are not provided the individualized sexuality education they need until problems arise. The reaction to problems is usually punitive in nature, leaving the person with ASD more confused about what is happen- ing within her body and her emotional state.

teaChINg SexuaLIty aCrOSS the LIfe SpaN Teaching sexuality begins early in life and continues through adulthood (see Box 13.1, Research Notes). The amount of material that needs to be addressed can be overwhelming. For- tunately, the Sexuality Information and Education Council of the United States (SIECUS)

Box 13.1 researCh Notes

Sexuality Knowledge and Experiences of People with ASD The following presents recent studies on the sexuality knowledge and experiences through the perspective of parents, teachers, and people with ASD. While not all inclusive, the studies were chosen because they present a representative sample across the ASD spectrum and envi- ronments. All three studies support the need for sexuality education within this population.

Kalyva (2010) assessed the difference in sexuality behaviors between lower-functioning and higher-functioning people with ASD from a teacher’s perspective. Teachers reported that children with lower-functioning forms of ASD demonstrated more issues related to social behav- ior and privacy. However, they were more concerned for children with higher-functioning ASD as they were educated in inclusive settings where sexually inappropriate behavior not only impacts social standing and friendship, but can become a legal issue.

Hellemans, Colson, Verbracken, Vermeiren, and Deboutte (2007) assessed the sexual functioning of young adults with ASD from the caregiver perspective. They found that people with ASD express an interest in sex and demonstrated sexual behavior. However, problematic sexual behavior occurred frequently. Problems identified were compulsive masturbation, ritual- istic sexual behaviors, difficulty achieving orgasm during masturbation, and sociosexual skills.

Mehzabin and Stokes (2011) compared the sexual functioning of people with ASD to typical peers through direct assessment of people with and without ASD. While both groups showed interest in sexual behaviors, they found people with high-functioning ASDs engage in fewer social behaviors, had less sex education, fewer sexual experiences, and more pronounced concerns for their future. However, they reported no differences regarding knowledge of private versus public behavior.

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provides material for sexuality education. SIECUS provides standards across the life span, a list of available curricula, and lesson plans for teaching sexuality topics. Educator resources can be found at http://www.siecus.org. The SIECUS standards provide an outline of what should be taught and when it should be taught.

Families, teachers, and IEP teams can use the standards to guide instructors on the skills to teach and when to teach them. However, we still struggle with who should teach them and where they should be taught. There are no easy answers to these questions. Each person with ASD is different and requires different levels of support. The IEP team is a perfect place to discuss issues related to sexuality education, plan for proactive sexuality education, and determine how the skills will be taught in different contexts, including home, school, and community.

CaSe StuDy 2: teaChINg SexuaLIty eDuCatION thrOugh COLLaBOratION Jon is a 14-year-old boy with ASD. His IEP team takes great care in individualizing his education plan. The team decided that Jon will take a health class in the general-education setting. When it was time for the sexuality education portion of the class, the teacher con- tacted Jon’s mom to see if she would like him to participate. They agreed it is important for Jon to have access to the same information as his peers. The teacher provided Jon with a copy of the daily lesson topics so that his parents can provide supplemental information and have a discussion at home. Jon is very excited about the topic of sexuality and freely discusses the information he learns with his parents. One day after school, Jon came home and explained that a classmate asked the teacher, “How will they know when they are ready for sexual inter- course?” The teacher explained to the students that each person is individual and has his own values. “Based upon your own and family values, you will know when you are ready. Talk to your parents.” Jon looked at his mother and said, “I’ve decided that I am ready to have sex.” His mother calmly looked at him and said, “You know that the responsibilities of being a man come along with having sex.” Jon looked at his mom in confusion. She said, “You know if you have sex you could have a baby? Are you ready to be a father?” Jon said that he thought he would be a good father. His mother replied by saying, “Yes, I think you will be a good father, but how will you buy food for your wife and baby?” Jon replied, “We will just eat here.” His mom replied, “No if you are a man, then you need to buy food for your own baby and wife.” Jon thought he could get a job. His mother agreed and asked, “Where will you live? Will you be able to make enough money working after school to pay your rent?” Jon thought, “You won’t let me live here?” His mom explained, “No when you are old enough to have sex and a baby, you are a man and need to live on your own. We can visit each other.” Jon thought about this for a while and responded, “I think I will wait until I am 21 years old to have sex.” While the idea of having sex at a set age versus when an intimate relationship poses a concern, Jon’s parents and IEP team are provided the time to teach him the complex skills of relationship development and sex.

COLLaBOratION Of the Iep team Collaboration of the IEP team is the key to success for teaching all skills. Travers and Tincani (2010) provide guidelines for IEP decision making. They suggest three areas that need to be taken into consideration when planning for sexuality education: the role of the IEP team, the involvement of the student, and anticipating and addressing disagreements on what should be taught and how it should be taught.

In order to successfully collaborate in designing a sexuality education program, IEP teams need to agree that (a) people with ASD have the right and possibility of having sexual relationships based upon their own desires and within their capability of management and (b) sexuality education should be based upon the social rules and norms of the person’s

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culture and home (Travers and Tincani, 2010). Once the IEP team agrees that sexuality education must be taught, determines what needs to be taught, and who shall do the teaching, it may consider appropriate curricula.

ChOOSINg a CurrICuLum tO teaCh SexuaLIty There are few sexuality curricula designed specifically for teaching students with ASD. As the number of students with ASD increases and these children become adolescents, more curricula will become available. Until then, families, teachers, and IEP teams need to identify the most appropriate curriculum to meet the needs of their students. There are several quality indicators a team can assess when choosing a curriculum. First, is it aligned with the National Sexuality Education Standards? By addressing these standards, a team can be assured the curriculum addresses skills from body and hygiene to social and relationship development. A good curriculum not only teaches about basic hygiene and protection but also teaches a person how to develop appropriate long-term intimate relationships. Second, does the curriculum address skills across the life span? Sexuality education begins in early childhood with learning about our bodies and developing friendships. Teaching these skills across the life span at developmentally appropriate times is necessary, as these skills are developmental in nature. Third, does the curriculum help students understand how to use skills in different contexts? Nothing will reduce social standing faster than making a contextual mistake regarding sexuality topics. Last but not least, does the curriculum use evidence-based practices for teaching students with ASD? While a curriculum might not specifically address this topic, teams can look at the types of interventions provided and determine if the interventions match those recommended by the National Autism Center (NAC, 2009).

Two curricula that come close to meeting these criteria are Intimate Relationships and Sexual Health (Davies & Dubie, 2012) and Teaching Children with Down Syndrome about Their Bodies, Boundaries, and Sexuality (Couwenhoven, 2007). Intimate Relationships and Sexual Health is a curriculum designed specifically for adolescents and adults with high-functioning ASD, and it is aligned with the national standards on sexuality. Even though it is designed for adolescents with ASD, it addresses earlier development through an assessment of prerequisite skills. The curriculum addresses sexuality across contexts by teaching proper terminology as well as slang. It uses visual strategies, peer modeling, and video modeling. However, the curriculum is designed for high-functioning individuals with ASD and is language based (material is presented in written format, lots of discussion activities, and written assignments). The curriculum could easily be adapted for learners who struggle with language-based activities by increasing visual supports, using social stories, and scripting.

Teaching Children with Down Syndrome about Their Bodies, Boundaries, and Sexuality, while not specifically designed for children with ASD, provides comprehensive lessons broken down into easy-to-teach components. This curriculum was published in 2007 and is not aligned with the SIECUS standards (2004) or the National Guidelines Task Force (1996). However, it does provide an outline of skills to teach across the life span. The curriculum does a good job of teaching sexuality skills across different contexts. The author uses circles and a five-point scale to help students differentiate behavior across contexts. The curriculum presents activities that are considered evidence based for children with ASD.

INDIVIDuaLIzINg CurrICuLa WIth eVIDeNCe-BaSeD StrategIeS For many students with ASD, individualization of sexuality-education supports is necessary. This leaves educators in a conundrum, as there are no identified evidence-based interventions to teach sexuality. In order to teach the skills, IEP teams can identify the standards that will be taught and match them to one of the evidence-based strategies recommended by the National Autism Center (2009). The NAC conducts extensive literature reviews to identify evidence-based practices and provides a guide to the practices across the life span. IEP teams must match the intervention with the skills that need to be taught. Table 13.1 provides a guide for matching a target skill to appropriate interventions (see Box 13.2, Diversity Notes).

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210 chAptEr 13 • SExuAlity EDucAtiOn fOr StuDEntS with ASD

taBle 13.1 Steps for Choosing Interventions

StepS CONSIDeratIONS

1. identify what skill needs to be taught. proactive: is the child approaching a developmental age where changes are inevitable? both social and biological?

reactive: is the child engaging in an appropriate behavior that must be addressed?

2. identify the age of the child. this is your starting point. however, do not teach skills in isolation. teach across the life span. for example, relationship development begins with teaching family relationships and friendships.

3. using SiEicuS standards, identify what skill should be addressed according to the age of the child.

Does the child have the skills identified by the SiEicuS standards for the younger years?

if not, teach these skills in conjunction with the age-appropriate skill. focus on developmentally appropriate skills. Meet the child where she is in terms of sexuality education.

however, remember that the child’s biological development may be out of synch with their social-emotional development.

4. using the nAc (2009) guide, identify the intervention options that are appropriate for the child’s age.

because there are no identified evidence-based interventions to teach sexuality to people with ASD, teachers must choose interventions validated for similar behaviors and skill acquisition.

5. Match the intervention to the skill. choose:

— the least intrusive intervention that has the most likelihood of success. — an intervention that has been validated for similar skill acquisition or

behavior reduction. — an intervention that can be taught with fidelity in all contexts. — an intervention that fits with the values of the family.

Box 13.2 Diversity Notes

Family Concerns and Service Needs Related to Sexuality Education for Children with ASD Sexuality is not just physical functioning and hygiene; it also relates to sexual knowledge, beliefs, attitudes, and values (Koller, 2000). Because beliefs, attitudes, and values differ across cultures, it is vital that we include and respect the family in sexuality education planning. Across cultures, parents report a need for support and guidelines in teaching their children with ASD about sexuality. Nichols and Blakeley-Smith (2010) assessed the concerns and ser- vice needs of parents who have children with ASD regarding sexuality. The findings suggest parents associate sexuality and disabilities in a negative, fearful way instead of as a positive development of meaningful relationships. For parents, the concerns outweigh their hopes and dreams of meaningful long-term sexual relationships for their children. Parents of children with ASD express concerns about their child’s social impairments related to acting appropri- ately with others and being exploited by others. They worry about the lack of understand- ing in the professional community about the characteristics of ASD that may place their children at risk. Issues included misinterpretation of behaviors, inability to communicate, and responding to situations as a crisis. Finally, parents desire guidance on how and what to teach their children regarding sexuality. Parents are unsure on how much their child under- stands, how much to teach, when to teach it, and how to teach the information (Nichols & Blakeley-Smith, 2010). According to Walker-Hirsh (2007), the development of long-term relationships could be the most difficult of tasks; however, people who develop meaningful long-term relationships have a greater sense of happiness. Isn’t happiness what all parents wish for their children, including those with ASD?

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chAptEr 13 • SExuAlity EDucAtiOn fOr StuDEntS with ASD 211

CaSe StuDy 3: INDIVIDuaLIzINg SexuaLIty eDuCatION traININg

Mark is a 13-year-old boy. He attends school at a regular middle school setting in a self- contained classroom for students with ASD. Mark has severe ASD symptoms, including communication, social, and sensory deficits. He eats lunch every day with typical peers, a “lunch bunch” established by his teacher. The peers in the lunch bunch are very kind to Mark and make a point to acknowledge him whenever they see him at the school. Mark has very basic expressive and receptive language skills. Unfortunately, he has not received any formal sexuality education and his IEP team has not addressed the issue of puberty. Up until this point in his physical maturation, he has shown very few signs of puberty and has no known interest in sex. Then Mark has his first erection in the classroom. He has no idea what is happening to him and he is frightened. He screams, pulls at his pants, and runs out of the classroom into the hallway. There are other students in the hallway. Some are very frightened by his behavior, while others laugh at him when they realize what is happening. Middle school students tend not to be kind or understanding. News of the incident quickly spreads throughout the school. The next day Mark’s lunch bunch tells the teacher they are frightened and embarrassed to eat lunch with Mark. While this scenario may seem funny at first, it is truly sad. Mark deserved—and had the right—to be taught what was going to happen to his body as he matured. The situation could have been prevented with proactive teaching. Puberty is inevitable and teaching about its effects needs to occur before the changes take place. As a result of his lack of preparation, Mark lost all of his social standing at the school. He soon learned that touching his penis erection felt good. His IEP team met and developed a plan to teach sexuality education with an immediate focus on masturbation.

BuILDINg SexuaLIty eDuCatION INterVeNtION pLaNS At a minimum, students should receive a basic health education course. Most will require more intense small-group instruction utilizing a specific curriculum for people with diverse learning needs. Many will require the development of individualized supports to teach specific skills across contexts. The first step for the IEP team is to identify the target behavior.

In each of these case studies, the target behavior is different and some are much more complex than others. Remember, each intervention plan will vary for different people based on culture, family values, and the needs of the child. Once the target skill is identified, the team can use four-term contingency as a planning guide. Four-term contingency helps the team layer the interventions in order to create a comprehensive plan. Good interventionists layer interventions across the contingency to increase the chance of success. The following describes the intervention plan across the four-term contingency for our case studies.

CaSe StuDy 1: aNgeLO After several months of trying to get Angelo services at his school, the district agrees to move him to a new school and provide him with an IEP. The IEP team at his new school decides to be proactive and develops an intervention plan to help Angelo apply skills that lead to dating. After reviewing the National Guidelines Task Force (1996) and determining which skills he already has, the IEP team decides to target teaching Angelo to socialize with girls to get their attention. It should be noted that the IEP team will also need to address teaching Angelo to identify social cues that tell him when a girl is not interested. The team develops supports across the four-term contingency (see Figure 13.1). Because Angelo was using maladaptive behaviors to seek attention from a girl, the team has decided to use a competing pathway chart to develop the plan.

The IEP team reviews NAC guidelines for evidence-based practices and decides to use visual strategies to teach the concept of a girlfriend and characteristics in a girlfriend, prompting in the form of scripts and conversation starters to increase socialization, a social story to help Angelo understand the whys and hows of social conversations, role-playing and video modeling to teach conversation skills, positive reinforcement to increase social interactions, and response interruption-redirection should any maladaptive behaviors occur. The team then decides who

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212 Chapter 13 • Sexuality eduCation for StudentS with aSd

will deliver the interventions. Angelo’s parents agree to have him read the social story in the morning before school and again in the evening. They will begin spending more time talking about social activities and how to handle social situations. The classroom teacher will help Angelo review the scripts and conversation starters prior to center-based activities and lunch each day, and the school counselor will include Angelo in a social group that uses role modeling and video modeling to learn how to socialize with girls. The entire team will monitor Angelo, pro- viding him with positive comments and reinforcement to his peers who engage with him when he is appropriate. If any of the maladaptive behaviors occur, they agree to use response interrup- tion-redirection. See Figure 13.2, a visual organizer for teaching the concept of a girlfriend.

Girlfriend

She cares for me

Spend time

together

Common interests

Same values

Attractive

Nice to me

I care for her

Figure 13.2 Visual Strategy for Teaching the Concept of a Girlfriend

Consequence Response interruption- redirection

Positive reinforcement for appropriate social interactions

Setting Events

Competing Pathways

Support Planning

– Desiring a girlfriend

Setting Events Visual Supports/ Graphic Organizer

– What is a girlfriend?

– What Characterisics do I desire?

Antecedents Prompting • Scripts • Conversation starters Social story

Behavior Teaching Role-playing

Video modeling

Desired Alternative – Socializing to build a relationship

Maintaining Consequence – Attention

Problem Behavior – Touching following staring at girls

Maintaining Consequence – Attention

Acceptable Alternative – Leave girls alone

Triggering Event – Girls are present.

Name: Angelo

Figure 13.1 Angelo’s Competing-Pathway Chart

Source: O’Neill et al. (1997)

Case study 2: Jon Jon’s IEP team meets to evaluate the success of his health education class. As a team, they decide he will receive social-skills instruction in a small group that targets understanding social relationships. After reviewing the National Sexuality Education Standards and assessing

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Chapter 13 • Sexuality eduCation for StudentS with aSd 213

his prerequisite skills using Intimate Relationships and Sexual Health (Davies & Dubie, 2012), they realize that Jon lacks basic social-skills development. Given Jon’s level of functioning, they decide to start by teaching him how to engage in small talk or social reciprocity. These supports will be used to teach Jon at home, in social-skills group, and in the classroom. The team uses the four-term contingency to build Jon’s supports (see Figure 13.3).

Case study 3: Mark Masturbation is one of the most discussed topics in sexuality education, but remains an uncomfortable topic for parents and teachers. Because Mark has been touching himself in pub- lic, the team decides to use a competing-pathway chart to develop his program across the four- term contingency. Figure 13.4 shows an example of Mark’s competing-pathway chart.

