modelos para el autismo

8/9/2019 Modelos para el autismo

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JOURNAL OF APPLIED BEHAVIOR ANALYSIS 2001, 34, 425446 NUMBER4 (WINTER2001)

SOCIAL STORIES, WRITTEN TEXT CUES, AND VIDEO FEEDBACK: EFFECTS ONSOCIAL COMMUNICATION OF CHILDREN WITH AUTISM

KATHYS. THIEMANN ANDHOWARD GOLDSTEINFLORIDA STATE UNIVERSITY

This study investigated the effects of written text and pictorial cuing with supplementalvideo feedback on the social communication of 5 students with autism and social deficits.Two peers without disabilities participated as social partners with each child with autismto form five triads. Treatment was implemented twice per week and consisted of 10 minof systematic instruction using visual stimuli, 10 min of social interaction, and 10 minof self-evaluation using video feedback. Results showed increases in targeted social com-munication skills when the treatment was implemented. Some generalized treatment ef-fects were observed across untrained social behaviors, and 1 participant generalized im-provements within the classroom. In addition, naive judges reported perceived improve-ments in the quality of reciprocal interactions. These findings support recommendationsfor using visually cued instruction to guide the social language development of youngchildren with autism as they interact with peers without disabilities.

DESCRIPTORS: autism, communication, visual cues, videotape feedback, peer in-

teraction

It is recognized that elementary studentswith autism demonstrate a restricted rangeof social communication skills such as lim-ited speech to initiate comments, request in-formation from others, listen and respond toothers, and interact in simple games(VanMeter, Fein, Morris, Waterhouse, & Al-len, 1997; Volkmar, Carter, Grossman, &Klin, 1997; Wetherby & Prutting, 1984).This limited repertoire of social communi-cative behaviors may interfere with academicprogress and friendship development. Iden-tifying effective interventions that improvesocial competence may lead to more positiveoutcomes with typical peers. For example,peer-mediated social interventions have beensuccessful in increasing social communica-tion of children with autism (Haring &

Support for this research was provided by GrantCFDA 84.023B from the U.S. Department of Edu-

cation, Office of Special Education and RehabilitativeServices. We acknowledge the assistance of KimberlyCrawford and Gina Easterly in the implementation ofthis study.

Address correspondence to Kathy S. Thiemann, Ju-niper Gardens Childrens Project, 650 Minnesota Av-enue, 2nd Floor, Kansas City, Kansas 66101-2800 (E-mail: [email protected]).

Breen, 1992; Kamps et al., 1992; Pierce &Schreibman, 1995; Sasso, Peck, & Garrison-Harrell, 1998); however, few peer-mediatedinterventions take advantage of the reportedvisual strengths of children with autism.

Only a few reports have focused on theuse of written or text-based visual cues toteach specific social communication skills tochildren with autism as they interact with

typical peers (Garrison-Harrell, Kamps, &Kravits, 1997; Kamps, Potucek, Lopez,Kravits, & Kemmerer, 1997). Studies focus-ing on unique competencies of some chil-dren with autism have revealed particularstrengths in visual-perceptual skills (Lincoln,Courchesne, Kilman, Elmasian, & Allen,1988), processing and interpreting static vi-sual stimuli (Hodgdon, 1995), hyperlexia(Whitehouse & Harris, 1984), and verbalcommunication (Tsai, 1992). Hyperlexia hasbeen described as a preoccupation with let-ters and words at an early age, and excep-tional word-recognition skills with delayedcomprehension of meaning (Healy, 1982).Quill (1997) recommended using visuallycued instruction (e.g., graphic cues) to im-prove social behavior.


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426 KATHY S. THIEMANN and HOWARD GOLDSTEIN

Types of visual cues that improve socialcommunication of children with autism in-clude written prompts and pictorial cues(Kistner, Robbins, & Haskett, 1988; Krantz& McClannahan, 1993), video feedback,and self-modeling of social behaviors andconversational skills (Charlop & Milstein,1989; Hepting & Goldstein, 1996; Kern-Dunlap et al., 1992). Kistner et al. took ad-vantage of the word-recognition skills of agirl with autism and hyperlexia to improveher functional language skills with adults.

Written prompts (e.g., verbal prompt:What do you want? written prompt:Want cookie.) were effective in teachingresponses to questions, with progress beingmaintained following the removal of writtencues. Individualized written social scriptsalso have been used effectively to teach ele-mentary students with autism to initiate andrespond to other classmates with autism(Krantz & McClannahan). An interventioncombining social initiation training andvideo feedback increased the frequency andlength of positive interactions and decreas-ed inappropriate social behavior of a high-functioning child with autism as he played

with a peer without disabilities (Oke &Schreibman, 1990). Video feedback of thedyads previous interactions was used toteach the child to differentiate parallel andinteractive play and successful or unsuccess-ful initiations.

Gray (1995) recommended using socialstories to help high-functioning individuals

with autism gain an accurate understandingof social situations. Social stories includefour to six sentences that describe factual in-formation regarding a social situation, pos-sible reactions of others in that social situa-tion, and directive statements of appropriateor desired social responses. However, studiesdocumenting the effectiveness of social sto-ries as a visual tool to improve social behav-iors of children with autism are limited (cf.Hagiwara & Myles, 1999; Norris & Dattilo,1999). Norris and Dattilo evaluated the ef-

fects of social stories on social behaviors ofan 8-year-old girl with autism. Following in-tervention sessions consisting of reading so-cial stories, the child continued to demon-

strate some inappropriate social skills duringlunch with peers, and no changes were notedin appropriate social skill use. Therefore, thesuccessful use of social stories to modify so-cial behaviors of children with autism awaitsfurther study.

