Behavioral Approaches to Early Intervention with Autism

1
Behavioral Approaches to Early Intervention
with Autism

• WAYNE W. FISHER
• Munroe-Meyer Institute and
• University of Nebraska Medical Center

2
Definition of Autism

• markedly abnormal or impaired development in
• social interaction
• Communication
• and markedly restricted repertoire of activities
  and interests.

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Autism Spectrum Disorders

• Neurological disorders characterized by "severe
  and pervasive impairment in several areas of
  development
• Autistic Disorder
• Asperger's Disorder
• Childhood Disintegrative Disorder (CDD)
• Rett's Disorder
• PDD-Not Otherwise Specified (PDD-NOS)

4
Prevalence of Autism

• Typically diagnosed within first three years
• 2 to 6 in 1,000 individuals (Centers for Disease
  Control and Prevention, 2001)
• Four times more prevalent in boys than girls

5
NIH Research Dollars Devoted to Autism

• When Compared with Other Serious Childhood
  Conditions, Autism is Much More Common, but Fewer
  Dollars Per Case are Spent on Autism.

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Prevalence of Autism and Other Conditions (Number
of Cases per 10,000 Children)
70
60
50
40
30
20
10
0
Autism
Juvenile Diabetes
Muscular Dystrophy
Leukemia
Cystic Fibrosis
7

NIH Research Dollars for Autism and Other
Conditions (Number of Dollars per Case)
140,000
120,000
100,000
80,000
60,000
40,000
20,000
-
Autism
Juvenile Diabetes
Muscular Dystrophy
Leukemia
Cystic Fibrosis
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Assessment and Diagnosis of Autism

• No medical tests for diagnosing autism
• Accurate diagnosis is based on observation of the
  individual's communication, behavior, and
  developmental levels.
• Autism Diagnostic Interview-R (ADI-R)
• Home and/or school observation
• Video analysis of behavioral observation

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Identifying the Genetic Bases of Autism Spectrum
Disorders

• Etiologic Workups Identify Specific Genetic
  Causes for Autism in About 20 of Cases.
• At the Munroe-Meyer Institute, Schaefer and
  Colleagues (2006) developed a 3-Tiered Approach
  that Identifies Genetic Causes in 40 of Cases.

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Early Screening for Autism (NICHD)

• Does not babble or coo by 12 months
• Does not gesture (point, wave, grasp) by 12
  months
• Does not say single words by 16 months
• Does not say two-word phrases on his or her own
  by 24 months
• Has any loss of any language or social skill at
  any age

12
Early Screening for Autism (CHAT)

• Does not display pretend play (e.g., pretending
  to drink from a toy cup)
• Does not point at objects to indicate interest
• Does not show interest in other children
• Does not enjoy peek-a-boo hide-and-seek or other
  social games
• Does not bring and show objects to parents

13
Genetics and Twin Studies

• Autism runs in families
• Heritability for autism is about 90
• Monozygotic twin concordance, 60-100
• Dizygotic twin concordance, 10
• Associated with abnormalities on chromosomes 7q,
  2q, and 15q

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Applied Behavior Analysis (ABA)

• What is ABA?
• How is it different from other approaches?
• How is it Done?

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How Effective is ABA for Autism?

• About 50 of Children with Autism and Mild Mental
  Retardation who Received Early Intervention with
  ABA Attain Normal IQs and are Educated in Regular
  Classrooms with Minimal Assistance.

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Outcomes of ABA for Autism
35
30
25
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Increases in IQ Scores
r .79
15
p
10
5
0
0
5
10
15
20
25
30
35
40
45
Hours per Week of Treatment
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How Effective is ABA for Autism?

• Early Intervention of Autism using ABA has been
  recommended by
• New York State Dept. of Health
• U.S. Surgeon General
• National Research Council
• Association for Science in Autism Treatment

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Cost-Benefit Analysis of Early, Intensive ABA
for Autism

• Average Lifetime Cost for a Person with Autism is
  over 4 million
• Average cost of Early, Intensive ABA is 150,000
  over about 3 years
• Average Lifetime Savings from ABA Treatment is
  Between 1.6 and 2.7 million

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Why is ABA Effective with Autism?