Mark’s IEP team determined that he needed to be taught what to do if he got an erection during the school day, how to masturbate, and when to masturbate. Mark’s teachers and parents needed a plan on how to respond if the behavior occurred and how to provide positive reinforcement if the behavior did not occur. The team reviewed the NAC’s evidence-based

Setting Events Support

Priming

Comic Strip Conversations

Antecedent Support

Priming

Review of potential words as natural cues.

Review of possible

responses

Behavior Teaching Support

Intraverbal Training

Respondiing to verbal

statements identifying

natural cues for verbal responses

Consequence Support

Positive Reinforcement

Peer Mentors as a natural reinforcer

Figure 13.3 Jon’s Four-Term Contingency Planning Sheet

Consequence Response interruption- redirection Positive reinforcement for not touching private parts in public

Setting Events

Competing Pathways

Support Planning

– Seeing pretty girls – Sexual video or pictures – Thoughts of sex – No setting event

Setting Events Decrease access to sexually explicit material that is not age appropriate.

Social story

Antecedents Visual instructions

What to do if I begin to get an erection?

Behavior Teaching When and how to masturbate?

– Visual schedule for home – Direct instruction

Desired Alternative – Masturbate in bedroom

Maintaining Consequence – Sensory stimulation

Problem Behavior – Touching his privates in public

Maintaining Consequence – Sensory stimulation

Acceptable Alternative – Do not touch his private parts in public

Triggering Event – Getting an erection

Name: Mark

Figure 13.4 Competing Pathway for Mark

Source: O’Neill et al. (1997)

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214 chAptEr 13 • SExuAlity EDucAtiOn fOr StuDEntS with ASD

intervention guide and chose the following interventions. The team decided to use social stories for understanding the whys and hows of managing an erection, visual instructions to redirect his attention if he got an erection (http://www.wikihow.com/Hide-an-Erection), a visual schedule at home that included private time, instruction on how to masturbate safely, positive reinforcement for not touching private parts during the school day, and response interruption-redirection should he touch his privates in public. The team decided that Mark’s dad would teach him how to safely masturbate using materials from Teaching Children with Down Syndrome about Their Bodies, Boundaries, and Sexuality (Couwenhoven, 2007) because the curriculum provides information using lots of pictures and easy-to-understand text. Mark’s parents would have him review the social story in the morning before school and again after school. Mark would use a token system for not touching his private parts in public. He could use the tokens to purchase video-game time at school and home. If the behavior occurred, the team would block the response by redirecting Mark to a task that required use of his hands and then reinforce compliance with their directions. See Figure 13.5 for an example of Mark’s social story.

When addressing masturbation, it is important to discuss and develop an intervention plan with the parents. There are cultural differences and family values that may need to be taken into consideration. Some religions believe that masturbation is wrong. These families may have a very difficult time accepting that their child is masturbating and want to punish the student for doing so. However, if parents understand that masturbation may be the only sexual outlet the person can obtain, that by not addressing the issue the behavior could become worse, and that by teaching that the bedroom is the private place to self-explore so the issue doesn’t become public, they are usually willing to address the issue. If they are not, the best option is to intervene using response interruption-redirection and positive reinforcement.

When teaching skills related to masturbation, it is important to teach students that the appropriate place for masturbating is their bedroom at home. The bathroom should not be taught as the appropriate place to masturbate as the person with ASD may not be able to discriminate between private and public bathrooms (Gerhardt, 2006). Masturbating in a public bathroom is outside of our cultural norm and places the person at risk for sexual exploitation and abuse.

Masturbation is normal (Ailey et al., 2003). Many people with ASD will learn to mastur- bate privately with no issues or concerns. Others may have difficulty understanding the private nature of masturbation, have difficulty reaching orgasm, and may develop maladaptive behav- iors surrounding masturbation. These individuals deserve access to the information they need to reach their full potential in their sexuality. For some people, masturbation may be the only realistic outlet for sexual release (Ailey et al., 2003; Koller, 2000).

When teaching sexuality education, parents and teachers need to remember to teach across contexts. People with ASD have difficulty with pragmatics: the social use of language in differ- ent contexts. As adults, sexuality is taught very professionally. Teachers use professional words and diagrams. However, when an adolescent with ASD goes into social settings with his peers, the words he hears and how he refers to those words is very different. IEP teams need to address what slang will be taught and who will teach it. Parents and teachers need to teach slang for

Figure 13.5 Social Story for Mark

All people have private parts. My private parts are my penis, testicles, scrotum, and butt. When I am in my bedroom it is OK for me to touch my privates. Sometimes it feels good to touch my privates.

Many boys and girls like to touch their private parts. This is called masturbation. Rubbing or touching my own penis is private and no one should see. I know I can wait until I get into my bedroom to masturbate.

Sometimes I want to touch my privates when I am in public. It is not OK to touch my privates in public. My friends, family and teachers do not like it when I touch myself in public. I know I can wait until I get in my bedroom to masturbate.

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chAptEr 13 • SExuAlity EDucAtiOn fOr StuDEntS with ASD 215

words across settings, help the child with ASD understand what the words mean, and help the child understand when to use the words and whom to use them with. For example, if a child refers to his penis as his “pee pee” at home with his mother, that will be OK. If he uses the same term in a middle school locker room, he will probably be teased. See Table 13.2 for an example of teaching terminology across contexts.

Both the teacher’s and student’s gender must also be taken into consideration when teaching sexuality to people with ASD. The majority of people with ASD are male, while the majority of teachers are female. While there is nothing wrong with females teaching males about sexuality, it is important that a male perspective is also provided in developing quality interventions. A male has a better understanding of the “hidden curriculum” of male sexuality through his experiences. By including a same-gender perspective, the social validity of the intervention will be increased.

Sexuality education for people with ASD remains a sensitive and controversial topic for teachers, parents, and IEP teams. We have not reached consensus on who should teach what stan- dard, how the standard should be taught, and where the skill should be taught. Teachers are pro- vided little-to-no training on addressing the topic with the children they serve. Parents report being unsure on how much information should be provided to their child with ASD. Through collaboration, the IEP team can address the sexuality needs of a person with ASD and effectively meet those needs while respecting the culture and values of the family. While the idea of discuss- ing sexuality may seem uncomfortable, the risks of not addressing the topic are far too great. It is our job as educators to help our students become fully self-determined adults. This includes assisting people with ASD in reaching their full potential in their own sexuality.

CaSe StuDIeS fOLLOW-up All three case studies in this chapter are true scenarios the author has witnessed personally. The following is a brief follow-up describing the student outcomes.

Angelo received intensive social-skill training at his new school and during a summer social-skills training program for people with high-functioning ASD. His mother reports that he is popular at his new school and has had two girlfriends. After receiving intensive social-skills training, Angelo reflected on his experiences with the girl at the old school and stated, “No wonder she thought I was stalking her!”

Jon continues to struggle with social interactions with his peers. He has not shown much interest in girls. He continues to struggle with the concept of sociosexual relationships. He recently told his mother, “I don’t understand the big deal about sex. I think I will get married but we won’t have sex until we want to have a baby.”

Mark is doing well. He quickly learned how to manage his body and masturbation. He no longer needs a token economy for not touching his privates in public. He is in high school now. He eats lunch daily with his peer buddies.

taBle 13.2 teaching across Contexts

prOper Name

WheN yOuNg ChILDreN are preSeNt

WheN maLe frIeNDS are preSeNt

WIth maLe aND femaLe frIeNDS preSeNt

WheN aDuLtS are preSeNt: pareNtS, teaCherS, aND DOCtOrS

penis pee pee Dick cock

Dick penis

Erection not discussed when children present

boner hard on

usually not discussed when girls are present

Erection

breasts boobies tits boobs Knockers

breasts tatas

breasts

butt behind Assbutt butt booty behind

bottom buttocks

please note that this list is not inclusive. terminology and setting will be determined by the culture and age of the students.

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216 chAptEr 13 • SExuAlity EDucAtiOn fOr StuDEntS with ASD

Chapter review QuestioNs

1. Identify and discuss three reasons why it is critical to provide individualized, yet comprehensive, sexuality edu- cation for people with ASD. (Objective 1)

2. What is SIECUS? How can you use the SIECUS resources to teach sexuality education to the people you serve? (Objective 2)

3. How can you use the SIECUS guidelines as a foundation for IEP collaboration? (Objective 3)

4. Name three necessary components of a sexuality educa- tion program that you should look for when assessing sexuality-education curriculum for students with ASD. Why are these areas important? (Objective 4)

5. Think about one sexuality-education skill. Describe three strategies you could use to teach the skill. (Objective 5)

summary

For children with ASD, sexuality education is critical. People with ASD have the same desires and fantasies as people in the general population, their desires are not reduced or deviant, and they want intimate relationships (Stokes & Kaur, 2005). However, the ability to develop appropriate intimate relationships may be impacted by the characteristics of ASD. Without sexuality education, people with ASD are at risk for making inappropriate sexual attempts, at risk for abuse and exploitation, and at risk for sexual-health issues. Each person with ASD is different and has different levels of support. The IEP team setting is a perfect place to discuss issues related to sexuality education; plan for proactive sexuality education; and determine how the skills will be taught in the different contexts of home, school, and community.

Teaching sexuality begins early in life and continues through adulthood. The Sexuality Information and Education Council of the United States provides material for sexuality education. SIECUS provides standards across the life span, a list of available curricula, and lesson plans for teaching

sexuality topics. Families, teachers, and IEP teams can use the standards to guide the skills to teach and when to teach them.

At a minimum, students should receive a basic health- education course. Most students will require more intense small-group instruction utilizing a specific curriculum for people with diverse learning needs. Many will require individualized supports to teach specific skills across contexts. Because there are no identified evidence-based strategies for teaching sexuality to people with ASD, IEP teams can use the National Autism Center’s guidelines on evidence-based strategies to choose the best intervention to teach the skill.

Through collaboration, the IEP team can address sexuality needs of a person with ASD and effectively meet those needs while respecting the culture and values of the family. While the idea of discussing sexuality may seem uncomfortable, the risks of not addressing this topic are far too great. Children with ASD deserve to understand intimate relationships and develop the skills necessary to engage in such relationships so they can become fully self-determined (Travers et al., in press).

iNterNet resourCes

Given the content of this chapter, we advise teachers and parents to preview all Internet material thoroughly before using the resource for educational purposes. Many times, Internet resources will have blogs or question-and-answer sections. Within these sections, well-intentioned Web sites may have little control of what is written and how quickly inappropriate content is removed. Even if you have used the Web site in the past, preview it before each teaching session. And as always, collaborate with families to ensure content matches the values of the family.

http://www.plannedparenthood.org/resources/ curricula-manuals-23515.htm

http://www.siecus.org http://www.srcp.org/index.html http://www.visualaidsforlearning.com/adolescent-

pack-learning.htm http://www.wikihow.com/Hide-an-Erection http://www.boardmakershare.com

Key terms

Collaboration 205 Curricula 205 Contexts 208

National Autism Center 209 Sexuality education 205

Sexuality Information and Education Council of the United States 207

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217

Transition to Postsecondary Environments for Students with Autism Spectrum Disorders

Chapter 14

Dianne Zager Pace University

Michael L. Wehmeyer University of Kansas

IntroductIon

Secondary school years are a critical time for students to develop behav- iors and skills that they will need for employment and adult living. High school programs must prepare students with disabilities for the transi- tion to the next chapter in their lives to effectively promote independence and quality of life (Hendricks & Wehman, 2009). In fact, it is the quint- essential role of secondary school educators to prepare students to lead productive adult lives. In this chapter, legislation related to transition preparation and services, research on transition practices, and strategies to enhance transition outcomes are covered with a particular focus on edu- cational needs of youth with ASD. The chapter considers the field from a pragmatic perspective by relating lessons learned from the study of autism and special education methodology to transition programming. The goals of the chapter are to (a) increase familiarity with the philosophical under- pinnings of transition as a process, (b) acquaint readers with legislation that has guided development of transition services, and (c) explain how research-based practices can enable educators and related service providers to improve transition outcomes for adolescents with ASD.

The information presented is designed as a starting point to guide educators and related practitioners as they support students with Autism Spectrum Disorder (ASD) to attain the highest possible level of success in education, employment, and adult living. The basic tenet of the chapter is that, with appropriate instruction and support, all students can learn to perform meaningful jobs and contribute to their community. Mov- ing beyond traditional education and intervention models that focus on remediating student deficits, the chapter focuses on strategies that build upon student strengths, interests, and preferences—while recognizing and appreciating the unique learning and behavior needs of individuals on the autism spectrum. Topics related to educational planning for tran- sition are addressed with attention to strategies for building competence in self-determination, executive functioning, social communication, and functional academic skills for employment and independent living.

In short, this chapter translates research on learning and behavioral characteristics of students with autism so that it converges with transition programming. Specific areas to be examined include education of functional academics, self-determination, social communication, and

chapter ObjEcTivES After reading this chapter, learners will be able to: 1. Understand current issues in

transition education related to the (a) history of the field, (b) legislation that has impacted transition services, and (c) gap between research and practice.

2. Have knowledge of evidence- based person-centered transition planning practices that respect preferences, interests, and personal strengths of students.

3. Be familiar with the roles of key personnel in the transition process and be able to discuss the interface among personnel, resources, and collaborating agencies to enhance outcomes for youth with ASD.

4. Be cognizant of characteristics inherent in autism, challenges that these traits can cause in the transition process, and strategies to mitigate these challenges.

5. Discuss the importance of promoting the self- determination of students with ASD and describe methods, materials, and strategies that are useful in developing related skills.

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218 chAPTEr 14 • TrAnSiTiOn TO POSTSEcOnDAry EnvirOnmEnTS fOr STuDEnTS wiTh ASD

executive functioning to improve employment outcomes. Transition is shown to be a complex multitiered process that when carried out effectively for students on the spectrum (a) respects the underlying characteristics of autism; (b) recognizes and accommodates cognitive, sensory, and social challenges; and (c) enables individuals to use their talents and interests to attain and sustain employment through building on their strengths.

overvIew and hIstory of the transItIon process and servIces

Before overviewing the historical antecedents to transition services, it is important to under- stand what the current requirements with regard to transition and transition services are for all students receiving special education services. The Individuals with Disabilities Education Act (IDEA) has, since 1990, required that the educational programs of adolescents with dis- abilities receiving special education services to include a focus on services and instructional needs to enable the student to “transition” from secondary education to postsecondary edu- cation and adult life. The term transition refers, generally, to the “life changes, adjustments, and cumulative experiences that occur in the lives of young adults as they move from school environments to independent living and work environments” (Wehman, 2006, p. 4).

The IDEA requires that the Individualized Education Programs (IEPs) of students receiving special education services ages 16 and over include transition services be addressed. IDEA defines transition services as follows:

a coordinated set of activities for a child with a disability that—(A) is designed to be a results-oriented process, that is focused on improving the academic and functional achievement of the child with a disability to facilitate the child’s movement from school to post-school activities, including post-secondary education, vocational education, integrated employment (including supported employment), continuing and adult education, adult services, independent living, or community participation; (B) is based on the individual child’s needs, taking into account the child’s strengths, preferences, and interests; (C) includes instruction, related services, community experiences, the development of employment and other post-school adult living objectives, and, when appropriate, acquisition of daily living skills and functional vocational evaluation [Section 1401(34)].

An extended discussion of these requirements is beyond the scope of this chapter, but it’s worth highlighting several aspects of the transition services requirements. First, transition services should address an array of outcomes, from postsecondary education to employment to independent living. Second, such services must take into account the child’s strengths, pref- erences, and interests, which places emphasis on the issues pertaining to self-determination discussed later in this chapter.

historical overview of transition

The transition of students with Autism Spectrum Disorders from school to postsecondary edu- cation and/or employment has been a continuing critical issue across our nation. As noted, IDEA defines transition services as a coordinated set of activities based on measurable post- secondary goals (34 C.F.R. § 300.43 [a] [1], 2011). With national figures showing 75% of adults with developmental disabilities unemployed (Van Laarhoven & Winiarski, 2012), per- sons with autism continue to face barriers to career development and employment (Carter, Austin, & Trainer, 2012; Hendricks & Wehman, 2009). While Employment First initiatives stress the importance of employment for persons with disabilities (Niemiec, Lavin, & Owens, 2009), only 6% of individuals with ASD gain competitive employment (Shattuck, Wagner, Narendorf, Sterzing, & Hensley, 2011).

The current system’s failure to adequately prepare adolescents with ASD for life beyond school is evidenced by studies, such as those conducted by Taylor and Seltzer (2010) and Bellstedt, Gillberg, and Gillberg (2005), in which Taylor and Seltzer found that 56% of adult

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subjects in their survey were in sheltered workshops or day activity centers; and Bellstedt, Gillberg, and Gillberg reported that 78% of a sample of 120 young adults with ASD were unemployed and not living independently. Wehman, Targett, West, and Kregel (2005) reported that people with developmental disabilities, including ASD, have not been obtaining the needed supports to prepare for employment. In another report, Wehman et al. (2012) noted that, in their programs, youth with ASD demonstrated better employment potential than had been realized to date, showing that access to intensive training in community-based environments improved employment outcomes for youth with ASD. Yet, despite evidence of the potential of people with autism to perform jobs, adult outcomes related to employment for this population remain extremely poor (Allen, Wallace, Greene, Bowen, & Burke, 2012; Cimera & Cowan, 2009).

