Schreibman, L., & Ingersoll, B. (2005).

Behavioral interventions to promote learning in

Behavioral Interventions to Promote Learning in Individuals with Autism

Laura Schreibman & Brooke Ingersoll

University of California, San Diego

The application of behavioral techniques to autism, like the diagnosis itself, has a

relatively short history. However the progress in the development and refinement of

behavioral treatment has been swift and impressive. Prior to the mid 1960’s,

psychodynamic therapy was standard in the treatment of children with autism, reflecting

the now antiquated theory that the cause of autism was psychogenic. The monumental

failure of the psychodynamic approach in the treatment of autism opened the door for the

emerging field of applied behavior analysis. Applied behavior analysis grew out of the

field of the experimental analysis of behavior, in which the general laws of learning

derived from work with animal populations were applied to socially significant

behaviors.

Behavioral procedures do not cure the disorder, but they have been shown to be

extremely effective in substantially improving the lives of people with autism and those

around them. The objectives of this chapter are: to describe current behavioral

intervention techniques for the treatment of autism and to discuss recent trends and

continued challenges for the future of this intervention model.

BEHAVIORAL INTERVENTION STRATEGIES

Current behavioral interventions can trace their roots to studies conducted in the

early 1960’s. Prior to this time, it was commonly believed that children with autism

could not learn. Ferster and DeMyer (1961; 1962) were among the first to demonstrate

that children with autism could indeed learn and would do so if the systematic application

of operant discrimination learning techniques was employed. They demonstrated that

these children could learn new, albeit non-functional, behaviors under conditions where

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correct answers were followed by contingent applications of reinforcement. Later, other

behavioral researchers demonstrated the utility of the systematic application of

reinforcement, prompting, fading, chaining, and other behavioral procedures (see

Schreibman, 1988, for a review).

These early studies were mostly concerned with addressing isolated behaviors.

Lovaas and his colleagues (e.g., Lovaas, 1977; Lovaas, Berberich, Perloff, & Schaeffer,

1966; Lovaas, Freitag, Gold, & Kassorla, 1965; Lovaas, Koegel, Simmons, & Long,

1973) were the first to develop a comprehensive, systematic package of behavioral

interventions that addressed a wide range of behaviors in children with autism. Such

interventions were associated with substantial decreases in inappropriate behaviors such

as self-injury, self-stimulation, aggression, and tantrums as well as substantial increases

in language, social, play, and academic skills. As the field of applied behavior analysis

has evolved, so too have the intervention techniques designed for use with these children.

Throughout this evolution, empirical validation and on-going monitoring of progress

through systematic data collection have remained central.

Structured Behavioral Interventions

Comprehensive structured behavioral interventions, also known as discrete trial

training, are widely used in early intervention programs for children with autism. These

procedures, described by Lovaas (1987), are very similar to the original operant

techniques described in the 1960’s. More recent elaborations have included increased

focus on non-academic skills such as play and peer interaction, decreased use of

aversives, and more varied delivery of reinforcement. Programs using this procedure

share the following basic components: 1) the learning environment is highly structured;

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2) target behaviors are broken down into a series of discrete sub-skills, and taught

successively; 3) teaching episodes are initiated by the adult; 4) teaching materials are

selected by the adult and rarely varied within a task; 5) the child’s production of the

target response is explicitly prompted; 6) reinforcers, albeit functional, are usually

unrelated to the target response; and 7) the child receives reinforcement only for correct

responding or successive approximations (Delprato, 2001).

Discrete trial training has been credited with success in teaching children a variety

of important behaviors (e.g., Baer, Peterson, & Sherman, 1967; Lovaas, Berberich,

Perloff, & Schaeffer, 1966; Metz, 1965; Schroeder & Baer, 1972). In addition, this

approach has been credited with impressive gains in children with otherwise poor

prognoses (e.g., Lovaas, 1987) and in accelerated skill acquisition (Miranda-Linne &

Melin, 1992). One oft cited study found that 47 % of preschool-aged children with

autism who had received intensive (40 hours per week) discrete trial intervention for two

years achieved normal intellectual and educational functioning compared to 2% who

received less intensive intervention (Lovaas, 1987). Although this study has been

criticized for several methodological flaws (e.g., lack of random assignment, selecting

only verbal subjects) (Mesibov, 1993), it demonstrates the tremendous benefit of

structured behavioral techniques in the instruction of children with autism.