• Comprehensive Teaches all skills (e.g., sitting,
  attending, imitating, direction following,
  language, social skills, self-help skills).
• Goal and Data Driven The focus on objective
  measurement and analysis of behavior provides
  ongoing feedback on progress and setbacks.

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Example of Individual Goals for Billy

• Decease self-injurious behavior
• Increase eye contact
• Increase spontaneous requesting
• Increase labeling skills
• Increase use of yes and no
• Increase imitation skills
• Increase matching skills
• Increase letter identification
• Increase self-feeding skills

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Teaching Imitation Using Discrete Trials

• Starts with simple responses (e.g., clapping).
• Sessions consisting of 10 trials each trial
  starts with the therapist saying Do this and
  then modeling the target response.
• Any approximation of clapping, results in
  delivery of a preferred reinforcer (e.g., toy).
• Otherwise, the therapist guides the childs hands
  to complete the response and then begins the next
  trial.

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Teaching Imitation Using Discrete Trials (cont.)

• Once the first response is mastered, the same
  procedure would be used to teach a second
  response (e.g., waving).
• After two responses are mastered in individual
  sessions, they would alternately be presented in
  the same session (e.g., Do this clapping Do
  this waving).
• Over time, additional responses are added until
  the child immediately imitates any new action the
  therapist does following the prompt, Do this.

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Generalization of Skills

• Skills taught during discrete trials are then
  generalized to natural settings.
• e.g., Clapping when another child answers
  correctly during group instruction or at a
  recital or school assembly.
• e.g., Waving to another person when entering or
  leaving a room.

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Billy Imitating a Model

100
Baseline
Differential Reinforcement Feedback
90
80
70
60
PERCENTAGE CORRECT (TOTAL)
50

40
30
20
10
0
1
2
3
4
5
6
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SESSIONS
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Why is ABA Effective with Autism (cont.)?

• Empirical Emphasis Treatments are based on
  principles and procedures supported by research.
• Intensity Level 25 to 40 hours per week for 3
  years.

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Early Behavioral Intervention for Autism

• Lovaas, 1987 McEachin et al., 1993 Smith et
  al., 2000
• Year 1--reduce aberrant behavior, teach
  attending, imitation, instruction following,
  speaking in short phrases, play skills, and
  self-help skills

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Early Behavioral Intervention for Autism

• Year 2--extend expressive vocabulary, more
  abstract concepts, extend treatment to group and
  community settings
• Year 3--pre-academic and academic skills,
  appropriate emotional expression, observational
  learning, and interactions and friendships with
  normally developing peers

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Assessing Children with Autism

• Periodic assessment for diagnosis and management
• Ongoing assessment for intervention

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Periodic Assessment for Diagnosis and Management

• Identify the childs overall strengths and
  limitations
• Determine the appropriate diagnosis or diagnoses
• Set the global goals for treatment

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Components of a Diagnostic Assessment

• Genetic/Etiologic Workup
• Assessment of Behavior/Symptoms
• Formal Audiologic Evaluation
• Cognitive Testing
• Assessment of Adaptive Behavior
• Speech/Language Evaluation

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Ongoing Assessment for Intervention

• Identify the specific behaviors to be increased
• Identify the specific behaviors to be decreased
• Identify effective reinforcers

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Assessment of Skills to Increase

• Attending Skills
• Compliance
• Following Simple Instructions
• Motor Imitation
• Vocal Imitation
• Matching
• Play Skills
• Social Skills
• Self-Help Skills

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Skill Assessment Areas

• Imitating Behavioral Chains
• Following Multi-Step Instructions
• Categorization
• Verbal Behavior-Listener Skills
• Verbal Behavior-Speaker Skills
• Pre-academic and Academic Skills

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Matching Skills Progression

• Identity matching with objects
• Identity matching with pictures
• Matching pictures to objects
• Matching objects to pictures
• Matching shapes, colors, letters, numbers
• Matching on 2 dimensions (color-shape)
• Matching by categories (e.g., animals, vehicles)
• Matching objects with their spoken names
• Matching pictures with their spoken names

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Social Skills Progression

• Shaking hands
• Making eye contact during greetings
• Imitating a smile
• Smiling reciprocally
• Appropriately getting someones attention
• Appropriately exchanging toys with a peer
• Playing a simple interactive game (roll ball)
• Showing appropriate affection (e.g., hugs)
• Taking turns during a simple game
• Making polite statements (e.g., Bless you. Your
  welcome.)
• Initiating a conversation (e.g., Did you watch
  the Huskers game?)