In a recent review of the literature, Taylor et al. (2012) found a lack of evidence to sup- port any specific vocational treatment approaches for adults with ASD; stating that, while there is evidence that vocational programs can improve employment outcomes, more research is needed to improve our understanding of vocational preparation for persons with autism. Schall, Targett, and Wehman (2013) reported a paucity of useful research on interventions to improve transition for persons with ASD. Furthermore, Wehman et al. (2012), found no suc- cessful transition models in the literature to describe specific practices for students with ASD.

Using data from the National Longitudinal Transition Study 2, Shattuck et al. (2011) examined postschool outcomes for persons with ASD. In addition to low employment lev- els, they found low levels of independence and poor self-determination ability; 80% percent still lived with parents and 40% reported no friendships. Self-determination is a critical com- ponent of employment and independent adult living (Thoma, Bartholomew, & Scott, 2009; Wehmeyer & Schwartz, 1997). Self-determination includes concepts of independence, free- dom of choice, self-direction, and responsibility (National Research and Training Center, 2002). Skills that comprise the core of self-determination competence include choice mak- ing, decision making, problem solving, goal setting, risk taking with safety, self-regulation, self-instruction, locus of control, perceptions of self-efficacy, self-advocacy, self-awareness, and self-knowledge (Bremer, Kachal, & Schoeller, 2003; Deci & Ryan, 2000). Research has shown that students who are more self-determined are more likely to achieve positive adult out- comes, including being employed at a higher rate and earning more per hour than peers who are not self-determined (Palmer & Wehmeyer, 2003; Wehmeyer & Schwartz, 1997).

Legislation that has Impacted service delivery

In 1978, an amendment to the Rehabilitation Act of 1973 (The Act) was passed, calling for a coordinated approach to research, development, information dissemination, and training to improve quality of life for persons with disabilities. The intent of The Act and the amendment was to empower individuals with disabilities to maximize employment, self-sufficiency, inde- pendence, inclusion, and integration in society. In response to The Act, the National Institute for Disability Rehabilitation and Research (NIDRR) was created with the mission of helping to ameliorate obstacles facing persons with disabilities and improving the quality of life for persons with significant disabilities through research and support.

In concert with the NIDRR mission, a new emphasis was placed on increasing oppor- tunities to make choices and enhance participation in everyday activities. This new empha- sis led to studies and projects to identify evidence-based practices that could develop useful and cost-effective employment intervention models. NIDRR identified Universal Design for Learning as a potential pathway toward meeting the goal of reducing obstacles to successful employment (Notice of Long-Range Plan for Fiscal Years 2005-2008, National Institute on Disability and Rehabilitation Research, 2006).

The Americans with Disabilities Act of 1990 addressed the need to fully include all persons in their communities. The Olmstead decision and the report on the New Freedom Commission on Mental Health (Executive Order 13263, 2002) followed suit by recognizing the need for models of effective practices to support independent living and employment. The Olmstead decision

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(Olmstead v. L.C., 527 U.S. 581) dictated that services to people with disabilities be provided in the most integrated settings appropriate to their needs. The New Freedom Initiative of 2001 recognized that people with disabilities needed a complete and appropriate education to join their communities as equal members. These legislative initiatives were intended to promote inclusion of people with disabilities in society by increasing access to universally designed programs. They highlighted the need for validated strategies to foster successful community living and presented directives for the development of sustainable models to promote inclusion of young adults with significant disabilities in postsecondary education to prepare them for employment and community integration. The Higher Education Act of 2008 continued the momentum by calling for expanded college access through comprehensive transition and postsecondary programs. A major focus of the Higher Education Act is on development of postsecondary teaching strategies, methods, and curriculum that are consistent with Universal Design for Learning (UDL).

While these legislative initiatives were well intentioned, employment outcomes did not substantially improve. Even with this properly targeted legislation, the need to translate knowl- edge on effective models generated through research and development continued, and rates of employment for persons with severe disabilities have remained poor. In reflection, it seems that the mandates actually preceded the technology of how to effectively transition students to adult- hood. A disconnect remains between the extant knowledge base in evidence-based transition practices and application of methods for supporting persons with autism in obtaining meaning- ful employment. The current state of the art in transition services has resulted in a devastating problem for large numbers of adults with autism, who remain unemployed and underemployed.

Further exacerbating the unemployment crisis for persons with autism, the demand for transition programs is actually increasing based on prevalence trends in ASD. Over the past four decades, public schools across the nation have responded to educational mandates to include students with disabilities in general education to the fullest extent possible. Although many students with severe disabilities are still educated in segregated settings, the increased numbers of students who have been successfully integrated into inclusive school programs, have resulted in more graduates interested in postsecondary education. Transition to postsec- ondary education has become the new inclusion frontier.

The goal of the legislative mandates has been to improve transition outcomes through reallocation of school time and resources to provide effective transition services. Such real- location has the potential to lead to sustainable systemic change, through which collabora- tive interdisciplinary teams may deliver effective transition services. To meet the goals of the Higher Education Act, Americans with Disabilities Act, and the Rehabilitation Act, admin- istrators will need to create a system that brings together educators and service providers to deliver evidence-based transition services in a cohesive manner.

Issues and consIderatIons In transItIon programmIng for students wIth asd

Transition is a broad term that generally encompasses preparation for moving forward to a new stage in life. Transition from high school to postsecondary settings involves preparation for post- secondary education, employment, independent living, and community integration. Each of these domains is especially challenging for people with autism because they require skills and abilities that, by nature, are challenging due to core deficits of this disability. Understanding how core characteristics of autism affect performance and interpersonal interaction can result in improved learning and transition outcomes (Zager, Alpern, McKeon, Maxam, & Mulvey, 2013).

Of interest in reports of low rates of employment for people with autism is the lack of discussion about (a) how to build on strengths and interests in employment intervention for persons with autism; (b) how to present opportunities to learn in varied ways to accommodate challenges associated with autism, such as sensory issues (e.g., hypersensitivity to noise, smell, or touch), distractibility, restricted interests, and repetitive behaviors; and (c) how to redirect behaviors that could be perceived negatively into work-related assets (e.g., overattention to detail, persistent attraction to specific activities).

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sensory Issues and environmental factors

Research informs us of the interplay between environmental factors and sensory issues for per- sons with autism (Ben-Sasson, Fluss, Cermak, Engel-Yeger, & Gal, 2008). Sensory integration problems may result in hyper- or hypo-sensitivity to environmental stimuli. Noise, lighting, smells, crowds, animals, and so on, may pose sensory discomfort for individuals with ASD. By taking into account these considerations, agitation and maladaptive behaviors may be reduced, therein increasing the likelihood of learning and skill mastery. Ecological inventories of poten- tial worksites can illuminate physical features of work settings and facilitate identification of suitable job sites.

social Interactions

Individuals with ASD may tend to have problems understanding and responding to subtle feel- ings within themselves and others (Zager et al., 2013). Because interpersonal communication is often challenging for people with autism, social behavior and preferences should be considered in work setting selection. While individuals with autism may desire comradery, they often tend to have difficulty initiating and engaging socially. Problems in understanding behaviors and feelings of others, referred to as Theory of Mind (Baron-Cohen, 2000) can result in inappro- priate responses that can be upsetting to both the individual with ASD and the recipient of such unusual behavior. Scripted social stories and role-playing in actual situations can increase understanding of others’ feelings and reactions, teach socially expected behavior, and allevi- ate potential problems stemming from misunderstandings. In addition, educating people with whom individuals with ASD will be interacting in postsecondary environments is often helpful.

Information processing

While language processing skills may improve as individuals mature (Howlin, Mawhood, & Rutter, 2000), communication challenges tend to persist into adulthood and may interfere with social interactions (Zager & Alpern, 2010). The ability to take in, register, decode, and comprehend unfamiliar abstract concepts is often difficult for persons with ASD. Individuals with ASD may struggle at various stages of comprehension building, including (a) input of new information to the brain, (b) organization of information, (c) encoding information for storage and later retrieval, and (d) expressing new concepts. Instructional planning should take into account the difficulty that persons with autism have in understanding abstract lan- guage and concepts. Teaching in the natural environment with an understanding of the core language and communication differences associated with autism helps to foster engagement (Zager et al., 2013). Information processing challenges can impact the degree of success that students achieve in postsecondary education and/or employment. Relating new concepts to actual experiences can enhance meaning when learning new knowledge.

executive functioning

Executive functioning pertains to a set of neurologically based skills that involves the process of managing oneself and one’s activities in order to accomplish goals. This set of skills is nec- essary to perform day-to-day tasks and is critical for planning and organizing thoughts and activities. Executive dysfunction can impact self-regulation and the ability to control atten- tion to task, language, social behavior, and functional skills. Problems in time management, organization of tasks, punctuality, pacing oneself, maintaining focus, and so on, can lead to unsatisfactory performance, resulting in agitation, anxiety, and depression—which in result in an escalation of dysfunction. Providing successful experiences to build executive competence is essential to transition success.

In summary, inherent characteristics of autism, as they affect behavior and learning for each student, should influence educational planning at all stages of development. By respecting the underlying characteristics of autism and building on student strengths while accommodat- ing cognitive, sensory, and social challenges, practitioners involved in transition programs can

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increase their students’ success. Individual talents, interests, and preferences are key factors in designing programs for students with autism. Personal interests, as well as challenges and edu- cational needs, change over time as individuals with ASD progress though different stages of development. Accordingly, educational strategies should evolve as individuals with ASD grow and develop from infancy through adulthood, to enable them to become increasingly engaged in their school, family, and community at a chronologically age-appropriate level.

autIsm InterventIon modeLs and the transItIon process

The extant research base in the field of special education shows that instructional effectiveness is improved through application of consistent implementation of evidence-based systematic practices and ongoing assessment. An overview of models and strategies that have been shown to be effective in educating students with autism is presented in this section. Intervention models commonly employed in the education of students with ASD include, but are not limited to applied behavior analysis (ABA), Training and Education of Autistic and related Communication-handicapped Children (TEACCH), and the Developmental, Individual difference, Relationship-based model (DIR). These approaches have varying degrees of empirical support. The reader is encouraged to consider how specific approaches might be adapted and combined on an individual basis to facilitate the transition process for youth with ASD.

There is abundant research documenting the effectiveness of ABA (see, e.g., Baer, Wolf, & Risely, 1968; Duker, Didden, & Sigafoos, 2004; Hundert, 2009; Iovannone, Dunlap, Huber, & Kincaid, 2003), as well as the effectiveness of TEACCH methodologies (Marcus, Lansing, Andrews, & Schopler, 1978; Mesibov, Browder, & Kirkland, 2002; Mesibov & Shea, 2010). In recent years, the DIR model also has garnered supportive data, as well (Greenspan, 1999; Greenspan & Wieder, 2007; Mahoney & Perales, 2005; Wieder & Greenspan, 2003). Regardless of the level of ability of students on the spectrum, these techniques can provide a framework for learning and may be continued into secondary school, as well as postsecondary environments, to facilitate transition to employment and adulthood.

applied Behavior analysis

For the purpose of this chapter, ABA refers to the systematic arrangement of the environment to increase the likelihood of the emission of a desired response. Applied behavior analysis has been shown to be highly effective in building skills, especially in the early developmental years, and also provides a solid scientific framework for education and transition program- ming. Behavioral techniques that (a) utilize positive reinforcement contingencies; (b) provide and fade prompts systematically while thinning reinforcement to build independent function- ing; (c) implement task analysis strategies to build skill fluency, generalization, and main- tenance; and (d) collect and analyze data on student progress and program effectiveness are essential when planning transition programs for individuals with autism.

A significant advancement in educating students with autism resulted from the realization that problem behaviors frequently have communicative intent and serve a function (Carr, 1977; Scott & Bennett, 2012). By analyzing problem behaviors and determining underlying causes and sustaining outcomes of these behaviors, educators may reduce maladaptive behaviors, a major reason for loss of jobs and lack of independence for people with autism. Functional analysis of behavior leads to insight into the purpose of behavior and helps to identify reinforcing consequences of the behavior. This useful information can be used to design environments and create learning situations that reduce maladaptive behaviors in the workplace and the community.

For older students who have benefited from years of behavioral intervention, transition instruction may be presented through a broader behavioral framework. Such behavioral pro- gramming can increase age-appropriate social behaviors required in inclusive community set- tings, where naturally occurring reinforcement is a powerful tool. Education models at the secondary school level frequently combine approaches, moving beyond highly structured ABA

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classrooms. High school programs tend to emphasize development of academic skills, inde- pendence, self-advocacy, and self-determination, with attention directed toward longitudinal lifelong planning.

teacch model

The TEACCH model is based on a philosophy that sees autism as a lifelong condition and designs instruction that is responsive to the culture of autism. TEACCH practices are grounded in an understanding of the characteristics of autism. Program design depends on assessment information to identify children’s strengths, skills, interests, and needs. The goals of the methodology are to build skills and independence.

Because many individuals with autism tend to learn best through visual cues, TEACCH intervention strategies include visual structure, work schedules, and task organization. Cus- tomized systems take into account challenges in communication, organization, generaliza- tion, concepts, sensory processing, change, and relating to others (Mesibov & Howley, 2003). Arranging the classroom to support student learning needs is foremost in structured teaching and is also critical in work situations. Schedules and work systems help to make expectations clear. Utilization of visual materials and cues has been shown to be effective in building skills (Mesibov et al., 2002) and enabling individuals with ASD to perform tasks independently, with less prompting from the teacher or job supervisor.

the developmental, Individual difference, relationship-Based model

The philosophical foundation for DIR is based on the importance of interactive relationships in development of language, cognition, and social interaction. An integrated understanding of human development is the cornerstone of this approach. DIR intervention is responsive to individual differences in auditory processing, visual/spatial, sensory modulation, motor plan- ning. DIR may have potential to enhance performance of older students for whom social rela- tionships become increasingly important, as well as benefitting young children, for whom it was initially developed.

case exampLe: Jordan

Jordan, a 20-year-old student with autism and intellectual disability, is entering his final year of secondary school. Jordan participated in a highly structured early childhood education program. While in early elementary school, Jordan received a substantial amount of one-on- one instruction that included discrete trial learning sessions, along with highly structured group lessons. In the intermediate grades, Jordan benefited from student-centered inclusive school experiences and structured teaching using the TEACCH model. Middle school required Jordan to navigate a new school, with more classes and more teachers. School-wide positive behavior supports within middle school and high school helped Jordan function successful in a fully inclusive environment and empowered him to learn and socialize among his peers. In his middle and high school years, increasing amounts of time were spent in community-based learning programs. While community settings were less structured than school-based class- rooms, his special education teachers conducted ecological inventories of the environments and built concurrent instructional programs within his school and the community, utilizing consistent behavioral practices in all settings designed to foster generalization, maintenance, and fluency of newly acquired skills to the community. Longitudinal planning designed to increase independent functioning along with person-centered planning influenced the design and implementation of ABA practices. Jordan was an active partner in planning his goals and identifying reinforcement that would be meaningful. As Jordan developed self-determination competence and self-advocacy skills, his access to naturally occurring reinforcement increased and helped to sustain his motivation.

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components of effectIve transItIon programmIng

Instructional approaches to prepare students with autism to be successful in work and adult living should focus on (a) building on strengths and interests, rather than on a deficit-based model; (b) presenting opportunities to learn in varied ways to accommodate challenges asso- ciated with autism, such as sensory issues (e.g., hypersensitivity to noise, smell, or touch), distractibility, restricted interests, and repetitive behaviors; and (c) turning behaviors that could be perceived negatively into work-related assets (e.g., overattention to detail, persistent attraction to specific activities). Educators should present intervention that encourages indi- viduals with autism to use their unique talents and interests to attain and sustain employment through building on their strengths; recognizing and accommodating cognitive, sensory, and social challenges; and respecting preferences and interests.

community-Based transition preparation

Because students with autism often have difficulty generalizing learned information to new situations (Wacker, Berg, Berrie, & Swatta, 1985), it is incumbent upon teachers at the sec- ondary level to conduct a large portion of instruction in settings beyond their classroom walls, utilizing community-based learning strategies for transition. Research studies have noted the importance of community-based instruction in the preparation of youth with autism and other severe disabilities (Berkell, 1992). So, for example, in preparing students for employment, instructional effectiveness can be enhanced by teaching job skills at real worksites; in prepar- ing students for postsecondary education, instruction could be delivered on college campuses. For developing independent living skills, partnerships with parents/caretakers can increase ability to perform everyday life skills by providing training in both school and home settings.

postsecondary education for students with autism spectrum disorders

While educators have made great strides in integrating students with ASD into general edu- cation in public schools (Smith, Polloway, Patton, & Dowdy, 2012), at the postsecondary edu- cation level, these students may experience substantial difficulty. Most especially, challenges in the areas of social interaction and executive functioning impact academic and social life to the extent that students often become frustrated and depressed. In order to prepare students with ASD for postsecondary education (PSE), educators need to promote independence (Kaweski, 2012) and encourage engagement in general education. It is essential that secondary teachers focus on building self-determination, self-advocacy, social competence, and executive func- tioning competence (Roberts, 2010; Wehmeyer & Patton, 2012) to prepare students for PSE. These skills are necessary for independent adulthood; they are part of an indispensible skill set (Zager & Alpern, 2010) for students with autism.