Despite these impressive findings, the highly structured behavioral approach has

been criticized on a number of grounds. First, the adult-directed nature of the instruction

and the fact that the target behavior is brought under tight stimulus control has been

shown to compromise the spontaneous use of the behavior (Carr, 1981). Second, the

highly structured teaching environment (Lovaas, 1977) and use of artificial reinforcers

4
(Koegel, O'Dell, & Koegel, 1987) has been shown to prevent generalization to the natural

environment (e.g., Spradlin & Siegel, 1982). Finally, the highly structured teaching

environment is not representative of natural adult-child interactions (Schreibman,

Kaneko, & Koegel, 1991).

Naturalistic Behavioral Interventions

Structured operant teaching techniques have been modified over the years to

address some of the shortcomings noted above. The resulting behavioral interventions

are more naturalistic and child-centered. The first naturalistic behavioral treatment was

designed by Hart and Risley (1968) to teach the use of descriptive adjectives to

disadvantaged preschoolers in a classroom setting. This study sought to increase

generalization and spontaneous use of skills by teaching them in the context of ongoing

classroom activities.

Since their original conception, naturalistic behavioral intervention techniques

have undergone a variety of procedural elaborations, yielding a variety of similar

intervention techniques, including incidental teaching (Hart & Risley, 1968; McGee,

Krantz, Mason, & McClannahan, 1983), mand-model (Rogers-Warren & Warren, 1980),

time delay (Halle, Marshall, & Spradlin, 1979), milieu teaching (Alpert & Kaiser, 1992),

interrupted behavior chains (Hunt & Goetz, 1988), and the natural language

paradigm/pivotal response training (PRT) (Koegel, O’Dell, & Koegel, 1987; Koegel,

Schreibman, Good, Cerniglia, Murphy, & Koegel, 1989). Although the specific

techniques were developed in different laboratories by researchers from different

academic backgrounds, these approaches are similar in that they all share the following

basic components: 1) the learning environment is loosely structured; 2) teaching occurs

5
within ongoing interactions between the child and the adult; 3) the child initiates the

teaching episode by indicating interest in an item or activity; 4) teaching materials are

selected by the child and varied often; 5) the child’s production of the target behavior is

explicitly prompted; 6) a direct relationship exists between the child’s response and the

reinforcer; 7) the child is reinforced for attempts to respond (Delprato, 2001; Kaiser,

Yoder, & Keetz, 1992).

Despite their similarity, the techniques differ conceptually. Incidental teaching,

mand-model, and time delay are all specific prompting procedures for increasing

language that are implemented once the child has expressed interest in an item or activity

(Miranda & Iacono, 1988). In the incidental teaching approach, the adult waits for the

child to initiate a request for a desired item or activity. The adult then prompts an

elaborated response. The mand-model approach was developed for children who do not

readily initiate (Rogers-Warren & Warren, 1980). In this procedure, the adult waits for

the child to indicate interest in an item and then places an instruction for a particular

behavior. If the child does not respond, the adult models the correct response for the

child to imitate. The time delay procedure was designed to transfer the child’s response

from a verbal cue given by the adult to the environment (Halle et al., 1979). In this

procedure, the adult waits for the child to indicate interest in an item and then approaches

the child with an expectant look. If the child does not respond within 15 seconds, the

adult uses a model or mand-model procedure. For all of these techniques, reinforcement

is the delivery of the desired item or activity. Milieu teaching includes all three of these

procedures as well as a direct model procedure in which the adult models language and

6
this child is expected to imitate the adult’s model to receive access to a desired item or

activity (e.g., Kaiser, Ostrosky, & Alpert, 1993).

The interrupted behavior chain procedure uses naturally-occurring routines as the

context for requesting items or assistance. This procedure is typically used with children

who have very limited initiations and are minimally motivated to communicate (Hunt &

Goetz, 1988). The child is allowed to begin an activity and then the adult prevents the

child from completing the next step of the routine. The adult then uses mand-model or

time delay to prompt the child to request the next step in the sequence. In this procedure,

reinforcement is the ability to complete the next step in the behavior chain. This

procedure differs from milieu teaching in that the instruction is presented after the child

begins the activity rather than before (Miranda & Iacono, 1988).

PRT was designed based on a series of studies identifying important treatment

components. It includes clear and appropriate prompts, child choice, turn-taking,

maintenance tasks, reinforcing attempts, responding to multiple cues, and a direct

response-reinforcer relationship. PRT does not define the specific types of prompts to

use; however, implementation of the procedure usually involves the same prompting

strategies as those used in milieu teaching and interrupted behavior chains. In contrast to

the other procedures which have focused almost exclusively on increasing verbal and

non-verbal communication, PRT has been adapted to teach a variety of skills including

symbolic (Stahmer, 1995) and sociodramatic play (Thorpe, Stahmer, & Schreibman,

1995), and joint attention (Whalen & Schreibman, 2003).