In summary, preliminary evidence existsfor the benefits of using visual stimuli to im-prove social communication of children withautism. Given the unique differences in so-cial, cognitive, and communication behav-iors of this population, some treatment ap-

proaches may be more beneficial than oth-ers. Treatment strategies that take advantageof childrens visual and verbal strengths mayimprove areas of weakness such as socialcommunication. For children with verballanguage and reading abilities, this could beaccomplished by using visually coded infor-mation such as social stories, pictorial or

written text cues, and video feedback. Thisstudy examined the effects of combining dif-ferent visual cues on the social communica-tion of elementary students with autism.

Typical peers participated as conversationpartners. The specific questions addressed

were: (a) Does a treatment program consist-ing of pictorial and text-based cueing (i.e.,social stories, pictures of social skills, and

written social phrases) with supplementalvideo feedback affect specific social com-munication skills of elementary students

with social impairments? (b) Do the treat-ment effects generalize to regular educationclassroom settings? (c) Do naive judges per-ceptions of the quality of the childrens social

interactions change after the treatment?

METHOD

PARTICIPANTS

Five children with social impairments and10 of their peers without disabilities (2 from


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427VISUAL STIMULI AND SOCIAL COMMUNICATION

Table 1

Participants Test Performance

Test

Participants

Dan Greg John Casey Ivan

CARS 25Nonautistic

39.5Severe

35Mild-moderate

36Mild-moderate

30Mild-moderate

PPVT-R 67 41 40 40 64

TOLD-2 primary:

Oral vocabularyGrammatic understandingGrammatic completion

1P1P

1P

1P1P1P

2P1P

2P

CELF-3:

Sentence assemblyFormulated sentencesRecalling sentences

TONI-2

2P1P1P3P 19P 9P 37P

1P1P1P3P

SSRS:Parent report:

Social skillsProblem behaviorsa

84100

71131

84110

60100

68118

Teacher report: Pre Post Pre Post Pre Post Pre Post Pre PostSocial skillsProblem behaviors

82106

87112

59135

91115

106135

103120

82120

84113

59135

91115

WRMT-R: WI subtest 87 65 77 120 65

Note. CARS, Childhood Autism Rating Scale (Schopler, Reichler, & Rochen-Renner, 1988); PPVT-R, Peabody PictureVocabulary TestRevised (Dunn & Dunn, 1981); TOLD-2, Test of Language Development2 Primary (Newcomer &Hammill, 1988); CELF-3, Clinical Evaluation of Language Fundamentals (Psychological Corporation, 1994); TONI-2, Testof Nonverbal Intelligence (Brown, Sherbenou, & Johnsen, 1990); SSRS, Social Skills Rating System (Gresham & Elliott,1990); WRMT-R Woodcock Reading Mastery TestsRevised (Woodcock, 1998). All scores reported are standard scores, with theexception of raw scores reported for the CARS and percentiles reported for TOLD-2 Primary, CELF-3, and TONI-2.

a Problem behaviors scale on the SSRS assesses negative behaviors, therefore higher scores equal more problem behaviors

than the average student in the standardization comparison group.

each focus childs classroom) from one ele-mentary school participated in the study.The children were assigned to a triad, con-sisting of 1 child with social impairmentsand 2 peers without disabilities (total of fivetriads). The 5 focus children were boys rang-ing in age from 6 years 6 months to 12 years2 months (M 9 years 2 months) who wereenrolled in Grades 1 through 5. All focuschildren were registered with the Florida

State Universitys Center for Autism and Re-lated Disabilities. Results of standardizedtesting are summarized in Table 1. None ofthe focus children or their peers demonstrat-ed hearing, vision, or physical motor im-pairments. For inclusion in the study, focus

participants demonstrated (a) impaired so-cial communication, (b) emerging or ac-quired word-identification skills, (c) func-tional verbal communication (i.e., were ableto communicate basic wants and needs usingphrases or simple sentences), and (d) full orpartial inclusion in regular education.

Dan (age 11 years 6 months) was fullyintegrated in fifth grade and received re-source support for most academic subjects

under the diagnosis of language impaired.Recent testing revealed that he scored justbelow the range for autism on the Child-hood Autism Rating Scale (CARS; Schopler,Reichler, & Rochen-Renner, 1988). Socialimpairment was confirmed through parent


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and teacher reports of delayed social skills onthe Social Skills Rating System (SSRS;Gresham & Elliott, 1990) and more than50% social deficits across three social obser-

vations (i.e., small-group work, recess, andmusic) using a social conversational skillschecklist. Dan communicated using simplesentences, mainly directed to adults. In-itiations to peers were minimal. His word-identification skills were at the 3.4 grade lev-el on the Woodcock Reading Mastery TestRevised (WRMT-R; Woodcock, 1998), andhe comprehended sentence-level text.

Greg (age 7 years 6 months) attended aregular first-grade classroom approximately30% of the day. He had been diagnosed

with autism and scored in the severe rangeof autism on the CARS. Greg demonstratedsevere delays in vocabulary and grammar;however, he made verbal requests and com-ments using sentences and scripted utteranc-es. He often initiated rough-and-tumblegames with peers during recess. Greg knewall letter names, could associate sounds toletters in simple words, and recognized somesight words.

John (age 8 years 2 months) was fully in-tegrated in a regular first-grade classroom.

He scored in the mild to moderate range ofautism on the CARS. He conversed usingsimple sentences and memorized scriptsfrom favorite movies or video games. Initi-ations to peers often consisted of inappro-priate facial expressions and verbal persev-erations. Johns word identification skills

were at the 1.4 grade level on the WRMT-R, and he comprehended short written sen-tences.

Casey (age 6 years 6 months) was inte-grated for approximately 30% of the day in

a regular first-grade classroom. He had beendiagnosed with autism and scored in themild to moderate range of autism on theCARS. Casey had characteristics of hyper-lexia, above-average decoding skills, and nor-mal nonverbal intelligence. His verbal rep-

ertoire consisted of echolalic utterances withsome spontaneous phrases directed mainlyto adults. Initiations to peers were rare.