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Preference assessments

• Children with developmental disabilities
  sometimes are not able to tell you what things
  they like or tell you when they want one thing
  instead of another.
• Researchers have developed preference assessments
  to identify what things people with disabilities
  like.

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Steps of preference assessments

• Step 1 Interview the parent with the RAISD to
  list the kinds of things that the child likes
• Step 2 get the actual items the parent nominated
  as highly preferred
• Step 3 allow the child to select items from the
  group
• Step 4 rank the items from high to low based on
  what the child chose

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Types of preference assessments

• Single-item type present each item from the
  group one at a time
• Choice type present all items 2 at a time and
  let the child choose between the 2.
• Group type present all items together and let
  the child select items from the group

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Single-item preference assm.

• Developed by Pace et al. (1985)
• 16 stimuli
• Each stimulus presented individually 10 times for
  5 seconds each
• The SI method identified highly preferred stimuli
  for all participants in the study
• However, subsequent research has shown that the
  SI method may also yield a high number of false
  positives

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100
90
80
70
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Percentage of trials chosen
50
40
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10
0
Toy Telephone
Barney Doll
Action Figures
Radio
Ball
Items
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Paired-Choice Preference Assessment

• Developed by Fisher et al. (1992, 1996)
• Take 5-10 top stimuli from the RAISD
• Each stimulus paired once with every other
  stimulus
• Two stimuli presented concurrently the
  participant was prompted to choose one
• The participants had to emit a choice

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Percentage of trials chosen
Items
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Group Preference Assessment- MSWO

• Multiple Stimulus without replacement (MSWO)
  developed by DeLeon and Iwata (1996)
• Compared three different preference assessments
  (PC method, MSWR, MSWO)
• Results obtained from MSWO were comparable to
  that obtained by the PC method

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100
90
80
70
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Percentage of trials chosen
50
40
30
20
10
0
Toy Telephone
Barney Doll
Action Figures
Radio
Ball
Items
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Preference assessment outcome

• Items that the child chooses are usually the most
  effective positive reinforcer.

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Improving Vocabulary Skills in Children with
Autism

• Recent behavior analytic work in autism has
  focused on teaching critical skills, ones that
  facilitate the acquisition of many subsequent
  skills (e.g., pivotal responses, behavioral
  cusps).

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Vocabulary as a Critical Skill

• Children in advantaged homes are exposed to, and
  learn two to three times as many words as those
  in disadvantaged homes (Hart and Risley, 1995).
• Correlation of .78 between parents use of
  non-business words with their kids and later IQ
• This discrepancy between advantaged and
  disadvantaged children is not ameliorated through
  schooling.

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Vocabulary as a Critical Skill (cont.)

• Vocabulary in the early school years is the
  single, best predictor of SAT scores and adult
  literacy.
• This is why Andy Biemiller has called vocabulary
  the Missing Link between reading mechanics and
  reading comprehension or literacy.

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Vocabulary and Reading

• Read the following word and raise your hand when
  you know what it is
• supercalifragilisticexpialidocious

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Individualized Vocabulary Lists with Normative
Relevance

• Normative word lists provide information on words
  that most children know
• Individualized word lists contain words that a
  child contacts on a routine basis
• Identifying words common to both types of lists
  may produce the larger increases in the childs
  working vocabulary

52
Developing an Individualized Vocabulary List

• Begin with a word list with a developmental
  progression
• Living Word Vocabulary (Dale O'Rourke, 1981)
• http//www.sci.sdsu.edu/lexical/select.php (Dale
  Fenson, 1996)

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Developing an Individualized Vocabulary List
(cont.)