Zager and Feinman (2012) suggested strategies to prepare students with ASD and related disabilities for postsecondary education environments. These include (a) providing clear expectations and directions while using concrete language; (b) providing consistent envi- ronments with structure with clear cut rules; (c) utilizing tools to assist with time manage- ment like to-do lists and intermediate benchmarks for assignments; (d) creating color coded schedules to keep at home, at school, and in the student’s school bag; (e) using organizers for desk, notebook, and school bag; (f) establishing a daily routine with specific time for each required activity; (g) scheduling time to organize desks and school bags; and (h) role-playing potentially troublesome situations in advance.

dIversIty Issues In postsecondary educatIon for students on the spectrum The dire conditions in which many American families live (DePanfilis, 2008) have important implications for how schools need to be structured and for how instruction should be presented (Westling, Fox, & Carter, 2013). Schools are increasingly challenged to meet the needs of a diverse population and to promote the involvement of families from

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a variety of cultural and economic backgrounds (Parette, Huer, & Peterson-Karlan, 2007). Research has shown that racially diverse and lower income students tend to be identified with autism at later ages or misidentified. (Travers, Tincani, & Krezmien, 2011). These data have implications for educators working with students from high-poverty communities as they transition beyond secondary school, in that they underscore a need for improved culturally responsive practices related to all learning environments, family engagement, access to needed support services, and instructional practices (Harmon, Kasa-Hendrickson, & Neal, 2009).

The program enabled the students with ASD to be among their own age peers from different backgrounds. Before the class began, several meetings were held with the students and their parents. The parents of the students with ASD were concerned about placing their children in an unfamiliar environment as none of the parents had exposure to institutions of higher learning, and much sensitivity and support was provided by the school team. Interest- ingly, because inclusion is common practice in many public schools, the other college students adjusted with few incidents to the addition of these new students. At one point, Rafe’s mother informed his teacher that when Rafe was 2 years old, his pediatrician suggested that he be placed in a special facility because he had a significant intellectual disability and would need intensive treatment. She said that now Rafe is the only boy from their neighborhood who is attending college.

universal design for transition employment Intervention model

The promotion of employment and integration of individuals with autism into their com- munity requires creation of effective sustainable models of employment intervention. One model that has been shown to be effective in transition programming for secondary school students with intellectual disabilities and that shows promise for students with ASD is Universal Design for Transition (UDT) (Thoma et al., 2009). A complementary evidence-based assessment/curriculum guiding model, the Self-Determined Learning Model of Instruction (SDLMI; Wehmeyer et al., 2003), discussed in the self-determination section, can facilitate transition through building self-determined exploration and steps toward independence.

Understanding how core characteristics of autism affect performance and interpersonal interaction can result in more positive relationships between individuals with autism and their teachers, resulting in improved learning situations (Zager et al., 2013). Further, infusing UDT with the SDLMI may fill an existing gap in transition programming for students with autism

case exampLe: rafaeL (rafe)

Rafe, a 19-year-old male of Latin American descent from a high-poverty urban community, was attending an inclusive high school program near his home. Because Rafe has a classifi- cation of Autism Spectrum Disorder and Intellectual Disability, he was eligible for public school services until the age of 21. However, when most of his high school buddies graduated, his school team noted that Rafe was no longer in an age-appropriate inclusive environment because the only students who were the same age as Rafe in his school had significant disabil- ities. The special education director approached a local private university and suggested that the university begin a campus-based inclusion program for students with autism, in collabora- tion with the local public school. The coordinator of the special education teacher preparation program at the university saw this as an opportunity to provide field work for teacher interns, and together they approached the Dean of the School of Education. After going through sev- eral channels within the public school central office and at the university, a pilot class was formed; and Rafe along with seven other diverse young adults with autism and intellectual disabilities from high need communities began attending a program at the university. The teacher and two paraprofessionals accompanied the students to classes, which they audited and then used as the basis for their curriculum. The students performed jobs on campus in which they were supervised by the high school staff and for which they received payment from their public school’s budget.

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by utilizing effective practices that can accommodate core characteristics of autism and enable students to take an active role in preparing for their future.

Principles and practices that form the foundation of UDT have been shown to be effective in preparing persons with disabilities for transition to work (Scott, Saddler, Thoma, Bartholomew, Alder, & Tamura, 2011; Wehmeyer & Palmer, 2003). The UDT approach provides the framework for training and support strategies, whereas the Self-Determined Career Development Model is used to guide individuals toward success in work and living situations. These practices will be combined, expanded, and adapted so that they may be customized to meet the unique learning needs of adults with autism. Such a model can help providers to address specific needs and interests associated with Autism Spectrum Disorders through individually customized methods.

Universal Design for Transition applies principles of UDL to support planning transition to employment and adult life so that all people have the opportunity to live and work within their community. It was created by building on principles of UDL and adding components of effective transition instruction, including multiple transition domains, multiple transition assessments, self-determination, and multiple resources/perspectives (Thoma et al., 2009).

The UDT approach has been shown to improve learning in secondary school students with developmental disabilities, including autism, and to increase engagement and percep- tions of self-efficacy (Scott et al., 2011). UDT offers (a) multiple means of representation, demonstrating various ways of acquiring information and knowledge; (b) multiple means of expression, providing alternatives for demonstrating what participants know; and (c) multiple means of engagement, tapping into interests to increase motivation (Rose & Meyer, 2006). UDT bases intervention on real-world tasks in community settings. It uses flexible program- ming so that multiple goals are addressed simultaneously.

In UDT, community-based employment tasks are scaffolded so that participants can enter tasks at their own level. Through UDT it is possible to infuse instruction in functional aca- demic content into real work tasks to achieve employment goals in meaningful ways for adults with autism. Goals are accomplished through concrete presentation of information related to individual interests and needs. Assistive technology plays a significant role in UDT as it offers multiple avenues for information acquisition, task completion, and expression of knowledge.

UDT and SDLMI are among the few practices in transition education that do have the support of efficacy studies. Although there is a dearth of information about specific transition practices for students with ASD (Wehman et al., 2012), utilization of these approaches has been shown to foster access to learning by removing barriers from work environments for persons with developmental disabilities (Thoma et al., 2009) and to improve employment outcomes (Wehmeyer et al., 2003).

In UDT programming, multiple avenues for service delivery can be designed for a wide range of nontypical learners, identifying and using strengths to meet their employment goals. Elements that can be included in the UDT are (a) varied work experiences in multiple employment settings that take into account students’ strengths as well as challenges often associated with autism, such as executive dysfunction, concrete thinking, rigidity, sensory issues, and social-communication challenges; (b) self-determination competence through use of information from the SDLMI to identify opportunities that take into account special tal- ents and skills that may have been developed and honed to high levels through over-selective interests in specific topics (e.g., trains, cars, animals, theater, food, mathematics); (c) multiple representations of learning tasks, such as modeling and video presentations, that take into account unique learning and behavior characteristics associated with autism (e.g., difficulty with abstract concepts, trouble with fast-paced or language, preference for well-organized visual presentation); (d) multiple engagement in varied work activities, such as individual work, cooperative tasks, and technology-driven activities, that take into account learning and behavior needs (e.g., difficulty with generalization of learned information to new situations, desire to have friends but inability to take initiative or act reciprocally, difficulty understand- ing expectations in cooperative group situations); (e) multiple expressions of knowledge, such

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as role-playing, drawing, and writing, that take advantage of skills and strengths that can be used to demonstrate competence; and (f) reflection and evaluation of learned knowledge through self-assessment, involving the need to look objectively at the consequences of one’s actions and considering the interpretation of, and response to, one’s acts by others. A visual depiction of components of a UDT employment preparation model developed by Thoma, Wehmeyer and Zager is provided in Figure 14.1.

In sum, UDT employment preparation utilizes knowledge gained from research of UDT and SDLMI to create an employment intervention model to provide training and sup- port to individuals with autism to enhance transition to employment and adult living and provide training infused throughout the intervention to build self-determination competence for adulthood.

promoting self-determination and student Involvement

The discussion of the UDT process alluded to the importance of promoting self-determination to transition outcomes and, particularly, to the implementation of the SDLMI to achieve more positive transition outcomes. In fact, research has linked higher self-determination to positive adult outcomes, including employment and independent living, for youth with special educational needs (Shogren, Palmer, Wehmeyer, Williams-Diehm, & Little, 2012; Wehmeyer & Palmer, 2003; Wehmeyer & Schwartz 1997), as well as to a higher quality of life (Lachapelle et al., 2005; Wehmeyer & Schwartz 1998). Further, most school standards for all students include a focus skills leading to enhanced self-determination (e.g., goal setting, problem solving, decision making, self-advocacy, self-management, and others) and when instruction is available school-wide to address these component elements, all students benefit (Wehmeyer, Field, Doren, Jones, & Mason, 2004). Finally, there is evidence that students with special educational needs can acquire the knowledge and skills to become more self-determined if provided such instruction (Algozzine, Browder, Karvonen, Test, & Wood, 2001; Wehmeyer, Palmer, Shogren, Williams-Diehm, & Soukup, 2013; Wehmeyer, Shogren, Palmer, Williams- Diehm, Little, & Boulton, 2012). Box 14.1 (Research Notes) provides description of a randomized trial study that shows the positive effects of promoting the self-determination of students across disability categories, including students with autism.

SDLMI: Phase I Employment

choices Employment assessment

SDLMI: Phase II: Set a Plan • Identification of individual needs re: academic skills • Identification of needs re: functional skills for employment/other community supports • Identification of needs re: further assessment • Identification of needs re: SD

Identification of multiple resources/perspectives

Implementation of UDT employment plan

Evaluation of plan: SDLMI: Phase III

Employment outcome

fIgure 14.1 UDT Employment Model

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Wehmeyer (2005) proposed a functional model of self-determination in which self- determined behavior refers to “volitional actions that enable one to act as the primary causal agent in one’s life and to maintain or improve one’s quality of life” (Wehmeyer, 2005, p. 117). An act or event is self-determined if the individual’s action reflects four essential characteris- tics: (a) the individual acted autonomously, (b) the behaviors were self-regulated, (c) the person initiated and responded to event(s) in a “psychologically empowered” manner, and (d) the per- son acted in a self-realizing manner. Self-determination refers to self (vs. other) caused action; people who are self-determined are actors in their own lives, rather than being acted upon.

The concept of causal agency is central to this perspective. Broadly defined, causal agency implies that it is the person who makes or causes things to happen in his life. One frequent misinterpretation of self-determination is that it means “doing it yourself.” When self- determination is interpreted this way, however, there is an obvious problem for most students with special educational needs, who frequently have limits to the number and types of activities they can perform independently. However, the capacity to perform specific behaviors is secondary in importance to whether one is the causal agent (e.g., caused in some way to happen) over outcomes those specific behaviors are implemented to achieve. Thus, students who may not be able to “independently” make a complex decision or solve a difficult problem may be able, with support, to participate in the decision-making process, and thus has the opportunity to be the causal agent in the decision-making process, and consequently, act in a self-determined manner.

Though there is only limited information pertaining to the self-determination of stu- dents with ASD, the findings that do exist support the need for such instruction. Recently, Chou, Skorupski, Wehmeyer, and Palmer (2013) compared the self-determination of 222 mid- dle and high school students with ASD, intellectual disability, or learning disabilities and found that, in the autonomous functioning domain, students with ASD scored lower than did

Box 14.1 research notes

As noted in the chapter, promoting self-determination has become best practice in transition supports and services for a variety of reasons. Recently, two studies have provided causal evidence of the importance of promoting self-determination to postsecondary-related outcomes. Wehmeyer Palmer, Shogren, Williams-Diehm, and Soukup (2013) conducted a randomized- trial control group study of the effect of interventions to promote self-determination on the self-determination of high school students receiving special education services under multiple categorical areas, including autism. Students in the treatment group (n = 235) received instruction using a variety of instructional methods to promote self-determination and student involvement in educational planning meetings over 3 years, while students in the control group (n = 132) received no such intervention. The self-determination of each student was measured using two instruments, The Arc’s Self-Determination Scale (Wehmeyer & Kelchner, 1995) and the AIR Self-Determination Scale (Wolman, Campeau, Dubois, Mithaug, & Stolarski, 1994), across three measurement intervals (at baseline, after 2 years of intervention, after 3 years of intervention). Using latent growth curve analysis, Wehmeyer and colleagues found that students with cognitive disabilities who participated in interventions to promote self-determination over a 3-year period showed significantly more positive patterns of growth in their self-determination scores than did students not exposed to interventions to promote self-determination. In a follow-up study of these same students, Shogren, Wehmeyer, Palmer, Rifenbark, and Little (in press) investigated adult outcomes 1 and 2 years after leaving school. The study measured employment, community access, financial independence, independent living, and life satisfaction outcomes. Results indicated that self-determination status at the end of high school predicted significantly more positive employment, career goal, and community access outcomes. Students who were self-determined were significantly higher in all of these areas. These two studies study provided causal evidence that promoting self- determination results in enhanced self-determination, and that enhanced self-determination results in more positive adult outcomes, including employment and community inclusion.

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students with learning disabilities or students with intellectual disability and lower than stu- dents with learning disabilities in all domains.

promotIng component eLements of seLf-determIned BehavIor Wehmeyer and colleagues (2003) have identified a set of component elements of self-determined behavior, including self-advocacy, goal setting and attainment, self-awareness, problem-solving skills, and decision-making skills, that, if as acquired by adolescents, lead to enhanced self-determination. Instruction in these component elements have been shown to promote self-determination and more positive postsecondary-related outcomes. Algozzine et al. (2001) conducted group- and single-subject design meta-analyses of studies in which individuals with disabilities had received some intervention to promote component elements of self-determined behavior, specifically, choice-making skills, decision-making skills, goal-setting and attainment skills, self-advocacy knowledge or skills, problem-solving skills, and self-awareness skills. The median effect size across 100 group intervention comparisons was 1.38, interpreted as a moderate effect. For the single-subject design studies, the median percentage of nonoverlapping data (PND) was 95%, with seven interventions with a PND of 100%. This is interpreted as a strong effect.

Subsequently, Cobb, Lehmann, Newman-Gonchar, and Morgen (2009) conducted a narrative metasynthesis—a narrative synthesis of multiple meta-analytic studies—covering seven existing meta-analyses examining self-determination and concluded that there is suffi- cient evidence to support interventions to teach or promote choice-making, problem-solving, decision-making, goal-setting and attainment, and self-advocacy skills as effective practices to promote self-determination. Relatedly, as noted in Box 14.2 (Trends and Issues Notes), the use of information and communication technology, such as tablet PCs and iPads, provide potential for students with autism to more successfully self-manage and self-regulate their action.

student InvoLvement In transItIon pLannIng As noted earlier in this chapter, IDEA emphasizes that transition services should be based upon student needs, interests, and preferences and requires that if transition services are discussed during the meeting, students be invited to attend. Promoting student involvement in transition planning has been shown to promote self-determination and to improve planning outcomes (Martin, Van Dycke, Christensen, Greene, Gardner, & Lovett, 2006; Mason, Field, & Sawilowsky, 2004). Test et al. (2004), for example, reviewed articles reporting 16 studies designed to evaluate the effects of interventions to promote student involvement and concluded that students across disability categories can become actively involved in the planning process and that instruction to promote such involvement results in enhanced student participation in the IEP process.

One of the benefits of student involvement in transition planning for students is enhanced self-determination. Williams-Diehm, Wehmeyer, Palmer, Soukup, and Garner (2008)

Box 14.2 trends and Issues notes

Research on new technologies, such as smart phones and tablet PCs or iPads, is only now emerging, but it seems likely that such innovations will provide tools to enable adolescents with autism to more independently and successfully regulate their own actions, particularly with more complex tasks. There are already a host of visual and audio prompting apps that run on smart phone or tablet/iPad platforms that are easy to set up and personalize and enable students to self-regulate a multistep, complex task (Stock, Davies, Wehmeyer & Lachapelle, 2011). Further, such devices will enable students to self-regulate actions, such as being involved in their own educational planning meetings. Lee, Wehmeyer, Palmer, Williams- Diehm, Davies, and Stock (2011) found that students across disability categories who used a computer-based reading support program to self-direct their involvement in a process to enable them to become more involved in their transition planning meeting achieved more positive outcomes, including greater self-determination, than did their peers who were involved in the same process without technology supports.

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studied the differences in level of self-determination between 276 students with disabilities divided into groups that differed by level of student involvement in the IEP meeting. Multivariate analysis showed significant differences between self-determination scores using two different measures for students in a high-involvement group versus students in a low-involvement group, indicating that students who were more involved in their meetings were more self-determined. A second multivariate analysis found, though, that students who were more self-determined (two groups, high or low self-determination) were more likely to be involved in their IEP meeting. Further, Wehmeyer, Palmer, Lee, Williams-Diehm, and Shogren (2011) conducted a randomized trial evaluation of an intervention to promote student involvement, finding a causal link between intervention with the Whose Future is it Anyway process and greater self-determination and transition planning knowledge.

