Journal of Autism and Developmental Disorders, Vol. 20, No.

1, 1990

Sustained A t t e n t i o n in Children with A u t i s m 1

Helen Bray Garretson 2

Hillcrest Educational Center
Deborah Fein
Boston University School of Medicine and University of Connecticut
Lynn Waterhouse
Trenton State College

Although many children with early infantile autism cannot maintain atten-
tion to externally imposed tasks, they may continue a repetitive behavior o f
their own choosing f o r long periods o f time. This study examined the per-
formance o f autistic and mental age matched normal children on a Continu-
ous Performance Test o f sustained attention. Results suggest that autistic
children's difficulties in sustaining attention on imposed tasks may be at-
tributable partly to a developmental delay and partly to the motivational con-
tingencies o f task rather than to a primary impairment in the ability to sustain
attention.

A l t h o u g h m a n y c h i l d r e n with e a r l y i n f a n t i l e a u t i s m c a n n o t flexibly a l l o c a t e
a n d m a i n t a i n a t t e n t i o n to e x t e r n a l l y i m p o s e d t a s k s f o r even a few m i n u t e s ,
t h e y m a y b e a b l e to c o n t i n u e a r e p e t i t i v e b e h a v i o r a l r o u t i n e o f t h e i r o w n
c h o o s i n g f o r l o n g p e r i o d s o f time. D o e s this e r r a t i c a b i l i t y t o s u s t a i n a t t e n -
t i o n r e p r e s e n t a p r i m a r y i m p a i r m e n t o f a t t e n t i o n in a u t i s t i c c h i l d r e n o r d o e s
it d e p e n d m o r e o n m o t i v a t i o n a l c o n t i n g e n c i e s o r specific t a s k d e m a n d s ? A t
least t h r e e h y p o t h e s e s ( n o t m u t u a l l y exclusive) c a n be f o r m u l a t e d :

~This project was supported by an NIMH grant MH 28605 to L. Waterhouse and D. Fein. We
appreciate the cooperation of the staff and students of League School, Newton, Massachusetts,
and the Nazarene Child Care Center in Beverly, Massachusetts. We gratefully acknowledge
the help of Hope Trefry, Dot Lucci, Kaye Cook, and Kathleen Sheher with data gathering
and analysis. Ross Rizley, Anne Copeland, Jaqueline Liederman, and Leslie Brody of the Boston
University Graduate Program in Psychology provided helpful comments at every stage of this
project.
2Address all correspondence to Helen Bray Garretson, Hillcrest Educational Center, 370 North
Street, Pittsfield, Massachusetts 01201.
101
0162-3257/90/0300-0101506.00/0 9 1990 Plenum Publishing Corporation
 102 Garretson, Fein, and Waterhouse