Ivan (age 12 years 2 months) was fully

integrated in second grade, except for re-source support for reading and math. No di-agnosis had been made at the time of thisstudy. On the CARS, he scored in the mildto moderate range of autism. Socially, heavoided interacting with peers but commu-nicated with adults on topics of personal in-terest (e.g., favorite movies, weather). Ivans

word-identification skills were at the 1.5grade level on the WRMT-R, and he couldread and comprehend short sentences.

The 10 typical peers were identified and

recommended by each focus childs regularclassroom teacher. Teachers were asked torecommend children who (a) did not showsocial communication difficulties, (b) couldprovide appropriate and positive social mod-els, and (c) consistently completed their

work so they could leave the classroom twiceper week to participate. The same peers par-ticipated as conversational partners through-out the study. Mixed genders (i.e., 1 girl and1 boy without disabilities) were in each triadexcept for one (all boys in Gregs group).

SETTINGS AND SESSIONS

All of the sessions took place in a mediaroom (8 m by 5 m) in the school library.Each triad came to the media room sepa-rately. During baseline, each triad attendedtwo 10-min sessions per week. Once a groupstarted treatment, they attended two 30-mintreatment sessions per week. Each treatmentsession consisted of (a) 10 min of systematicinstruction (i.e., social story instruction,

written text cue rehearsal, role play), (b) 10

min of engagement in a social activity, and(c) 10 min of self-evaluation using videofeedback. All interactions took place at acrescent-shaped table in the media room.Session and activity agendas and an adaptedclock (i.e., red section decreased as time de-


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creased) were used to assist with knowledgeof task expectations and transitions. Totalnumber of sessions ranged from 30 to 38over a period of 15 to 19 weeks.

DEPENDENT MEASURES ANDDATACOLLECTION

All experimental sessions were audio andvideotaped. The videocamera was locatednear the participants, at a distance that didnot interfere with the interaction. A secondcassette recorder was positioned on the vid-eocamera and played a prerecorded audible15-s interval tape for 10 min. A direct ob-servation coding system was used to code thefrequency of occurrence of all appropriate

and inappropriate social communicationmeasures for the students with social im-pairments. Social communication behaviors

were coded live by one of two trained re-search assistants during the 10-min social ac-tivity in 15-s intervals to assist with inter-observer agreement calculations. Thus, with-in each 15-s interval recording, observerscoded the occurrence of any of the four ap-propriate and four inappropriate social lan-guage measures (see Table 2). Prior to turn-ing in the coding sheets for analysis, the

same observer reviewed the audio and vid-eotape after each session, making correctionsas necessary. Reviewing the videotapes per-mitted closer observation of nonverbal com-municative behaviors (e.g., head nod or headshake to respond).

The four primary dependent social mea-sures were contingent responses, securing at-tention, initiating comments, and initiatingrequests (see Brinton & Fujiki, 1984; Love-land, Landry, Hughes, Hall, & McEvoy,1988; Mentis, 1994; Prutting & Kirchner,

1987; Stone & Caro-Martinez, 1990). Oth-er measures were frequency of inappropriatediscourse skills such as topic changes, unin-telligible responses, other, and no responses(see Table 2).

In addition, the investigators measured

collateral effects of the treatment package onthe focus childrens topic maintenance skills.Data on the childrens average number of se-quential verbal utterances per conversational

episode were collected over a sample of pre-and posttreatment sessions. A 3-s pause orchange in topic signaled the end of one con-versational episode. Average length of mul-tiple turns per conversational episode wascalculated by adding the total number of se-quential utterances related to the same topic(initiated by focus child or peer) expressedin one 10-min coding interval, and dividingby the total number of conversational epi-sodes. These data were collected and aver-aged over the last five baseline sessions (just

prior to initiation of treatment of the firstsocial skill) and the last five treatment ses-sions for each child.

EXPERIMENTAL DESIGN

A multiple baseline design across two tothree social communication skills replicatedacross five triads was used to assess changesin social communication skills of the focusparticipants. The possible pool of targetedsocial communication skills were (a) secur-ing attention, (b) initiating comments, (c)

initiating requests, and (d) contingent re-sponses. For each participant, two or threesocial communication skills were targeted fortreatment. The discourse skills taught werecounterbalanced among the triads.

PROCEDURE

Baseline

During baseline, each triad engaged inone 10-min social activity per session. A ro-tation of three types of social activities cen-tered on (a) thematic or pretend play (e.g.,

restaurant or grocery store), (b) boardgames, and (c) art or science projects. Aminimum of five different activities for eachtype of social play was used. Social activitiesselected were based on current classroomcurricular topics, familiar routines, or child


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Table 2

Definitions for Appropriate and Inappropriate Social Language Measures

Social skills Description

Appropriate

Contingent response (CR) Coded if the focus childs utterance is contingent on a peers immediate priorutterance, within a 2-s interval following the peers utterance, through (a) ac-knowledging (e.g., hmm) or direct or partial repetition of the utterance, (b)agreeing (e.g., head nod, yeah), (c) answering peers question, (d) responding

with a related comment about observable objects or events within the ongoingactivity, (e) confirming or clarifying a question or comment from the peer(e.g., What did you say?).

Securing attention (SA) Coded if the focus child (a) requests attention or acknowledgment from peers(e.g., Hey! See this? or Look.), (b) calls the peers name to gain atten-tion, or (c) uses gestures or vocalizations to establish joint attention with thepeer (e.g., taps on shoulder, hold an object up to show peers).

Initiating comments (IC) Descriptive comments that are related to the ongoing topic or event, but notcontingent on a peers prior utterance and not used to request information,and the focus child (a) provides a comment following a 3-s interval after apeers last utterance, (b) initiates a new idea or topic that relates to the ongo-

ing joint activity or topic but is not a request, (c) compliments the peer (e.g.,You did it!) or himself, (d) reinforces the peer for winning, (e) expressesenjoyment to the peer regarding their interaction together (e.g., This isfun!). The childs utterance was coded as IC if it met the criteria of (b) to(e) within the 3-s interval.