As with transition planning in general, there is little research examining student involvement in educational planning specifically with students with ASD. In fact, among the 16 studies reviewed by Test and colleagues (2004), there were 309 students involved, and of those, only one was identified with autism. More recent studies, though, are including stu- dents with ASD. For example, the Wehmeyer et al. (2011) study of the effects student involve- ment included 27 students with ASD. Again, however, there is a need for more research with regard to the effects of student involvement in transition planning on transition plans and outcomes for students with ASD.

seLf-determIned LearnIng modeL of InstructIon An instructional strategy with causal evidence to promote self-determination and other positive transition-related outcomes is the Self-Determined Learning Model of Instruction (Wehmeyer, Palmer, Agran, Mithaug, & Martin, 2000), mentioned as a part of the UDT process. The SDLMI is a model of teaching based on the component elements of self-determined behavior (e.g., problem solving, goal setting, self-regulation) and research on student-directed learning that is designed to enable teachers to teach students to set and attain goals in multiple content areas, from academic to functional to behavioral. Implementing the SDLMI consists of a three-phase instructional pro- cess: “set a goal” (Phase 1), “take action” (Phase 2), and “adjust goal or plan” (Phase 3). Each instructional phase presents a problem to be solved by the student. The student solves this problem by posing and answering a series of four Student Questions per phase. Teachers support students to learn these questions, modify them to make them their own, and apply them to self-selected goals. Each question is linked to a set of Teacher Objectives and a list of Educational Supports that teachers can use to enable students to self-direct learning. In each instructional phase, the student is the primary causal agent for choices, decisions, and actions, even when actions are teacher directed (see Wehmeyer et al., 2000).

More than a dozen quasi-experimental or single-subject design studies have shown the potential efficacy of the SDLMI to promote self-determination and goal attainment (Wehmeyer, Abery, Mithaug, & Stancliffe, 2003). Two recent studies establish it as an evidence-based practice. Wehmeyer et al. (2012) conducted a switching replication, randomized-trial control group study on the impact of intervention with the SDLMI on student self-determination. Data on self-determination using multiple measures was collected with 312 high school students with cognitive disabilities in both control and treatment groups. Wehmeyer and colleagues examined the relationship between the SDLMI and self-determination using structural equation modeling. After determining strong measurement invariance for each latent construct, these researchers found significant differences in latent means across measurement occasions and differential effects attributable to the SDLMI. This was true across disability category, though there was variance across disability populations. In other words, instruction using the SDLMI resulted in enhanced self-determination. Next, Shogren et al. (2012) reported findings from a cluster or group randomized-trial control group study examining the impact of the SDLMI on student academic and transition goal attainment and access to the general education curriculum for students with intellectual disability and learning disabilities. Students in the treatment group had significantly higher levels of goal attainment and access than their peers in the control group.

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summary

Individual choices of postsecondary settings (e.g., vocational preparation program, college, employment) may vary depend- ing on aspirations, interests, abilities, and even economic factors. Regardless of the next step that is taken after high school, performance expectations and accessibility of sup- port services in the selected postsecondary environment are likely to differ substantially from those that were available in secondary school.

As we have documented, transition outcomes for students with ASD are, too often, poor. This is, in part, because there has been too little focus on practices that can promote successful adult outcomes for these young people. There is a significant need for research that documents the efficacy of various strate- gies to promote a successful transition with students with ASD. It seems clear that these important strategies will incorporate universal design principles and will promote self-determination.

case exampLe: phILIpp

Philipp is a high school junior who receives special education services under the categorical areas of autism and communication disorders. Philipp planned to attend the community col- lege in his town and wanted to live in his own apartment when he did so. He knew he needed money to be able to move out of his family’s home, but didn’t know how much or how to go about determining how much. His parents were supportive, but Philipp had often expressed desires, only to have them fade away without action, so were content to have him continue to live at home at least while he went to community college. Philipp’s teacher, working with his parents, decided that Philipp should identify some goals that might lead him to eventu- ally achieve his desire to live in his own apartment. She supported Philipp to go through the SDLMI process, beginning with identifying which goal was most important to begin with. Philipp’s discussion with his teacher and family as he considered the questions in the first phase of the model showed him that there were many problems to solve to get to his goal of living on his own, not the least of which was money. Since Philipp was still a junior, however, and had a little time, he and his teacher determined that the first step would be to set a goal to find out how much apartments cost near the community college. During the second phase of the model, Philipp and his teacher set an action plan, consisting of calling apartment com- plex managers in the area around the college, and developed a self-monitoring plan to track the number of calls and their results. In the final phase, Philipp tracked his calls and recorded prices for apartments. He found that newer apartments and apartment complexes closer to the community college were more expensive, but that there were several older complexes within walking distance that appeared to be in a safe area that were less expensive. With that infor- mation in hand, Philipp began the SDLMI process again to identify which goal to set next to move him toward his eventual goal of living on his own and going to college.

chapter revIew QuestIons

1. Describe the history, relevant legislation, and current state of the art in transition education and services for persons with autism and significant disabilities with regard to employment statistics. (Objective 1)

2. List and explain the guiding principles of person-centered transition planning. (Objective 2)

3. List the key personnel and their roles and agencies and their functions in planning and implementing successful transition plans. (Objective 3)

4. How can educators integrate academic objectives and tran- sition goals to enhance learning outcomes? (Objective 4)

5. Discuss the importance of executive functioning and self-determination competence in preparing for and sus- taining employment. (Objective 5)

Key terms

Transition services 217 Transition planning 229

Secondary education 218 Self-determination 217

Universal design for transition 225

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Organization for Autism Research (OAR): http:// researchautism.org. OAR’s mission is to apply research to the challenges of autism.

Think College: http://thincollege.net. Growing out of the University of Massachusetts, this organization provides technical assistance, research and publications related to postsecondary education for persons with intellectual disabilities.

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261

A Abbacchi, A., 7 Abbott, R., 99, 105 Abbs, J. H., 202 ABC data collection, 65 Abery, B., 230 Abramson, J., 113, 185 Activity schedules, 184 Adams, C., 100, 104, 105 Adams, E., 170, 171 Adamson, L. B., 97, 101, 105 Adams, T., 136 Adaptive behavior, 6 Addison, L., 22 Adrien, J. L., 197 Agran, M., 230 Ahearn, W. H., 143 Ahlsen, E., 113 Aided AAC systems, 184 Ailey, S. H., 206, 214 Akullian, J., 109, 134 Alaimo, D., 71–72 Alber, S. R., 89 Alberto, P., 64 Alberto, P. A., 89 Albin, R., 77 Albin, R. W., 63, 64, 66, 67, 68, 77, 185,

212, 213 Alder, N., 226 Algozzine, B., 155, 227, 229 Alisanki, S., 15 Allaire, J., 184 Allen, K. D., 219 Allman, J. M., 103 Almason, S. M., 91 Al Otaiba, S., 160 Alpern, C., 221, 224, 225 Alpert, C. L., 117 Alwell, M., 28 Amanullah, S., 15 Amari, A., 88 American Psychiatric Association, 3, 103,

124, 170 American Speech-Language-Hearing Association,

184 Amerine-Dickens, M., 81 Anderson, J., 185 Anderson, W., 18 Andrellos, P. J., 203

Andrews, C. E., 222 Angell, M. E., 50, 52 Antecedent, 62 Antecedent-based intervention, 68–69

environment, predictability of, 71–73 instruction, features of, 73–75 learner preferences, 69 making choices, opportunities to, 73 pain or discomfort, 75 positive atmosphere, creation, 75–77 reinforcing activities, embed demands into,

69–71 Antecedent stimulus, 82 Apichatabutra, C., 77 Apple, A. L., 109 Applied behavior analysis (ABA), 29, 222–223

chaining instructional strategy, 88 challenging behaviors addressing, 92–95 discrete trial training (DTT), 82–85 discrimination training, 87 error correction procedures, 86–87 errorless learning, 85–86 family involvement, 92 individual instructional time intensity,

92–95 instructional focus and delivery, variations of,

89–92 introduction to, 80–82 modeling instructional strategy, 88–89 principles of behavior, 80 progress monitoring, 89 shaping process, 87–88 teaching skill acquisition, 82–89 teaching students with autism, 82

Arantes, J., 120 Areas of human function, 184

body support, protection, and positioning, 185 categories, 183–188 communication, 184–185 education and transition, 186 environmental interaction, 186 existence, 184 sports, fitness, and recreation, 186–188 travel and mobility, 185

Arick, J. R., 30 Arora, T., 103 Asaro, K., 164 Asperger Disorder, 3–4 Asperger Syndrome Diagnostic Scale, 6 Aspy, R., 202

The Assessment of Basic Language and Learning Skills—Revised (ABLLS–R), 19

Assessment of Functional Living Skills (AFLS), 152

Assistive technology (AT), 182 Assistive technology service delivery systems

acquisition, 189 application, 189 assessment, 188–189 evaluation, 189

Atance, C. M., 102 Attanasio, V., 113 Attwood, T., 9, 10, 14, 15, 97, 105, 124,

125, 126 Augmentative and alternative communication

(AAC), 113–114, 184 manual sign, 113 picture exchange communication system, 114 speech-generating devices, 114 system or device, selecting, 114

Austin, D., 218 Austin, J. L., 100 Autism, definition of, 5 The Autism Diagnostic Interview—Revised

(ADI-R), 5 The Autism Diagnostic Observation Schedule—

Generic (ADOS-G), 5 Autism Society of America, 2, 4 Autism Spectrum Disorders (ASDs)

Asperger Disorder, 3–4 The Autism Diagnostic Interview—Revised

(ADI-R), 5 The Autism Diagnostic Observation

Schedule—Generic (ADOS-G), 5 case studies, 1–2, 40–42, 96–97, 123–124,

141–142, 169–170, 181, 192, 205–206, 211–215

causes of genetics, 7–8 historical context, 6 role of environment, 7

characteristics of language deficits, 8–10 social differences, 10–12

classic autism, 3 comprehensive treatment models, 28–29 diagnosis of, 4–6, 42–44 generalization and maintenance, 15 learning challenges and, 15–16 National Professional Development Center, 25

Index

Z02_BOUT6877_02_SE_IDX.indd 261 1/8/16 3:38 PM

262 INDEX

Automatic reinforcers, 80 Aversive qualities, 68 Axe, J. B., 75 Ayers, K. M., 109

B Baer, D. M., 85, 89, 92, 144, 222 Bailey, A., 5, 7, 108 Bailey, D. B., 175 Bailey, J. S., 83 Baird, G., 4, 97, 196 Bakeman, R., 101, 105 Baker, D., 111 Baker, M., 175, 176, 177 Bakermans-Kranenburg, M., 173 Bakermans-Kranenburg, M. H., 3 Bakermans-Kranenburg, M. J., 97 Balla, D. A., 6, 64 Banda, D. R., 110 Bandura, A., 134 Bara, B. G., 104 Baranek, G., 170, 171, 173 Baranek, G. T., 7, 97, 195, 196, 197 Barbera, M., 91 Barbera, M. L., 115, 116, 117, 118, 119, 120 Bargh, J. A., 136 Barnes-Holmes, D., 115 Barnett, C., 170, 171 Barnett, K. N., 166 Barnhill, G. P., 6, 12, 15, 144 Baron-Cohen, S., 4, 10, 11, 46, 97, 124, 126,

127, 221 Barrett, M., 160 Bartholomew, C., 226 Bartholomew, C. C., 219, 225, 226 Bartolucci, G., 124 Barton, M., 97 Barton, M. L., 6 Bashe, P. R., 9, 13 Bassette, L., 185 Bateman, B. D., 18 Bates, E., 100 Bauman, M., 97 Bean, J., 105 Beelman, A., 134 Behavioral teaching strategies, 25 Behavior support plan (BSP), 67, 77 Behne, T., 101 Beighley, J., 23 Bellini, S., 109, 124, 125, 131, 134, 135 Bellstedt, E., 218–219 Benderix, Y., 55 Benner, L., 124, 131 Bennett, K., 175, 222 Bennetto, L., 104 Ben-Sasson, A., 221 Benson, P., 48 Benton, T., 195 Berg, M., 120 Berg, W. K., 73, 224 Berkeley, S. L., 196, 200 Berkell, D. E., 224 Bernad-Ripoll, S., 28

Berrie, P., 224 Berthiaume, C., 13 Berument, S. K., 5 Bettleheim, B., 6 Beukelman, D. R., 184 Bierman, K., 133 Biernat, K. A., 45, 53 Billingsley, F., 109 Blackhurst, E., 187 Blackorby, J., 159 Blair, C., 202 Blakeley-Smith, A., 210 Blaser, E., 179 Blatcher, J., 46 Blossom, M., 102 Blum-Dimaya, A., 176 Bock, S. J., 6, 50, 52 Bogin, J., 63 Bolding, N., 73 Boles, M., 186 Bolton, J., 83, 84 Bolton, P., 7 Bond, S., 124 Bondy, A., 73, 113, 114, 116, 184, 185 Boone, R., 76 Bosco, F. M., 104 Bouck, E. C., 185 Boulton, A., 227, 230 Boutot, E. A., 3, 11, 37, 90, 103,

174, 205 Bowen, S. L., 219 Bowser, G., 189 Boyd, B., 28, 29, 30, 173, 176 Boyd, B. A., 45 Bradley, E., 7 Bradshaw, J. L., 202 Brand, D. A., 43 Bremer, C. D., 219 Bremner, R., 124 Bretherton L., 100 Brian, J., 7 Bricker, D., 69, 70, 83 Brick, M. L., 6 Brierley, S., 111 Brimacombe, M., 199, 200 Broca’s area, 103 Brooks, A. P., 13 Brooks Gunn, J., 77 Browder, D., 227, 229 Browder, D. M., 222 Browning-Wright, D., 22 Brown, J., 124 Brown, J. L., 103 Brown, L., 38 Brown, R. T., 3 Brown, T., 45 Bruinsma, Y., 99 Bruner, J., 100 Bruno, E. M., 135 Bryan, L. C., 27 Bryan, M., 124 Bryant, D. P., 37 Bryson, S., 7, 104 Bryson, S. E., 135

Bucciarelli, M., 104 Buchan, K. A., 138 Buggey, T., 109 Buitelaar, J., 173 Bundy, C., 101 Burack, J. A., 13 Burke, R. V., 219 Burnette, C., 97, 105 Burny, E., 159 Burrows, L., 136 Burton, D., 135 Butler, E., 15 Butler, L. B., 135

C Caffo, B., 195, 200 Calculator, S., 184 Caldwell, N. K., 88 Cali, P., 124 Callahan, K., 21 Calloway, C., 105 Camaioni, L., 100 Camarata, S., 81 Camargo, S., 186 Campeau, P., 228 Capps, L., 12 Carbone, V., 113 Carbone, V. J., 73, 74 Card, J., 10 Cardon, T. A., 147 Carlson, J. I., 69 Carnerero, J. J., 91 Carnett, A., 32 Caron, S. L., 44 Carpenter, M., 101 Carper, R. A., 195 Carr, E., 23, 99, 105 Carr, E. G., 69, 75, 185, 222 Carr, J. E., 73, 91 Carrow-Woolfolk, E., 108 Carter, A., 105, 179 Carter, A. S., 46 Carter, C., 11, 111 Carter, E. W., 218, 224 Carter, J. F., 138 Carter, M., 28, 110, 184 Carter, S. L., 182 Casey, S. D., 138 Castiello, U., 197 Causal agency, 228 Caviness, V. S., 195 Centers for Disease Control and Prevention, 2,

101, 102 Cermak, S. A., 221 Cervetti, M., 109 Chaining instructional strategy, 88 Chakrabarti, S., 4 Chalfin, S., 101 Chandler, S., 196 Chappell, C., 196 Charlop-Christy, M. H., 88, 109 Charlop, M. H., 30, 109, 175 Charman, T., 4, 97, 99, 105, 196

Z02_BOUT6877_02_SE_IDX.indd 262 1/8/16 3:38 PM

INDEX 263

Chawarska, K., 5, 105 Cheng, Y., 186 Chen, M., 136 Cherkassky, V. L., 196 Chiang, C. H., 97 Child and family-centered decision making,

33–34 data-driven instruction, 34–35 systematic generalization, 35

Childhood Autism Rating Scale, 6 Children with ASD

common social skills deficits, 124–127 family and, 52–53 family issues across lifespan

adolescence, 56–57 adulthood, 57 elementary school years, 55–56 infancy and early childhood, 55

functional play characteristics in, 172 guidelines for selecting appropriate

educational objectives for behavioral goals, 18 cognitive skills, 18 fine and gross motor skills, 18 functional and symbolic communication

system, 18 independent organizational and self-help

skills, 18 language and nonverbal communication

skills, 18 social skills, 18

issues for, 171, 172, 173 motor deficits, 196–200 object manipulation characteristics in, 171 parental priorities for, 44–45 parents, impact on

depression, 45 family involvement, 48 family needs, 47–48 impact over time, 47 positive impact, 47 stress, 45

play characteristics and issues, 170–171 play-focused interventions for, 169–179 play materials, adapting, 175–179 sexuality education for, 210 siblings, impact on, 53–54

adjustment, 54–55 social-communication skills in, 104–105 social skills assessment, 128–130 social skills training, 130–139 symbolic play characteristics in, 173 teaching to play, 174–175