Empirical studies comparing naturalistic to the more structured techniques have

validated the position that naturalistic strategies lead to more generalized and

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spontaneous use of skills (Charlop-Christy & Carpenter, 2000; Delprato, 2001; McGee,

Krantz, & McClannahan, 1985; Miranda-Linne & Melin, 1992). In addition, studies have

found that parents who have been trained to implement these techniques exhibit more

positive affect while teaching their children (Schreibman et al., 1991) and both the

parents and children exhibit more happiness and interest and less stress during family

interactions (Koegel, Bimbela, & Schreibman, 1996) than families in which the parents

have been trained to implement highly structured behavioral techniques. These findings

suggest that the naturalistic approach is more enjoyable for parents and children and leads

to a more positive family interaction style than the structured approach.

One question that has not yet been answered is whether intensive naturalistic

interventions lead to similar or superior intellectual improvement as that which has been

reported for intensive structured intervention (Lovaas, 1987). This comparison is

difficult because intensive naturalistic intervention is typically conducted in classrooms,

often inclusion-based, and targets functional behaviors (e.g., McGee, Daly, & Jacobs,

1994), whereas intensive structured intervention is typically conducted in the home and

often targets more cognitive behaviors, thus confounding any sort of direct comparison.

Augmentative and Alternative Communication Strategies

One area of common difficulty in the treatment of children with autism is

teaching communication strategies to non-verbal children. Throughout the years several

types of augmentative/alternative communication strategies based on behavioral

principles have been utilized with children with autism and other severe communication

handicaps. These strategies include sign language (e.g., Carr, Binkoff, Kologinsky, &

8
Eddy, 1978), picture boards and picture point systems (Mirenda & Santogrossi, 1985;

Reichle & Brown, 1986), and picture exchange systems (Bondy & Frost, 1994).

Sign language has historically been the preferred method of treatment for non-

verbal children. However, sign language is symbolic and requires the ability to imitate;

therefore, many non-verbal children fail to acquire it. In addition, as the majority of the

population is unfamiliar with signs, children using this system are often unable to

communicate in the community.

Picture or iconic systems have been used to teach functional communication to

children with autism who fail to acquire verbal or signed language. These systems (e.g.,

picture boards, picture exchange) seem to be easier to acquire than sign language

(Anderson, 2002) and are readily recognizable to individuals that have not been trained in

the system, thus increasing the number of people with whom the children can

communicate successfully. The Picture Exchange Communication System (PECS) is the

most widely used iconic systems for non-verbal children (Bondy & Frost, 1994). This

system requires that the child exchange a picture for a desired item or activity. Although

the research on the effectiveness of PECS is limited, it has found wide acceptance in

school-based intervention programs. Currently, more controlled research on this

technique is being conducted and findings suggest it is efficacious and that acquisition of

PECS leads to increases in vocal speech (Charlop-Christy, Carpenter, Le, LeBlanc, &

Kellet, 2002).

One important question is which augmentative/alternative communication system

is most effective for increasing communication skills in non-verbal children with autism.

One study compared acquisition rates of modified signs and PECS pictures in non-verbal

9
preschoolers with autism. Six children were trained to request desired items via each

system. Results indicated that all six participants acquired pictures more rapidly and

demonstrated better generalization to novel stimuli with PECS than with sign. However,

the children had more spontaneous initiations and were more likely to pair verbalizations

with sign (Anderson, 2002). In addition, this study found that children indicated a clear

preference for one system over another, suggesting the importance of individualizing

augmentative/alternative communication systems to the child’s needs and preference.

Another important question is whether teaching pictures or sign to non-verbal

toddlers and preschoolers is superior to a language only approach. Although, there is

little controversy over using augmentative/alternative communication systems with non-

verbal, school-age children who have already shown the inability to acquire spoken

language, there is less consensus whether to begin with an augmentative/alternative

communication system for non-verbal toddler and preschool-age children who are just

beginning intervention (i.e., Bondy & Frost, 1994; McGee, Morrier, & Daly, 1999).

These results suggest a continued need for research examine augmentative/alternative

communication systems. We need to determine what child characteristics may be

associated with success in verbal versus augmentative communication systems (e.g.,

PECS, sign). Also we need to examine which of these systems may promote vocal

language in children with differing characteristics. Obviously there is much to do in this

area of research.

Self-Management

Another struggle in the treatment of children with autism is independent learning.