Initiating requests (IR) Coded if focus childs utterance is related to the ongoing topic or event, but notcontingent on a peers prior utterance and not used to clarify something thepeer said (would be CR), and the focus child requests information or actionsfollowing a 3-s interval after a peers last utterance.

Inappropriate

Topic change (TC) Coded with or without a change in materials or games if the focus child (a)interrupts (definite overlap of words) a peer to introduce a new topic that hasnot been discussed previously or to reintroduce a previous topic, (b) changesthe topic to something unrelated to and noncontingent on the peers priorutterance, (c) comments tangential to some aspect of the peers previous utter-ance but there is an ambiguous semantic referent not immediately recogniz-able. Verbal turns that follow a TC are coded as CR, IC, IR or SA if theconversation follows the changed or shifted topic.

Unintelligible (UN) Utterances that are not interpretable or are unintelligible to the coder after lis-tening to the audiotape a minimum of three times.

Other (OT) Any (a) animal noises or other vocalizations, (b) stereotypic or perseverative ut-terances (considered perseverative on the third utterance; if another childspeaks or the child continues the perseveration at a later time, start over andcode the first two utterances as they are defined, (c) delayed echolalia that isnoninteractive.

No response (NR) Child does not respond verbally or nonverbally within 3-s to (a) a peers requestfor information, requests for actions, or protests; (b) if the child is performingan action requested by the peer that takes longer than 3-s, wait to see if hecompletes the task and give him credit if he does, or (c) if the peer asks thesame question again within the 3-s interval, the utterance is not coded, and

the time frame starts at 0 after the peers second question. If the child doesnot respond after the peer repeats himself two or more times, code as NR.


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Figure 1. Example of pictorial and written textcues used to teach the social communication skill ofsecuring attention, referred to as getting friends tolook.

preferences whenever possible. To determinechild familiarity and preferences, parents

were given a checklist of 10 examples of ac-tivities for each of the three categories and

asked to check the top five choices theirchild was most familiar with and would en-joy doing while interacting with peers. Se-lected social activities had unifying themes,predictable turn-taking sequences, and ex-changeable participant roles.

Prior to starting a baseline session, the ex-aminer and children read the session agendaand discussed rules and tasks for the activity.Once the children understood how to in-dependently perform the activity, the timer

was set for 10 min and the examiner left the

table. No adult interactions with childrenoccurred during the baseline sessions. Oncetreatment began on the first target socialcommunication skill (securing attention),baseline measurement continued for the oth-er three social communication measures.

When treatment was initiated for the secondsocial skill (initiating comments), mainte-nance data were collected on the first socialskill (securing attention), and baseline datacontinued to be collected for the other twosocial skills (initiating requests and contin-

gent responses).

Peer Orientation

After baseline, the 2 peers without dis-abilities from each group met with the pri-mary investigator (one group at one time)for one 30- to 45-min orientation sessionbefore the treatment sessions began. Eachpeer was given a notebook titled How YouCan Talk to Your Friends, with the follow-ing four skills listed: (a) Get your friendsattention before you start talking to them,

(b) Talk to your friends about what you aredoing, (c) Ask questions and answer yourfriends questions, and (d) Take turns, de-cide on rules, and solve problems together.Under each of these sentences was one hand-drawn picture of two children interacting

with topic bubbles (as in cartoons) abovetheir heads (see Figure 1). The peers read thesentence for each skill, talked about why theskill might be important, and then generatedand wrote (in a topic bubble) an example ofan appropriate social utterance that matchedthe skill. Finally, peers were told they wouldreceive prizes (e.g., stickers, toys) for remem-bering how to talk to new friends.

Treatment

Direct social skills instruction was provid-

ed to each focus child in the context of thetriad (i.e., peers present). Treatment sessions

were 30 min in length and occurred twiceper week for each triad. The 30 min inter-vention session consisted of 10 min of in-struction using the visual stimuli, 10 min ofsocial interaction, and 10 min of video feed-back.

Instruction using social stories, text cues, andpictures of social skills. Four social stories(Gray & Garand, 1993) were written to de-scribe the four primary social skills targeted

during treatment. The content of the socialstories included (a) securing attention (i.e.,getting friends to look) (see Table 3), (b)initiating comments (i.e., start talking tomy friends), (c) initiating requests (i.e., askmy friends questions), and (d) contingent


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Table 3

Social Story Stimuli

Example social story: Getting Friends to LookFriends like playing with different toys and games.Friends like to show each other what they are doing.

Sometimes a friend calls my name and says look.This means they want to show me something, and they

like it if I look.I can try to call my friends name or say look to show

them what I am doing.Comprehension questions for social story: Getting Friends

to LookWhat can friends show each other?Do friends say your name to get you to look at them?If a friend calls your name, what should you do?Do they like it if you dont look at them?What can you say to get your friends to look at you?

responses (i.e., keep talking to my friends).

The social stories were written according toGrays (1995) rules for including descriptive,perspective, and directive sentences. For

John, Ivan, and Dan, a hand-drawn coloredpicture depicting two children performingthe target social skill was placed at the bot-tom of the story, along with two empty topicbubbles above the childrens heads. For ex-ample, the skill securing attention had apicture of one child tapping another childon the shoulder (see Figure 1). To assist incomprehension of social expectations, pho-

tographs of Casey and Greg and their peerswere placed under their social stories, withtopic bubbles drawn above their heads.