Child-specific interventions, 131 Chitwood, S., 18 Chou, Y., 6 Chou, Y.C., 228 Christensen, W. R., 229 Christie, J., 101, 102 Chung, B. I., 143 Chung, M. C., 43 Church, C., 15 Cicchetti, D. V., 6, 64 Cimera, R. E., 219

Ciullo, S., 162 Clarke, P., 96 Clarke, S., 73 Clark, K. M., 143 Clark, M., 109, 136 classic autism, 3 Clifford, T., 34 Coates, A. M., 88 Cobb, B., 229 Cobb, S., 186 Cognitive functioning, 6 Cognitive priming strategies, 137 Cohen, D., 11 Cohen, H., 81 Cohen, H. G., 94 Cohen, I. L., 200 Cole, P., 138 Collaboration, 50, 189, 205

communication, 52 diagnosis, struggle for, 50 of IEP team, 208–209 services, fighting for, 50 trusting relationship, 52

Collateral skill interventions, 131 Collet-Klingenberg, L., 23, 25, 28, 63, 76 Collings, N., 179 Colson, K., 207 Common Core State Standards (CCSS), 158–159 Communication, 97

assessment, 106–108 Communicative intent, 100–102 Community-based transition preparation, 224 Comprehensive treatment model (CTM), 28 Compton, D. L., 159 Computer-assisted instruction (CAI), 76, 186 Consequences, 63 Constable, S., 160, 164 Constantino, J., 7, 193, 199, 200 Constantino, J. H., 7 Constantino, J. N., 6, 7 Contexts, 208 Contextual fit, 77 Contextually inappropriate

behavior, 78 Conti-Ramsden, G., 101 Cook, B. G., 22, 160 Cook, C., 22 Cook, E. H. J., 7 Coolican, J., 104 Coonrod, E. E., 5, 11, 43 Cooper, B., 159 Cooper, J. O., 62, 150, 154 Corbett, B. A., 29 Corness, M., 93, 94 Costall, A., 171 Cost–benefit analysis, 43 Coster, W., 203 Coster, W. J., 203 Courbois, Y., 227 Courchesne, E., 195 Courchesne, R. Y., 195 Courtade, G. R., 166 Couwenhoven, T., 209, 214 Cowan, R. J., 219

Cox, A., 4, 97, 135 Coyle, C., 138 Craft, M. A., 89 Crais, E., 7, 170, 171, 173 Creaghead, N., 105 Crisp, C., 206, 214 Crockett, J. L., 49 Crone, D. A., 77 Crooke, P. J., 12 Crowley, E. P., 50, 52 Crowson, M., 10, 11, 105 Crozier, S., 28, 90 Cuccaro, M. L., 46 Curricula, 205 Cuskelly, M., 54 Cuvo, A., 113, 114

D Dadlani, M., 104 Daggett, J., 136 Daily living skills

assessments of, 150–152 barriers to learning, 145–146 challenging behaviors, 147 concerns, 145 core characteristics that impact

outcomes and goals, 143 social significance, 143–145

data collection prodecures, 153–154 elementary grades, 148 goals and objectives, development, 152 independence, 145 instructional strategies, 149–152

behavior analytic principles, 149–150 generalization of skills, 150

measurement of goals and progress, 152–153 prerequisite skills, 147 secondary/adult grade, 148–149 toddler/preschool age, 147–148 transition training and planning, 149 visual analysis of progress, 154

Dale, E., 46 Damasio, A. R., 197 Daneshvar, S., 88 D’Ardia, C., 103 Data collection, 89

prodecures, 153–154 Data-driven instruction, 34–35 D’Ateno, P., 109 Davies, C., 209, 213 Davies, D., 229 Davies, D. K., 229 Davis, H., 186 Davis, H. R., 195 Davis, J. L., 110, 114 Davis, N., 105 Davis, T., 32, 147 Dawson, G., 30, 97, 99, 105, 124, 148 Deboutte, D., 207 Deci, E. L., 219 Deckner, D. F., 101, 105 Deeney, T., 203 degli Espinosa, F., 45

Z02_BOUT6877_02_SE_IDX.indd 263 1/8/16 3:38 PM

264 INDEX

Delaney, J., 11 Delano, M. E., 160, 164 Delgado, C., 105 Demaray, M. K., 128 DePanfilis, D., 224 DePerczel, M., 73 Desoete, A., 159 Dettmer, S., 72, 182 Device, 186 Devis, K., 110, 184 Dewey, D., 53 Diagnostic and Statistical Manual of Mental

Disorders (DSM-V),3 Didden, R., 111, 113, 114, 147, 222 Dietz, C., 97, 173 Differentiation, 159 DiGangi, S. A., 11 DiLavore, P., 5, 97 Direct assessments, 66 Discrete trial instruction, 109 Discrete trial training (DTT),

29, 82–85 maintenance and generalization, 85

Discrimination training, 87 Discriminative stimulus, 82 Distal control, 198 Doepke, K. J., 49 Donaldson, A., 30 Donaldson, J. B., 160, 165 Donehower, C., 12 Doren, B., 227 Doss, S., 91 Douglas, S., 173 Dove, D., 219 Dowdy, C. A., 224 Drasgow, E., 158 Drasgow, E., 113, 114 DSM-V Autism Spectrum Disorder, 143 Dubie, M., 209, 213 Dubois, P., 228 Duijiff, S. N., 7 Duker, P., 176 Duker, P. C., 222 Dunlap, G., 14, 72, 73, 142, 148,

185, 222 Dunn, L., 108 Dunn, M., 104 Duran, J. B., 110, 113, 114 Durkin, K., 10, 101 Dvortcsak, A., 176 Dyches, T. T., 155 Dykstra, J., 7, 173

E Earles, T., 105 Earles-Vollrath, T. L., 110,

113, 114 Early intervention, 48–49 Early Start Denver Model

(ESDM), 30 Ebeling, H., 104 Eberhard, J. M., 89 Eccles, M. P., 22

Echoic instruction, 91 Echoics, 118 Edelson, M. G., 3, 206 Edelson, S. M., 182 Edmonds, M., 163 Education Tech Points, 189 Edwards, K. S., 43 Eigsti, I., 104 Eikeseth, S., 81, 93, 94 Eisenberg, J., 108 Eldevik, S., 81, 93, 94 Elias, M. J., 135 Elliot, S., 130 Elliot, S. N., 130 Elliott, C. D., 6 Elliott, S. N., 128 Embrechts, M., 104 Engeland, H., 173 Engel-Yeger, B., 221 Enz, B., 101, 102 Error correction procedures,

86–87 Errorless learning, 85–86 Establishing operations (EOs), 130 Estes, A., 124 Estes, A. et al., 99, 105 Evidence-based practices (EBPs), 158

common focused interventions, 25–28 comprehensive treatment

models, 25–28 definition of, 21, 23 National Autism Center’s National Standards

Report, 23–24 visual supports, 25–28

Executive functioning, 221–222 Expressive verbal language, 106 Extinction procedures, 68 Eye-gaze coordination, 198

F Fad treatments, 32 Falco, R., 30 Falco, R. A., 30 Family issues across lifespan children

with ASD adolescence, 56–57 adulthood, 57 elementary school years, 55–56 infancy and early childhood, 55

Farrell, D. A., 88 Fecteau, S., 13 Fein, D., 6, 97, 125 Feinman, S., 224 Feinstein, C., 125 Fender, D., 46 Fenty, N. S., 166 Fernald, M., 124 Fielding, P., 76 Field, S., 227, 229 Filipek, P. A., 195 Fine, D., 11 Finelli, J., 97 Finnegan, C., 185

Fischer, M., 105 Flanagan, S., 185 Flannery, K. B., 77 Flavell, J. H., 126 Fleming, R. K., 49 Flippin, M., 184 Flory, M. J., 200 Fluency, 161 Fluss, R., 221 Flynn, S., 113, 185 Focused interventions, 25 Foley, C., 12 Fombonne, E., 4 Forness, S. R., 131 Fouse, B., 18 Fowler, C. H., 186 Fox, L., 224 Fox, Lise L., 36 Fox, N., 10 Franco, F., 105 Franco, J., 111 Frea, W., 136 Freeman, B. J., 21 Freeman, K. A., 109 Freeman, S., 175 Freeman, S. F., 105 Friman, P. C., 62 Fristoe, M., 108 Frith, U., 4, 9, 14, 126 Frost, L., 184 Frost, L., 73, 113, 114, 116 Fuchs, D., 159, 167 Fuchs, L. S., 159 Fujiwara, Y., 176 Functional assessment and behavior support

planning collecting behavior data, 64–66 hypotheses, developing and testing, 66–67,

67–68 team establishing and behavior identifying,

63–64 Functional Assessment & Curriculum for

Teaching Everyday Routines (FACTER), 151–152

Functional behavior assessment (FBA), 78, 129

Functional communication, 184 Functional independence, 148 Functionality, 38 Functionally equivalent replacement

behavior, 67 Functional play, 171–172 Functional skills, 145 Fundamental motor skills,

193–194 Furniss, F., 135

G Gabbard, C. P., 193 Gagie, B., 72 Gajria, M., 162 Gal, E., 221 Ganz, J. B., 72, 110, 113, 114, 182

Z02_BOUT6877_02_SE_IDX.indd 264 1/8/16 6:04 PM

INDEX 265

Garand, J. D., 28 García-Asenjo, L., 91 Gardener, P., 109 Gardner, J. E., 229 Gardner, J. M., 200 Garner, N., 229 Garner, N. W., 73 Garon, N., 104 Garrett Mayer, E., 7 Garrett-Mayer, E., 97 Garrigan, E., 109, 136 Gast, D. L., 27 Gates, M. A. M., 13 Gaudiano, B. A., 149 Geiger, K. B., 73 Geller, E. S., 81 Generalization, 130, 139 Gense, M. H., 30 Gerhard, M., 186 Gerhardt, P., 205, 206, 207, 214 Gerig, G., 196 Geurts, H. M., 104 Ghaziuddin, M., 15 Giacin, T. A., 75 Giesbers, S., 31 Gilchrist, A., 135 Gillberg, C., 9, 218–219 Gillott, A., 135 Glover, T., 186 Goetz, L., 28 Goin-Kochel, R., 7 Goldberg, M. C., 195, 200 Goldfeld, N., 11 Goldman, R., 108 Goldring, S., 202 Gomez, A., 73 Goodwyn, F. D., 110, 114 Gougeon, N. A., 207 Gracco, V. L., 202 Graham, S., 158, 164 Grandin, T., 182 Grant, N., 27 Graupner, T. D., 81, 94 Gray. C., 133, 134 Gray, C. A., 28 Gray, D. E., 54 Gray, T., 7 Green, D., 196 Greene, B. A., 229 Greene, B. F., 81 Greene, D. J., 219 Green, G., 21, 94 Green, G., 43 Green, J., 135 Green, J., 97 Green, J. A., 6 Greenson, J., 30 Greenspan, S., 222 Green, V., 147 Greiss-Hess, L., 202 Gresham, F., 130 Gresham, F. M., 127, 130 Gresham, F. M., 124 Gresham. F. M., 129 Grey, D. E., 47

Griffin, C. C., 165 Griswold, D. E., 6, 15 Groen, A. D., 93 Grossi, B., 160, 164 Grossman, B. G., 202 Gruber, C. P., 6 Guadagnoli, M. A., 199 Guenther, T., 90

H Haelewyck, M. C., 227 Hagiwara, T., 6, 15 Hagopian, L. P., 88 Hahn, J. E., 206, 214 Hairrell, A., 163 Hale, C. M., 104 Haley, S., 203 Haley, S. M., 203 Halle, J., 23 Halliday, M., 100 Hall, L., 28, 29, 30 Hall, S., 13 Haltiwanger, J., 203 Haltiwanger, J. T., 203 Hameury, L., 197 Hamlett, C., 159 Hamre-Nietupski, S., 38, 88 Ham, W., 219, 226 Handleman, J. S., 187 Hanley, G. P., 66, 81 Hanline, M. F., 163 Happe, F., 99, 105 Harding, J. W., 73 Harin, A., 200 Harlacher, J. E., 76 Harmon, C., 225 Harrington, J. W., 43 Harris, K. R., 158, 164 Harris, O. L., 188 Harrison, P., 6 Harris, S. L., 187 Harrower, J., 11 Hart, B. M., 30, 81 Hart, S. L., 110 Haskett, M., 28 Hassaram, B., 162 Hastings, R. P., 45, 53, 55 Hatton, D., 23, 25, 28 Hauck, M., 125 Hawkins, R. O., 62 Hayden, D., 18 Hazlett, H. C., 196 Healy, O., 31 Heath, A. K., 110, 113, 114 Heflin, L., 71–72 Heflin, L. J., 138 Heimerl, S., 196, 200 Hellemans, H., 207 Hemmeter, M. L., 90, 92 Hemmeter, M.L., 175 Hendricks, D., 217, 218 Hendrix, E., 12 Hen, L., 221 Hensley, M., 218, 219

Hepburn, S. L., 97 Herbert, J. D., 149 Herbert, M. R., 195 Hermelin, B., 13 Heron, T. E., 62, 150, 154 Herr, C. M., 13, 18 Herrera, A. M., 202 Hetzroni, O. E., 188 Heward, W. L., 62, 89, 150, 154 Heyl, B. S., 50, 52 Higgins, K., 76 High-tech, 184 Hill, E. L., 10, 14 Hillenbrand, K., 101, 102 Hilton, C. L., 193, 199, 200 Hirasawa, N., 176 Hobbs, J. Q., 175, 176, 177, 178 Hobson, J., 173, 177 Hobson, R., 173, 177 Hoch, H., 89, 176 Hodapp, R., 101 Hodgdon, L., 185 Hogan, K. L., 97 Hong, E. R., 110 Hopf, A., 124, 131 Hori, M., 196 Horner, R., 23 Horner, R. H., 63, 64, 66, 67, 68, 75 Horner, R.H., 77 Horner, R. H., 77, 81, 89, 127, 185,

212, 213 Houston, T. L., 13 Howard, J. S., 86, 94 Howard, M., 97, 99 Howley, M., 223 Howlin, P., 221 Huber, H., 14, 72, 142, 222 Hudson, J., 6 Huer, M., 188 Huer, M. B., 188, 225 Huggins, A., 15 Hughes, C., 130, 229, 230 Hulit, L., 97, 99 Hume, K., 28, 29, 30, 72, 124, 146, 174, 175,

176, 177, 178 Humphries, A., 136 Hundert, J., 222 Hutton, A. M., 44 Hwang, B., 130

I IDEA, 49 IEP team, 208–209 IJzendoorn, M., 173 Ilan, A. B., 76 Illocutionary stage, 100 Imitation learning, 88 Incidental teaching, 90 Individual instructional time intensity, 92–95

duration of intervention, 94–95 weekly intensity of intervention, 92–94

Individualized Education Program (IEP) development of

annual goals and objectives, 16, 17–20

Z02_BOUT6877_02_SE_IDX.indd 265 1/8/16 3:38 PM

266 INDEX

child’s present level of performance, 16 educational placement, 16 evaluation of, 16 related services, 16 time and duration of services, 16

Individualized Family Service Plan (IFSP), 48 Individual students, strategies for, 38 Information processing, 221 Ingersoll, B., 109, 176 Ingersoll, B. R., 186 Initiation, 136 Initiation of joint attention (IJA), 99 Instruction

differentiation of, 166–167 features of, 73–75

functionally relevant instruction, 73–74 qualities of instruction, 74–75

self-determined learning model of, 230 Instructional approach selection, 35 Instructional control, 83 Instructional focus and delivery, variations of, 89–92

incidental and milieu teaching strategies, 90 maintenance and generalization, 89–90 verbal behavior, 90–92

Intervention, 108–112 Intraverbal behavior, 91 Intraverbals, 119 Iovannone, R., 14, 72, 142, 222 Ivey, J. K., 45 Iwata, B. A., 66, 74, 81, 83

J Jacobson, J. W, 43 Jacobson, J. W., 43 Jahoda, A., 46 Jahr, E., 81, 93, 94 Jasper, S., 109 Jitendra, A. K., 162, 165 Johnson, C. P., 82 Joint attention, 98–100 Jones, B., 227 Jones, E., 99, 105 Jones, H. A., 165 Jones, W., 11 Jorgensen, C. M., 184 Jorgensen, J. D., 225, 226 Jung, S., 176 Jussila, K., 104 Just, M. A., 196

K Kachal, M., 219 Kageyama, H., 196 Kaiser, A. P., 90, 117 Kakana, D., 177 Kaldy, Z., 179 Kalyva, E., 207 Kaminsky, L., 53 Kamphaus, R. W., 64 Kanner, L., 3, 125 Karlof, K. L., 48 Karmel, B. Z., 200 Karns, C. M., 195