1. The usual externally imposed tasks are too complex and changing
for autistic children who tend to prefer simple, repetitive pursuits. Research
with a variety of tasks has documented the inability of autistic children to
manage complex tasks. Children with autism are "overselective" in that they
respond to limited discriminative cues (Cook, Anderson, & Rincover, 1982;
Fein, Waterhouse, & Tinder, 1979; Lovaas, Koegel, & Schreibman, 1979;
Wilhelm & Lovaas, 1976), with little flexibility in their scanning to detect
other important information, especially on complicated tasks. Some theor-
ists have suggested that an underlying state of hyperarousal leads to the con-
stricted behavioral repertoire and the preoccupations with simple, repetitive
stimuli (Hutt & Hutt, 1968). Stereotyped movements may serve as arousal
displacement activities to modulate tension (Kinsbourne, 1980).
A task of sustained attention such as the Continuous Performance Test
(CPT; Rosvoid, Mirsky, Sarason, Bransome, & Beck, 1956) does not require
the subject to shift strategies; rather it tests the child's ability to maintain
a single strategy over time. Frankel, Freeman, Ritvo, and Pardo (1978) have
suggested that a repetitive stimulus may be inherently reinforcing for chil-
dren with autism. If the everyday difficulty getting autistic children to main-
tain attention on tasks is due to the complex and changing nature of these
tasks, autistic children might be expected to perform within normal limits
on a simple, continuous performance task.
2. Autistic children's motivation for mastery or for social reward is in-
sufficient to maintain performance. Motivational abnormalities in autism
have been studied primarily to determine what aspects of the learning and/or
testing situation improve task performance. The bulk of behavior modifica-
tion research and clinical techniques (Ferster, 1961; Lovaas, 1977) empha-
sizes that strong primary reinforcers (Dunlap & Egel, 1982), sensory
stimulation (Hung, 1978; Murphy, 1982), or idiosyncratic preferred reinforcers
facilitate task-relevant learning in autistic children (Koegel & Egel, 1979). Social
reinforcers such as smiles of frowns, do not as predictably elicit the expected
results (Howlin, 1978; Wing, 1978) although some children with autism are semi-
tive to interpersonal manipulations of the experimental situation. Clark and
Rutter (1981) demonstrated that clear structure and high interpersonal de-
mand increased attention and performance on a model-building task.
Most cognitive research with autistic children does not consider that
the reinforcement contingencies of the learning situation may significantly
affect their performance. Reinforcement parameters are critical to evaluate
because motivation is an intrinsic and crucial component of attention, and
what may appear as a cognitive or attentional deficit could be related rather
to motivational deficits (Kinsbourne, 1983). If motivational deficits are key
to the autistic child's difficulty with everyday tasks, then varying incentives
on the CPT should alter performance, and the proper incentive conditions
might bring performance within normal limits.
Sustained Attention in Autistic Children 103

3. Autistic children have a deficit in maintaining attention on external-

ly imposed stimuli over and above their motivational state and their prefer-
encefor simple stimuli. This is not a single hypothesis but a group of related
ideas suggesting fundamental perceptual and attentional anomalies (Cohen
& Johnson, 1967; Gold & Gold, 1975; Ornitz & Ritvo, 1976; Rimland, 1964;
Schopler, 1965, 1966) affecting the taking in of stimuli from the external
environment. If there exists a primary abnormality in such a system, one
might expect that although simple stimuli and effective incentives would max-
imize performance on a signal detection task such as the CPT, such perfor-
mance would remain defective.
In the current study, a modified version of the CPT was run with 23
children with autism and 23 normal children, manipulating rate of presenta-
tion (slow vs. fast, reflecting task difficulty) and reinforcement modality (so-
cial vs. tangible, reflecting motivational differences). If the third hypothesis
which suggests fundamental perceptual or attentional abnormalities is cor-
rect, one would expect impaired performance on the CPT even under condi-
tions of high motivation and simple repetitive stimuli and responses. If task
complexity underlies the autistic child's impairment in sustained attention,
performance on a simple CPT might be most affected by the rate of presen-
tion, while if motivational variables are crucial, the reinforcement modality
might be the critical factor.

METHODS

Subject Population

Subjects for this study were 23 children who attended a day school for
children with autism. A review of the children's school and medical records
indicated that all of the children had demonstrated symptoms of early in-
fantile autism before the age of 36 months. Data were collected before the
publication of DSM-III-R but behavioral data were available from a Be-
havior Rating Scale (Fein, Walerhouse, Lucci, & Snyder, 1985) filled out by
teachers. Each student was evaluated for the presence of behaviors that
matched specific DSM-III-R diagnostic criteria. See Table I for examples
of common behaviors reported and their corresponding DSM-III-R criteria.
All children met DSM-III-R diagnostic criteria for 299.00 Autistic Disorder.
The children ranged in chronological age from 4 years 11 months to
19 years 2 months (M = 12 years 4 months, SD = 3 years 10 months). The
sample included 5 girls and 18 boys, 5 nonwhite subjects, and a wide SES
range. Children were excluded from the study if they had no comprehensible
language or if they utilized sign language as their primary means of commu-
nication. Mental age on the Peabody Picture Vocabulary Test (PPVT) ranged
 104 Garrelson, Fein, and Waterhouse

