oxidation of heavy 1- olefins (c - c ) with tbhp using a
TRANSCRIPT
tervention targets is largely a matter of establishing prio-rities. The target behaviors under investigation rangedfrom single words or phrases in isolated contexts toconversational interactions in varying contexts.
This review focuses on peer-reviewed research ar-ticles published in the past 20 years that evaluated com-munication treatments with children with autism. Thefollowing minimal selection criteria were used to jus-tify reviewing an article:
1. Program descriptions or case studies with noexperimental design were excluded.
2. Only empirical studies that reported resultswith measures of some aspect of languageform, content, or use in individuals with autismwere included.
3. Only studies reporting reliability estimates for thedependent variables under investigation or stud-ies using standardized instruments were included.
Tables I to VI summarize approximately 60 stud-ies that evaluated the effectiveness of child languagetreatment approaches. The columns provide (a) ratingsof internal validity, external validity, and generalization
This review focuses on experimental research ontreatment effectiveness applied to speech and languageskills of individuals with autism. Studies reviewedsought to evaluate whether changes in communicationskills were associated with treatment protocols ratherthan uncontrolled factors, such as maturation or every-day learning opportunities. The positive effects of treat-ment may cover a wide range of communication skillsincluding comprehension, production, and social use oflanguage form (phonology, syntax, morphology), con-tent (semantics), and use (pragmatics).
Appropriate communication depends on the use ofa vast array of linguistic skills, made all the more com-plicated when they must be applied collectively andadapted to interactions with others. Particular inter-ventions may target one of these domains, but their in-tent is usually to influence children’s ability to usecommunication to control, understand, and participatein their social world. It is important to keep in mindthat most children with autism have deficiencies acrossa variety of linguistic domains, and the selection of in-
Communication Intervention for Children with Autism:A Review of Treatment Efficacy
Howard Goldstein1
Empirical studies evaluating speech and language intervention procedures applied to childrenwith autism are reviewed, and the documented benefits are summarized. In particular, inter-ventions incorporating sign language, discrete-trial training, and milieu teaching procedureshave been used successfully to expand the communication repertoires of children with autism.Other important developments in the field stem from interventions designed to replace chal-lenging behaviors and to promote social and scripted interactions. The few studies of the par-ent and classroom training studies that included language measures also are analyzed. Thisarticle seeks to outline the extent to which previous research has helped identify a compendiumof effective instructional practices that can guide clinical practice. It also seeks to highlightneeds for further research to refine and extend current treatment approaches and to investi-gate more comprehensive treatment packages.
KEY WORDS: Autism; communication intervention; language development; social interaction.
Journal of Autism and Developmental Disorders, Vol. 32, No. 5, October 2002 (© 2002)
3730162-3257/02/1000-0373/0 © 2002 Plenum Publishing Corporation
1 The Florida State University, Tallahassee, Florida, 32306-1200.
Tab
le I
.C
omm
unic
atio
n In
terv
entio
ns In
corp
orat
ing
Sign
Lan
guag
e
Parti
cipa
nts
Expe
rimen
tal
Inde
pend
ent
Dep
ende
nt
Gen
eral
izat
ion
Ref
eren
ces
(n)
desi
gnva
riabl
esva
riabl
esm
easu
res
Res
ults
Dur
atio
n
Bra
dy &
Sm
ouse
,6
yr o
ld (1
)Si
mul
tane
ous
Sign
onl
y, s
peec
h R
ec (s
peec
h, s
ign,
and
!ex
perim
ente
rsTC
sig
nific
antly
bet
ter t
han
21 s
essi
ons
1978
treat
men
t on
ly, &
TC
TC) R
s (th
ree
actio
ns !
spee
ch a
lone
I, IV
, II
desi
gnth
ree
colo
rs !
3 ob
ject
s)C
arr &
Dor
es,
mut
e; 6
–11
MB
L !
Ss &
Rec
(TC
) lab
elin
g C
ompr
ehen
sion
of
Not
ass
esse
d2
chn
acq
rec
sign
s M
edia
n tri
als
to19
81yr
s (6
)tra
inin
g se
tsw
ith g
ood
(4)
spee
ch v
ersu
s si
gns
and
4 ch
n ac
quire
d cr
iterio
n "
97–2
86; 6
vers
us p
oor (
2)
rec
sign
s an
d sp
eech
, se
ts o
f 4 o
bjec
tsim
itato
rspr
edic
ted
by v
erba
l II
, III
, IV
imita
tion
scor
esC
arr,
Prid
al, &
6–
16 y
r C
ompa
rison
of
Rec
(sig
n an
d R
ec (s
ign
and
spee
ch)
Not
ass
esse
dN
o di
ffer
ence
in s
ign
Sign
s→!
20–3
00D
ores
, 198
4(1
0)4
good
ver
sus
6 sp
eech
) lab
elin
g in
la
belin
gdi
scrim
inat
ion,
but
big
trial
s to
crit
erio
n; in
poor
imita
tors
two
grou
psdi
ffer
ence
in s
peec
h10
00 tr
ials
mos
tdi
scrim
(not
cor
rela
ted
spee
ch d
iscr
ims
not
with
MA
or l
angu
age
lear
ned;
3 p
airs
II, I
II, I
Vag
eof
obj
ects
Whe
rry
& E
dwar
ds,
5 yr
(1)
Sim
ulta
neou
s Pr
ompt
ing
and
Rec
Rs
to s
peec
h,N
ot a
sses
sed
Poor
acq
uisi
tion
data
3 da
ily s
essi
ons
18
1983
treat
men
t, di
ffer
entia
lsi
gns,
& T
C) (
9an
d no
diff
eren
ces
!da
ys in
terv
entio
nco
unte
r bal
ance
d re
info
rcem
ent
verb
s !
9 co
lors
!9
cond
ition
stx
s an
d te
ache
rsno
uns)
; als
oin
itiat
ions
and
eye
I, IV
, IV
cont
act
Bar
rera
, Lob
ato-
mut
e; 4
yr
Alte
rnat
ing
Sign
onl
y, s
peec
hEx
pres
sive
labe
ling
!pe
rson
s &
TC
→su
perio
r lea
rnin
g 26
–104
tria
ls to
Bar
rera
, Sul
zer-
old
(1)
treat
men
ts
only
, and
TC
(tot
alan
d le
vel o
fst
imul
ire
plic
ated
!gr
oups
of
crite
rion
for 1
0 TC
Aza
roff
, 198
0de
sign
com
mun
icat
ion)
prom
ptin
gw
ords
wor
ds, 2
1 w
ords
I, IV
, II
lear
ned
in 1
2 se
ssio
nsB
arre
ra &
Sul
zer-
echo
lalic
;A
ltern
atin
gSp
eech
onl
y ve
rsus
Ex
pres
sive
labe
ling
Not
ass
esse
dTC
→fa
ster
and
mor
e 52
–88
trial
s to
Aza
roff
, 198
36–
9 yr
(3)
treat
men
tsTC
and
leve
l of
com
plet
e le
arni
ng
crite
rion
in T
Cde
sign
prom
ptin
gre
plic
ated
!gr
oups
of
cond
ition
and
65–
82w
ords
& c
hild
ren
in s
peec
h co
nditi
on;
6–10
wor
ds le
arne
dI,
II, I
Vin
16–
25 s
essi
ons
Layt
on 1
988
6–9
yr,
Ran
dom
Spee
ch a
lone
ver
sus
Exp
and
rec
!se
tting
s &
All
txs
effe
ctiv
e fo
r 90
40-
min
. dai
lym
od-s
evas
sign
men
t to
sign
alo
ne v
ersu
s(s
igns
/wor
ds)
pers
ons;
3 m
osgo
od im
itato
rs, s
peec
h se
ssio
ns; R
ec M
"au
tism
(60)
four
mat
ched
alte
rnat
ing
vers
usfu
nctio
nal v
ocab
ular
ym
aint
enan
ceal
one,
less
eff
ectiv
e fo
r 11
–31
wor
ds/s
igns
;gr
oups
(goo
dsi
mul
tane
ous
txs
poor
imita
tors
Exp
M "
3–30
and
poor
w
ords
/sig
nsI,
I, II
imita
tors
)
Yod
er &
Lay
ton,
M
in v
erba
l;M
ultig
roup
Spee
ch a
lone
ver
sus
Tota
l num
ber o
f chi
ld-
!se
tting
sSi
gn a
lone
→le
ss c
hild
-90
40-
min
. dai
ly19
883–
7 yr
old
sra
ndom
ass
ign;
sign
alo
ne v
ersu
sin
itiat
ed s
poke
nin
itiat
ed s
peec
h; v
erba
lse
ssio
ns(6
0)ap
titud
e !
tx
alte
rnat
ing
vers
usw
ords
abili
ty p
redi
cted
pos
t-tx
inte
ract
ion
sim
ulta
neou
s tx
svo
cabu
lary
I, I,
III
anal
ysis
Cas
ey, 1
978
6 an
d 7
yr,
MB
L !
SsPa
rent
s ta
ught
to%
inte
rval
s of
com
mu-
!se
tting
sC
lear
incr
ease
s in
20 s
essi
ons
(4)
use
sign
sni
catio
n at
tem
pts
and
com
mun
icat
ion
&in
appr
opria
te b
ehav
ior
decr
ease
s in
inap
prop
riate
beha
vior
for 2
of
II, I
II, I
I4
child
ren
Not
e: R
oman
num
eral
s in
the
first
col
umn
deno
te ra
tings
of i
nter
nal v
alid
ity, e
xter
nal v
alid
ity, a
nd g
ener
aliz
atio
n, re
spec
tivel
y, b
ased
on
the
follo
win
g cr
iteria
:In
tern
al v
alid
ity: I
, Pro
spec
tive
grou
p or
sin
gle-
subj
ect d
esig
n ex
perim
ent c
ompa
ring
alte
rnat
ive
treat
men
ts; I
I, pr
e-po
st g
roup
des
ign
or s
ingl
e-su
bjec
t des
ign
with
relia
ble,
obj
ectiv
e ou
tcom
es m
easu
res;
III,
pre-
post
, ex
post
fact
o, o
r sin
gle-
subj
ect d
esig
ns w
ith q
uest
iona
ble
inte
rnal
val
idity
or m
easu
rem
ent.
Exte
rnal
val
idity
: I, R
ando
m a
ssig
nmen
t of w
ell-d
efin
ed c
ohor
ts a
nd a
dequ
ate
sam
ple
size
; II,
nonr
ando
m a
ssig
nmen
t, bu
t wel
l-def
ined
coh
orts
and
ade
quat
e sa
mpl
e si
ze o
r rep
licat
ion
acro
ss 3
or m
ore
sub-
ject
s in
a s
ingl
e-su
bjec
t des
ign;
III
, wel
l-def
ined
pop
ulat
ion
of th
ree
or m
ore
subj
ects
in s
ingl
e-su
bjec
t des
igns
or
sam
ple
of a
dequ
ate
size
in g
roup
des
igns
; IV
, sm
all s
ampl
e in
gro
up d
esig
n or
one
or
two
subj
ects
in s
ingl
e-su
bjec
t des
ign.
Gen
eral
izat
ion:
I, C
onsi
sten
t gen
eral
izat
ion
to f
unct
iona
l set
ting
beyo
nd tr
eatm
ent s
ettin
g w
ithou
t fur
ther
inte
rven
tion
or r
obus
t soc
ial v
alid
atio
n re
sults
; II,
long
-term
mai
nten
ance
or
gene
raliz
atio
n to
one
setti
ng b
eyon
d tre
atm
ent s
ettin
g; II
I, in
terv
entio
n oc
curr
ed in
nat
ural
set
ting
or o
utco
me
mea
sure
with
doc
umen
t rel
atio
n to
func
tiona
l out
com
es; I
V, n
ot a
ddre
ssed
or o
ther
.M
BL
= M
ultip
le B
asel
ine
Des
ign;
TC
= T
otal
Com
mun
icat
ion;
Rec
= R
ecep
tive;
Exp
= E
xpre
ssiv
e; R
= R
espo
nse;
chn
= c
hild
ren;
Tx
= tre
atm
ent.
Tab
le I
I.D
iscr
ete
Tria
l Tra
inin
g
Parti
cipa
nts
Expe
rimen
tal
Inde
pend
ent
Dep
ende
nt
Gen
eral
izat
ion
Ref
eren
ces
(n)
desi
gnva
riabl
esva
riabl
esm
easu
res
Res
ults
Dur
atio
n
Koe
gel,
O’D
ell,
&
Dun
lap,
198
8
II, I
I, II
McI
lvan
e et
al.,
1984
II, I
V, I
V
Han
dlem
an, 1
979
II, I
I, I
Han
dlem
an, 1
981
II, I
I, II
I
Seca
n, E
gel,
&
Tille
y, 1
989
II, I
I, I
Egel
, Sha
fer,
&
Nee
f, 19
84
II, I
I, II
Buf
fingt
on, K
rant
z,
McC
lann
ahan
, &
Poul
son,
199
8
II, I
I, I
seve
re c
omm
u-ni
catio
n de
lay;
3–
11 y
r (4)
18 y
r (1)
6–7
yr (4
)
5–12
yr (
6)
5–9
yr (4
)
6–8
yr (4
)
4–6
yr (4
)
Rev
ersa
l des
ign
Mul
tiple
pro
be
desi
gn !
Rs
MB
L !