Karp, K. S., 166 Karvonen, M., 227, 229 Kasa-Hendrickson, C., 225 Kasari, C., 21, 97, 105, 175 Kasper, T., 113 Kaufman, A. S., 6 Kaufman, N. L., 6 Kaur, A., 206 Kavale, K. A., 131 Kaweski, W., 224 Kazak, S., 7 Keehn, B., 196 Keenan, M., 109 Keith, K. D., 227 Kelchner, K., 73, 228 Keller, T. A., 196 Kelly, J. L., 195 Kemper, T. L., 195 Keown, C. L., 196 Kerns, K. A., 45 Kerr, S., 10, 186 Kim, J. A., 135 Kincaid, D., 14, 72, 133, 142, 222 Kingsley, E., 43 Kirby, B. L., 9, 13 Kirkland, C., 222 Kisacky, K. L, 109 Kissi-Debra R., 13 Kistner, J., 28 Kjelgaard, M. M., 104 Klassen, P.W., 7 Klin, A., 3, 5, 11, 105 Klingner, J. K., 163, 167 Klohr, C. L., 193, 199, 200 Knott, F., 46 Koegel, L., 99, 111, 175 Koegel, L. K., 11, 30, 74, 81, 135, 136 Koegel, R., 49, 92, 99, 111, 175 Koegel, R. L., 11, 30, 74, 81, 135, 136, 185 Kohler, F. W., 45, 52, 138 Koller, R. A., 210, 214 Konrad, M., 229, 230 Koubler–Ross, E., 43 Kovshoff, H., 45 Kramer, B., 22 Krantz, P., 177 Krantz, P. J., 27, 28, 136 Kraper, C., 179 Kregel, J., 219 Krezmien, M., 33 Krezmien, M. P., 225 Krueger-Crawford, L., 43 Krug, D. A., 30 Kubina, R., 117 Kuhn, J. C., 46 Kuhn, S. C., 22 Kuroda, M., 46

L Lachapelle, Y., 227, 229 Ladd, G. W., 124, 130 LaFrance, M., 132 Lajonchere, C., 7 Lambert, W., 159

Lambros, K. M., 129 Lancaster, B. M., 88 Lancioni, G., 31, 111, 113, 114 Landa, R., 7, 97 Landrum, T. J., 160, 166 Langone, J., 109 Lang, R., 31, 32, 111, 147, 175 Language, 97, 102 Language deficits, 8–10

language in odd ways, 9 literal interpretation of, 9–10 pragmatic language, 8–9

Lansing, M., 222 Lantz, J., 146 Larmande, C., 197 Larson, E., 56 LaRue, R. H., 33 Lattimore, J., 225, 226 Laubscher, E. H., 113 Laurent, A., 112 Laushey, K. M., 138 Lavin, D., 218 Leaf, R., 111 LeBlanc, L. A., 73, 88 Lechago, S. A., 91 Le Couteur, A., 5 Lee, A., 173, 177 Lee, H. J., 6 Leekam, S., 97 Leekam, S. R., 97 Lee, T. D., 199 Lee, Y., 229, 230 Legal mandates

early intervention, 48–49 special education, 49–50

Legerstee, M., 105 Lehmann, J., 229 Leinonen, E., 104 Le, L., 109 Lenoir, P., 197 Lenz, K. B., 159 Lerman, D. C., 22 Leroux, A., 162 Levi, G., 103 Levine, J. M., 126 Levin, L., 109 Levy, S. E., 46 Leyden, K. M., 196 Lieberman, R., 171 Linan-Thompson, S., 162 Lingo, A. S., 166 Lin, T. L., 97 Listerud, J., 46 Liszkowski, U., 101 Little, T., 227, 230 Locke, J. L., 101 Locutionary stage, 100 Loftin, R., 146 London, E., 200 Longitudinal research, 47 Long, J. S., 49, 92 Loos, L., 30 Loos, L. M., 30 Lopez, B., 97 Lopez, B. R., 196, 200

Z02_BOUT6877_02_SE_IDX.indd 266 1/8/16 3:38 PM

INDEX 267

Lord, C., 5, 27, 97, 104, 108 Lord, C. et al., 97 Losardo, A., 83 Losel, F., 134 Losh, M., 12 Loucas, T., 196 Loukusa, S., 104 Lovaas, I., 49 Lovaas, I. O., 81, 92, 93, 94 Lovaas, Ivar, 109 Lovaas, O. I., 29 Loveland, K. A., 136 Lovett, D. L., 229 Lowrey, K. A., 158 Low-tech, 184 Luce, S. C., 21 Lucyshyn, J. M., 77 Ludlow, L. H., 203 Luiselli, J. K., 63, 68 Lund, E. M., 110, 114 Lutz, M., 7 Lydon, H., 31

M Macdonald, H., 7 MacDonald, R., 109, 136 MacDonald, R. P., 143 MacDuff, G., 177 MacDuff, G. S., 27, 28 Machalicek, W., 111, 147, 175 MacKenzie, M. J., 77 Macks, R. J., 54, 55 Magee, S., 21 Mahoney, G., 222 Makris, N., 195 Malecki, C. K., 128 Mandell, D. S., 34, 46 Mands, 91, 115 Mangiapanello, K., 109 Manjiviona, J., 197 Manning-Courtney, P., 105 Mann, J. A., 77 Mann, J. C., 77 Manson, J., 30 Marcus, L., 27 Marcus, L. M., 222 Mari, M., 197 Marks, B. A., 206, 214 Marks, D., 197 Markus, J., 104, 105 Marraffa, C., 197 Martineau, J., 197 Martin, J., 230 Martin, J. E., 229 Marvin, A., 97 Mason, C., 227, 229, 230 Mason, L. H., 164 Mason, R. A., 110 Mastergeorge, A. M., 29 Mathematics, 165–166 Mathur, S. R., 131 Matson, J., 23 Matson, M., 23 Mattila, M. L., 104

Maurer, R. G., 197 Maurice, C., 21 Mavropoulou, S., 177 Mawhood, L., 221 Mayer, G., 22 Mayer, M. D., 83, 84 Mayo, C., 132 Mayo, P., 136 Mazaleski, J. L., 74 Mazam, S., 221, 225 Mazzotti, V. L., 186 McArthur, D., 97 McCart, A., 93 McClannahan, L., 177 McClannahan, L. E., 27, 28, 136 McComas, J. J., 89 McConnell, S. R., 130, 131, 137, 138 McCord, B. E., 66 McCormick, C., 126 McCullough, K. M., 138 McDonough, J., 219, 226 Mcduffie, A., 171 McDuffie, A., 99 McDuffie, K. A., 166 McEachin, J., 111 McEachin, J. J., 81 McEvoy, M. A., 138 McGee, G., 23 McGrath, P., 186 McIntyre, L. L., 46 McKenna, K., 7 McKeon, B., 221, 225 McLean, M. E., 92, 175 McMahan, G. A., 188 McNerney, E., 111 McNew, S., 100 McPheeters, M. L., 219 McWilliams, R., 88 Meadan, H., 111 Meade, L. S., 200 Meckes, L., 11 Medium-tech, 187 Mehzabin, P., 207 Melichar, J. F., 184 Melloy, K. J., 138 Melogno, S., 103 Meltzoff, A., 97, 99, 105 Merrell, K. W., 76 Mesibov, G., 107, 176, 177, 223 Mesibov, G. B., 182, 222 Meta-analysis, 131 Meyer, A., 166, 183, 226 Michael, J., 62, 111 Milieu teaching, 90 Miller, B., 185 Miller, J. F., 184 Miller, P. H., 126 Miller, S., 76 Miller, S. A., 126 Milstein, J. P., 109, 175 Miltenberger, R., 68, 69, 72, 74, 75 Ming, X., 199, 200 Minnes, P., 34 Minshew, N. J., 196 Mirenda, P., 99, 113, 114, 184, 185

Mithaug, D., 228, 230 Mithaug, D. E., 230 Mittman, B. S., 22 Miyahara, M., 196 Mize, J., 124, 130 Modeling instructional strategy, 88–89 Modified-Checklist for Autism in Toddlers, 6 Moilanen, I., 104 Molinelli, A., 219, 226 Moniz, A., 160, 164 Montminy, K., 133 Moore, C., 97 Moore, D., 186 Morales, M., 105 Morcus, M. E., 7 More, C., 76 More, C. M., 76 Morgan, K. et al., 97 Morgan, L., 97 Morgen, A., 229 Morris, C., 88 Moses, P., 195 Moss, D., 76 Mostofsky, S. H., 195, 200 Motivation, 62–63, 136 Motor deficits, 196–200

and autism, 14–15 investigation of, 194–196

Motor impairments, 200–201 Mottron, L., 13 Movement

importance of, 193 taxonomies, 193–194

Mulick, J. A., 43 Mullen, E. M., 6 Muller, R. A., 196 Mulloy, A., 31, 111 Multimedia supports, 185 Mulvey, J., 221, 225 Mundschenk, N. A., 138 Mundy, P., 10, 11, 97, 100, 104, 105 Munson, J., 97, 99, 105 Murdock, L. C., 175, 176, 177, 178 Murphy, C., 115 Murphy, G., 13 Murray, D., 105 Myers, S. M., 82 Myles, B. S., 6, 15, 27, 72, 145, 182 Myller, R., 166

N Naber, F., 173 Naber, F. B. A., 97 Nakanishi, K., 196 Narendorf, S., 218, 219 Narendorf, S. C., 159 National Academy of Sciences., 82 National Autism Center, 23, 24, 30, 31,

32, 209 National Autism Center’s National Standards

Report, 23–24 National Institute on Disability and

Rehabilitation Research, 219 National Professional Development Center, 25

Z02_BOUT6877_02_SE_IDX.indd 267 1/8/16 3:38 PM

268 INDEX

National Professional Development Center on Autism Spectrum Disorders, 23, 25, 32

National Research and Training Center, 219 National Research Council, 106, 108, 149 National Research Council., 21, 149 Nation, K., 96 Naturalistic behavioral interventions, 29 Naturalistic behavioral teaching practices,

29–30 Early Start Denver Model (ESDM), 30 pivotal response training, 29–30 STAR program, 30

Nayate, A., 202 Neal, A. R., 105 Neale, M., 229, 230 Neal, L. I., 225 Neef, N. A., 83 Neely, L., 186 Negative reinforcement, 62 Neisworth, J. T., 109 Neitzel, J., 63, 69, 73 Newell, L., 100 Newman-Gonchar, R., 229 Newport, J., 206 Newport, M., 206 Newton, J. S., 63, 64, 66, 67, 68, 212, 213 Newton, N., 206 New York State Department of Health, Early

Intervention Program, 82 Nichols, S., 210 Nichols, S. E., 196, 200 Nicklas, E., 77 Niemiec, B., 218 Nietupski, J., 38, 88 Nightengale, N., 97 Nikopoulos, C. K., 109 Nirje, B., 37 Noens, I., 97, 103, 104, 105 Nonverbal communication, 99, 125 Nordstrom, B., 55 Normalization, 37–38 Normandin, J. J., 195 Norquist, V., 175

O Oakland, T., 6 Obiakor, F. E., 155 Object manipulation, 171 O’Dell, M. C., 30 Odom, S., 23, 25, 28, 29, 30, 175, 176,

177, 178 Odom, S. L., 22, 138 Office of Special Education Programs., 188 Offit, P., 32 Ogletree, B., 105, 112 Ohtake, Y., 28 Okada, S., 28 Oliver, C. M., 13 O’Neill, D. K., 102 O’Neill, R. E., 63, 64, 66, 67, 68, 212, 213 O’Neill, R. W., 185 O’Neil, R., 124 Opioid-excess theory, 31 Oram, J. K., 196

O’Reilly, M., 31, 111, 113, 114, 147, 175 O’Reilly, M. F., 113 Orelove, F. P., 27 Oren, T., 105 Orsmond, G. I., 53–54 Osborne, L. A., 93, 94 Osterling, J., 97, 99, 105 Ostrosky, M. M., 111, 117 Ostryn, C., 184 Ousley, O. Y., 97 Owen-DeSchryver, J. S., 75 Owens, L. A., 218 Owens, R., 99 Ozonoff, S., 4, 7, 8, 202

P Palinkas, L., 179 Palmer, S., 227, 228, 229, 230 Palmer, S. B., 219, 225, 226, 227, 230 Pancari, J., 75 Paone, D., 89 Papadopoulou, E., 177 Papanikolaou, K., 7 Paparella, T., 175 Papke, M. R., 135 Paredes, S., 109 Parette, H. P., 225 Parette, P., 188 Parker, R. I., 110, 113, 114 Park, H. R., 6 Park, R. D., 124 Partnership of States, 182 Patrick, P. A., 43 Patton, J. R., 224 Paul, R., 5, 97, 104, 107, 109 Pavlov, I. P., 80 Peer-mediated intervention (PMI), 138 Pekar, J. J., 195, 200 Pennington, R. C., 186 Perales, E., 222 Pérez-González, L. A., 91 Performance deficit, 127 Perlocutionary stage, 100 Perpich, D., 102 Perrot, A., 197 Perryman, T., 7 Perske, R., 37 Peters, J., 124, 131 Peterson-Karlan, G. R., 225 Peterson, S., 185 Petursdottir, A. I., 91 Pfingsten, U., 134 Phonemic awareness, 161 Phonics, 161 Physical therapy, importance of, 201–202 Pickles, A., 5, 7, 196 Picture Exchange Communication System

(PECS), 113, 184 Pierce, K., 28 Pierce, K. L., 109 Pierce, T., 76 Pinto, M. A., 103 Pinto-Martin, J., 46 Pitney, L. V., 196, 200

Piven, J., 196 Pivotal response training (PRT), 29–30, 111,

135 Play and Language Program for Early Autism

Intervention, 19 Play environment, 175–176 Play-focused interventions

functional play, 171–172 object manipulation, 171 symbolic play, 172–174

Play materials, adapting, 175–179 incorporating interests, 176–177 visual instructions, 177–178 visual organization, 178–179

Poehlmann, J., 46, 49 Poe, M., 196 Polloway, E. A., 144, 224 Pond, M. A., 108 Positive behavioral support strategies, 25 Positive reinforcement, 62, 138–139 Poulson, C. L., 103 Powell, N. J., 186 Powell, S. K., 195, 200 Powell-Smith, K. A., 133 Powell, S. R., 159 Pozdol, S. L., 5, 11 Pragmatics, 102 Pratt, C., 124 Prendeville, J. A., 105 Pressley, M., 126 Preston, D., 110, 184 Pretti-Frontczak, K., 69, 70 Priming, 136 Prince, A., 195 Principles of behavior, 80 Prior, M., 197 Pritchard, L., 11 Prizant, B., 97, 105, 108, 112 Prizant, B. M., 182 Professional development, 167 Progress monitoring, 89 Prompt dependence, 155 Prompt fading, 150 Prompts, 137 Provost, B., 196, 200 Proximal stability, 198 Punishment procedures, 77 Pyle, N., 162

Q Quality Indicators for Assistive Technology

(QIAT), 189 Quality resources, 167 Quill, K. A., 8, 27, 28, 97, 98, 104, 106, 108,

182, 184, 185 Quinn, M. M., 131

R Rachman, J. Y., 12 Ramdoss, S., 111 Ramsden, A. H., 97 Rao, S. M., 72 Rapin, I., 104

Z02_BOUT6877_02_SE_IDX.indd 268 1/8/16 3:38 PM

INDEX 269

Rasing, E., 176 Rastam, M., 9 Raulston, T., 32 Reading, 161–163

instruction, 163 research to practice, 162 review of the research, 162–163

Receptive language, 104 Reciprocal interactions, 99 Reciprocity, 126 Reddy, V., 171 Reed, H. K., 75 Reed, P., 93, 94, 189 Reeve, R. E., 54, 55 Reeve, S., 176 Regester, A., 111, 175 Reichle, J., 91 Reichler, R. J., 6 Reichow, B., 81, 175 Reid, G., 196 Remington, B., 45 Renner, B. R., 6 Repetitive behaviors and restricted interests, 12

and autism imagination, 14 insistence on sameness, 13 rigid behavior, 14 savant skills, 13–14 self-injurious behaviors and aggression, 13 stereotypical mannerisms, 12–13

Repp, A. C., 83 Research and practice, 160–167

instruction, differentiating and modifying, 166–167

mathematics, 165–166 quality resources and professional

development, 167 reading, 161–163 writing outcomes, 164–165

Resnick, L. B., 126 Response to joint attention (RJA), 99 Responsivity to multiple cues, 136 Reszka, S., 184 Reynhout, G., 28 Reynolds, C. R., 64 Reznick, S., 7 Rhea, P., 104 Rice, M. L., 102 Richards, S., 73 Rich, S., 124 Riehle, E., 219, 226 Rimland, B., 6 Rinehart, N. J., 202 Rios, P., 7 Risely, T. R., 144, 222 Risi, S., 5 Risley, T. R., 30, 81 Rispoli, M., 31, 110, 111, 114, 147, 175,