Table I. Examples of Behavior Rating Scale Items Used to Match Diagnostic Criteria
DSM-III-R criterion
A1. Marked lack of awarness of the
existence or feelings of others
A3. No or impaired imitation
B4. Marked abnormalities in the pro-
duction of speech
B5. Marked abnormalities in the form
or content of speech including
sterotyped and repetitive use of
speech, use of "you" when "I" is
meant, ideosyncratic use of words
or phrases
C1. Stereotyped body movements
C4. Unreasonable insistence on follow-
ing routines in precise detail
C5. Markedly restricted range of
interests and a preoccupation with
one narrow interest
Rating scale item
Has the child seemed "hard to reach" or "in
a shell?"
Has the child ignored people as if they did
not exist?
Has the child imitated other children at play?
Has the child used hollow sounding speech?
Has the child used words which mean some-
thing only to him/her?
Has the child shown repetitive hand or arm
flapping, finger posturing, or clapping?
Has the child insisted things must be done
the same way each time?
Has the child been preoocupied with certain
objects or topics?

f r o m 3 years 2 m o n t h s to 10 years 2 m o n t h s ( M = 5 years 8 m o n t h s , SD

-- 1 year 6 m o n t h s ) . M e n t a l age o n the D r a w - A - D e s i g n Test ( D A D ) f r o m the
M c C a r t h y Scales of Children's Abilities (McCarthy, 1972) ranged from 3 years
6 m o n t h s to 9 years 6 m o n t h s ( M = 6 years, SD -- 2 years 1 m o n t h ) .
It is evident t h a t these autistic c h i l d r e n r e p r e s e n t e d a wide range o f r e t a r d a -
t i o n . P e a b o d y IQs r a n g e d f r o m b e l o w 40 to 90 with M = 51.8, SD = 15.72.
N o r m a l c o n t r o l children, recruited t h r o u g h a day care center, a h o u s -
ing project, a n d c h u r c h b u l l e t i n b o a r d , were m a t c h e d o n the basis o f sex
a n d m e n t a l age. T h e n o r m a l s a m p l e i n c l u d e d two n o n w h i t e c h i l d r e n a n d
represented a wide SES range. T w o c o n t r o l g r o u p s were f o r m e d , o n e o n the
basis o f P P V T scores ( P P V T n o r m a l s ) a n d o n e o n the basis o f D A D scores
( D A D normals). F i n d i n g s were c o m p a r a b l e for b o t h c o n t r o l groups; only the
c o m p a r i s o n s with the D A D g r o u p are r e p o r t e d here. N o r m a l s r a n g e d f r o m
3 years to 9 years 6 m o n t h s o n the D A D ( M = 5 years 9 m o n t h s , S D =
1 year 11 m o n t h s ) a n d were m a t c h e d case b y case to the autistic children,
w i t h i n 2 raw score p o i n t s , r e p r e s e n t i n g a m a x i m u m o f 1 year d i f f e r e n c e in
m e n t a l age e q u i v a l e n t s .

Testing A p p a r a t u s

T h e C o n t i n u o u s P e r f o r m a n c e Test o f R o s v o l d et al. (1956), which con-

sists o f letters r a p i d l y p r e s e n t e d over a n a p p r e c i a b l e i n t e r v a l o f time, was
Sustained Attention in Autistic Children 105

modified to use more easily discriminable and familiar stimuli. The stimulus
material consisted of 23 simple black line drawings of common objects and
animals from the Peabody Picture Vocabulary Test. These were filmed in
a random but predetermined order of presentation in three epochs of 4 min
each (Slow1, Fast, Slow2) on Super-8 films. In order to be sure that the pic-
tures were discriminable for the children, only pictures on an earlier test of
the PPVT were included. Pictures that were conceptually unclear, out of date,
visually complicated, representing verbs, or which included human or animal
body parts were excluded from the stimulus list. The chair was chosen as
the target stimulus because it represented an emotionally neutral familiar ob-
ject of medium figure complexity.
Each testing session included three epochs, varying in rate of presenta-
tion (Slow1, Fast, Slow2). The slow version of the task introduced a stimu-
lus every 3 sec for a duration of 1.5 sec (27 frames) followed by 1.5 sec (27
frames) of white space. The fast version introduced a stimulus picture every
second for a duration of 0.7 sec (13 single frames) followed by 0.3 sec (5
frames) of white space. Films rather than slides were used to avoid the audi-
ble click of the changing side which may have served an arousing or cuing
function. The response apparatus was a button-press with an audible click
mounted on a board and placed in front of the child. The response was
recorded by an ongoing event recorder in the next room, which noted onset,
duration, and termination of key pressing.