Q s
ets,
BC
BC
BC
-re
stric
ted
vers
us
mul
tiple
nat
ural
se
tting
s
MB
L !
Q s
ets,
BC
BC
BC
-re
stric
ted
vers
us
mul
tiple
nat
ural
se
tting
s
MB
L !
Q fo
rms
and
subf
orm
s (e
.g.,
how
Qs
rela
ting
to
actio
n, m
eans
, af
fect
) and
Ss
ATD
(obj
ect v
ersu
s se
lf po
sitio
ning
) an
d M
BL
!Ss
MB
L !
Rs
Rei
nfor
ce v
erba
l atte
mpt
sve
rsus
sha
ping
mot
orsp
eech
pro
duct
ion
Excl
usio
n pr
oced
ure
to
teac
h fo
od n
ames
Diff
eren
tial r
einf
orce
men
tan
d co
rrec
tion
proc
e-du
re
Diff
eren
tial r
einf
orce
men
tan
d co
rrec
tion
proc
e-du
re
Pict
ure
train
ing
usin
g di
f-fe
rent
ial r
einf
orce
men
tan
d m
odel
ing
corr
ectio
npr
oced
ure
Dis
cret
e-tri
al tr
aini
ng w
ithdi
ffer
entia
l rei
nfor
ce-
men
t pro
mpt
ing,
and
m
odel
ing
Mod
elin
g, p
rom
ptin
g, to
ken
rein
forc
emen
t, an
d pr
aise
Aff
ect r
atin
gs a
nd
chan
ges
in
phon
emic
pr
oduc
tion
scor
es
Exp
spee
ch a
nd s
ign
voca
bula
ry
1 w
ord
Rs
to w
h-Q
s
1 w
ord
Rs
to w
h-Q
s
Rs
to w
hat,
how
, and
w
hy-Q
s to
pic
ture
s
Com
preh
ensi
on o
f pr
epos
ition
s—be
hind
, in
fron
t of,
next
to,
Ges
tura
l and
ver
bal
Rs
(atte
ntio
n, a
ffec
t, an
d re
fere
nce)
4 ye
ar fo
llow
-up
for 3
chn
!no
vel w
ords
!se
tting
s an
d ad
ults
(i.e
., ho
me)
!se
tting
s (i.
e.,
corn
er o
f cl
assr
oom
)
!st
oryb
ook
and
natu
ral
cont
exts
and
to
Q-a
skin
g
!no
vel s
timul
ian
d R
topo
gra-
phie
s
!pr
obe
stim
ulus
an
d to
cla
ssro
oman
d so
cial
val
id-
ity ra
tings
of
vide
os
Slig
htly
bet
ter a
ffec
t rat
ings
in v
erba
l atte
mpt
con
di-
tion;
eff
ects
on
spee
ch
prod
uctio
n di
fficu
lt to
in
terp
ret
2–10
rec
mat
chin
g tri
als
befo
re b
egan
nam
ing
food
s
Trai
ning
in m
ultip
le
setti
ngs →
grea
ter
gene
raliz
atio
n to
hom
e fo
r 3 o
f 4 c
hn a
nd e
qual
lyhi
gh g
en fo
r 4th
chi
ld
No
cons
iste
nt d
iffer
ence
inle
arni
ng a
nd g
ener
ally
as
soci
ated
with
2 tr
aini
ngco
nditi
ons
Rap
id le
arni
ng w
ith p
ix
refe
rent
s, n
o ge
n !
Q
subf
orm
s an
d fo
rms;
fair
to g
ood
gen
!co
ntex
ts,
2–5
sess
ions
inte
rspe
rsed
train
ing
stim
uli r
emed
i-at
ed p
oor g
en; a
nd n
o Q
aski
ng
Posi
tioni
ng o
bjec
ts d
id n
otge
n to
pos
ition
ing
self
and
vice
ver
sa w
ithou
t mul
ti-pl
e ex
empl
ar o
r int
ersp
er-
sal t
rain
ing
Zero
bas
elin
e →
robu
st
effe
cts
repl
icat
ed a
cros
s R
cat
egor
ies
and
chn,
ge
n pr
obe
data
par
alle
led
train
ing
data
. Cla
ssro
omda
ta n
ot p
rese
nted
. Goo
dso
cial
val
idity
resu
lts.
14–2
4 se
ssio
ns
10 fo
od n
ames
3 se
ssio
ns p
er
day,
20
train
ing
trial
s→10
0–17
40
trial
s to
crit
erio
n pe
r set
of 5
Rs
3 se
ssio
ns p
er
day,
20
train
ing
trial
s→40
–156
0 tri
als
to c
riter
ion
per s
et o
f 5 R
s
3–9
train
ing
sess
ions
pe
r Q fo
rm
3–12
trai
ning
se
ssio
ns p
er S
fo
r 2 p
repo
sitio
ns
57–6
9 se
ssio
ns
Koe
gel,
Cam
arat
a,
Val
dez-
Men
chac
a,
& K
oege
l, 19
98II
, II,
I
Kra
ntz,
Zal
ensk
i, H
all,
Fens
ke, &
M
cCla
nnah
an,
1981
—Ex
p 1
II, I
I, I
Kra
ntz
etal
.,19
81—
Exp
2II
, II,
I
Kra
ntz
etal
.,19
81—
Exp
3
II, I
V, I
I
Gol
dste
in &
Bro
wn,
19
89
II, I
V, I
Not
e: R
oman
num
eral
s in
the
first
col
umn
deno
te ra
tings
of i
nter
nal v
alid
ity, e
xter
nal v
alid
ity, a
nd g
ener
aliz
atio
n re
spec
tivel
y, b
ased
on
the
follo
win
g cr
iteria
:In
tern
al v
alid
ity: I
, Pro
spec
tive
grou
p or
sin
gle-
subj
ect d
esig
n ex
perim
ent c
ompa
ring
alte
rnat
ive
treat
men
ts; I
I, pr
e-po
st g
roup
des
ign
or s
ingl
e-su
bjec
t des
ign
with
relia
ble,
obj
ectiv
e ou
tcom
es m
easu
res;
III,
pre-
post
, ex
post
fact
o, o
r sin
gle-
subj
ect d
esig
ns w
ith q
uest
iona
ble
inte
rnal
val
idity
or m
easu
rem
ent.
Exte
rnal
val
idity
: I, R
ando
m a
ssig
nmen
t of w
ell-d
efin
ed c
ohor
ts a
nd a
dequ
ate
sam
ple
size
; II,
nonr
ando
m a
ssig
nmen
t, bu
t wel
l-def
ined
coh
orts
and
ade
quat
e sa
mpl
e si
ze o
r rep
licat
ion
acro
ss 3
or m
ore
subj
ects
in a
sin
gle-
subj
ect d
esig
n; II
I, w
ell-d
efin
ed p
opul
atio
n of
thre
e or
mor
e su
bjec
ts in
sin
gle-
subj
ect d
esig
ns o
r sam
ple
of a
dequ
ate
size
in g
roup
des
igns
; IV
, sm
all s
ampl
e in
gro
up d
esig
n or
1to
2 s
ubje
cts
in s
ingl
e-su
bjec
t des
ign.
Gen
eral
izat
ion:
I, C
onsi
sten
t gen
eral
izat
ion
to f
unct
iona
l set
ting
beyo
nd tr
eatm
ent s
ettin
g w
ithou
t fur
ther
inte
rven
tion
or r
obus
t soc
ial v
alid
atio
n re
sults
; II,
long
-term
mai
nten
ance
or
gene
raliz
atio
n to
one
setti
ng b
eyon
d tre
atm
ent s
ettin
g; II
I, in
terv
entio
n oc
curr
ed in
nat
ural
set
ting
or o
utco
me
mea
sure
with
doc
umen
t rel
atio
n to
func
tiona
l out
com
es; I
V, n
ot a
ddre
ssed
or o
ther
.M
BL
= M
ultip
le B
asel
ine
Des
ign;
TC
= T
otal
Com
mun
icat
ion;
Rec
= R
ecep
tive;
Exp
= E
xpre
ssiv
e; R
= R
espo
nse;
chn
= c
hild
ren;
Tx
= tre
atm
ent.
!st
imul
i, se
tting
s,an
d pe
ople
!pe
rson
s,
setti
ngs,
nov
el
mat
eria
ls, a
ndm
odal
ity
(writ
ing)
!un
train
ed s
timul
i
!se
tting
s
!un
train
ed s
timu-
lus
com
bina
tions
and
setti
ngs
Qs
lear
ned,
use
d w
ith le
sspr
efer
red
item
s an
d ge
ner-
aliz
ed. A
vera
ge 6
new
exp
noun
labe
ls le
arne
d/w
k
Chn
qui
ckly
lear
ned
and
gen
whe
n ta
ught
incr
easi
ngly
long
er u
ttera
nces
Chi
ldre
n qu
ickl
y le
arne
d an
dge
nera
lized
Zero
bas
elin
e→ro
bust
ef-
fect
s fo
r sen
tenc
es a
ndcl
ear e
ffec
ts fo
r par
a-gr
aphs
64 re
c an
d 64
exp
3-w
ord
Rs
lear
ned
thro
ugh
peer
mod
-el
ing
of 3
rec
#5
exp
Rs
for o
ne c
hild
and
4 re
c #
2 ex
p R
s fo
r sec
ond
child
and
gen
to h
ome
16–3
4 se
ssio
ns
Tota
l !10
0 da
ys
2–3
mo,
36–
54
sess
ions
5–8
mo
13 s
essi
ons
3–5
yr (3
)
7–13
yr (
4)
5–10
yr (
3)
5 yr
(2)
2–3
yr (2
)
MB
L !
Ss
MB
L !
lang
uage
ca
tego
ries
MB
L !
wh-
conc
epts
MB
L !
setti
ngs
(hom
e an
d sc
hool
) #ta
sks
(sen
tenc
es a
nd
para
grap
hs)
MB
L !
Rs
(sub
mat
rices
) an
d m
odal
ities
Mod
elin
g, p
rom
ptin
g im
ita
tion,
rein
forc
ed w
ith
desi
red
item
s in
a b
ag
Toke
n re
info
rcem
ent a
ndm
odel
ing
in d
iscr
ete-
trial
form
at
Ver
bal p
rom
ptin
g/fa
ding
an
d di
ffer
entia
l rei
n-fo
rcem
ent
Mod
elin
g, re
hear
sal,
prom
ptin
g, a
nd fa
ding
Mod
elin
g of
item
s se
lect
edfr
om o
bj-p
rep-
loca
tion
subm
atric
es
Num
ber o
f “w
hat’s
that
” Q
s as
ked,
new
nou
ns
prod
uced
Des
crip
tions
of o
bjec
ts
and
pict
ures
Ver
b #
Col
or #
Shap
e/si
ze #
Labe
l
Rs
to w
h-Q
s (4
–5
conc
epts
eac
h fo
r wha
t,ho
w, a
nd w
hy Q
s
Rs
to w
h-Q
s ab
out p
ast
even
ts
Rec
Rs
to a
nd
prod
uctio
n of
ob
j-pre
p-lo
catio
n ut
tere
nces
Tab
le I
II.
Mili
eu T
each
ing
Parti
cipa
nts
Expe
rimen
tal
Inde
pend
ent
Dep
ende
nt
Gen
eral
izat
ion
Ref
eren
ces
(n)
desi
gnva
riabl
esva
riabl
esm
easu
res
Res
ults
Dur
atio
n
Cha
rlop,
Sc
hrei
bman
, &
Thib
odea
u, 1
985
II, I
I, II
Cha
rlop
& W
alsh
, 19
86
II, I
I, II
Cha
rlop
&
Tras
owec
h, 1
991
II, I
I, I
Inge
nmey
& V
an
Hou
ten,
199
1
II, I
V, I
I
Mat
son,
Sev
in, B
ox,
Fran
cis,
& S
evin
, 19
93
II, I
I, II
McG
ee, A
lmei
da,
Sulz
er-A
zaro
ff, &
Fe
ldm
an, 1
992
II, I
I, II
Nee
f, W
alte
rs, &
Eg
el, 1
984
II, I
I, II
McG
ee, K
rant
z, &
M
cCla
nnah
an, 1
985
II, I
I, II
MB
L !
Ss
MB
L !
Ss
and
setti
ngs
MB
L !
Ss a
nd s
et-
tings
MB
L !
beha
v-io
rs
MB
L !
beha
v-io
rs
MB
L !
Ss
MB
L !
Ss
MB
L !
pairs
of
prep
s w
ith
ATD
and
MB
L!
Ss
Tim
e-de
lay
proc
edur
e
Tim
e de
lay
proc
edur
e an
d pe
er
mod
elin
g in
2nd
se
tting
Pare
nts
taug
ht ti
me-
dela
y pr
oced
ure
Tim
e-de
lay
proc
edur
e (m
odel
de
scrip
tions
of c
ar
play
and
dra
win
g)
Two
Rs
each
taug
ht
usin
g tim
e de
lay
vers
us m
odel
ing
and
visu
al c
ue fa
ding
pr
oced
ures
Peer
inci
dent
al
teac
hing
(wai
t for
R
Q in
itiat
ion,
RQ
im
it, p
rovi
de
rein
forc
er a
nd p
rais
e)
Dis
cret
e-tri
al
tuto
ring
sess
ions
(“
is th
is a
___
?”)
vers
us a
cros
s-th
e-da
ych
ild R
Q-in
itiat
ed
embe
dded
tx
(“do
you
wan
t ___
?”)