During the 10-min instructional period,the focus child read one social story target-ing one social skill, and was asked four orfive simple interrogative and wh questionsto assess his comprehension of the story con-tent (see Table 3). The examiner and peerslistened and provided assistance in readingthe sentences and answering the comprehen-sion questions, if necessary. Once the focus

child was 75% to 80% accurate in answeringthe social story comprehension questions,the examiner presented the materials for theactivity and explained the rules and tasks.She then showed all the children the text cuecard. On this card was the hand-drawn pic-

ture of the two children (or the individualphotographs of Casey or Greg) performingthe target social skill. Two to three utteranc-es appropriate to the target social skill and

matched to the upcoming activity were writ-ten in separate topic bubbles and were at-tached to the text cue card. For example, toteach the skill secures attention, wordssuch as look, watch this, or a childsname were written in the topic bubbles. The

written text cues varied from sentence start-ers (e.g., Can I ? to initiate a request),to one- to three-word phrases or simple sen-tences. The focus child rehearsed the utter-ances on the cue card three or more timesthrough reading aloud, role play (i.e., prac-

tice using props from upcoming activity),and reading again. To provide access to allwritten cues throughout the social activity,the social story was placed on a flip chart inthe direct line of vision of the focus childand the cue card was left on the table nextto him. The examiner then told the childrento try to remember the story and to beginusing the target skill (e.g., get a friend tolook) while they play. Parents were given acopy of each social story as it was introducedto read daily with their child at home, and

were asked to monitor daily reading of thestory through completion of weekly check-lists.

10-min social interaction. During the 10-min social activity, the examiner remained ata distance from the group. If the focus childdid not spontaneously use the target socialskill (i.e., read the text cue or generated anew example) at least once per minute, theexaminer provided a visual (or, if necessary,verbal) prompt by pointing to one of the

written text cues. If the focus child did ex-

press the target skill within the 1-min inter-val, prompts were not provided. Due to ahigh level of adult dependency observedduring the first few sessions, Caseys peers

were taught how to prompt him to use thewritten text cues. For all triads, only the chil-


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dren with social impairments (not the peers)received adult prompts to perform the targetsocial skill.

Videotaped feedback.Immediately after the

10-min social activity, the examiner tapedthe picture of the social skill and written textcues (topic bubbles) on the bottom of a tele-vision. All the children in the triad sat inchairs in front of the television. Each childhad a clipboard with the target social skill

written at the top of a sheet of paper (e.g.,I started talking for initiating comments).The paper also had two columns markedyes circled in green and no circled in red

with a line crossed through it. The examinerplayed the videotape of the interaction,

paused it after one conversational exchange,and asked the children if they heard exam-ples of the targeted social skill. The tape wasinitially paused after correct peer models,and the peers and the focus child evaluatedthe one individuals performance. The ex-aminer then paused the tape after the focuschild demonstrated the skill and asked allgroup members to evaluate his performance.The tape was paused a minimum of threetimes. If the focus child had not demonstrat-ed the target behavior during the video play-

back, peer modeling and discussion with thefocus child occurred. Checks were ex-changed for tickets that were used to obtainsmall toys or other rewards.

Treatment modifications. For John andCasey treatment was modified for the finalfive or six sessions because of reduced oc-currences of previously targeted social skills.The previously targeted social skills (i.e., ini-tiating comments and requests, securing at-tention, contingent responses) were com-bined into one social story and represented

on a larger cue card by the original socialskill pictures (John) or photographs (Casey).One social phrase for each target social skill

was written in separate topic bubbles andattached to the cue card. Thus, there werethree possible social skills and three possible

written cues that the children could chooseto express in the social activity. Social storyinstruction and rehearsal procedures werethe same as in earlier treatment sessions.

Videotaped feedback forms were modified toallow self-evaluation and feedback on allthree social skills at one time. That is, allthree skills were listed on the sheet of paper,

with two columns (for yes or no) undereach skill.

Slight modifications in the primary treat-ment procedures were implemented solelyfor Ivan. During the first seven treatmentsessions, Ivan often became frustrated whenasked to read the social story or written textcues aloud. Further, he also appeared to be

upset about being singled out from his peersduring the instruction time. Thus, the treat-ment procedures were modified slightly inthe following manner: (a) Ivan and his peerstook turns reading the social story aloud, (b)Ivan and his peers took turns rehearsing the

written text cues, and (c) a written text cuewas placed in front of each child during thesocial interaction. Video feedback proce-dures did not change.

Maintenance

During treatment of the second socialcommunication skill, maintenance data werecollected for the first social skill, and baselinedata collection continued for the other twopotential social skill targets. Similarly, duringtreatment of a third social skill, maintenancemeasures were collected on the first two so-cial skills treated. Data-collection procedures

were the same as baseline.

Generalization Probes

Generalization probes were conducted in

the classroom for Greg, John, and Casey for3 or 4 days. In the classroom, social storyinstruction and videotaped feedback wereomitted from the procedures. The focuschildren read the written text cues (soc-ial phrases) once prior to engaging in an


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Table 4

Social Validity Questionnaire Completed by Teachers and Graduate Students Pre- and Posttreatment

Rate target childs social interaction behaviors (in comparison to typical peers):1. Target child attends to, and is actively and appropriately involved in, the activity with his friends.2. Target child starts talking about the activity with appropriate comments or questions.

3. Target child responds to his friends comments.Rate typical peers social interaction behaviors with target child:4. Friends attend to and attempt to draw the target child into the activity or interaction.5. Friends respond to the target childs verbal and nonverbal (e.g., gestures, actions) communication.6. Friends start talking (e.g., ask questions, say comments) to the target child.

Note. Each question was rated on a scale of 1 to 5, with 1 not at all, 2 much less than average for age group, 3 somewhat less than average, 4 average for age group, and 5 better than average.

already-scheduled 10-min activity with thesame peers. Classroom activities were pre-determined by the regular education teacher,and included reading big books, workingon computers, completing math worksheets,

or doing art projects.