• Identify words that the child is likely to
  contact on a daily basis
• Morning Routine
• Places, people, activities, items
• Mealtime
• Foods, utensils, kitchen and dining room items
• Playtime
• toys, activities, people

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Developing an Individualized Vocabulary List
(cont.)

• Daycare or school
• People, actions, objects
• Places like church, stores, restaurants
• What is done there, What they sell, What you buy
• Household chores and activities
• What they are called, Who does them

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Developing an Individualized Vocabulary List
(cont.)

• Special events
• Birthdays, holidays, vacations
• Sports and hobbies
• Materials used, players, positions, What they do
• Things in the yard and neighborhood
• Animals, trees, vehicles, names of neighbors

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Developing an Individualized Vocabulary List
(cont.)

• Keep a 3-day diary and write down the names of
  people, objects, activities, and actions and add
  any new words to your list

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Developing an Individualized Vocabulary List
(cont.)

• Enter the individualized list into a spreadsheet
  next to the normative word list
• Sort both lists alphabetically
• Identify words common to both lists
• Re-sort the lists developmentally
• Begin teaching common words ordered
  developmentally

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Behavior Analytic Approaches to Vocabulary
Development

• From a behavior analytic perspective, teaching
  vocabulary involves the establishment of specific
  types of conditional discriminations, ones
  involving a spoken or written word as component
  of the four-term contingency.

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Conditional Discriminations Involving Deictic
Words

• Deictic words specify identify or spatial or
  temporal location from a given referent or
  perspective.
• Children with autism have particular difficulty
  learning deictic words because they require
  conditional discriminations (or have shifting
  referents).
• Examples I, you, me first, last this, that
  here, there.

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Conditional Discriminations Involving Social
Skills

• Social approaches to other individuals are likely
  to produce reinforcement under certain conditions
  and not others (e.g., requests to play when a
  parent is busy or not).
• Interactive play and joint attention require the
  child to simultaneously attend to objects and
  people.

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Three- and Four-Term Contingencies

• Stimulus Response Reinforcer
• Conditional Stimulus Stimulus Response
  Reinforcer
• With spoken-word-to-picture discriminations, a
  spoken word is the conditional stimulus that
  specifies which of the comparison stimuli the
  individual should respond to produce
  reinforcement.

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Spoken-Word-to-Picture Discriminations

• Point to Dog

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Building Working Vocabularies

• Spoken-word-to-picture discriminations are
  critical to the development of vocabulary skills.

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Functional Approaches to Teaching Conditional
Discriminations in Autism

• Unmotivated learners
• Learners requiring extra-stimulus prompts
• Inattentive Learners
• Severely Limited Learners

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Teaching Conditional Discriminations to
Inattentive Learners

• Extend prior work on differential observing
  responses (DORs) by embedding an
  identity-matching task into a graduated-prompting
  procedure to teach spoken-word-to-picture
  relations to children with autism.

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Treatment and Control Conditions

• Control
• Verbal prompt to point to test stimulus
• No feedback for correct or incorrect responses
• Graduated prompting
• Sequential verbal, modeled, and physical prompts
• Praise and edible delivered for correct
  response following the verbal prompt
• Identity-matching
• Identical to graduated-prompting except the
  modeled prompt was replaced with an
  identity-matching task
• ID prompt Therapist held up a picture
  identical to the test stimulus and said, This
  is Alex. Point to Alex

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100
90
Graduated
Prompting
Identity Matching
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70
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Percent Correct
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30
20
10
Control
Jane
0
0
5
10
15
20
25
30
35
40
Sessions
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Control
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Teaching Vocabulary in Autism

• These cases illustrate how identifying the
  functional deficit responsible for a childs poor
  performance on spoken-word-to-picture relations
  can be used to develop an effective intervention
  to improve the childs working vocabulary.

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Social Skills Training

• Have the parent identify one or more peers who
  are willing to help promote social behavior
• Have the parent identify activities that both
  your child and the peer enjoy
• Possible activities include rolling a ball,
  Lego blocks, basketball and hoop, puzzles,
  musical instruments, crayons, play dough,
  dressing up in costumes, duck-duck-goose,
  ring-around the rosy, trucks and cars, make
  believe games like playing doctor

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Social Skills Training

• Practice the activity with your child and note
  any prompts, reinforcers, or assistance you
  provide.
• Before the activity starts, teach the peer to
  deliver the same prompts, reinforcers, and
  assistance as you did when you practiced with the
  child.