Trad
ition
trai
ning
(W
here
is th
e __
_?,
prom
pt, a
rbitr
ary
rein
-fo
rcer
) ver
sus
Inci
den-
tal t
rain
ing
(Whe
re is
___?
, Tel
l me
whe
re,
prom
pt e
labo
ratio
n,
acce
ss to
RQ
ed it
em
Obj
ect R
Qs
(fou
r per
child
); al
l but
one
ch
ild c
ould
labe
l ob
ject
s
Spon
tane
ous
exp
of
“I li
ke/lo
ve y
ou”;
ey
e co
ntac
t, sm
iling
, ap
proa
ch/to
uch
Soci
al p
hras
es to
ad
ults
% o
f tria
ls w
ith s
pont
a-ne
ous
desc
riptio
ns o
fpl
ay
Soci
al p
hras
es—
hello
, pl
ay w
ith m
e, e
xcus
em
e, th
ank
you,
hel
p m
e
% in
terv
als
of
posi
tive
reci
proc
al
inte
ract
ions
, %
inte
rval
s of
in
itiat
ions
% c
orre
ct y
es/n
o R
s
Prep
pro
duct
ion
to
desc
ribe
loca
tion
of
edib
les
and
toys
!se
tting
s,
unfa
mili
ar
pers
ons,
unt
rain
edst
imul
i
!se
tting
s an
d re
spon
se g
en
!lo
catio
ns a
nd
pers
ons
!se
tting
s, 5
wk
and
4 m
o fo
llow
up
!pe
ople
and
se
tting
s
!se
tting
s; te
ache
r ra
tings
of s
ocia
l co
mpe
tenc
e; p
eer
soci
omet
ric
ratin
gs
!ne
w s
timul
us
item
s an
d Q
type
s (a
ctio
ns,
poss
essi
ons
and
spat
ial r
elat
ions
)
!te
ache
rs s
ettin
gs, a
ndst
imul
us a
rran
gem
ents
Chi
ldre
n (w
ho c
ould
labe
l)qu
ickl
y le
arne
d an
d ge
nera
lized
RQ
ing
once
time
dela
y im
plem
ente
d
Tim
e de
lay
and
not p
eer
mod
elin
g ef
fect
ive,
va
riabl
e ge
n !
setti
ngs
(unt
il tim
e de
lay
impl
emen
ted)
and
littl
e ge
n to
anc
illar
y be
havi
ors
Tim
e de
lay →
spon
phr
ase
use
in 4
of 6
, 4 o
f 7, a
nd 2
of 6
con
text
s, re
spec
tivel
y;ge
n or
loss
of c
ontro
l for
othe
r con
text
s; g
ood
mai
nt.
Tim
e de
lay →
imm
edia
te
incr
ease
in s
pont
aneo
ussp
eech
, gen
to u
ntra
ined
ac
tions
w/in
5 s
essi
ons
Bot
h tre
atm
ents
eff
ectiv
e fo
r inc
reas
ing
self-
initi
ated
Rs
to n
onve
rbal
cue
s (e
.g.,
ther
apis
t ent
erin
g ro
om,
pres
enta
tion
of a
gam
e)
Incr
ease
in re
cipr
ocal
in
tera
ctio
ns a
nd le
ss
teac
her i
nvol
vem
ent;
spec
ific
effe
cts
on s
pon
verb
al R
Qs
not c
lear
Embe
dded
inst
ruct
ion
asso
ci-
ated
with
rapi
d im
prov
e-m
ent i
n R
ing;
gen
to “
is
this
a _
__?”
Qs
only
afte
rin
trodu
ced
in e
mbe
dded
inst
ruct
ion,
goo
d ge
n !
Q ty
pes
Bot
h tx
s eq
ually
eff
ectiv
e fo
rac
q an
d re
tent
ion,
inci
den-
tal t
each
ing →
bette
r, bu
tin
com
plet
e ge
n !
setti
ngs
(less
gen
!ar
rang
emen
ts)
and
mor
e sp
onta
neou
spr
oduc
tions
3–6
bloc
ks o
f 10
train
ing
trial
s
!45
–60
days
25–3
4 m
o of
obs
er-
vatio
n an
d 1–
4 m
os o
f tra
inin
g
22 s
essi
ons
33–4
7 se
ssio
ns, 2
–16
sess
ions
to le
arn
each
resp
onse
17–3
8 se
ssio
ns
38–6
2 se
ssio
ns, t
x ef
fect
est
ablis
hed
in 1
–7 d
ays
90 s
essi
ons,
!30
se
ssio
ns o
f tra
in-
ing
to a
ppro
xim
ate
mas
tery
5–11
yr (
7)
6–8
(4)
Echo
lalic
; 7–
8 yr
(3)
10 y
r (1)
4–5
yr, e
chol
alic
an
d lim
ited
Rs
(3)
3–5
yr (3
)
4–6
yr (4
)
6, 8
, 11
yr (3
)
Koe
gel,
O’D
ell,
&
Koe
gel,
1987
III,
IV, I
II
Hw
ang
& H
ughe
s,20
00
II, I
I, I
Koe
gel,
Cam
arat
a,
Koe
gel,
Ben
-Tal
l, &
Sm
ith, 1
998
I, II
, I
Lask
i, C
harlo
p, &
Sc
hrei
bman
, 198
8
II, I
I, I
Not
e: R
oman
num
eral
s in
the
first
col
umn
deno
te ra
tings
of i
nter
nal v
alid
ity, e
xter
nal v
alid
ity, a
nd g
ener
aliz
atio
n re
spec
tivel
y, b
ased
on
the
follo
win
g cr
iteria
:In
tern
al v
alid
ity: I
, Pro
spec
tive
grou
p or
sin
gle-
subj
ect d
esig
n ex
perim
ent c
ompa
ring
alte
rnat
ive
treat
men
ts; I
I, pr
e-po
st g
roup
des
ign
or s
ingl
e-su
bjec
t des
ign
with
rel
iabl
e, o
bjec
tive
outc
omes
mea
-su
res;
III,
pre-
post
, ex
post
fact
o, o
r sin
gle-
subj
ect d
esig
ns w
ith q
uest
iona
ble
inte
rnal
val
idity
or m
easu
rem
ent.
Exte
rnal
val
idity
: I, R
ando
m a
ssig
nmen
t of w
ell-d
efin
e co
horts
and
ade
quat
e sa
mpl
e si
ze; I
I, no
nran
dom
ass
ignm
ent,
but w
ell-d
efin
ed c
ohor
ts a
nd a
dequ
ate
sam
ple
size
or r
eplic
atio
n ac
ross
3 o
r mor
esu
bjec
ts in
a s
ingl
e-su
bjec
t des
ign;
III,
wel
l def
ined
pop
ulat
ion
of th
ree
or m
ore
subj
ects
in s
ingl
e-su
bjec
t des
igns
or s
ampl
e of
ade
quat
e si
ze in
gro
up d
esig
ns; I
V, s
mal
l sam
ple
in g
roup
des
ign
or 1
or
2 su
bjec
ts in
sin
gle-
subj
ect d
esig
n.G
ener
aliz
atio
n: I
, Con
sist
ent g
ener
aliz
atio
n to
fun
ctio
nal s
ettin
g be
yond
trea
tmen
t set
ting
with
out f
urth
er in
terv
entio
n or
rob
ust s
ocia
l val
idat
ion
resu
lts; I
I, lo
ng-te
rm m
aint
enan
ce o
r ge
nera
lizat
ion
toon
e se
tting
bey
ond
treat
men
t set
ting;
III,
inte
rven
tion
occu
rred
in n
atur
al s
ettin
g or
out
com
e m
easu
re w
ith d
ocum
ent r
elat
ion
to fu
nctio
nal o
utco
mes
; IV
, not
add
ress
ed o
r oth
er.
MB
L =
Mul
tiple
Bas
elin
e D
esig
n; A
TD =
Alte
rnat
ing
Trea
tmen
ts D
esig
n; R
Q =
Req
uest
; Q =
Que
stio
n; R
= R
espo
nse;
Tx
= tre
atm
ent;
gen
= ge
nera
lizat
ion;
Rec
= R
ecep
tive;
Exp
= E
xpre
ssiv
e; c
hn =
child
ren.
MB
L !
Ss
MB
L !
Ss
Rev
ersa
l des
ign
AB
AC
AB
with
coun
terb
al-
ance
d or
der
MB
L !
Ss
Chi
ld-s
elec
ted
stim
uli,
mod
elin
g (w
/o im
itatio
n R
Q),
com
mun
icat
ive
atte
mpt
s re
info
rced
, with
acce
ss t
o to
ys a
nd
soci
ally
Soci
al in
tera
ctiv
e tra
inin
gw
ith a
dult
partn
er
(con
tinge
nt im
itatio
n,
envi
ronm
ent a
rran
ge-
men
t, ex
pect
ant l
ook,
natu
ral r
einf
orce
rs)
Ana
log
(dis
cret
e-tri
al)
vers
us n
atur
alis
tic
teac
hing
pro
cedu
res
Pare
nts
taug
ht N
atur
al
Lang
uage
Par
adig
m
(rei
nfor
ce a
ttem
pts,
tu
rn ta
king
, var
y ta
sk,
shar
e co
ntro
l)
Imita
tive,
def
erre
d im
itativ
e, a
nd s
pon-
tane
ous
wor
d pr
oduc
tion
Freq
of c
hild
eye
co
ntac
t, jo
int a
tten-
tion,
and
mot
or
imita
tion
Acc
urac
y of
targ
etph
onem
e pr
oduc
tion
and
inte
lligi
bilit
y ra
t-in
gs b
y na
ïve
judg
es
Freq
uenc
y of
par
ent
and
child
ver
baliz
a-tio
ns
!se
tting
s
!se
tting
(nov
el c
lass
-ro
om w
ith te
ache
r) a
ndso
cial
val
idity
ratin
gsof
vid
eota
pes
!se
tting
s (h
ome
with
pare
nts,
sch
ool w
ithpe
ers)
!3
setti
ngs
Follo
win
g 2
and
19 m
o of
ana
-lo
g te
achi
ng, N
atur
al L
ang
Para
digm
impl
emen
ted →
incr
ease
in im
med
imita
tion
and
even
tual
ly s
pont
aneo
usut
tera
nces
(but
afte
r 4 o
r 5
mo)
Incr
ease
s in
thre
e ta
rget
be-
havi
ors
repl
icat
ed a
s tra
in-
ing
was
initi
ated
acr
oss
Ss.
Goo
d ge
nera
lizat
ion,
esp
e-ci
ally
for e
ye c
onta
ct, b
utm
inim
al fo
r joi
nt a
ttent
ion.
Rob
ust e
ffec
ts o
n so
cial
va-
lidity
msr
es
Cor
rect
pro
duct
ion
in c
onve
r-sa
tion
lang
uage
sam
ples
muc
h gr
eate
r for
pho
nem
esin
nat
ural
istic
tx c
ondi
tion
repl
icat
ed w
ithin
and
ac
ross
chi
ldre
n pl
us g
en !
setti
ngs
Cle
ar e
xper
imen
tal e
ffec
ts fo
r7
of 8
fam
ilies
2 h/
2 !
wee
k/ov
er
30 m
o
58 o
bser
vatio
n se
ssio
ns
54–9
4 se
ssio
ns
13–2
0 se
ssio
ns; 5
–9
pare
nt tr
aini
ngse
ssio
ns
4 an
d 5
yr (2
)
Prev
erba
l 32
–43
mo
(3)
3–7
yr (5
)
4 m
ute
and
4ec
hola
lic
5–9
yr (8
)
Tab
le I
V.
Com
mun
icat
ion
Inte
rven
tions
to R
epla
ce C
halle
ngin
g B
ehav
ior
Parti
cipa
nts
Expe
rimen
tal
Inde
pend
ent
Dep
ende
nt
Gen
eral
izat
ion
Ref
eren
ces
(n)
desi
gnva
riabl
esva
riabl
esm
easu
res
Res
ults
Dur
atio
n
Car
r & D
uran
d,
1985
—Ex
perim
ent 1
II, I
I, IV
Car
r & D
uran
d,
1985
—Ex
perim
ent 2
II, I
I, IV
Dur
and
& C
arr,
1987
—Ex
perim
ent 1
II, I
I, IV
Dur
and
& C
arr,
1987
—Ex
perim
ent 2
II, I
I, IV
Dur
and
& C
arr,
1987
—Ex
perim
ent 3
II, I
I, IV
Dur
and
& C
arr,
1992
—Ex
perim
ent 1
II, I
I, IV
Dur
and
& C
arr,
1992
—Ex
perim
ent 2
&
3
II, I
I, II
7–14
yr (
4)
7–14
yr (
4)
7–13
yr (
4)
7–13
yr (
4)
7–13
yr (
4)
3–5
yr (1
2)
3–5
yr (1
2)
AB
AC
AC
AB
A
AB
AC
AC
AB
AC
AB
AC
AC
AB
A
AB
AB
AB
AB
A
MB
L !
Ss
AB
AC
AC
AB
A
(bas
elin
e at
tent
ion
and
dem
and
cond
ition
s)
AB
AB
AC
; 2
mat
ched
gro
ups
(Fun
ctio
nal
Com
mun
icat
ion
Trai
ning
ve
rsus
tim
e-ou
t)
Easy
task
s w
ith 1
00%
at
tent
ion;
Eas
y w
ith
33%
atte
ntio
n;
Diffi
cult
task
s w
ith
100%
atte
ntio
n
Rel
evan
t and
irr
elev
ant R
s (I
don
’t un
ders
tand
and
Am I
doin
g go
od w
ork?