Although many behavioral treatment strategies are effective at teaching new skills, the

10
presence of a treatment provider is usually necessary to maintain these behavioral gains.

Techniques that encourage learning and maintenance of behavior without increased

reliance on teacher or parent monitoring are thus highly desirable.

Self-management has been shown to reduce reliance on a therapist in normally

functioning individuals (Kopp, 1988). These procedures include self-evaluation of

performance, self-monitoring, and self-delivery of reinforcement. Self-management

procedures have been adapted for use with individuals with autism and developmental

delay. They typically involve teaching the individual to identify appropriate and

inappropriate behavior, record his or her own behavior using stickers or other material,

and to reward him or herself after exhibiting the appropriate behavior or refraining from

the inappropriate behavior. The presence of the therapist is gradually faded so that the

individual is able to continue to display appropriate behaviors in an unsupervised setting.

Eventually the self-management materials are also faded so that the individual is able to

demonstrate self control completely independently (Koegel, Koegel, & Parks, 1990).

Self-management procedures have been used to address a variety of behaviors in

individuals with autism. They have been used to decrease inappropriate behavior such as

self-stimulation (e.g., Mancina, Tankersly, Kamps, Kravits, & Parrett, 2000; Koegel &

Koegel, 1990) and perseverative play (Newman, Reinecke, & Meinberg, 2000) as well as

to increase appropriate behavior such as toy play (Stahmer & Schreibman, 1992), social

initiations (Koegel, Koegel, Hurley & Frea, 1992) and independent interactions with

typical peers (Shearer, Kohler, Buchan & McCullough, 1996).

While self-management has been shown to be successful with higher-functioning

individuals with well-established verbal language, lower-functioning individuals with

11
limited or no language are less likely to benefit from this approach. Accordingly,

adaptations to the typical self-management procedure have been developed for use with

these lower-functioning individuals. Pictorial self-management uses photographs of

individual steps of a task in a book format. This procedure involves teaching the child to

complete the step associated with each picture, turn the page to view the next picture, and

reinforce him or herself after the task is complete. This strategy has been shown to

increase lower-functioning children’s ability to perform self-help skills in the absence of

adult supervision (Pierce & Schreibman, 1994).

Video Instruction

Recently, an interest in combining behavioral techniques with video for autistic

individuals has emerged. Video technology has some intrinsic appeal as an instructional

tool for this population. First, although not well documented in the literature, people

have often suggested that children with autism are visual learners and typically excel in

treatment modalities that rely on visual stimuli (e.g., Campbell, Lison, Borsook, Hoover,

& Arnold, 1995; Charlop & Milstein, 1989; Schreibman, Whalen, & Stahmer, 2000;

Pierce & Schreibman, 1994). Second, motivation may be enhanced because most

children (including children with autism) typically enjoy watching videos. Third,

videotapes can be replayed repeatedly without any variation, which might enhance

learning in a population that benefits from predictability. Finally, the use of video does

not typically require the direct intervention of an adult.

Video modeling has been the most well researched form of video instruction for

children with autism. Modeling research has shown that these children can learn new

behaviors through the observation of predictable and repeated sequences (Charlop,

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Schreibman, & Tryon, 1983). Video modeling presents target behaviors in video format

and has been shown to improve various skills in individuals with autism, including

conversational speech (Charlop & Milstein, 1989, Sherer, et al., 2001), verbal responding

(Buggey, Tombs, Gardener, & Cervetti, 1999), helping behaviors (Reeve, 2001),

purchasing skills (Haring, Kennedy, Adams, & Pitts-Conway, 1987) and daily living

skills (Shipley-Benamou, Lutzker, & Taubman, 2002). This medium has also been

shown to increase vocabulary, emotional understanding, attribute acquisition, number of

play actions, duration of play, and play-related statements (Schwandt, Pieropan, Glesne,

Lundahl, Foley, & Larsson, 2002).

In addition to modeling, other forms of video technology have recently been used

in combination with different behavioral techniques to promote appropriate behaviors.

These include procedures such as priming (Schreibman, Whalen, & Stahmer, 2000),

discrimination training (Matsuoka & Kobayashi, 2000), and self-management (Thiemann

& Goldstein, 2001).