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Social Skills Training

• Supervise the initial session closely and deliver
  praise and preferred items for appropriate social
  behaviors like,
• Smiling
• Initiations, spoken or gestured (Look, Watch
  me, Your turn, My turn)
• Turn-taking and sharing
• Teach the peer and the target child to deliver
  praise to each other for these same behaviors.

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Initial Toilet Training Instructions for Parents

• On a regular schedule (e.g., hourly), prompt the
  child to go into the bathroom and pull down their
  pants.
• If the child is wet or soiled, clean and change
  them with minimal attention (dont talk to the
  child) and then leave the bathroom.
• If the child is dry, have them feel their
  underwear and praise (Good job! Your pants are
  dry.)
• Have the child sit on the toilet and immediately
  deliver their most preferred reinforcer and then
  allow the child to immediately get off the toilet
  and leave the bathroom.

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Initial Toilet Training (Cont.)

• Keep a log and record whether the child was wet,
  soiled, or dry, and whether they voided in the
  toilet.
• Repeat 9 more times (or trials) , once every
  hour.
• For the next 10 trials, set a kitchen timer and
  have the child sit on the toilet until the timer
  goes off and then deliver the reinforcer.
• Mix up the lengths of the toileting sits (e.g.,
  starting with 5, 8, 6, 10, 7, 9, 6, 9, 5, 10, 8,
  and 7 seconds).
• If at any point, the child voids in the toilet,
  immediately praise, deliver the reinforcer and
  allow them to get off the toilet and leave the
  bathroom.

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Initial Toilet Training (Cont.)

• Get the child used to the toilet (cont.).
• For the next 10 trials, double the lengths of the
  toileting sits (e.g., 12, 14, 10, 18, 16, 20, 12,
  18, 10, 16, 20, and 14 seconds).
• Continue doubling the lengths of the sits until
  the child is sitting on the toilet for 5 minutes
  once every hour.
• When ½ of the childs voids are in the toilet,
  stop providing reinforcement for completing
  5-minute toileting sits without voiding (i.e.,
  only voiding in the toilet produces
  reinforcement).

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Methods of Identifying Evidenced-Based Practices
in Autism

• Who evaluated the research literature on the
  treatments?
• Single Expert, Expert Panel, Trained Technicians
• How thorough was the literature search?
• Keywords used PubMed, Psych Abstracts, ERIC,
  CINAHL, SOCAbstract
• Were specific criteria applied to judge the
  quality of each research study?
• Were specific criteria applied to rate the
  strength of evidence for each treatment?
• Were reliability checks done to check the
  accuracy of the ratings?

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ResearchAutism.Net

• Did not specify who evaluated the research
  literature
• Did not specify the literature search methods
• Did use specific criteria to judge the quality of
  each research study
• Did use specific criteria to rate the strength of
  the evidence supporting each treatment
• Did not conduct reliability checks

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ResearchAutism.Net Criteria

• Grade A Randomized control trials.
• Grade B Well conducted clinical trial (e.g.,
  ABAB matched comparison group).
• Grade C Case series (minimum 3 cases) conducted
  by independent researchers (e.g., AB design
  poorly matched groups)
• Grade D Single case study or case series by
  researchers involved in developing the therapy

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ResearchAutism.Net Criteria

• ??? Very Strong Positive Evidence
• 2 Grade A studies or
• 1 Grade A and 3 Grade B studies
• ?? Strong Positive Evidence
• 2 or more Grade B studies
• with majority showing positive results
• ? Limited Positive Evidence
• At least 1 Grade B Study
• 2 or more Grade C Studies
• with majority showing positive results
• ? Insufficient or Mixed Evidence

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ResearchAutism.Net Criteria

• Similar criteria are used to rate interventions
  in terms of negative evidence and evidence that
  the treatment may be harmful
• X Some Negative Evidence
• XX Strong Negative Evidence
• XXX Very Strong Negative Evidence
• Limited Evidence of Harmful
  Effects
• Strong Evidence of Harmful
  Effects
• Very Strong Evidence of Harmful
  Effects