)
Soci
al a
ttent
ion
and
task
dem
ands
Tim
e-ou
t (re
mov
ing
task
dem
ands
) co
ntin
gent
on
ster
eoty
py
Imita
tion,
tim
e de
lay,
cor
rect
ion
proc
edur
e to
teac
h “h
elp
me”
B-A
ttent
ion
redu
ced
from
100
% to
33%
of
mat
chin
g tri
als;
C
-incr
ease
diffi
culty
of
task
s to
33%
cor
rect
le
vel &
CR
F
FCT-
imita
tion,
tim
e de
lay
train
ing
of “
Am
Ido
ing
good
wor
k?”
(in M
"18
min
) TO
-sim
ilar t
rain
ing
of
“My
nam
e is
___
” (1
8 m
in)
% in
terv
als
of
prob
lem
beh
avio
r (a
ggre
ssio
n,
tant
rum
s, s
elf-
inju
ry)
% in
terv
als
of
prob
lem
beh
avio
r an
d re
leva
nt a
nd
irrel
evan
t Rs
% in
terv
als
of
ster
eoty
pic
beha
vior
s
% in
terv
als
of
ster
eoty
pic
beha
vior
s(h
and
flapp
ing,
bod
yro
ckin
g)
% in
terv
als
of “
Hel
p m
e” R
Qs
and
ster
eoty
pic
beha
vior
s
% in
terv
als
of
chal
leng
ing
beha
vior
s,co
rrec
t mat
chin
g R
s,Tr
aine
r beh
avio
rs
% in
terv
als
of
chal
leng
ing
beha
vior
an
d un
prom
pted
at
tent
ion
RQ
s (A
m I
doin
g go
od w
ork?
)
!tra
iner
s (A
BA
B in
Ex
perim
ent 3
)
Littl
e ad
ult a
ttent
ion
and
high
task
diffi
culty
→in
crea
sed
prob
lem
beh
avio
rs fo
r di
ffer
ent S
s
Com
mun
icat
ive
repl
acem
ent
beha
vior
s fo
r sam
e fu
nc-
tion
only
(sol
iciti
ng
atte
ntio
n or
hel
p) →
less
prob
lem
beh
avio
r
Diffi
cult
task
→in
crea
sed
ster
eoty
py
Con
tinge
nt re
mov
al o
f tas
k de
man
ds →
incr
ease
dst
ereo
typy
Teac
hing
chi
ldre
n to
RQ
as
sist
ance
→re
duce
d st
ereo
typy
Red
uced
adu
lt at
tent
ion
was
asso
ciat
ed w
ith in
crea
sed
prob
lem
beh
avio
r in
all
12 c
hild
ren
Bot
h tre
atm
ents
suc
cess
ful,
but o
nly
grou
p th
at
rece
ived
FC
T ac
ross
se
tting
s m
aint
aine
d lo
w
rate
s of
pro
blem
beh
avio
rsw
naï
ve te
ache
rs
31 s
essi
ons
20–4
0 se
ssio
ns
28 s
essi
ons
23–3
6 se
ssio
ns
25 s
essi
ons
27 s
essi
ons
Expe
rimen
t 2—
27se
ssio
ns
Expe
rimen
t 3—
18
sess
ions
Hor
ner &
Bud
d,
1985
II, I
V, I
I
Bird
, Dor
es, M
oniz
, &
Rob
inso
n, 1
989
II, I
V, I
Wac
ker,
Stee
ge,
Nor
thup
, Sas
so,
Ber
g, R
eim
ers,
C
oope
r, C
igra
nd,
& D
onn,
199
0
II, I
I, II
I
Har
ing
& K
enne
dy,
1990
II, I
V, I
II
Schr
eibm
an &
Car
r, 19
78
II, I
V, I
I
McM
orro
w &
Fox
x,
1986
—Ex
perim
ent 1
II, I
V, I
I
McM
orro
w &
Fox
x,
11 y
r (1)
27 a
nd 3
6 yr
(2
)
7 (w
aut
.), 9
, 30
yr (
3)
15 y
r-au
tism
; 19
yr D
own
synd
rom
e (2
)
7 an
d 15
MR
(2
)
21 y
r (1)
MB
L !
beha
vior
s
!M
BL
!Ss
and
MB
L !
Trai
ners
for S
2
ATD
and
Rev
ersa
l de
sign
s
AB
CB
CB
MB
L !
Ss
MB
L !
Q ty
pes
(iden
ti-fic
atio
n, in
tera
ctio
n,fa
cts/
figur
es)
Prom
pts,
rein
forc
e-m
ent,
corr
ectio
n us
ed to
teac
h si
gn
RQ
s in
sim
ulat
ion
setti
ng a
nd th
en
natu
ral s
ettin
g
FCT
(toke
n ex
chan
ge fo
r S1
and
sig
ns fo
r S2)
af
ter s
erie
s of
DR
O a
ndD
RI c
ondi
tions
RQ
s (e
.g.,
Plea
se) t
augh
t w
ith le
ast-m
ost p
rom
pt-
ing;
TO
or g
radu
ated
gu
idan
ce c
onse
quen
ces
for p
robl
em b
ehav
iors
DR
O a
nd ti
me-
out i
n ta
sk
and
leis
ure
cont
exts
Taug
ht “
I don
’t kn
ow”
in
R to
pre
viou
sly
echo
ed
Qs,
pro
mpt
-fad
ing
Pres
ent a
nsw
er c
ard,
sile
nce
cue,
ask
Q, p
oint
to c
ard,
repe
at Q
with
out c
ard
% c
orre
ct s
ign
prod
uc-
tion
Gra
bbin
g, y
ellin
g,an
d si
gn R
Qs
durin
gsc
hool
day
Mea
n se
lf-in
jury
Rs/
RQ
an
d Fr
eq s
elf-
inju
ry #
aggr
essi
on
% o
f int
erva
ls w
ith p
rob-
lem
beh
avio
r; in
de-
pend
ent s
igni
ng o
r sw
itch
pres
ses
(S2)
,pr
ompt
s
3 st
ereo
typi
c be
havi
ors
per p
artic
ipan
t (%
in-
terv
als)
# of
“I d
on’t
know
,” a
p-pr
opria
te, &
ech
olal
ic
Rs
Cor
rect
Rs
to Q
s in
3
cont
ent a
reas
&
echo
lalia
!se
tting
s
!tra
iner
s, s
ettin
gs,
and
task
dem
ands
!th
erap
ists
!be
havi
ors
(rat
e of
cor
rect
Rs
in
task
con
text
)
!un
train
ed Q
s,
wh-
Q ty
pes,
and
pe
rson
s
!pe
rson
s
Alth
ough
sig
ns le
arne
d in
si
mul
atio
n se
tting
, sig
n us
e an
d re
duct
ion
in m
alad
ap-
tive
beha
vior
s oc
curr
ed
only
afte
r tra
inin
g in
nat
-ur
al s
ettin
g
S1—
imm
edia
te re
duct
ion
in
self-
inju
ry a
nd s
pont
aneo
usR
Qs →
!0
afte
r 12
wk
of
FCT
S2—
robu
st e
ffec
ts o
n pr
ob-
lem
beh
avio
r (!
0 af
ter
8 w
k) a
nd in
crea
ses
in
spon
tane
ous
com
mun
icat
ion
S1—
com
pone
nt a
naly
sis
show
edth
at F
CT
and
TO (a
nd n
otD
RO
) →in
crea
se s
igni
ng a
ndde
crea
sed
prob
lem
beh
avio
r;FC
T an
d gr
adua
ted
guid
ance
mos
t eff
ectiv
e fo
r S3;
FC
Tal
one
effe
ctiv
e fo
r S2
DR
O a
nd n
ot T
O re
duce
d pr
oble
m b
ehav
ior (
and
in-
crea
sed
corr
ect R
s) in
task
cont
ext a
nd o
nly
TO re
-du
ced
prob
lem
beh
avio
r in
leis
ure
cont
ext
Gen
eral
ized
redu
ctio
n in
echo
lalic
resp
ondi
ng a
fter
taug
ht “
I don
’t kn
ow”
R,
mai
ntai
ned
at 1
mo
follo
w-u
p
70–1
00%
ech
oes
in b
asel
ine
repl
aced
with
cor
rect
re-
spon
ses
whe
n pa
use-
poin
tpr
ompt
s pr
ovid
ed, p
oint
ing
fade
d
35 s
choo
l da
ys
S1 !
120
wee
ks; S
2!
200
wee
ks
29, 1
4, a
nd 4
2 se
s-si
ons
27 a
nd 3
0 se
ssio
ns
37 s
essi
ons
daily
30–
40
min
, 95
sess
ions co
ntin
ued
1986
—Ex
perim
ents
2
and
3II
, IV
, II
Foxx
, Faw
, McM
orro
w,
Kyl
e, &
Bitt
le, 1
988
II, I
I, II
Dav
is, B
rady
, Will
iam
s,
& H
amilt
on, 1
992
II, I
V, I
I
Koe
gel,
Koe
gel,
&
Surr
att.
1992
I, II
, II
Not
e: R
oman
num
eral
s in
the
first
col
umn
deno
te ra
tings
of i
nter
nal v
alid
ity, e
xter
nal v
alid
ity, a
nd g
ener
aliz
atio
n, re
spec
tivel
y, b
ased
on
the
follo
win
g cr
iteria
:In
tern
al v
alid
ity: I
, Pro
spec
tive
grou
p or
sin
gle-
subj
ect d
esig
n ex
perim
ent c
ompa
ring
alte
rnat
ive
treat
men
ts; I
I pre
-pos
t gro
up d
esig
n or
sin
gle-
subj
ect d
esig
n w
ith re
liabl
e, o
bjec
tive
outc
omes
mea
sure
s;II
I, pr
e-po
st, e
x po
st fa
cto,
or s
ingl
e-su
bjec
t des
igns
with
que
stio
nabl
e in
tern
al v
alid
ity o
r mea
sure
men
t.Ex
tern
al v
alid
ity: I
, Ran
dom
ass
ignm
ent o
f wel
l-def
ine
coho
rts a
nd a
dequ
ate
sam
ple
size
; II,
nonr
ando
m a
ssig
nmen
t, bu
t wel
l-def
ined
coh
orts
and
ade
quat
e sa
mpl
e si
ze o
r rep
licat
ion
acro
ss 3
or m
ore
subj
ects
in a
sin
gle-
subj
ect d
esig
n; I
II, w
ell-d
efin
ed p
opul
atio
n of
3 o
r m
ore
subj
ects
in s
ingl
e-su
bjec
t des
igns
or
sam
ple
of a
dequ
ate
size
in g
roup
des
igns
; IV
, sm
all s
ampl
e in
gro
up d
esig
n or
1 o
r 2
subj
ects
in s
ingl
e-su
bjec
t des
ign.
Gen
eral
izat
ion:
I, C
onsi
sten
t gen
eral
izat
ion
to f
unct
iona
l set
ting
beyo
nd tr
eatm
ent s
ettin
g w
ithou
t fur
ther
inte
rven
tion
or r
obus
t soc
ial v
alid
atio
n re
sults
; II,
long
-term
mai
nten
ance
or
gene
raliz
atio
n to
one
setti
ng b
eyon
d tre
atm
ent s
ettin
g; II
I, in
terv
entio
n oc
curr
ed in
nat
ural
set
ting
or o
utco
me
mea
sure
with
doc
umen
t rel
atio
n to
func
tiona
l out
com
es; I
V, n
ot a
ddre
ssed
or o
ther
.M
BL
= M
ultip
le B
asel
ine
Des
ign;
FC
T =
Func
tiona
l Com
mun
icat
ion
Trai
ning
; TO
= T
ime-
Out
; NLP
= N
atur
al L
angu
age
Para
digm
; RQ
= R
eque
st; Q
= Q
uest
ion;
R =
Res
pons
e; T
x =
Trea
tmen
t; ge
n =
gene
raliz
atio
n.
21 y
r (1)
13, 3
6, 4
0 yr
(3
)
7 w
ith D
own
synd
rom
e an
d 5
yr (2
)
3–4
yr o
ld (3
)
MB
L !
Q s
ets
MB
L !