SOCIAL VALIDITY

Seven regular education teachers and sixgraduate students in speech-language pa-thology who were unfamiliar with the pur-pose of the study provided subjective ratingsof changes in social interactions between thechildren with social impairments and theirpeers. For each triad, 2-min vignettes of so-cial interactions before and after treatment

were recorded on a separate videotape. The

order of presentation of the pre- and post-treatment sessions recorded on this video-tape were random, and were presented blindto the raters. The 13 judges independentlyrated specific social behaviors for the focuschildren and their peers by completing a 5-point Likert-type scale (i.e., 1 not at all,3 somewhat less than average, 5 betterthan average) for six questions (see Table 4).Questions 1 through 3 targeted the focuschilds social behaviors towards their peers,and Questions 4 through 6 targeted thepeers social behaviors toward the focus chil-dren.

INTEROBSERVERAGREEMENT

Prior to baseline data collection, two cod-ers were trained to a criterion level of 80%

interobserver agreement. After the primarycoder (a masters level student in commu-nication disorders) reviewed the audio andvideotapes of each session, a secondary coder(a doctoral student in communication dis-

orders) independently reviewed the audioand videotapes of 30% of all experimentalsessions. Using the final coding sheets, anagreement was scored if both observers cod-ed the occurrence of the specific social com-munication behaviors within the same inter-val (5 s). Disagreements were scored if thecoders did not agree on the type of socialbehavior or if one coder did not observe thebehavior. Percentages of interobserver agree-ment were then calculated by dividing thenumber of agreements by the sum of agree-

ments plus disagreements and multiplyingby 100%. Interobserver agreement was con-sistently above 80% for all participants.

Agreement ranged from 87% to 100% forDan (M 92%), 81% to 94% for Greg (M 89%), 80% to 100% for John (M 92%), 83% to 100% for Casey (M 93%),and 84% to 95% for Ivan (M 90%).Treatment fidelity was monitored for 20%of the treatment sessions using a checklist ofthe treatment procedures. Mean treatmentfidelity was 89% (range, 82% to 100%).

RESULTS

Focus Childrens SocialCommunication Progress

Frequencies of targeted social languageskills and adult prompts during the 10-min


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social interaction for the focus children arepresented in Figures 2 through 6. Also in-cluded are data showing the frequency ofuntreated social communication skills for

Dan and Ivan and changes in inappropriatesocial behaviors for Greg, John, and Casey.Dan and Ivan emitted low levels of inappro-priate social behaviors.

Dan demonstrated few attention-securingbehaviors during baseline, with an average of0.5 per session (see Figure 2). Followingtreatment, Dan increased his attempts to se-cure a peers attention to an average of 6.7per session (unprompted). During treatmenton the next social skill (initiating com-ments), improvements in securing attention

declined to an average of 4.6 per session inthe absence of text cues and prompts, butwere still maintained above baseline levels.The treatment was effective in doublingDans frequency of comments from an av-erage of 6.5 to 16.4 per session, with prog-ress being maintained (M 19) in the ab-sence of prompts. His frequency of initiatingrequests improved to an average of 11 persession (compared to a mean of 3.1 in base-line) once treatment began on the first be-havior targeted (securing attention). This

rate of requesting continued during treat-ment on initiating comments. Once treat-ment began on initiating requests, Dan in-creased his unprompted requests to peersfrom an average of 7.3 in baseline to 19.3per session. Contingent responses were nottargeted in treatment, because this socialskill steadily improved over the course of in-tervention.

With the exception of Session 10, Gregengaged in low rates of securing attentionduring baseline, with an average of 5.2 per

session (see Figure 3). Following treatment,he increased this behavior to 9.9 per session.These improvements were maintained as textcues and prompts were faded in treatment.

Although Gregs securing attention withouttext cues during treatment of the next social

skill (initiating comments) was variable, hisaverage performance (M 10.3) was abovebaseline. Gregs baseline data revealed an av-erage of 7.8 comments per session, with a

higher number of comments emitted duringa number of sessions that involved playing aboard game. The treatment resulted in anincrease in comments to 12.6 per sessionand more stable performance across differentsocial activities (i.e., thematic play and art orscience projects). These improvements con-tinued as prompts were faded, with an av-erage of 27.8 comments emitted per main-tenance session. Treatment on initiating re-quests resulted in an increase from an aver-age of 6.6 requests during baseline to 20.3

per session. Generalization data revealed noclear transfer of improved target behaviors tothe modified classroom activities. Overall,Gregs average rate of inappropriate socialbehaviors decreased by almost 50% aftertreatment was implemented on the first so-cial skill (i.e., Sessions 15 to 37; M 8 persession) compared to baseline (M 15 persession).

Due to low baseline performance of ini-tiations, the behaviors of initiating com-ments and initiating requests were combined

into one category for John and Casey andwere targeted simultaneously. The data pre-sented in Figures 4 and 5 (initiating com-ments and requests) reflect occurrences ofboth of these social communication behav-iors. Immediate treatment effects were ob-served for John for initiations and securingattention (see Figure 4). Specifically, he in-creased his initiations from an average of13.3 per baseline session to 19 per session.His average rates of securing attention in-creased from 3.9 in baseline to 5.8 per ses-

sion. During maintenance, John initiallycontinued to comment and make requests topeers, as verbal prompts were faded, with anaverage rate overall of 21.2 per session.However, changing to treatment on a newsocial skill resulted in a reduction in initia-


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Figure 2. Frequency of appropriate social communication skills during baseline, treatment, and maintenanceconditions for Dan during 10-min sessions.


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Figure 3. Frequency of coded social communication skills during baseline, treatment, maintenance, andclassroom conditions for Greg during 10-min sessions.


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Figure 4. Frequency of coded social communication skills during baseline, treatment, maintenance, andclassroom conditions for John during 10-min sessions.