Procedures

The original testing design of the research called for four sessions rein-
forced in a Social, Tangible, Tangible, Social sequence to control for order
and practice effects. Data on all four conditions were gathered for children
with autism. The children without autism found the task boring to the point
of being aversive and so many normal children were unwilling to complete
the third or fourth session that it proved impossible to gather enough data
for analysis. T-test comparisons of the minute-by-minute scores between the
two social and two tangible sessions indicated that there were no significant
performance differences for the autistic children between comparably rein-
forced minutes, suggesting that differences in performance between the so-
cial and tangible condition are not due to order effects. A similar analysis
on those normal children who did complete all sessions produced the same
results. Therefore, only the first and second sessions for both autistic and
normal children have been compared. This represents a possible confound-
ing variable which is addressed in our discussion section.
For reinforcement in the social condition, the child was enthusiasti-
cally told "Good work, [child's name]," after every fifth correct target iden-
 106 Garretson, Fein, and Waterhouse

tification (FR = 5) without establishing eye contact or touching the child.

In the tangible condition, the child identified a preference for pretzels or pen-
nies and could hear and see the reinforcer dropped into a bowl to the side
of the examiner after every fifth correct response (FR = 5) but was not able
to touch it until the end of the testing sessions.

Training Procedure

Because it was important that the subjects reliably make the perceptu-
al discrimination and accurately perform the task before the test of sustained
attention began, the training sessions were as specific, structured, and lengthy
as necessary to help each child meet a standard level of accuracy. Phase
I o f the discrimination training consisted of an interactional training proce-
dure with a booklet of 36 pictures (12 target stimuli, 24 nontarget stimuli).
Mild punishment in the form of a firm "no, only press this when you see
the chair" and removal of the child's hand from the button was used when
the child responded to a nontarget or during an interval.
When the child responded correctly, without prompting, to three tar-
gets and three nontarget stimuli, Phase 2 o f the training was started. This
consisted o f a filmed standard practice presentation at the 3-sec slow speed
constructed with an initially high rate of critical stimuli, gradually decreas-
ing to the 30~ rate used in the experimental trials. Children were reinforced
for every correct response with the appropriate reinforcement of that day
until the child reached the criterion of 9/12 correct responses to target stimuli
and not more than 3/27 errors of commission to nontarget stimuli.
Phase 3 of the training procedure utilized the same training film but
moved to the standard reinforcement schedule of FR = 5, according to the
reinforcement condition o f the day until the child met the criterion o f 9/12
correct responses and not more than 3/27 errors o f commission. Testing on
the first slow epoch began immediately after the child met the established
criterion. Training to criterion was repeated before every new testing ses-
sion. Four autistic children were unable to meet the training criterion after
two training sessions and were not included in the sample population.
Observations of each child during the full length o f both testing ses-
sions were performed by an observer who noted on the event recorder any
occurrences of looking away from the screen, self-stimulation, verbal self-
monitoring, other meaningful verbalizations and vocalizations. These data,
which reflect an attempt to identify the ongoing relationship between behavior
and accuracy on the CPT, will be reported separately.
Sustained Attention in Autistic Children 107

RESULTS

Dependent measures were evaluated with a repeated measure analysis

of variance in which the m a j o r between subject factor was categorization
as autistic versus normal. Scores were tested for the m a j o r within-subject
factors of Reward (Social vs. Tangible), Rate of Presentation (Slow1, Fast,
Slow2), and Time (minutes T1-T4) and any interactions of these variables.
Any scores that were coded in the form of a proportion (e.g., accuracy rates)
were subject to an arc sine t r a n s f o r m a t i o n before the analyses.