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ResearchAutism.Net Criteria

• Treatments with very strong evidence ???
• Picture Exchange Communication
• Early Intensive Behavioral Intervention
• Resperidone

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ResearchAutism.Net Criteria

• Treatments with strong evidence ??
• Antidepressants
• Cognitive Behavioral Therapy
• Melatonin

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ResearchAutism.Net Criteria

• Treatments with limited positive evidence ?
• Gluten- and casein-free diet
• Social Stories
• TEACCH

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ResearchAutism.Net Criteria

• Treatments With Very Strong Negative Evidence XXX
• Dimethylglycine (DMG)
• Facilitated Communication
• Secretin

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ResearchAutism.Net Criteria

• Treatments With Strong Negative Evidence XX
• Auditory Integration Therapy
• Treatments With Some Negative Evidence X
• Patterning Therapy

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ResearchAutism.Net Criteria

• Treatments With Very Strong Evidence of Harmful
  Effects
• Testosterone regulation
• Dolphin Therapy
• Immune globulin
• Anti-convulsants
• Chelation

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ResearchAutism.Net Criteria

• Similar criteria are used to rate interventions
  in terms of negative evidence and evidence that
  the treatment may be harmful
• X Some Negative Evidence
• XX Strong Negative Evidence
• XXX Very Strong Negative Evidence
• Limited Evidence of Harmful
  Effects
• Strong Evidence of Harmful
  Effects
• Very Strong Evidence of Harmful
  Effects

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Drug Treatment of Asperger Syndrome

• Targeted pharmacological treatment of specific
  symptoms
• ADHD symptoms with psychostimulants
• Depression, OCD with SSRIs
• Severe aggression/agitation with atypical
  antipsychotic medications

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Treatment of Asperger SyndromeSkill Building

• Skills are taught and practiced in a therapeutic
  setting and then moved to natural settings
• Teaching specific social and communication skills
  
• Watching and learning from peers
• Initiating a conversation
• Use of nonvocal communication (eye contact,
  smiling, nodding)
• Perspective taking
• Turn taking during conversation, games, and
  activities
• Preferred items and activities are more available
  when youre with a friend

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Treatment of Asperger SyndromeSelf-Monitoring

• Teach initial self-monitoring skills with
  independent work and self-help tasks
• On-task behavior, household chores
• Have the child practice collecting data with you
  as a model
• Child self-monitoring while you collect parallel
  data
• Provide back-up reinforcers for target behaviors
  and for correct self-monitoring

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Self-Monitoring of Social and Communication
Behaviors

• Once the child has mastered self-monitoring for
  independent work, begin targeting social
  behaviors
• Set up and videotape a short social activity
  (e.g., initiating a conversation about sports)

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Treatment of Asperger SyndromeDecreasing Rigidity

• Increasing flexibility and reducing OCD symptoms
• Choose your battles
• Anticipate and prepare the child for situations
  in which there may be multiple outcomes
• Set up planned changes in routine where the
  change is better
• Taking turns with the Boss Hat

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Naturalistic Teaching Strategies

• First developed to increase language among
  economically disadvantaged preschoolers (Hart
  Risley, 1968)
• Instruction occurred during unstructured play
  time
• Area was baited with preferred toys and
  materials
• Students initiated each teaching trial
• Naturally occurring consequences were used

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Naturalistic Teaching Strategies, contd

• These original incidental teaching strategies
  have since been adapted and expanded to include
• Multiple Incidental Teaching (MITs)
• Mand-Model
• Pivotal Response Training (PRT)
• Natural Environment Training (NET)
• Natural Language Paradigm

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Naturalistic Teaching Strategies, contd

• Examples of teaching to real life situations
• Teach food requests during snacks and meals
• Teach toy requests during play time
• Teach body parts during tickle games or bath time
• Teach actions or prepositions on the playground

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Naturalistic Teaching Strategies, contd