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tions, especially securing attention (M 3.1per session) during maintenance. During thecombined treatment condition (i.e., instruc-tion and text cues used for all three previ-

ously targeted skills) or booster sessions,Johns average initiations improved to 31.3per session, a rate higher than initial treat-ment levels. Securing attention recovered to5.7 per session, which was similar to initialtreatment levels. Johns contingent responsesto peers were highly variable during baseline,ranging from 3 to 33 per session (M 13.9). Treatment was effective in stabilizinghis performance on this social skill. His re-sponses to peers in treatment ranged from13 to 20 (M 15.7). Generalized improve-

ments in the classroom were not observedfor initiations and securing attention (M13.3 and 4.0 per session, respectively); var-iability of contingent responses reoccurredduring classroom social interactions (M 16.8; range, 5 to 38).

Casey demonstrated low baseline perfor-mance on all targeted social behaviors (seeFigure 5). For example, he engaged in anaverage of 2.7 initiations (both commentsand requests) per 10-min activity duringbaseline. Treatment doubled Caseys un-

prompted initiations to an average of 6.5 persession. Slight improvements were observedfollowing treatment on securing attention, asadult prompts were faded, with an increasefrom an average of 0 in baseline to 1.8 persession. Treatment effects for initiations andsecuring attention were not maintained

without text cues or prompts. Once treat-ment began on contingent responses, Caseyincreased his answers to peers questionsfrom 3.6 to 19.6 per session. The combinedtreatment led to recovered improvements in

Caseys unprompted initiations (M 12.2per session) and securing attention (M 2.2per session). Although a gradual decrease incontingent response behaviors was observedduring the combined treatment, Caseys av-erage number of responses to peers (M

14.6 per session) was higher than baseline.In the classroom, Casey demonstrated somegeneralization for two of three trained socialbehaviors. He continued to initiate com-ments and requests to peers at an averagerate of 10.3 per classroom session, and se-cured attention at a rate of 4.0 per session.

Ivan demonstrated variable initiation ofcomments during baseline, with an averagerate of 8.5 per session (see Figure 6). Thefrequency of his initiations did not change

with the onset of treatment. Following im-plementation of the modified treatment pro-cedures (Treatment 2), Ivans frequency ofcomments steadily increased to an average of15 per session, and he maintained these im-

provements at an average of 17.5 per session.The treatment also was effective in improv-ing Ivans average rates of securing attention,

which increased from 2.0 during baseline to9.3 per session. Baseline data revealed rela-tively high frequencies of initiating requestsand contingent responses; thus, these skills

were not targeted.Multiple-turn interactions. Topic mainte-

nance skills improved for all focus childrenas reflected in increases in their averagenumber of utterances per conversational ep-

isode during a sample of the last five baselinesessions (before treatment on the first socialskill) and the last five treatment sessions. Forexample, Dans average number of utterancesper conversational episode increased from anaverage of 1.9 in baseline to 3.4 at the endof treatment. Gregs ability to maintain top-ics improved from an average of 3.8 to 5.1utterances per episode. John increased hisaverage utterances per episode from 2.4 to4.1 after treatment. Ivan and Casey doubledtheir number of utterances to maintain con-

versational topics, with Casey improvingfrom an average of 0.6 to 2.9 utterances andIvan improving from 2.4 to 4.9 utterances.

Social Validity Assessment

Judgments of the quantity and quality ofchanges in specific social behaviors and in-


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Figure 5. Frequency of coded social communication skills during baseline, treatment, maintenance, andclassroom conditions for Casey during 10-min sessions.


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Figure 6. Frequency of appropriate social communication skills during baseline, treatment, and maintenanceconditions for Ivan during 10-min sessions.


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Table 5

Summary of Teacher and Graduate Student Social Validity Ratings Pre- and Posttreatment

Teacher ratings Graduate student ratings

Child

Pre

M SD

Post

M SD

Pre

M SD

Post

M SD

Dan

Greg

TCa

Pb

TCP

2.73.02.23.6

1.83.33.34.2

4.04.73.74.3

1.71.22.71.5

2.32.02.22.9

2.73.51.53.1

3.04.04.24.1

2.01.70.80.4

John

Casey

TCPTCP

1.41.81.72.8

1.33.21.74.0

3.33.63.24.1

1.61.12.21.0

1.91.81.41.6

1.21.60.82.6

3.54.02.73.4

1.01.72.83.0

Ivan TCP

2.01.5

2.32.3

4.34.1

1.30.4

2.11.2

1.21.2

4.13.9

1.62.2

Note. 1 not at allregarding active involvement in activity, verbal initiations, or responses to peers comments; 5 betterthan averageengagement in these three social behaviors.

a TC Target childs social behavior ratings.b

P

Peers social behavior ratings.

teractions between the focus children andtheir peers are presented in Table 5. Follow-ing treatment, all 13 raters consistently re-ported improvements in reciprocal social be-haviors between the focus children and theirpeers. Specifically, ratings of the focus chil-drens active involvement in the interaction,use of comments or questions, and responsesto peers utterances improved fromnot at allor much less than average for age group to

somewhat less than average to average for agegroup. Improvements in the peers attemptsto draw the focus children into the interac-tion, respond to their communication at-tempts, and initiate comments or questionsalso were reported.

DISCUSSION

An intervention that combined social sto-ries, pictorial and written text cues, and sup-plemental video feedback was effective in in-

creasing specific social communication skillsof 5 young students with autism as they in-teracted with typical peers. Following imple-mentation of the visually mediated treatment,the children with social impairments dem-onstrated improved and more consistent rates

of targeted social behaviors compared to base-line performance. Treatment effects were rep-licated across four different social behaviors.Experimental control was demonstrated overthree targeted social skills by Dan, Greg, andCasey and two social skills for John and Ivan.

Although marked increases in Johns abilityto respond contingently to peers were not ob-served, he did demonstrate more consistentand relevant responses after treatment. For

Ivan, a slight modification in treatment pro-cedures resulted in treatment effects acrossboth social behaviors targeted (initiatingcomments and securing attention). Thesefindings also demonstrate the importance ofindividualizing social interventions.