Research examining the effect of the type of model used in video based

instruction has been equivocal. One study compared the effectiveness of using the target

child as the videotaped model (self-as-a-model) to a similar-aged child model (other-as-

model). This study found that although neither technique proved to be clearly superior,

some individual children responded better to one or the other (Sherer et al., 2001). In

contrast, a study comparing the use of video to in vivo instruction suggested that video

modeling promotes faster acquisition and better generalization of new behaviors than in

vivo modeling (Charlop-Christy, Le, & Freeman, 2000). In addition, these authors

argued that video modeling is more cost effective because it does not require the use of a

13
live model (Charlop-Christy et al., 2000). Although this is only a preliminary study, it

offers some interesting considerations. Research examining alternative behavioral

applications of video and fine-tuning current video instruction techniques is certainly

warranted.

One cautionary note related to the use of video instruction (and other similar

technologies) is that it not be used to the exclusion of in vivo behavioral interventions.

Just because a child may learn certain skills better with one type of intervention does not

mean that the intervention is better overall. One reason that children with autism may

learn well from video is because video instruction can eliminate the social demands that

in vivo instruction requires. However, like all children, children with autism are required

to function in a social world and must be able to learn from their social environment.

Therefore, it is suggested that the use of video instruction be balanced with the use of in

vivo instruction, regardless of the efficacy of video instruction.

FUTURE DIRECTIONS AND CONTINUED CHALLENGES IN BEHAVIORAL

TREATMENTS

The past 15 to 20 years have brought a tremendous broadening and sophistication

of behavioral technology as it is applied to people with autism. The earlier work in the

area has laid the foundation for the current state-of-the-art and for what will follow. The

fact that we now view some of our early efforts as relatively “simplistic” and are now

much more effective and efficient in providing treatment should in no way be considered

as criticism of these earlier efforts. Quite the contrary. We are not moving away from

our early efforts; rather we are moving beyond them. Simply put, we would not be where

14
we are now, if we have not been there first. Our future directions and challenges are

represented in the current research of our field.

Generalization and Maintenance of Treatment Gains

One of the continued challenges in the treatment of children with autism is the

generalization of treatment gains across environments and over time (e.g., Lovaas et al.,

1973). The use of naturalistic behavioral teaching techniques and training family

members to be intervention providers has been shown to improve generalization (McGee

et al.,1985; Koegel, Schreibman, Britten, Burke, & O’Neill, 1982). Despite these efforts,

generalization remains an obstacle in the treatment of many children with autism. Future

studies which focus on improving the generalization and maintenance of skills in children

with autism are needed.

Individualization of Treatment

The importance of individualization of treatment has long been recognized and is

reflected in the creation of a child’s IEP (individualized education plan). In this sense it

is used to emphasize the need for individualized educational goals. However, the field is

just beginning to recognize that there is no one treatment best suited to meet these goals.

In fact, arguments relating to which behavioral treatment is superior are essentially

meaningless because no treatment can boast substantial success in more than 50-70% of

children. This variability in child response calls for the individualization of treatment

strategies. Treatment variables and how they interact with child, family, and service

provider characteristics are also crucial elements in the individualized treatment equation.

The ultimate goal is to be in a position to determine a priori which treatment procedures

15
will be most effective and efficient with a particular child and a particular family

situation, at a particular point in treatment.

Research on child characteristics that best predict treatment outcome for a

particular intervention is just beginning (e.g., Anderson, 2002; Ingersoll, Schreibman, &

Stahmer, 2001) but is hugely important. For example, one study has identified a

behavioral profile of children who are likely to respond well to PRT and a separate

profile of children who are likely to have a poor response to this treatment (Sherer &

Schreibman, in press). These findings can help determine which children are

appropriate candidates for PRT as well as provoke additional research to determine which

alternative treatment options are most appropriate for children who meet the profile of a

“non-responder” to PRT (Schreibman, Stahmer, & Cestone, 2001). Importantly, this

subsequent study also found that the profile predicted outcome for PRT but not for

another behavioral intervention, Discrete Trial Training, thus suggesting the profile is

indeed predictive of a specific treatment and not just response to treatment in general. As

a field it is important to continue to fine-tune this line of research, thus deriving the most

benefit from early intervention.

In addition to child characteristics, it is also important to consider the individual

characteristics of the child’s caregivers. The field is just beginning to examine how

family variables interact with treatment effectiveness. The effects of ethnicity, culture,

marital status, parental attitudes, parental age, level of education, socioeconomic status,

and other factors all may affect how treatment is best delivered and the ultimate

effectiveness of the treatment. For example, research has shown that children of more

responsive and educated parents are more likely to benefit from prelinguistic milieu

16
teaching, while children of less responsive and educated mothers benefit more from

responsive small group instruction (Yoder & Warren, 1998). Also, training in self-

management may be more successfully implemented by parents for whom child

independence is important (Schreibman & Koegel, 1996). However, certain cultures may

not place a strong emphasis on child independence; thus, the parents may not choose to

use self-management with their child or may use it ineffectively. Another example is the

effect of stress. It has been shown that parents of children with autism report being under

high levels of stress (e.g., Koegel, Schreibman, Loos, & Derlich-Wilhelm, 1992).