184, 186 Rispoli, M. J., 110, 113, 114 Rivera, V., 124 Rivers, J. W., 54 Robbins, F., 28 Robbins, F. R., 142, 148 Roberts, K. D., 224

Roberts, M. C., 3 Roberts, N. E., 76 Robertson, G., 108 Roberts, W., 7 Robins, D., 97 Robins, D. L., 6 Rockwell, S. B., 165 Rogers, S., 23, 25, 28, 29, 30, 124, 130,

172–173 Rogers, S. J., 4, 7, 8, 30, 81, 97, 202 Rogers, T., 7 Roid, G. J., 6 Rome-Lake, M., 15 Romski, M. A., 101, 105, 184 Rose, D., 166 Rose, D. H., 183, 226 Ross, P., 54 Roth, P. H., 47 Rourke, B. P., 160 Rownd, C. V., 46 Roxburgh, C. A., 73, 74 Rubin, E., 112, 182 Rupley, W. H., 163 Rusch, F. R., 184 Ruskin, E., 97, 99, 105, 126 Rutgers, J., 3 Rutherford, M., 172–173 Rutherford, M. D., 97 Rutherford, R. B., 131 Rutherford, R. B. Jr., 131 Rutter, M., 5, 7, 108 Rutter, N., 221 Ryan, L., 160, 164 Ryan, R. M., 219 Ryder, N., 104 Rytting, N., 102

S Sacks, G., 162 Saddler, B., 164 Saddler, S., 226 Sailor, W., 185 Sainato, D., 176 Salentine, S., 77 Sallows, G. O., 81, 94 Salzer, M. S., 34 Sandall, S., 92 Sandall, S.R., 175 Sandberg, A., 113 Sansosti, F. J., 133 Sasso, G. M., 138 Sathe, N. A., 219 Sauvage, D., 197 Sawilowsky, S., 229 Scatterplot data, 66 Schachter, F. F., 101 Schall, C., 219, 226 Schalock, R., 227 Scheuermann, B., 36 Schiller, E., 159 Schlosser, R. W., 110, 113 Schoeller, K., 219 Schopler, E., 6, 27, 107, 176, 177, 222 Schreibman, L., 28, 29, 30, 136

Schreibmen, L., 109 Schuler, A. L., 11, 28 Schultz, W., 11 Schumaker, K. M., 225, 226 Schumm, J. S., 163, 167 Schwartz, I. S., 92, 109 Schwartz, M., 73, 219, 227 Schwichtenberg, A., 46, 49 Scientifically based research, 149 Scott, J., 222 Scott, L. A., 219, 225, 226 Scripting, 136 Searle, J. R., 100 Secondary education, 218 Secord, W., 108 Self-determination, 36–37, 217 Self-determined behavior, 229 Self-management, 136 Self-monitoring, 138 Self-regulated strategy development, 164, 165 Self-stimulatory behaviors, 11, 12 Seltzer, M. M., 53–54, 218 Semantics, 102 Semel, E., 108 Sensory integration therapy (SIT), 31 Sensory issues and environmental factors, 221 Service, 182 SETT Framework, 188 Setting events, 66 Sevcik, R. A., 184 Sexuality education, 205, 206–207

building intervention plans, 211 curriculum to teach sexuality, 209 individualizing curricula with evidence-based

strategies, 209–210 individualizing training, 211 teaching through collaboration, 208 understanding need for, 205–206

Sexuality Information and Education Council of the United States, 207

Shah, P. K., 195 Shane, H. C, 185 Shane, H. C., 113 Shaping process, 87–88 Shapiro, T. F., 135 Sharp, H. M., 101, 102 Sharp, I. R., 149 Shattuck, P. T., 159, 218, 219 Shearer, D. D., 138 Shear, P., 105 Shea, V., 107, 176, 177, 222 Sheehan, M. R., 89 Sheinkopf, S. J., 94 Sherer, M., 109 Shih, P., 196 Shillingsburg, A., 113 Shogren, K., 111, 175, 227, 230 Shogren, K. A., 230 Shore, C., 100 Shore, E., 101 Shukla-Mehta, S., 21 Shunway, S., 97 Shyman, E., 22 Siegel, B., 94, 175 Sigafoos, J., 31, 91, 111, 113, 114, 175, 222

Z02_BOUT6877_02_SE_IDX.indd 269 1/8/16 3:38 PM

270 INDEX

Sigman, M., 97, 99, 105, 126 Sigman, M. D., 105 Siklos, S., 45 Simmonds, D. J., 195, 200 Simmons, D., 163 Simmons, J. O., 92 Simmons, J. Q., 49 Simonoff, E., 196 Simpson, A., 109 Simpson, R. L., 6, 27, 72, 110, 114, 145, 149,

182 Sindelar, P. T., 165 Singh, N., 113, 114 Siperstein, G. N., 48 Sivberg, B., 55 Skill acquisition, 82–89, 150 Skill acquisition deficit, 127 Skill acquisition strategies, 133–136

additional strategies to promote, 136 pivotal response training, 135–136 social problem solving, 134–135 social scripting and script fading, 136 social stories , 133–134 video modeling and video self-modeling, 134

Skill deficits, 127 performance deficits versus skill acquisition

deficits, 127 Skinner, B. F., 62, 80, 87, 88, 90, 91 Skjeldal, O., 4 Skorupski, W., 228 Smith, B., 43 Smith, B. J., 92, 175 Smith, B. R., 76 Smith, C. E., 75 Smith, D. D., 69 Smith, M., 30 Smith-Myles, B., 105 Smith, R., 11 Smith, R. G., 74, 196 Smith, S., 6 Smith, T., 81, 93, 94, 109 Smith, T. E. C., 224 Smith, V., 99 Smolik, F., 102 Social acceptability, 129 Social anxiety, 124 Social cognition, 126 The Social Communication Questionnaire

(SCQ), 5 Social competence, 124, 128 Social differences, 10–12

and autism, 10 emotional expressions and affect, 12 imitation, 11–12 joint attention, 10–11 play, 11 theory of mind, 10

Social exchanges, 198 Social initiation, 125–126 Social interactions, 221 Social problem solving (SPS), 134 Social reciprocity, 126 The Social Responsiveness Scale, 6 Social skills, 124

assessment, 128–130

deficits, 124–127 evaluation of, 128–129 functional behavior assessment and, 129–130 programs , 130–132 training, 130–139

Social Stories™, 133 Social validity, 129 Soenksen, D., 45, 52 Solis, M., 162 Solomon, M., 29 Sood, S., 162 Soong, W. T., 97 Sorce, J. F., 113, 185 Soukup, J. H., 229 Spann, S. J., 45, 52 Sparkman, C. R., 94 Sparrow, S. S., 6, 64 Sponheim, E., 4 Spooner, F., 76 Sprague, J. R., 63, 64, 66, 67, 68, 212, 213 Sprenger, M., 103 Stages of grief, 43 Stahmer, A., 136, 179 Stancliffe, R. J., 230 Standard motor skill assessments, 202–203 Stanislaw, H., 94 Staples, K. L., 196 Starr, E., 7 Steele, J., 202 Steinek, V., 108 Sterzing, P., 218, 219 Sterzing, P. R., 159 Stevens, J. S., 49 Stimulus overselectivity, 15 Stirling, L., 173 Stock, S., 229 Stock, S. E., 229 Stokes, M., 206 Stokes, M. A., 206, 207 Stokes, T. F., 85, 89 Stolarski, V., 228 Stoneman, Z., 54 Stoner, J. B., 50, 52 Stone, W., 11, 99 Stone, W. L., 5, 43, 97 Storey, K., 63, 64, 66, 67, 68, 212, 213 Strain, P. S., 75, 138 Strategies for Teaching based on Autism

Research (STAR) program, 30 Streiner, D. L., 135 Streusand, W., 31 Students with ASD

academic expectations that impact, 158–159 academic outcomes, 159–160 applied behavior analysis, 79–95 communication assessment and intervention,

105–121 connecting research and practice, 160–167 educating, principles of

functionality, 38 independence, 37 normalization, 37–38 self-determination, 36–37

intervention models and transition process, 222–223

applied behavior analysis, 222–223 developmental, individual difference,

relationship-based model, 223 TEACCH model, 223

learners with autism, communication characteristics of, 103–105

postsecondary education for, 224–225 rationale and objectives, 205 self-determination and student involvement,

promoting, 227–230 sexuality education for, 205–216 social communication, importance, 97–102

joint attention, 98–100 language, 97, 102 symbol use and communicative intent,

100–102 students, educating, 160 teaching sexuality across life span, 207–208 transition process and services, 218–220

historical overview of, 218–219 legislation, service delivery impact,

219–220 transition programming, components of

community-based transition preparation, 224

transition programming, issues and considerations, 220–222

executive functioning, 221–222 information processing, 221 sensory issues and environmental factors, 221 social interactions, 221

Styner, M., 196 Sugai, G., 81, 127 Sugiyama, T., 196 Suhrheinrich, J., 29 Sullivan, M., 97 Sumutka, B. M., 144 Sundberg, M., 111 Sundberg, Mark L., 145, 151 Sundberg, M. L., 115, 116, 117,

118, 120 Sutherland, D., 107, 109, 114 Swanson, E., 163 Swanson, T. C., 6 Swatta, P., 224 Sweeney-Kerwin, E., 113 Swensen, S., 11 Swettenham, J., 4, 97 Swinkels, S., 173 Swinkels, S. H. M., 97 Sylwester, R., 103 Symbolic play, 172–174

pretend play, 172–173 social play, 173

Symbol use, 100–102 Syntax, 102 Systematic generalization, 35 Szatmari, P., 7, 124, 135

T Tact instruction, 91 Tacts, 117 Taft, R. J., 164 Tager-Flusberg, H., 97, 104

Z02_BOUT6877_02_SE_IDX.indd 270 1/8/16 3:38 PM

INDEX 271

Takemoto, C., 18 Tamura, R., 226 Tandy, R., 76 Tankersley, M., 160 Tantam, D., 124 Targett, P., 219 Task analysis, 150 Taubman, M., 111 Taylor, B., 109 Taylor, B. A., 109 Taylor, J. L., 159, 218, 219 TEACCH Transition Assessment Profile

(TTAP), 19 Teasley, S. D., 126 Teitelbaum, O., 195 Teitelbaum, P., 195 Test, D. W., 186, 227, 229, 230 Texas Statewide Leadership for Autism Training,

199, 203 Thibodeau, M. G., 30 Thiss, W. R., 219, 226 Thoma, C. A., 219, 225, 226 Thompson, A. L., 89 Thompson, E., 225, 226 Thompson, T., 102 Thomson, J. R., 50, 52 Thunberg, G., 113 Tien, K., 6, 184 Tigue, Z. D., 195 Tincani, M., 3, 28, 33, 103, 110, 114, 184, 205,

208, 209, 225 Tingstad, K. I., 13 Todd, A. W., 75 Todd, R. D., 7 Tojo, Y., 46 Tomasello, M., 101 Toombs, K., 109 Tostanoski, A., 32 Toth, K., 97, 99, 105 Touchette, P. E., 86 Trainer, A. A., 218 Training and Education of Autistic and related

Communication-handicapped Children (TEACCH) model, 223

Transfer trials, 91, 120–121 Transition employment intervention model,

225–227 Transition planning, 229

student involvement in, 229–230 Transitions, 55 Transition services, 217 Travers, J., 3, 33, 76, 205, 208,

209, 225 Travis, L., 126 Troutman, A. C., 64, 89 Tsatsanis, C., 12 Tsatsanis, K. D., 160 Tsujii, M., 196 Tunali, B., 136 Turnbull, A. P., 93 Turner-Brown, L., 176 Turner, L. M., 5, 11 Turygin, N., 23 Twachtman-Cullen, D., 9, 105,

106, 107

Twachtman-Reilly, J., 9 Twardosz, S., 175 Tyler, N. C., 69

U Uchiymam, T., 46 Unaided AAC systems, 184 Unestablished treatments,

30–32 Universal Design for Learning

(UDL), 166 Universal design for transition, 225 U.S. Department of Health and Human

Services, 82

V Valcke, M., 159 Valdez-Menchaca, M., 81 Valentino, A., 113 van Berckelaer-Onnes, I., 97, 103, 104,

105 van Daalen, E., 97 van der Meer, L., 114 van der Meer, L. A., 110, 114 Van Der Meer, L. A. J., 184 Van Dycke, J., 229 van Engeland, H., 97 Vangala, M., 109 Van Houten, R. V., 81 van Ijzendoorn, M. H., 97 VanJzendoorn, M. J., 3 Van Laarhoven, T., 218 Varley, J., 30 Vaughn, A., 10 Vaughn, S., 162, 163, 167 Vaupel, M., 76 Veenstra Vanderweele, J., 7 Veenstra-VanderWeele, J., 219 Velde, B., 11 Verbal behavior, 90–92 Verbal operants, 113

progression of mands, 117 teaching echoics, 118–119 teaching intraverbals, 119–120 teaching manding, 115–117 teaching tacting, 117–118

Verbracken, C., 207 Vermeiren, R., 207 Vernon, T. W., 74 Video modeling, 109, 134 Vilensky, J. A., 197 Vincent, Y., 185 Vismara, L. A., 81 Visual supports, 73 Vocational skills, 45 Voice output communication aids

(VOCAs), 184 Volden, J., 104 Volkmar, F., 3, 5, 11, 105 Volterra, V., 100 Vorndran, C. M., 22 Vorstman, J.A., 7 Vosniadou, S., 102

Vostanis, P., 43 Vukelich, C., 101, 102 Vyse, S., 32

W Wacker, D. P., 73, 83, 224 Wadsworth, G., 77 Wagner, G. C., 199, 200 Wagner, M., 159, 218, 219 Wainer, A. L., 186 Wakabayashi, A., 11, 46 Waldfogel, J., 77 Waldo, P., 136 Walker-Hirsch, L., 210 Wallace, D. P., 219 Wallace, M., 22 Wallace, M. D., 81 Waller, J., 46 Walsh, P. N., 227 Walter, A., 135 Wang, M., 93 Ward, N. J., 45 Warren, Z., 219 Waterhouse, L., 125 Watson, L., 7, 170, 171, 173 Watson, L. R., 184 Watt, N., 97 Weak central coherence, 160 Webber, J., 36 Wechsler, D., 6 Wehman, P., 217, 218, 219, 226 Wehmeyer, M., 73, 224, 229 Wehmeyer, M. L., 73, 219, 225, 226, 227,

228, 230 Wehmeyer, M.L., 228 Wehmeyer, M. L., 228, 229, 230 Weil, L., 11 Weintraub, J., 105 Wei, X., 159 Welsh, M., 124 Welterlin, A., 33 Wendt, O., 110 Wentz, E., 9 Werner, E., 97 Wernicke’s area, 103 Wert, B. Y., 109 Werts, M. G., 88 Westling, David L., 36 Westling, D. L., 224 West, M., 219 Wetherby, A., 97, 105, 108, 112 Wetherby, A. M., 97 Whalen, C., 76, 136 Whalon, K., 163 Whalon, K. J., 160 Wheeler, J. J., 182 Wheelwright, S., 4, 11, 46 Whelan, B. M., 75 Whitby, P. J. S., 205 White, J., 104 White, M. R., 193, 199, 200 Whiten, A., 124 White, R., 73 Whitman, T., 103

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272 INDEX

Whitman, T. L., 7, 14 Whitney, T., 166 Widaman, K., 124 Wieder, S., 222 Wie, M., 21 Wiig, E., 108 Wilcox, M. J., 147 Wilder, L. K., 155 Williams, C., 96 Williams-Diehm, K., 227,

229, 230 Williams, E., 171 Williams, G., 91 Williams, J. A., 30 Wilson, C. L., 165 Wilson, D., 73 Wilson, F. J., 135 Winett, R. A., 81 Winiarski, L., 218 Winter, J., 29, 30 Winter-Messiers, M. A., 13 Wishart, J. G., 105 Wishner, J., 111

Wittman, P. P., 11 Witzel, B. S., 165 Wolcott, N., 170, 171 Wolery, M., 23, 81, 88, 175 Wolfberg, P. J., 11, 28 Wolfe, P. S., 184 Wolf, M. M., 144, 222 Wolman, J., 228 Wolrey, M., 175 Wood, C. E., 13 Wood, C. L., 76, 186 Wood, W. M., 227, 229, 230 Wright, B., 96 Wright, H. H., 46 Wright, S., 73 Writing outcomes, 164 Wynn, J. W., 93

Y Yale, M., 105 Yamane, M., 176 Yanagihara, M., 28

Yell, M. L., 158 Yodar, P. J., 97 Yoder, P., 99, 171 Yoshido, Y., 46 Young, G. S., 202 Young, H. E., 30 Yu, S., 111

Z Zager, D., 160, 165, 221, 224,

225 Zaghlawan, H. Y., 111 Zaidman-Zait, A., 99 Zanolli, K., 136 Zarcone, J. R., 74 Zhang, Y., 193, 199, 200 Ziccardi, R., 195 Ziegler, D. A., 195 Zimmerman, L., 108 Zirpoli, T. J., 71, 72 Zittel, L. L., 196, 200 Zwaigenbaum, L., 7

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