Ss
MB
L !
train
ers
Rev
ersa
l des
ign
(BC
BC
)w
ith c
ount
erba
lanc
ing
Imm
edia
te (E
xper
imen
t 2)
and
dela
yed
(Exp
eri-
men
t 3) m
odel
ing
of a
n-sw
ers
by a
noth
er a
dult
Pres
ent a
nsw
er c
ard,
si-
lenc
e cu
e, a
sk Q
, poi
nt
to c
ard,
repe
at Q
with
-ou
t car
d
Serie
s of
hig
h-pr
obab
ility
R
Q a
dmin
iste
red
prio
r to
eac
h lo
w-p
roba
bilit
y R
Q
Ana
log
(dis
cret
e-tri
al)
vers
us N
LP te
achi
ng
proc
edur
es
Cor
rect
Rs
to Q
s in
2
cont
ent a
reas
&
echo
lalia
Cor
rect
ver
bal l
abel
s in
R
to Q
s, e
chol
alic
Rs
% c
orre
ct R
s to
RQ
s
Dis
rupt
ive
beha
vior
an
d la
ngua
ge ta
rget
be
havi
ors
!no
vel s
timul
i in
Expe
rimen
t 3
!un
train
ed Q
s an
d se
tting
s
!ad
ults
exp
effe
cts
for
lang
uage
targ
ets
not p
rese
nted
gr
aphi
cally
, but
sm
all-m
oder
ate
effe
cts
impl
ied
by
cond
ition
ave
rage
s
Mod
elin
g →
imm
edia
te in
-cr
ease
s in
cor
rect
Rs
to Q
s an
d go
od m
aint
enan
ce
Cue
s-pa
use-
poin
t tra
inin
g →
corr
ect l
abel
ing
Rs
and
de-
crea
sed
echo
lalia
, gen
eral
-iz
ed !
setti
ngs
Imm
edia
te in
crea
se in
Rs
to
low
-pro
babi
lity
RQ
s w
hen
tx a
dmin
iste
red;
gen
afte
r im
plem
ente
d by
2–3
adu
lts
Con
sist
ently
less
than
20%
di
srup
tions
in N
LP c
ondi
-tio
ns a
nd 2
0–90
% in
ana
-lo
g co
nditi
ons;
51 s
essi
ons
and
48
sess
ions
!87
tria
ls
!25
day
s,
max
of 4
0 tri
als/
day
11–1
6 se
ssio
ns
Tab
le V
.In
terv
entio
ns to
Pro
mot
e So
cial
and
Scr
ipte
d In
tera
ctio
ns
Parti
cipa
nts
Expe
rimen
tal
Inde
pend
ent
Dep
ende
nt
Gen
eral
izat
ion
Ref
eren
ces
(n)
desi
gnva
riabl
esva
riabl
esm
easu
res
Res
ults
Dur
atio
n
McG
ee, K
rant
z,
McC
lann
ahan
, 198
4
II, I
I, II
Shaf
er, E
gel,
&
Nee
f, 19
84
II, I
I, II
Gol
dste
in,
Kac
zmar
ek,
Penn
ingt
on, &
Sh
afer
, 199
2II
, II,
III
Cha
rlop
& M
ilste
in,
1989
II, I
I, I
Gol
dste
in &
Cis
ar,
1992
II, I
I, II
Not
e: R
oman
num
eral
s in
the
first
col
umn
deno
te ra
tings
of i
nter
nal v
alid
ity, e
xter
nal v
alid
ity, a
nd g
ener
aliz
atio
n, re
spec
tivel
y, b
ased
on
the
follo
win
g cr
iteria
:In
tern
al v
alid
ity: I
, Pro
spec
tive
grou
p, o
r si
ngle
-sub
ject
des
ign
expe
rimen
t com
parin
g al
tern
ativ
e tre
atm
ents
; II,
pre-
post
gro
up d
esig
n or
sin
gle-
subj
ect d
esig
n w
ith r
elia
ble,
obj
ectiv
e ou
tcom
es m
ea-
sure
s; II
I, pr
e-po
st, e
x po
st fa
cto,
or s
ingl
e-su
bjec
t des
igns
with
que
stio
nabl
e in
tern
al v
alid
ity o
r mea
sure
men
t.Ex
tern
al v
alid
ity: I
, Ran
dom
ass
ignm
ent o
f w
ell-d
efin
e co
horts
and
ade
quat
e sa
mpl
e si
ze; I
I, no
nran
dom
ass
ignm
ent,
but w
ell-d
efin
ed c
ohor
ts a
nd a
dequ
ate
sam
ple
size
or
repl
icat
ion
acro
ss th
ree
orm
ore
subj
ects
in a
sin
gle-
subj
ect d
esig
n; II
I, w
ell-d
efin
ed p
opul
atio
n of
thre
e or
mor
e su
bjec
ts in
sin
gle-
subj
ect d
esig
ns o
r sam
ple
of a
dequ
ate
size
in g
roup
des
igns
; IV
, sm
all s
ampl
e in
gro
up d
esig
n or
1 or
2 s
ubje
cts
in s
ingl
e-su
bjec
t des
ign.
Gen
eral
izat
ion:
I, C
onsi
sten
t gen
eral
izat
ion
to f
unct
iona
l set
ting
beyo
nd tr
eatm
ent s
ettin
g w
ithou
t fur
ther
inte
rven
tion
or r
obus
t soc
ial v
alid
atio
n re
sults
; II,
long
-term
mai
nten
ance
or
gene
raliz
atio
n to
one
setti
ng b
eyon
d tre
atm
ent s
ettin
g; II
I, In
terv
entio
n oc
curr
ed in
nat
ural
set
ting
or o
utco
me
mea
sure
with
doc
umen
t rel
atio
n to
func
tiona
l out
com
es; I
V, n
ot a
ddre
ssed
or o
ther
.M
BL
= M
ultip
le B
asel
ine
Des
ign;
RQ
= R
eque
st; Q
= Q
uest
ion;
R =
Res
pons
e; T
x =
treat
men
t; ge
n =
gene
raliz
atio
n.
13–1
5 yr
(3)
5–6
yr (4
)
3–6
(5)
6–7
yr (3
)
Pres
choo
l (3)
intri
ads
with
two
typi
cal p
eers
MB
L !
asse
rtive
R c
lass
es
MB
L !
Ss
AB
CB
reve
rsal
MB
L !
Ss a
ndm
ultip
le p
robe
!co
nver
satio
ns
MB
L !
scrip
ts
Mod
elin
g, re
hear
sal,
and
toke
n re
info
rcem
ent
Peer
s ta
ught
to s
hare
and
give
pla
y di
rect
ions
usi
ng
mod
els,
pro
mpt
s,pr
actic
e, a
nd fe
edba
ck
Tria
ds w
ith tw
o ty
pica
lpe
ers
prom
pted
to
atte
nd to
, com
men
t,an
d re
spon
d to
Ss
durin
g pl
ayPe
er v
ideo
mod
elin
g of
scr
ipte
d co
nver
satio
ns a
ndtim
e de
lay
Thre
e so
ciod
ram
atic
play
scr
ipts
with
10
beha
vior
s fo
r eac
h of
thre
e ro
les
taug
ht
% in
terv
als
with
pos
i-tiv
e an
d ne
gativ
e as
serti
ons
to p
eers
durin
g ca
rd g
ame
and
ball
gam
eM
otor
-ges
tura
l and
voca
l-ver
bal i
nitia
-tio
ns a
nd re
spon
ses
Ver
bal a
nd n
onve
rbal
com
mun
icat
ion
acts
and
adul
t mon
itorin
gbe
havi
ors
Rs
varia
tions
, Q a
skin
g,sc
ripte
d co
nver
sa-
tions
Trai
ned
and
untra
ined
them
e-re
late
d an
dun
rela
ted
soci
albe
havi
ors
Gen
to
untra
ined
pos
itive
asse
rtion
s an
d 4.
5m
o fo
llow
-up
!se
tting
s
No
!un
train
ed
topi
cs,
pers
ons,
se
tting
s, a
ndst
imul
i, so
cial
valid
atio
n!
peer
gr
oupi
ngs
Tx →
clea
r inc
reas
es re
plic
ated
acro
ss fo
ur R
cla
sses
& S
s,st
rong
er e
ffec
ts fo
r pos
itive
as
serti
ons
Rap
id im
prov
emen
t in
soci
al
beha
vior
s (m
ainl
y R
s) d
urin
gpe
er tr
aini
ng; f
ollo
wed
by
gen
to tr
nd p
eer o
nly
in p
lay
grou
p; tr
aini
ng n
eede
d fo
r gen
!se
tting
sPe
er s
trate
gy u
se a
ssoc
iate
d w
ith in
crea
sed
soci
al b
ehav
ior,
but m
ainl
y no
nver
bal f
or a
ll bu
t 1 c
hild
Incr
easi
ng q
uick
and
robu
st g
enpr
oduc
tion
of 3
-beh
avio
r co
nver
satio
ns a
fter m
ax o
f 3 o
f5
or 6
con
vers
atio
ns m
odel
ed
Each
scr
ipt l
earn
ed in
crea
sing
lyqu
ickl
y an
d →
them
e-re
late
din
tera
ctio
n, p
lus
mai
nten
ance
and
gen
to u
ntra
ined
, rel
ated
ut-
tera
nces
18 s
essi
ons
and
4.5
mo
follo
w-u
p
3–6
peer
trai
n-in
g se
ssio
ns
39–5
1 se
ssio
ns
3–20
vid
eovi
ewin
gs to
reac
h cr
ite-
rion
6–15
sess
ions
/scr
ipts
and
30–3
9 pl
ayse
ssio
ns
Tab
le V
I.Pa
rent
and
Cla
ssro
om T
rain
ing
Ref
eren
ces
Parti
cipa
nts
(n)
Expe
rimen
tal d
esig
nIn
depe
nden
t var
iabl
esD
epen
dent
var
iabl
esR
esul
tsD
urat
ion
Har
ris, W
olch
ilk,
& W
eltz
, 198
1
III,
IV, I
VH
owlin
& R
utte
r, 19
89
II, I
I, II
IH
arris
, Han
dlem
an,
Kris
toff
, Bas
s, &
G
ordo
n, 1
990
III,
IV, I
VO
zono
ff &
Cat
hcar
t, 19
98
II, I
I, IV
Joce
lyn,
Cas
iro,
Bea
ttie,
Bow
, &
Kne
isz,
199
8
I, II
, IV
Not
e: R
oman
num
eral
s in
the
first
col
umn
deno
te ra
tings
of i
nter
nal v
alid
ity, e
xter
nal v
alid
ity, a
nd g
ener
aliz
atio
n, re
spec
tivel
y, b
ased
on
the
follo
win
g cr
iteria
:In
tern
al v
alid
ity: I
, Pro
spec
tive
grou
p or
sin
gle-
subj
ect d
esig
n ex
perim
ent c
ompa
ring
alte
rnat
ive
treat
men
ts; I
I, pr
e-po
st g
roup
des
ign
or s
ingl
e-su
bjec
t des
ign
with
relia
ble,
obj
ectiv
e ou
tcom
esm
easu
res;
III,
pre-
post
, ex
post
fact
o, o
r sin
gle-
subj
ect d
esig
ns w
ith q
uest
iona
ble
inte
rnal
val
idity
or m
easu
rem
ent.
Exte
rnal
val
idity
: I, R
ando
m a
ssig
nmen
t of w
ell-d
efin
ed c
ohor
ts a
nd a
dequ
ate
sam
ple
size
; II,
nonr
ando
m a
ssig
nmen
t, bu
t wel
l-def
ined
coh
orts
and
ade
quat
e sa
mpl
e si
ze o
r rep
licat
ion
acro
ss3
or m
ore
subj
ects
in a
sin
gle-
subj
ect d
esig
n; II
I, w
ell-d
efin
ed p
opul
atio
n of
thre
e or
mor
e su
bjec
ts in
sin
gle-
subj
ect d
esig
ns o
r sam
ple
of a
dequ
ate
size
in g
roup
des
igns
; IV
, sm
all s
ampl
e in
grou
p de
sign
or 1
–2 s
ubje
cts
in s
ingl
e-su
bjec
t des
ign.
Gen
eral
izat
ion:
I, C
onsi
sten
t gen
eral
izat
ion
to fu
nctio
nal s
ettin
g be
yond
trea
tmen
t set
ting
with
out f
urth
er in
terv
entio
n or
robu
st s
ocia
l val
idat
ion
resu
lts; I
I, lo
ng-te
rm m
aint
enan
ce o
r gen
eral
-iz
atio
n to
one
set
ting
beyo
nd tr
eatm
ent s
ettin
g; II
I, in
terv
entio
n oc
curr
ed in
nat
ural
set
ting
or o
utco
me
mea
sure
with
doc
umen
t rel
atio
n to
func
tiona
l out
com
es; I
V, n
ot a
ddre
ssed
or o
ther
.
30–7
4 m
o (1
1)
3–11
yr (
30)
4–5
yr (1
0)
2–5
yr (2
2)
2–6
yr a
nd p
aren
ts(3
5)
Two
grou
ps tr
nd (h
ome
vers
us la
b tre
atm
ent?