Perhaps parents who are under a good deal of stress at a point in time would be poor

candidates to implement training with their child; a clinician may then be the treatment

provider of choice. At a later time, if the stress is reduced, these parents could perhaps

very effectively implement the treatment.

It is also important to recognize teacher variables that predict the ability to learn

and implement different intervention techniques. Given that the majority of intervention

for children with autism is provided by teachers and paraprofessionals who may not have

an extensive background in treatment techniques for this population, it is important to

identify the best ways to teach them and discern which techniques they are likely to use.

In response to increased attention on individualization of treatment, many researchers and

service providers have come to recognize that multiple behavioral methodologies have a

place within a comprehensive treatment program. Although there are still strong

proponents of particular intervention philosophies, researchers and service providers must

challenge themselves to explore multiple options for individual children. Most

researchers and service providers have broadened their view of teaching methodology;

17
however, despite the incorporation of multiple behavioral methodologies, change is still

slow. Ideally we will develop a set of formulas that will allow us to evaluate a child and

based upon research results be able to prescribe the best treatment for this child at this

time. Continued assessment would then allow us to alter the child’s treatment regimen in

response to the child’s changing needs. We are still in the initial stages of being able to

match treatment procedures with specific children but continued research in this area will

no doubt be tremendously important in determining treatment decisions.

Integration of Disciplines

Although behavior modification provides a wealth of techniques to encourage

learning and change behavior, the field has come to recognize that autism is a complex

disorder, the cause of which cannot be explained by learning theory alone. To this end,

the field has gravitated towards other disciplines to help in the development of more

effective intervention targets and tools.

One such discipline is developmental psychology. Since their conception,

naturalistic behavioral intervention strategies targeting communication have been heavily

influenced by developmental research on language acquisition in typical children. More

recently, some naturalistic behavioral interventions have added techniques traditionally

limited to the developmental literature such as indirect language stimulation and

contingent imitation to produce a combined approach such as Enhanced Milieu Teaching

(Hemmeter & Kaiser, 1994), Prelinguistic Milieu Teaching (Warren, Yoder, Gazdag &

Kim, 1993), and Reciprocal Imitation Training (Ingersoll, 2003).

Another recent trend has been the use of behavioral techniques to target deficits in

autism identified in developmental literature, but previously ignored in the behavioral

18
literature. Many such autistic deficits, such as reciprocal imitation (Ingersoll &

Schreibman, 2001; 2002), joint attention (Whalen & Schreibman, in press), symbolic

play (Stahmer, 1995), and theory of mind (Garfinkle, 2000) which were originally

identified in by developmental psychologists have been targeted using behavioral

techniques in the past several years.

In addition, there has been an interest in whether targeting early social-

communicative behaviors that are theoretically linked to later emerging behaviors in

typical development, lead to increased development of these later emerging behaviors in

autism. For example, Whalen (2001) used a behavioral methodology to teach young

children with autism to make joint attention initiations and found increases in language

despite the fact that it was not directly targeted. Similarly, Ingersoll (2003) found

increases in language, play, and joint attention after targeting reciprocal imitation.

Behavioral research that is focused on targeting behaviors within a developmental

framework is exciting, and can only enhance the effectiveness of our interventions.

Future behavioral research will need to draw on the rapidly developing field of

neuroscience. For example, more recent imaging techniques have confirmed the

presence of attentional deficits (e.g., Courchesne et al., 1994), originally observed

behaviorally (Lovaas, Schreibman, Koegel, & Rehm, 1971), which are likely involved in

the development of a variety of autistic behaviors. In addition, recent work has suggested

that face processing is impaired in autism and may lead to some of the abnormal social

behavior observed in this population (Schultz et al., 2000). Newer behavioral research

focused on targeting deficits identified by the field of neuroscience may lead to exciting

new gains in child outcome. Additionally, imaging studies which examine functional

19
changes in neurological systems that are a result of behavioral therapy will help to

identify whether our treatment contributes to brain reorganization. Such studies are

currently underway.