• Capturing and contriving client motivation
• Before meals
• Before / after naps
• Before / after playing outside
• Interrupting daily routines (e.g., getting
  dressed)
• Withholding parts of an activity
• Introducing novel items

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Natural Language Paradigm, contd

• Critical features of NLP include (Koegel et al.,
  1997 Laski, Charlop, Schreibman, 1988)
• Client-initiated trials
• Frequent exchange of materials (My turn)
• Multiple speech targets across trials
• Multiple exemplars per speech target
• Reinforcement of client approximations
• Shared control of the interaction

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Natural Language Paradigm, contd

• NLP is used to target play and speech
• - Vocal imitation - Labels
• - Requests - Model appropriate play
• - Turn-taking
• Use of multiple high-preference toys may
  facilitate client compliance and minimize problem
  behavior

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Natural Language Paradigm, contd
Provide access to ball (15 sec)
Repeat response 2x during play
My turn
Child responds
Ball Car Lion
Restrict Access
Show item for 3-5 sec
Doll Boat Balloon
Provide vocal model
Repeat model up to 3x
Child DOES NOT respond
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Providing Choices in NLP

• Present 2-3 toys and say Pick one
• Wait 5 sec
• If a toy is selected, remove extra toys and
  restrict access to the chosen toy
• If selection is not made, replace one or more
  toy(s) and present a 2nd choice
• If selection is not made, the therapist should
  select the toy for the next trial

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Using Prompts in NLP

• Two kinds of prompts
• Vocal models for prompting speech
• Play models for prompting toy interaction
• New choice trials are introduced if the client
  does not respond to three vocal models for a
  single toy

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Using Prompts in NLP, contd

• Vocal models
• Occur every 5 sec without a client response
• Include phrases naming or describing the toy or
  its actions
• The therapist should change the vocal model every
  other trial with a single toy

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Using Prompts in NLP, contd

• Play models
• Occur at the beginning of every trial and with
  vocal models, as applicable
• Include demonstrating use of the toy
• Imitation of play models should be praised during
  the childs turn

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Using Prompts in NLP, contd

• Examples of vocal models
• Truck
• Yellow
• Truck rolls
• This truck is fast
• See the big truck
• Its a dump truck

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Using Prompts in NLP, contd

• Opportunities for play models
• Truck ? Roll it
• Yellow ? Move the parts
• Truck rolls ? Roll it
• This truck is fast ? Roll it fast
• See the big truck ? Crash it
• Its a dump truck ? Have it dump a toy

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Using Prompts in NLP, contd

• Examples of vocal models
• Bear
• Soft bear
• Brown bear
• Jumping bear
• Give bear a hug
• Bear waves
• Bear sleeps

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Using Prompts in NLP, contd

• Opportunities for play models
• Bear ? Pet it
• Soft bear ? Squeeze it
• Brown bear ? Make it sit
• Jumping bear ? Make it jump
• Give bear a hug ? Hug it
• Bear waves ? Make it wave
• Bear sleeps ? Make it lay down

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Using Prompts Review

• At the beginning of each trial
• Show the toy for 3-5 sec without modeling speech
• Provide a vocal and a play model
• Every 5 sec without a client response
• Repeat the vocal and play models up to 3x
• At least 2x after a client response
• Repeat the vocal model
• Change the vocal model every other trial

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Delivering Consequences in NLP

• Reinforce vocal approximations and all prompted
  or unprompted appropriate play
• Descriptive praise access to toy
• Better reinforcers for better behavior (i.e.,
  new, improved, unprompted)
• Adjust criteria for success, over time, to
  reflect clients changing skill level

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Steps in NLP - Review

• Step 1 Give client a choice
• Step 2 Show item Pause Provide models
• Step 3 Client imitates Praise Toy
• OR
• No response Prompt up to 3x
• Step 4 Repeat model 2x and praise imitation
• Step 5 My turn
• Step 6 Repeat steps 2-4
• OR
• Offer a new choice

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Summary

• Naturalistic teaching strategies offer a flexible
  and effective approach to language instruction
  for children with autism
• NLP, specifically, can be used to
• improve communication and play repertoires
• facilitate generalization of new skills
• minimize problem behavior during instruction

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