Dans and Gregs improvements general-ized across targeted social behaviors. For ex-ample, after being taught how to gain apeers attention, Dan would add a commentor request (e.g., Jamie, its your turn) togive directions, state rules, or ask questions.Greg also demonstrated generalized im-provements, in that treatment on initiatingrequests led to an increase in his use of com-ments. These generalized treatment effectspossibly reflect interrelated social behaviorsthat underlie initiations.


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Casey showed some generalization of skilluse during interactions with his peers in theclassroom in that he continued to use the

written text cues to initiate and maintain their

attention. Greg and John did not transfer useof new social language skills to the classroom.In the classroom, there were two main factorsthat may have contributed to limited gener-alization. First, the typical peers acted more astutors with the focus children than was ob-served in treatment. For example, during thefirst classroom session, Johns peers directed ahigh number of instructions to assist him incompleting a math worksheet to which he fre-quently responded with frustration. Second,the classroom activities (e.g., reading books,

doing worksheets) were different from the so-cial activities used in the study (e.g., boardgames, thematic play). Improved generaliza-tion may have been facilitated by using moresocially oriented classroom activities, as hasbeen reported elsewhere (Kamps et al., 1997;

Wolfberg & Schuler, 1993).Overall, maintenance data across partici-

pants were not compelling. In the absence ofvisual cues or as new treatment phases began,3 of the 5 participants maintained some of thepreviously targeted social skills. These 3 chil-

dren maintained improvements in initiatingcomments to peers, with Dan also maintain-ing his ability to gain a peers attention. Thisgeneral lack of maintenance across targeted so-cial behaviors has important implications.First, the marked or gradual return to baselineperformance observed for some participantsfollowing removal of adult prompts and visualcues suggests that the visual cues may havebeen responsible for initial treatment effects.Second, some participants with social impair-ments may require more intensive treatment

to learn certain social communication skills.For example, the extended length of time nec-essary to effect change in securing attentionand the improvements observed followingbooster treatment sessions indicate that thisparticular skill may be more difficult for some

children with autism. Premature removal ofadult- or peer-mediated prompts may lead toloss of treatment gains. Treatment effects mayhave been more evident and durable had

training continued for a longer period, andhad prompts been introduced and faded moregradually in the generalization setting. Thesefindings underscore the importance of trainingnew communication skills to a proficient leveland creating social opportunities for ongoingpractice.

The findings of this investigation contrib-ute in several ways to the treatment efficacyliterature for improving communication ofchildren with social deficits related to autism.First, this research documents the potential

benefits of using visual supports to teach newsocial language skills for verbal children whohave some reading ability. It is difficult toconclude which visual strategies (social sto-ries, written cues, video feedback) in thetreatment package were the most beneficial.

Additional research is needed to assess the ef-fectiveness of using social stories that aim toimprove social communication or behaviorsof children with autism with varied language,cognitive, and social competencies.

Second, by the end of treatment all par-

ticipants demonstrated improved topicmaintenance skills. These collateral improve-ments are noteworthy given the persistentand significant difficulties reported for thispopulation in using social-communicativebehaviors to initiate, respond, and maintainconversations (Lord & Magill-Evans, 1995;Loveland et al., 1988). Similar discourse dif-ficulties have also been reported for high-functioning children with autism who haveaverage intelligence (Ramberg, Ehlers, Ny-den, Johansson, & Gillberg, 1996). Other

secondary changes included decreased inap-propriate social behaviors for some children.These findings are consistent with Koegeland Freas (1993) research that found treat-ing social behaviors within a similar responseclass leads to positive changes in untreated


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social behaviors, and extend their findings tointeractions between elementary students

with autism and their peers. Interventionsthat improve basic conversational skills and

decrease inappropriate social behaviors, ei-ther directly or indirectly, may lead to moreopportunities to participate in day-to-dayclassroom social interactions and ultimately

will help these children to be accepted mem-bers of the school social network.

Third, the current study adds to researchdocumenting the effectiveness of using text-based cues to improve social communicationbehaviors of children with autism (Garrison-Harrell et al., 1997; Kamps et al., 1997). Forexample, the social validation results con-

firmed the benefits of using text-based cuesto improve reciprocal social interaction be-haviors for children with and without socialimpairments. These findings may assist fu-ture social intervention research that seeks toguide social program planning and imple-mentation of effective practices for school-age children with similar communicativeand academic profiles.

In summary, this study examined the effectsof combining pictorial and written text cues

with supplemental video feedback on the so-

cial communication of 5 elementary studentswith social deficits related to autism. A num-ber of previously documented social interven-tion strategies were effectively combined intoone treatment package to improve the chil-drens social communication competence dur-ing interactions with typical peers. Capitaliz-ing on the visual modality resulted in higherrates of socially desirable communicationskills, lower rates of inappropriate communi-cation behaviors, and improved conversationalskills. Together, the results of this study sup-

port clinical recommendations for using text-based visual cues to guide the social commu-nication development of children with autism(Quill, 1997; Schuler, 1995) and provide ev-idence of the benefits of integrating estab-lished social intervention techniques.

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Received August 29, 2000Final acceptance August 20, 2001

Action Editor, Craig H. Kennedy


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STUDY QUESTIONS

1. Describe the general context in which the study took place and the types of data that were collected.

2. How were the focus and peer participants selected?

3. The experimental design was described as a multiple baseline design across behaviors (skills). How did themanner in which treatment was implemented create a second experimental design?

4. Describe the three types of instructional interventions used in the study.

5. How was generalization assessed?

6. Summarize the results obtained with respect to the acquisition of target behaviors and maintenance andgeneralization to untrained skills and new settings.

7. Therapeutic effects were attributed primarily to the antecedent (visual) components of the treatment. What

sources of reinforcement may have influenced participants behavior?

8. The authors noted that increased rate of responding was an index of improvement. Under what conditionswould high rates of verbal responding be undesirable?

Questions prepared by Claudia Dozier and Pamela Neidert, The University of Florida

modelos para el autismo

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