),re
peat
ed m
easu
res
desi
gn
Mat
ched
gro
up
com
paris
on
Gro
up a
ssig
nmen
t,m
atch
ed b
ut n
ot ra
n-do
mly
ass
igne
d
Trea
tmen
t ver
sus
no-
treat
men
t com
paris
on,
mat
ched
gro
ups
Ran
dom
ized
con
trolle
dtri
al, 1
6 in
exp
erim
en-
tal g
roup
and
19
in d
ayca
re o
nly
grou
p
10 w
eekl
y pa
rent
train
ing
grou
pm
eetin
gs a
nd 6
cons
ulta
tive
hom
evi
sits
Pare
nts
taug
ht b
ehav
-io
ral t
echn
ique
s(q
uest
ions
, rep
eti-
tion,
exp
ansi
on,
corr
ectio
n,pr
ompt
s, a
nd re
in-
forc
emen
t)
Inte
grat
ed v
ersu
sse
greg
ated
cla
sses
TEA
CC
H-b
ased
hom
e pr
ogra
m, b
utno
trea
tmen
t fi-
delit
y m
easu
res
12 w
k of
lect
ures
,co
nsul
tatio
ns a
tda
y-ca
re c
ente
rsfo
r sta
ff a
nd p
ar-
ents
, and
fam
ilysu
ppor
t
Num
ber c
orre
ct a
ndhi
ghes
t ste
p on
hi-
erar
chy
of 2
1 co
m-
mun
icat
ion
skill
s
Freq
uenc
y of
com
-m
unic
ativ
e sp
eech
,ec
hola
lia a
nd n
on-
com
mun
icat
ive
ut-
tera
nces
, inc
reas
eco
mpl
exity
Pres
choo
l Lan
guag
eSc
ale
Psyc
hoed
ucat
iona
lPr
ofile
-Rev
ised
—7
deve
lopm
enta
ldo
mai
ns
Aut
ism
Kno
wle
dge
Qui
z, R
atin
gA
utis
m S
ympt
oms,
EI a
nd P
resc
hool
Dev
elop
men
t Pro
-fil
es, F
amily
as-
sess
men
t and
stre
ssm
easu
res,
sat
isfa
c-tio
n m
easu
re
Larg
e ef
fect
s fo
r 2 o
f 5ve
rbal
chi
ldre
n, m
od
effe
cts
for 2
non
verb
alch
ildre
n, o
ther
eff
ects
min
imal
. Sig
nific
ant v
er-
bal v
ersu
s no
nver
bal !
time
inte
ract
ion.
No
chan
ges
at 1
yr f
ollo
w-u
p.C
lear
exp
erim
enta
l eff
ects
for m
othe
rs a
nd C
hn;
Sign
ifica
nt in
crea
se in
child
ren’
s so
cial
utte
r-an
ces,
mor
phem
es, a
ndre
duct
ion
in in
com
pre-
hens
ible
and
non
verb
albe
havi
or fo
r exp
erim
enta
lgr
oup.
Hig
h co
rrel
atio
nbe
twee
n m
othe
rs’ a
ndch
ildre
n’s
lang
uage
chan
ges
No
pret
est-p
ostte
st g
roup
diff
eren
ces
Sign
ifica
nt g
rp !
time
ef-
fect
s on
imita
tion,
fine
and
gros
s m
otor
, and
nonv
erba
l cog
nitiv
e do
-m
ains
Sign
ifica
nt g
rp !
time
in-
tera
ctio
n fo
r one
of s
ixde
velo
pmen
tal d
omai
ns(i.
e., l
angu
age)
; als
o gr
p!
time
diff
eren
ce in
Aut
ism
Qui
z fo
r mot
hers
and
child
car
e w
orke
rs
10 w
k
18 m
o in
terv
entio
n, c
om-
paris
on a
fter 6
mo
repo
rted
5–11
mos
8–12
trai
ning
ses
sion
s,
10 w
k of
trea
tmen
t, 4
mo
betw
een
pre-
and
post
-test
s
12 w
k
results of each study; (b) summaries of the ages andnumber of subjects included in individual studies; (c)the experimental designs; (d) the independent variablesunder investigation or an outline of the treatment com-ponents; (e) the measures used to evaluate primary ef-fects and generalized effects; (f ) a summary of results,and (g) an estimate of the duration of training or thestudy length. The studies were categorized to reflect sixprimary approaches to the development of communica-tion interventions that are commonly applied to chil-dren with autism. Table I summarizes studies thatincorporated sign language into training. Table II sum-marizes studies using a variety of largely operant ap-proaches to language intervention that appear to bepresented in discrete trial training formats. Table III in-cludes studies that sought to teach language using var-ious milieu language teaching paradigms. Table IVsummarizes studies that investigated the relationship be-tween problem behaviors and communication skills.Table V includes studies that sought to promote socialand scripted interactions that focused on language skills.Table VI includes more general parent and classroomtraining approaches that included measures of language.
COMMUNICATION INTERVENTIONSINCORPORATING SIGN LANGUAGE
Much research has explored the effects of intro-ducing gestural and visual modes of communicationthrough augmentative and alternative communicationsystems. Clearly, the use of augmentative and alterna-tive communication systems has spurred the develop-ment of language skills with a great number of childrenwho had extremely limited communication abilities.Presenting language stimulation using the visual modal-ity seems to capitalize on an area of relative strengthfor many children with autism. Table I includes nineexperiments that investigated the benefits of introduc-ing signs with children with autism. Experiments usingcommunication systems using pictures, symbols, print,vocal output devices, and such are reviewed in theMirenda chapter (this volume). Of course, great interestin the latter area was generated given the miraculousclaims offered by proponents of “facilitated commu-nication.” When those claims have been subjected torigorous experimental scrutiny, however, evidence ofmeaningful communication under the control of indi-viduals with autism was found lacking (see Green,1994; Jacobson & Mulick, 1995).
Dating back to the late 1970s some investigatorsfocused on the use of sign language systems. A num-
Communication Intervention 385
ber of studies compared the effects of teaching ex-pressive vocabulary using speech, sign, or total com-munication (speech # sign) input (BarreraLobatos-Barrera, & Sulzer-Azaroff 1980, 1983; Lay-ton, 1988; McIlvane, Bass, O’Brien, Gerovac, & Stod-dard, 1984; Yoder & Layton, 1988). Other studiestaught receptive vocabulary (Brady & Smouse, 1978;Carr & Dores, 1981; Carr, Pridal, & Dores, 1984;Wherry & Edwards, 1983) or both expressive and re-ceptive vocabulary (Layton, 1988). The results of thesestudies are rather consistent. Sign or total communica-tion training resulted in quicker and more completelearning of vocabulary than speech training for manyparticipants. The participants who benefit most seemto be those with more limited communication reper-toires, whereas more sophisticated participants, and es-pecially those with better verbal imitation skills, aremore likely to learn from systematic discriminationtraining regardless of the mode of communication. Par-ticipants with good verbal imitation skills are morelikely to demonstrate speech production in addition toor in lieu of sign production than participants with poorverbal imitation skills (Carr & Dores, 1981; Carr, Pri-dal, & Dores, 1984; Yoder & Layton, 1988). The onestudy (Yoder & Layton, 1988) that sought to explorewhether other factors might predict spoken vocabularyperformance found verbal imitation to account for amajority of the variance (R2 " .63), and that 78% ofthe variance could be accounted for by adding age andIQ to the regression model. In some studies the extentof the repertoire taught was quite limited; for example,Hinerman, Jensen, Walker, and Peterson (1982) taughta participant to request “milk” and “cookies.” Very fewstudies progressed beyond single words; Keogh, Whit-man, Beeman, Halligan, and Starzynski (1987), in astudy with older students, taught brief dialogues. Mostof the studies employed single-subject experimental de-signs with 1 to 10 participants. Two studies enrolled 60participants each and randomly assigned participants tofour treatment conditions (Layton, 1988; Yoder & Lay-ton, 1988).
Although interest in this area has waned, the gen-eral findings are fairly clear. Total communication ap-pears to be a viable treatment strategy for teachingreceptive and expressive vocabulary (i.e., languagecontent) to individuals with autism. The presentationof speech alone is less effective for individuals whohave poor verbal imitation skills in particular. Althoughfew studies explored the use of sign alone, it is con-traindicated because the likelihood of children pro-ducing speech is diminished. In contrast, totalcommunication often results in comprehension and pro-
duction of both signs and speech. Because the focus ofthese studies has been on teaching vocabulary for themost part, one can assume that investigators have notpursued this approach to the point of teaching sign lan-guage as an alternative communication system to chil-dren with autism. Thus it would appear that presentingsigns as well as speech is mainly an effective adjunctstrategy for jump-starting early vocabulary learning.Signs represent another symbolic system for represent-ing objects and actions in the world that children withautism hopefully will be motivated to request, label, andcomment upon. Signs are less transient than words, andgestures and signs are easier to prompt than verbal pro-ductions. Whether these or other reasons underlie theirbenefits is largely a matter of speculation at this point.
INTERVENTIONS INCORPORATINGDISCRETE TRIAL TRAINING FORMATS
Table II summarizes 12 experiments that investi-gated methods of teaching comprehension and/or pro-duction of various language content (e.g., vocabularyand phrases) and forms (e.g., verb # adjectives # nounutterances). One study focused on speech production(i.e., phonology) (Koegel, O’Dell, & Dunlap, 1988),and one study focused on gestural communication(Buffington, Krantz, McClannahan, & Poulson, 1998).The majority of the experiments taught children to pro-duce single-word responses or single phrases (e.g.,“What’s that?”). However, children’s responses re-quired discrimination of language forms (e.g., differ-ent types of wh-questions). The last four experimentsin Table II taught sentences.
These studies investigated teaching proceduresthat were employed in a variety of discrete-trial train-ing formats. Thus various differential reinforcementand correction procedures with modeling of responsesand prompting-fading procedures are commonalities.Not surprisingly, these procedures are largely effectivein teaching the behaviors of interest. Perhaps the mostimpressive of these studies are those experiments inwhich the training was organized to teach increasinglycomplex productions. Krantz, Zalewski, Hall, Fenski,& McClannahan (1981) taught children to describe ob-jects and pictures using four-term sentences (verbs #colors # shape/size # labels) and to answer a varietyof what, how, and why questions about immediate andthen past events with single or multiple sentences.
One should note that the questions addressed bythese studies typically went beyond straightforward ef-fects of instruction to explore procedures that might
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produce more efficient learning or generalized treat-ment effects. For example, McIlvane et al. (1984)demonstrated that exclusion procedures in which un-known food names are presented in the context ofknown foods resulted in accurate receptive respondingand that expressive naming emerged without specifictraining after relatively few trials. Although the exclu-sion procedure (akin to process of elimination) is ef-fective for teaching basic concepts or novel words in amanner that permits generative language learning, itsuse with children with autism is not evident in the lite-rature. This work has been replicated and extended withother individuals with severe developmental disabili-ties, however.
Buffington et al. (1998) demonstrated that chil-dren with autism could be taught to include gestures toaccompany simple verbal responses to improve theircommunication. It is not clear in the article whether thetraditional training provided affected gestural and ver-bal communication skills equally, but social validitymeasures indicated that their communicative attemptswere virtually indistinguishable from age-matched typi-cal peers. Although the children generalized to probesusing novel materials, data on carryover to natural en-vironments were not included.
Research on autism also has contributed greatly tothe literature on generalization-promoting strategies. Awell-established technology for producing generaliza-tion is still under development, based largely on theconceptualization of several strategies forwarded byStokes and Baer (1977) in their landmark article. Forexample, when a multiple exemplar approach did notproduce consistent results (Egel, Shafer, & Neef,1984; Handleman, 1979, 1981), investigators devel-oped additional strategies to overcome deficiencies ingeneralization exhibited by children with autism. In-vestigators found that minimal additional training wasrequired. Also, embedding instruction across the dayor interspersing different types of trials proved rathereffective (Egel, et al. 1984; McMorrow & Foxx, 1986;Neef, Walters, & Egel, 1984; Secan, Egel, & Tilley,1989). These findings seem to indicate that general-ized effects are not likely when generalization probesare easily discriminated from the training situation.However, if training exemplars are selected carefully,are sampled broadly from natural contexts relevant tothe child, and are embedded within those contexts,then widespread generalization across settings islikely to result.
Perhaps the experiment in which generalizationwas most clearly elucidated was an application ofmatrix-training procedures to object-preposition-location
utterances (e.g., penny under couch) with two pre-schoolers with autism (Goldstein & Brown, 1989). Inthat study, recombinative generalization to new utter-ances occurred predictably as new preposition and lo-cation words were learned via peer modeling in thecontext of 6 to 8 utterances systematically selected from64 possible combinations of 4 known objects, 4 un-known prepositions, and 4 unknown locations. Gener-alization accounted for 95% of the 128 responsesgenerated. Generalization from production to compre-hension did not occur until modeling in that modalitywas demonstrated, however. The conditions that pro-duce cross-modal transfer remain elusive.
In summary, experiments involving discrete-trialtraining formats have provided a foundation for the de-velopment of procedures needed to teach discrimina-tive performances that children with autism had notlearned on their own. In contrast to the investigationsin the late 60s and the 70s, there has been increasingattention on teaching somewhat more sophisticated lan-guage and on improving the generalized use of new lan-guage skills. These advances have been in response tothe often-disappointing effects of discrete-trial teach-ing on the everyday functioning of children withautism. The need to assess and program generalizationfrom training situations into everyday living contextshas inspired application of many of the same instruc-tional strategies within the natural milieu of home,school, and community contexts.
INTERVENTIONS DESIGNED FORIMPLEMENTATION IN THE NATURALMILIEU
Table III presents summaries of 12 studies that in-vestigated time delay, milieu language teaching, or nat-ural language paradigm interventions. Time delay is aprompting procedure in which a delay is imposed be-tween a stimulus and a prompt or a hierarchy ofprompts. The delay can be held constant (e.g., 5 seconds)or can be lengthened progressively until the child an-ticipates the prompt and produces the desired verbal ormotor response. Time delay procedures have estab-lished rapid and often generalized language produc-tions, especially requesting, when the communicationsskills are in children’s repertoire but rarely used (e.g.,Charlop, Schreibman, & Thibodeau, 1985). In manystudies it is not clear whether children are acquiringnew skills, however. Correction procedures usually ap-pear to accompany the use of time-delay procedures;so modeling with or without prompts to imitate tends
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to be an additional intervention component (Charlop &Trasowech, 1991; Charlop & Walsh, 1986). Charlopand Walsh (1986) found that implementing a time delayprocedure was associated with spontaneous productionsof “I like/love you,” whereas peer modeling of this ut-terance was not effective. Matson, Sevin, Box, Fran-cis, and Sevin (1993) found modeling and the fadingof visual cues as effective as the time delay procedurein teaching social phrases. McGee, Krantz, and Mc-Clannahan (1985) found traditional training with arbi-trary reinforcers as effective as incidental teaching withrequested items serving as reinforcers when teachingchildren to produce prepositions; but better general-ization across settings and more spontaneous produc-tions resulted from incidental teaching. Likewise, Neefet al. (1984) found greater generalization of yes/no re-sponses to various question types when teaching trialswere embedded across the day in comparison to tutor-ing sessions.