As a field, we should also collaborate with treatment approaches that are not

considered behavioral, but nonetheless, share some common elements with behavioral

interventions. For example, the TEACCH model or structured teaching (Lord, Bristol, &

Schopler, 1993) uses many forms of visual supports, such as picture schedules, to help

individuals with autism navigate their world. Although the use of picture schedules is not

inherently behavioral, many behavioral interventions have incorporated their use. For

example, pictorial self-management combines the use of a picture schedule with self-

reinforcement. Similarly, social stories (Gray & Garand, 1993), which provide a brief

vignette of expected behavior in an upcoming social situation are in fact a form of

priming, which has been shown to be an effective behavioral strategy with children with

autism (Schreibman, Whalen, & Stahmer, 2000; Zanolli, Daggett, & Adams, 1996).

Another intervention approach commonly used with children with autism is the

developmental approach. This approach, which includes floor time (Greenspan &

Wieder, 1998), is focused on building emotional reciprocity. One key component to floor

time, following the child’s lead, is also central to naturalistic behavioral strategies.

Another central component, opening and closing circles of communication, shares many

similarities with prompting and reinforcement strategies used in the naturalistic

behavioral interventions. Although proponents of the developmental approach do not

consider it behavioral, in many ways it is more similar to naturalistic behavioral

interventions than naturalistic and structured behavioral interventions are to each other

20
(Prizant, Wetherby, & Rydell, 2000). Similarly, sensory integrative therapy is also

focused on following the child’s lead and gradually increasing the level of demands to

help the child increase his or her fine motor, play, language, and sensory processing skills

(e.g., Ayres, 1972).

One very obvious difference between behavioral and non-behavioral approaches

is the focus on data collection and validation Despite their common use and likely

benefit, most non-behavioral interventions have not been empirically validated leading

many behaviorists to doubt their efficacy. In recent years, the TEACCH model and

social stories have undergone empirical study (e.g, Norris & Datillo, 1999; Ozonoff &

Cathcart, 1998) while developmental and sensory integrative interventions have lagged

behind. Future research which examines the efficacy of these types of interventions and

their overlap with behaviorally-based interventions will undoubtedly improve both fields

and result in better treatment options for children with autism.

A second difference between behavioral and non-behavioral approaches is the use

of fidelity of implementation. Traditionally, behaviorists rigorously define their

procedures and monitor their correct implementation. These definitions create a

common language among intervention providers and assist in the consistent

implementation of the intervention. Other disciplines are beginning to recognize the

importance of fidelity of implementation. As we progress in our collaboration, it is

hoped that we continue to challenge ourselves to define fidelity of implementation and

manualize our interventions to insure consistency of treatment implementation.

One struggle in collaboration between disciplines is the confusion between

specific behavioral techniques and general principles of applied behavior analysis among

21
professionals in other disciplines, as well as the public at large. In fact, some

professionals have challenged the use of applied behavior analysis for children with

autism because they are uncomfortable with the highly structured, adult-directed

techniques used in discrete trial training, without recognizing that discrete trial training is

only one of many behavioral techniques (e.g., Greenspan & Wieder, 1998). (In reality,

the term “applied behavior analysis” refers to a specific research methodology – not a

particular form of treatment.) As a field, we must clarify our principles to other

disciplines in a clear manner that can highlight the similarities between disciplines and

encourage collaboration.

Collaboration Among Service Providers

Behavioral interventionists have become less focused on treatment provided

exclusively by specialists in clinic settings, recognizing that children need to learn within

the context of their daily lives (e.g., as provided by naturalistic teaching strategies).

Treatment is being delivered by individuals with a wide range of experience in a variety

of settings. Behavioral interventionists and researchers have also recognized the

importance of family participation in treatment. Research has shown that parents can be

trained to implement behavioral procedures with their children with autism and that this

training leads to increases in a variety of skills (e.g., Alpert & Kaiser, 1992; Hemmeter &

Kaiser, 1994). In addition, research has shown that parent training leads to more durable

improvement than clinic-based treatment (Koegel et al., 1982).

There has also been an increase in the use of siblings (Celiberti & Harris, 1993)

and peers as intervention agents (e.g., McGee, Almeida, Sulzer-Azaroff, & Feldman,

1992; Pierce & Schreibman, 1995; 1997). Research suggests that typical children as

22
young as two years old can be trained to use behavioral strategies with peers with autism

(Ingersoll & Stahmer, 2002). Sibling and peer-implemented behavioral interventions

have been shown to increase children with autism’s social interaction (McGee et al.,

1992), language (Pierce & Schreibman, 1997), and joint attention skills (Ingersoll &

Stahmer, 2002; Pierce & Schreibman, 1997).