Milieu language teaching is a family of proceduresthat are designed to capitalize on children’s desires andinterests in their natural environments to embed teach-ing opportunities. Incidental teaching (cf. Hart & Risley,1975), perhaps the hallmark of milieu language teach-ing, requires that the child initiate an attempt to com-municate, usually to make a request. Mand-modelprocedures were developed to teach fundamental com-munication skills that could be used to make requeststo children who are not initiating. Then time-delay pro-cedures could be used to teach independent use of thoseskills. Other procedures that are designed for use in nat-ural environments with a focus on following the child’slead might be considered forms of milieu languageteaching (e.g., the Natural Language Paradigm).
Milieu language teaching is usually used to teachrequesting, because high motivation is inherent whenindividuals are requesting desired items that presum-ably function as reinforcers. However, an examinationof Table III reveals that a variety of communicativefunctions are being taught to children with autism usingmilieu teaching procedures: preverbal communication(eye contact, joint attention, and motor imitation,Hwang & Hughes, 2000); spontaneous productions of“I like/love you” (Charlop & Walsh, 1986); descrip-tions of drawings and car play (Ingenmey & VanHouten, 1991); social amenities such as “please, thankyou, excuse me, you’re welcome, hello” (Matson et al.,1993); positive interactions with peers (McGee,Almeida, Sulzer-Azaroff, & Feldman, 1992), answersto “Where is ___?” questions (McGee et al. 1985);phoneme production (Koegel, Camarata, Koegel, Ben-Tall, & Smith, 1998); and simply increased talking
(Laski, Charlop, & Schreibman, 1988). It is notable thatparents have been taught to implement time delay pro-cedures (Charlop & Trasowech, 1991) and the NaturalLanguage Paradigm (Laski et al., 1988). The NaturalLanguage Paradigm (NLP) is a multiple component in-tervention that continues to evolve because it has notalways been operationalized the same way (e.g.,Koegel, O’Dell, & Koegel, 1987; Laski et al., 1988).Characteristics of this approach have begun to be clar-ified, especially when contrasted with discrete-trialtraining. For example, Koegel et al. (1998) clearly con-trasted the procedural differences in analog (discrete-trial) versus naturalistic (NLP) intervention approachesbased on selection of stimulus items, steps in training,interaction patterns, response-reinforcer contingencies,and the types of consequences provided.
Research on milieu language teaching procedureshas been extensive and seems to be applicable to teach-ing early language skills to a broad population of chil-dren (see Kaiser, Yoder, & Keetz, 1992). Most of theapplications to children with autism have focused onMand-model and time-delay procedures to accommo-date their deficiencies in communicative initiations. In-vestigators have had success when applying fairlywell-established procedures that have been used withother populations.
At this point, there is no compelling evidence thatmilieu teaching procedures are clearly more effectivethan the procedures that have developed out of discrete-trial procedures. Indeed, one might argue that there isa great deal of commonality in the procedures em-ployed. An analysis of naturalistic language interven-tion procedures offered by Hepting and Goldstein(1996) includes many of the instructional techniquesfound in the discrete-trial teaching literature. One canargue that milieu language teaching procedures can bemore easily incorporated into everyday activities andreduce the need to program for generalization. Suchcomparisons of treatment approaches are not necessar-ily straightforward. An examination of Table II indi-cates that many interventions using discrete trialtraining have produced impressive generalization re-sults. Also, a comparison of Tables II and III shows lit-tle overlap in the target behaviors that were taught usingdiscrete-trial and milieu teaching procedures.
Comparison studies have yielded mixed results. Inone such comparison study, Elliott, Hall, and Soper(1991) taught receptive and expressive vocabulary to23 adults with autism and severe to profound mentalretardation using discrete-trial and natural languageteaching techniques using a crossover design withmatched groups; they found no significant differences
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in acquisition or generalization. Koegel et al. (1998)contrasted traditional (analog) articulation training witha naturalistic approach (Natural Language Paradigm)in a single-subject experiment (counterbalanced rever-sal design) and found much greater generalization toconversational language samples for phonemes taughtusing the naturalistic procedures.
Yoder et al. (1995) argue that teaching approachesmay differ depending on the language skills beingtaught or the linguistic sophistication of the children.Only in the case of sign language interventions (Yoder& Layton, 1988) have these correlational analyses beendone with children with autism. Nevertheless, a care-ful inspection of the correlational findings used to de-tect aptitude-by-treatment interactions indicates thatfew children consistently fall into the regions of sig-nificance that are differentially predictive of outcomes(e.g., Cole, Mills, Dale, & Jenkins, 1996; Yoder et al.,1995; Yoder & Warren, 1999). Defining profiles thatare predictive of differential treatment effects is thuslikely to be difficult. Experimental investigations ofaptitude-by-treatment interaction hypotheses have yetto be done with any children with developmental dis-abilities, let alone children with autism.
COMMUNICATION INTERVENTIONS TOREPLACE CHALLENGING BEHAVIOR
Table IV presents a summary of 17 experimentsin which communication skills have been taught as al-ternative to a variety of maladaptive or challenging be-haviors (e.g., stereotypy, aggression, tantrums, propertydestruction, self-injury, echolalia). This aspect of com-munication intervention emphasizes a view of languageas a means of control over one’s environment. Inter-ventions represented in this segment of the literaturehave been applied to especially challenging cases, mostoften children and adults with severe developmentaldisabilities and severe behavior problems, many ofwhom have been diagnosed with autism. Investigatorshave developed procedures for identifying antecedentand consequent variables that appear to motivate chal-lenging behavior in individuals with severe disabilities.Carr and Durand (1985) hypothesized that challengingbehaviors could serve a communicative function. Thisobservation has inspired numerous investigations inwhich individuals with autism and other disabilities aretaught specific language skills to serve the same com-municative function as their challenging behavior. Be-cause of the potential to prevent the development ofchallenging behavior by focusing on communication
training early, Table IV and this section of the reviewincludes data on older individuals with autism, manyof whom we can assume were not treated successfullywhen they were younger.
When individuals with autism are taught commu-nication skills that serve efficiently and effectively asalternative behaviors, reductions in challenging be-haviors result (Bird, Dores, Moniz, & Robinson, 1989;Carr & Durand, 1985; Durand & Carr, 1987, 1992;Horner & Budd, 1985). Determining the motivation ofchallenging behavior is important, because a typical re-sponse of allowing individuals to escape demands whenthis is the motivation for stereotypic behavior, for ex-ample, may serve to reinforce the undesired behavior(Durand & Carr, 1987). Although manipulation of con-sequences or teaching communication in other contextsmay be associated with initial reductions in challeng-ing behaviors, functional communication training con-ducted in a variety of natural contexts is associated withbroader generalization and greater maintenance of ef-fects (Bird et al., 1989; Durand & Carr, 1992; Horner& Budd, 1985). Identifying the function of challengingbehaviors and developing effective interventions isoften complicated. Wacker et al. (1990) demonstratedthat multiple-component interventions are sometimesmore effective than functional communication trainingalone. Haring and Kennedy (1990) showed that the mo-tivation of challenging behavior could vary based oncontext (task versus leisure contexts) as well.
Schreibman and Carr (1978) found that they couldreplace echoing of questions with a general verbal re-sponse (“I don’t know”). McMorrow and Foxx (1986)demonstrated that inhibiting the echoing of questionsaccompanied with teaching of correct responses (eitherthrough written cues or peer modeling) resulted in ap-propriate responding. They suggest the benefits ofteaching individuals to pause before responding. In sub-sequent extensions to this work (McMorrow, Foxx,Faw, & Bittle 1987; Foxx, Faw, McMorrow, Kyle, &Bittle 1988), they found that subsequent to cues-pause-point training, participants were able to apply their la-beling repertoire to untrained questions in a variety ofgeneralization settings. Davis, Brady, Williams, andHamilton (1992) demonstrated that embedding requeststhat are unlikely to obtain a response (low-probabilityrequests) within a series of requests that are respondedto readily (high-probability requests) can improve in-struction following. Koegel, Koegel, and Surratt (1992)found that teaching language targets to 3- to 4 year-olds using NLP procedures resulted in less disruptivebehavior than when using analog procedures in a dis-crete-trial format. However, data were not displayed
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adequately to determine whether consistent changes inlanguage responding were under such clear experi-mental control. In general, these studies demonstrateseveral effective strategies for remediating echolalia,noncompliance, and disruptive behavior in childrenwith autism.
This is an especially important area because of theintense interest in managing challenging behavior ofchildren with autism in school, as well as in home andcommunity settings. The replacement of challenging be-haviors with appropriate and increasingly sophisti-cated communication skills has the potential to havefar-reaching implications for academic achievement, so-cial relationship development, and vocational outcomes.
INTERVENTIONS TO PROMOTE SOCIAL ANDSCRIPTED INTERACTIONS
Table V summarizes studies from a larger body ofliterature on facilitating social skill development (seeMcConnell article, this volume). These five studieswere selected because of their inclusion of communi-cation measures. Two studies taught facilitative strate-gies to peers. When peers were taught to share and giveplay directions (Shafer, Egel, & Neef, 1984) or to at-tend to, comment, and respond to peers with autism(Goldstein, Kaczmarek, Pennington, & Shafer, 1992),children with autism demonstrated increased social-communicative interaction (mainly responding) duringplay. Maintenance and generalization across settings islargely dependent upon prompting peers to continueusing the facilitative strategies.
A common concern found in the literature is thedifficulty in getting children with autism to initiate in-teractions. A number of modeling and prompting ap-proaches have been used successfully to increaseinitiations, however. McGee et al. (1984) used model-ing, rehearsal, and token reinforcement to teach olderchildren with autism assertive statements to use withpeers during a card game and a ball game.
Investigators have taught scripted interactions ofvarying length and complexity. Charlop and Milstein(1989) showed videotapes of peers engaging in three-turn conversations. Goldstein and Cisar (1992) devel-oped sociodramatic play scripts involving three rolesthat were taught to triads with two typical peers and achild with autism; 10 behaviors per role were delin-eated with nonverbal, single word, or sentence-longvariations of each of the 30 steps in the sequence. Ineach of these studies children with autism demonstratedimproved peer interaction and the children produced
untrained as well as trained variations or elaborationson the scripts.
Given that a problem relating to others is a coresocial deficit associated with autism, the effectivenessof these interventions in increasing social interactionwith peers in particular is quite striking. Increased so-cial interactions can set the stage for other develop-ments as well, e.g., generalized use of newly acquiredlanguage skills, modeling of new language skills, in-clusion in more normalized educational settings, and,hopefully, the development of positive, long-lasting re-lationships with peers and others. This aspect of theliterature helps provide insights into methods for in-corporating communicative interventions into naturalenvironments of children with autism.
CLASSROOM AND PARENT INTERVENTIONSAPPLIED TO GROUPS
Table VI includes five group design studies thatseemed to focus on teaching communication skills orfocused their evaluations on language measures. SeeRogers (1998) for a review of evaluations of compre-hensive treatment programs, most of which were ap-plied for 2 or more years. Harris, Wolchik, and Weltz(1981) taught parents facilitative interaction skills andexamined effects on a hierarchy of communicationskills. Results were difficult to interpret (e.g., the na-ture of the groups); nevertheless, after 10 weeks, analy-ses revealed a significant verbal ability by timeinteraction, because the children with better imitationskills were the children who benefited most from treat-ment. No further improvements were evidenced afterparent training was terminated based on a 1-year fol-low-up. Howlin and Rutter (1989) conducted a matchedgroup comparison in which parents were taught behav-ioral techniques thought to facilitate language develop-ment. After 6 months of intervention, parents in theexperimental group talked more to their children andused more language facilitative forms. In turn, their chil-dren showed a significantly superior increase in socialutterances and morphemes, as well as a reduction intheir incomprehensible or nonverbal behaviors. Harris,Handleman, Kristoff, Bass, and Gordon (1990) admin-istered the Preschool Language Scale after 5 to 11months of intervention to 10 “matched” children withautism who were enrolled in integrated or segregatedpreschool classes and found no differences. Ozonoff andCathcart (1998) compared 22 “matched” children whoenrolled in the TEACCH program or a wait-list control.After 10 weeks of treatment, results revealed significant
390 Goldstein
group by time interactions on three of seven domainson the PEP-R, but not on the language domain.
The single randomized, controlled trial (n " 16 #19) compared typical day care with a day care that in-cluded 12 weeks of lectures and consultations for staffand families (Jocelyn, Casiro, Beattie, Bow, & Kneisz,1998). A significant group by time interaction effectwas shown for one of six developmental domains as-sessed using the Early Intervention or Preschool De-velopmental Profiles—the language domain.