Given the variety of treatment providers and intervention settings in any one

child’s intervention program, collaboration is indispensable. Most children with autism

receive intervention in multiple settings throughout their lifetime. Parents and teachers

may not be using the same techniques, which in some cases can lead to a breakdown in

behavior. For example, many non-verbal children in are on PECS in their classrooms;

however, many of their families are not familiar with the system, do not have the

materials in the home, or do not know which pictures their child can use. In this

situation, the lack of collaboration between the home and the school may lead to missed

opportunities to build communication. Interventionists need to plan for collaboration

between all environments to ensure consistency in program implementation. Future

research on ways to facilitate collaboration between settings is certainly warranted.

Continuum of Services

Much of the early behavioral research was conducted with older children,

adolescents, and adults with autism and other severe disabilities. With the recognition of

the importance of early intervention, there has been a tremendous increase in research

devoted to treatments for young children with autism. This focus is necessary and

exciting has likely yielded better long-term outcomes for individuals with autism in

general. However, despite better outcomes with the provision of early intervention

23
services, the prognosis for adults with autism is still very poor. Therefore, it is necessary

that research on treatment options for older individuals with autism grow in step with the

research on these options for young children.

Dissemination

Another extremely important issue is: How can behavioral researchers rapidly

disseminate our findings so that they are widely applied. Like most scientific disciplines,

behavioral interventions are developed and reported in professional journals. However,

parents, teachers, and other frontline treatment providers are unlikely to be among the

audience of the journals. We need to specifically target outlets that reach these

personnel. Thus, publication of our work in media outlets and the popular press might be

quite effective in making our treatments known.

Several behavioral methodologies have done this so far. Structured behavioral

techniques have received widespread acceptance in both home-based and school

programs, largely because they have been described in excellent detail in several

commercially-available manuals (e.g., Leaf & McEachin, 1999; Maurice, Green, & Luce,

1996). Similarly, PECS, which also has a comprehensive training manual (Frost &

Bondy, 2000), has received wide-acceptance in school programs across the country.

Discrete Trial Training has enjoyed a level of success and advocacy far beyond its

objectively determined effectiveness (as mentioned earlier, no treatment is effective with

all children with autism). Why is this the case? Probably because of the Lovaas (1987)

study reporting that 47% of very young children provided with 40 hours a week of this

treatment achieved “normal” functioning. Despite cautions about the methodology of the

study and the fact that the study participants might not be representative of the wide

24
range of children with autism, parents understandably applauded the treatment as a

potential “cure” and demanded the treatment for their children. (Interestingly, however,

few people seem to notice that 53% did NOT achieve normal functioning.) The Internet,

autism organizations, etc. all provided a ready vehicle for the dissemination of this very

hopeful information from the Lovaas study to parents so eager for an answer to their

child’s condition. This, in additional to widespread popular media coverage proved to

make intensive Discrete Trial Training very popular indeed.

Conversely, some of the newer and more promising naturalistic behavioral

interventions, self-management techniques, and the use of video technology have

received less widespread acceptance, and remain primarily within an academic setting.

Several possibilities for this difference in rate of dissemination arise. First, it is possible

that there are less well-known, well-detailed manuals for these techniques. Second, it is

possible that more naturalistic techniques, self-management, and video technology are

more complex and less user-friendly for families and educators without a background in

behavioral techniques. It is important for us to determine these barriers so that they can

be overcome.

Another important goal of dissemination is to monitor the fidelity of

implementation of behavioral treatments used in the community. Many of the teachers

and therapists providing intervention to individuals with autism in the community do not

have a firm background in behavioral principles. Given this reality, it is important to

determine the quality of behavioral interventions being provided in the community as

opposed to those provided in academic research settings and research training procedures

to increase the effectiveness of intervention in the community.

25
 CONCLUSIONS

As our knowledge of autism has increased, so too have the behavioral

interventions designed to treat the disorder. One of the strengths of the field of behavior

modification is the reliance on data collection to validate our procedures and monitor

progress. As our own field has grown, we have become more open to differing treatment

philosophies, more reliant on a variety of treatment providers, and more influenced by

other fields. This expanding view of behavior analysis can only serve to improve

interventions for individuals with autism. It is arguably the case that behavioral

intervention is the most thoroughly studied treatment modality in the field. While one

can cite some methodological shortcomings in some of the studies (e.g., small Ns, lack of

random assignment) it is the case that these are endemic not only to research on

behavioral interventions but of autism treatment in general. The necessity for continued

research on effective treatments for this population is crucial and doubtless behavioral

interventions will be in the forefront of this research for some time to come.

26
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