Our confidence in the results of these studiesshould be tempered for a number of reasons. They suf-fer from a lack of true experimental designs (except forthe Jocelyn et al., 1998 study), small samples, short in-tervention periods, the absence of treatment fidelitymeasures, and sketchy descriptions of the interventions.In general, these group design studies reviewed reveallittle about what specific treatments or components ofintervention programs result in clinically significantimprovements in communication development. Thelack of randomized controlled clinical trials in theautism literature may seem disappointing. It can be ar-gued that sufficient knowledge has been accumulatedin the literature reviewed in previous sections to put to-gether treatment packages that are likely to be highlysuccessful in improving educational outcomes and dailyfunctioning of children with autism. However, the dif-ficulty in doing this should not be underestimated.
DISCUSSION OF THE STATE OF THELITERATURE
Participant Selection and Description
One will notice the lack of specificity in the col-umn used to summarize the participants in Table I toVI. It is difficult to provide brief summaries of devel-opmental levels and severity of impairments of partic-ipants with any confidence based on informationpresented in most journal articles. The level of detailand the nature of participant descriptions vary. Someinvestigators give priority to narrative descriptions, andothers rely largely on standardized assessments.Clearly, the field would benefit from a set of conven-tions that would help standardize the sharing of de-scriptive information about participants.
One of the limitations of this review is that it ig-nores a broader treatment literature that is pertinent tochildren with autism. Developmental disabilities re-searchers do not always report or highlight diagnosesof autism for a number of possible reasons: they maythink that the diagnosis is not relevant given their in-
terest in developing instructional procedures with broadapplicability; they may not have access to diagnosticrecords or may choose not to pursue diagnosticworkups. Nevertheless, many investigations describechildren with severe developmental disabilities who ex-hibit autistic characteristics. For example, Stoddard,McIlvane, and their colleagues (e.g., McIlvane, Dube,Green, & Serna, 1993; McIlvane et al., 1984) at theShriver Center have conducted extensive research withexceedingly difficult-to-teach individuals with devel-opmental disabilities. Their research is largely absentfrom this review. Yet, they have developed effectiveprocedures for individuals who have had difficulty inlearning simple discriminations and have used thosebehaviors as the basis for establishing conditional dis-criminations. Most of their participants have progressedto the point of learning equivalent relationships amongconcepts and various symbolic representations (e.g.,spoken words, pictures, written words, signs, graphicsymbols, and verbal productions). Their advances ininstructional technology and errorless learning proce-dures, as well as the work of others, may have greatrelevance to children with autism. A focus solely onstudies that enrolled children with autism may avert ourattention from other important findings in the educa-tional treatment literature. An alternative approachmight be to develop a database around target behaviorsto a greater extent than was accomplished in this paper.
Treatment Components
The descriptions of the actual training proceduresused by investigators are often quite sketchy. A reviewof “naturalistic” language intervention studies by Hep-ting and Goldstein (1996a) cautions us from assumingthat treatment procedures are equivalent even when in-terventions are called the same thing (e.g., “incidentalteaching” or “interactive”). Further specification isneeded to delineate what treatment components areplanned as part of a treatment program, to determinethe extent to which the treatment components are infact implemented as part of a treatment program (treat-ment fidelity), and to begin to determine what compo-nents are more and less responsible for treatment effects(component analyses). Perhaps the taxonomy used byHepting and Goldstein (1996a) provides a starting pointfor specifying treatment components. They were ableto classify 34 language-treatment studies based on theinclusion of eight procedures that manipulated an-tecedents (prompting imitation, manding verbalization,requesting elaboration or clarification, waiting for ini-tiations or responses, arranging the environment, mod-
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eling, repeating/expanding/recasting, and descriptivetalking) and three procedures that manipulated conse-quences (delivering desired consequences, praising,minimal encouragers). The under-specification of whatinstructional procedures are active in interventions rep-resents a large obstacle to those interested in conduct-ing treatment comparisons.
Treatment Intensity
No literature was found that directly sought toevaluate the effects of delivering treatments with vary-ing frequency or intensity. Some relevant informationcould potentially be extracted from the literature, how-ever. Most single-subject experiments present data thatallow one to assess the rapidity of learning. It is diffi-cult to evaluate treatment intensity data in a straight-forward manner. For example, some investigators mayseek to increase the frequency of communication skillsalready in the repertoire of participants. One might ex-pect quicker effects in those cases than when teachingtotally unfamiliar behaviors. Other investigators indi-vidualize their selection of target behaviors by identi-fying new skills that are developmentally appropriateand functional for their participants, but some investi-gators are better at this than others. The greater the dis-crepancy between targeted behaviors and the presentrepertoire of participants, the longer one might expectthe acquisition process. On the other hand, errorlesstraining procedures may be especially effective withchildren with autism, but they do not necessarily max-imize the efficiency of learning. This can be remediedwith probes of more sophisticated performances, butone necessarily expects errors to occur when task de-mands exceed present capabilities.
Placebo Effects in Single-Subject Experiments
One of the concerns that should be considered inquasi-experimental research is the possibility of placeboeffects. In particular, one would want to be confidentthat treatment effects are not attributable to the effectsof the added attention given to participants enrolled in atreatment study, to the effects of repeated testing or mea-surement, or other threats to internal validity. Repeatedmeasurements over time have the potential to minimizeconcerns about placebo effects if treatment effects areclearly and consistently associated with implementationof treatment conditions and if two other conditions aremet. First, investigators need to have reliable and validmeasures. Second, data collection within conditions, andin baseline or control conditions in particular, must be
sufficient to establish stability in performance. Interpre-tation of results is severely compromised when investi-gators are lax about the latter requirement (cf. Johnston& Pennypacker, 1993; Sidman, 1960).
These requirements do not discount the possibilitythat peers and teachers in educational settings, for ex-ample, are not displaying behaviors other than thoseunder examination that have an influence on childrenwith autism. Consequently, it is advantageous to keepindividuals and data collectors blind to the schedule oftreatment implementation. For example, children whoare taught communication skills through video model-ing might view brief videos that are unrelated to the skillsbeing taught until they are scheduled to begin the lan-guage intervention condition. In that way the classroomobservers, teachers, and others are unaware of when thetreatment is initiated (e.g., Hepting & Goldstein, 1996b).
Also, social validity assessments are gaining wideracceptance in the literature, whereby naïve raters makejudgments about the behavior of participants usuallybased on pre- and post-treatment videotapes presentedin a random order. These social validity assessmentsallow one to judge whether the treatment effects arereadily discernable. They also can help to validate themeasures taken by observers and researchers and alle-viate some of the concerns that changes are attributableto biased recording on their part.
CONCLUSIONS
This body of research has emanated from a num-ber of disciplines, primarily psychology and specialeducation, as well as communication sciences and dis-orders. It is notable that children with autism are over-represented in the language intervention literaturegenerally; approximately 26% of language interventionstudies include this comparatively small population interms of prevalence (Goldstein & Hockenberger, 1991).The bulk of the child language intervention researchhas sought to develop effective treatments for our mostchallenging cases and thus have targeted more rudi-mentary language skills. Two reasons for this empha-sis come to mind. First, teaching language to childrenwith severe communication deficits has profound im-pacts on the lives of both the children and the peoplewho interact with them everyday. Rudimentary lan-guage skills can make a tremendous difference in theability of children to control their environment. In ad-dition, language has been found to be an adaptive al-ternative to highly disruptive forms of communication(such as tantrums, aggression toward others, or self-
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injurious behavior). Second, more information is avail-able on early language development than later languagedevelopment. Having a more complete knowledge ofdevelopmental milestones and their sequencing makesit easier to identify treatment goals that are develop-mentally appropriate. As the complexity of the lan-guage system grows, one begins to address the subtletiesand nuances of effective communication that are harderto define. The full complement of language skills thatcome into play as the demands of development and newsituations expand has yet to be defined adequately, letalone addressed in treatment studies. Indeed, knowl-edge of the effects of language treatment has developedincrementally. Experimental studies have focused(largely to their credit) on restricted treatment goalsand relatively short-term outcomes.
The accumulated knowledge of the effects of spe-cific treatments on particular target behaviors hasresulted in a compendium of fairly sophisticated in-structional procedures, but the development of aneffective technology is in its infancy. Because mostexperiments are designed to assess the effects of a re-stricted set of treatment components on certain aspectsof language development, it is conceivable that treat-ment programs that draw upon a number of empiricallysupported approaches and are individualized to meetthe specific needs of children with autism have the po-tential to have robust clinical effects. The process ofcompiling this technology into long-term, comprehen-sive treatment programs remains an ambitious, com-plex challenge. Speech-language pathologists andservice delivery teams are aware of the multifacetednature of communication and realize that the com-plexities of the developing language system that chil-dren must acquire to be fully competent communicatorsis not well understood. Nevertheless, they need to drawupon the existing knowledge base to develop treatmentprograms to address the multiple needs of individualchildren and their families. What behaviors should beincluded? How should skills from different communi-cation domains be sequenced? How should the programbe adapted based on the child’s age, educational envi-ronment, families’ wishes, cultural milieu, etc.? Few in-dividuals, be they researchers, teachers, speech-languagepathologists, or parents, would be satisfied with thescope and sequence reflected in available training pro-grams, many of which were developed decades ago.
Investigators interested in evaluating larger treat-ment packages face an even stiffer challenge. First, theyneed to identify appropriate outcome measures. Thereis considerable danger in depending upon global mea-sures of change in language development that may not
be sensitive to changes associated with their interven-tion efforts. Because of the relationship between lan-guage skills and other academic and social domains,one can argue that comprehensive language treatmentprograms are likely to have significant impacts on long-term outcomes, such as academic achievement, the ex-tent of special education services required, schooldropout rates, and vocational placements. How differentaspects of language relate to these important outcomeshas yet to be delineated. To help us understand theserelations and other moderating influences, it is impor-tant to measure primary and short-term outcomes. Also,it is essential that direct intervention effects are docu-mented to help us interpret results, especially whenlong-term outcomes are modest or absent.
Second, researchers must specify, measure, andcontrol the active variables in their interventions. Asmentioned earlier, it is difficult to extract informationon treatment procedures in the literature. This problemtends to be compounded in the case of comprehensivetreatment programs. Furthermore, one must specify theextent to which interventionists should be expected orallowed to individualize treatments to meet the needsof children with a broad range of developmental lev-els. It is critical that when comprehensive interventionsare evaluated that treatment components are specifiedin an operational manner. Measures need to be devel-oped to judge the fidelity of the treatment that is ad-ministered over time.
We need to encourage behavioral scientists tocontinue pursuing the promising results that have beensummarized in this review. When we have evidenceof treatments that are effective at teaching functionalcommunication skills, this is a beginning point andnot an end point. We have not discovered a silver bul-let and we are unlikely to do so. Teaching childrenwith autism tends to be a difficult, painstaking en-deavor. We have made much progress, but we mustrecognize that progress will continue to be slow if thescientific community continues to publish only aboutthree experimental studies per year that address sucha complex problem: teaching communication to chil-dren with autism. More investigators should be en-couraged to pursue these promising findings. A singlestudy may help to identify a promising treatment ap-proach, but a number of systematic replications areneeded to begin to:
● refine treatments by adding useful componentsor by eliminating superfluous ones.
● maximize the breadth of generalization and thedurability of treatment effects.
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● delimit the contextual conditions under whichthe treatment protocol is effective.
● delineate with whom the treatment is more andless effective.
● identify other behaviors to which the treatmentcan be applied effectively.
● elucidate psychological mechanisms or learningprocesses that help us understand why the treat-ment is effective.
Based on this review, one can conclude that sub-stantial evidence exists to claim that effective interven-tions exist to teach communication skills to children withautism. Even though the vast majority of the studiesreviewed were conducted with few subjects, with fewexceptions investigators were able to demonstrateclearly and repeatedly that the initiation of their treat-ment was associated with improved communicativeperformance. In many cases, the effects are dramaticbecause control conditions show conventional com-munication to be so minimal for many children withautism. For children with at least rudimentary speechand language skills, who are verbally imitative, for ex-ample, there are an array of approaches that may yieldfairly rapid learning. For children who are nonverbal,more precise programming and slower progress islikely. Are there interventions that have been shown tobe efficacious in teaching relatively complete commu-nication systems to the most challenging children withautism? I do not think so. But a knowledge base isavailable to help guide efforts to expand the commu-nication repertoires of those challenging cases.
The literature provides little direction in terms ofservice delivery models or the intensity of services thatare more likely to maximize communication interven-tion efforts. Logical arguments can be made related toopportunities to learn. It is hard to imagine a variablethat is more predictive of learning than opportunitiesto respond (Greenwood, 1991). But that begs the ques-tion of the quality of instruction. The literature re-viewed is firmly grounded in principles of learningderived from operant and social learning perspectivesand their descendants. Effective communication inter-ventions will depend on good decision making on a va-riety of fronts. For example, careful programming isneeded: to select useful objectives, to provide envi-ronments that set the occasion for meaningful commu-nication, to provide functional reinforcers that eventuallyare available with regularity in the natural environment,and to provide scaffolds (models, prompts, corrections,and encouragement) that are faded to promote inde-pendent and spontaneous communication. Developing
comprehensive communication intervention programsfor children with autism represents a major challenge,perhaps involving a healthy dose of art. Yet, the avail-able literature provides a scientific foundation thatshould allow us to discriminate interventions that arepurely art and imagination from those that are builtupon treatment procedures with empirical support.
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