Hit Rate

The basic measure o f accuracy, hit rate, is defined as the total correct
responses out of the total number of target stimuli presented. An overall view
of the 24 nested cell design and m a j o r accuracy results can be gained f r o m
Figure 1, which shows (autistic vs. normal) mean hit rates, minute by minute.

Social Reinforcement Tangible Reinforcement

Slow Fast Slow~ Slow Fast Slow 2

1"1 T2 T3 "r4 T1 T2 T3 T4 TI T2 T3 T4 T1 l"z "1"3 T4

I | I | i i i i t I ! i I 1 I |
.92
.9C
\
c
.88
.86
"/~' \
cL
o .84 \/"
. .82 \

)
u
.80
.78
\
"6 .76
~ .74
.72
o
.70
o. .68
.66
r

. .62
x
.60 V
.58
.56

Autistic
...... DAD N o r m a l s

Fig. 1. Hit rate (group means for each minute): Group x Reward x Rate of Presentation
x Time.
108 Garrelson, Fein, and Wsterhouse

This illustrates how accuracy appears sensitive to the major factors of Time,
Rate of Presentation, and Reward. Repeated measures ANOVA revealed that
for both autistic and normal children, hit rate deteriorated over time within
each epoch (vigilance decrement) and was lower on the fast task, the more
difficult task.
Although we expected globally poorer performance for the children with
autism, group differences were evident only for changes in reinforcement
during the third trial (Slow2). For autistic children, Slow~ performance was
significantly lower than the Slow, performance but only under social rein-
forcement. The ANOVA data show the effect of group membership on two
interactions: Group • Reward, F(1, 36) = 8.52, p = .006, and Group •
Reward • Rate, F(2, 72) = 4.76, p = .011. Figure 2 illustrates the three-

.go

~
A "\
c .85
0 /
*2 *\ o
0

s .8o
t-
.--

V
>,
o .75
I.
-i
O
O
<
.70
O
1.0
r
er

-I- .65

t I I I I I

SlOW Fast Slow 2 Slow Fast Slow 2

Social Tangible

Autistic

DAD Normals
Fig. 2. Hit rate: G r o u p • Reward x Rate o f Presentation.
Sustained Attention in Autistic Children 109

way interaction using the hit rate means for the groups. Post hoc testing (New-
man Keuls) indicated that autistic children's performance in the Slow2 con-
dition under social reinforcement was significantly poorer than normals' and
poorer than their own performance during the tangibly reinforced condition.
It should be pointed out that under tangible reinforcement the performance
of both groups on Slow2 was not significantly different from the Slow, con-
dition.

Signal Detection Measures

A decline in hit rate over time may indicate a decline in perceptual sen-
sitivity or an increased need to be sure about the accuracy of the response
being made. From signal detection theory, sensitivity (d') is the ability to dis-
criminate the signals from nonsignals, and response bias (reflected in a higher
false alarm rate) reflects more indiscriminate responding on the part of the
subject. P(A), a nonparametric equivalent of d' described in McNicoll's (1972)
volume on signal detection theory, was calculated for each time, each epoch,
and each condition for each child. Repeated measures ANOVA on percep-
tual discriminability P(A) followed the same pattern as the hit rate data in
showing a differential group effect on Slow2 under social reinforcement,
Group • Reward • Rate of Presentation; F(2, 72) = 7.24, p = .001.
The false alarm rate (FA), the total incorrect out of the total number
of nontarget signals, reflects the subject's responding bias. Repeated meas-
ures ANOVA on FA indicated only one major significant effect, that of fewer
false alarms in the fast Rate of Presentation, F(2, 72) = 8.7, p < .001. No
interactions were significant.
The significance of P(A) is heightened by the lack of significance in
FA. While the measure of discriminative sensitivity P(A) demonstrated a
differential effect of social reinforcement by group, the false alarm rate did
not. In other words, cautiousness in responding did not change with rein-
forcement changes, but processing capacity did; autistic children's perceptu-
al discrimination improved with tangible reinforcement.

Individual Differences

The frequency distribution of overall accuracy scores within the group

of autistic children was similar to that of normal children both in range and
shape. Table II shows the numbers of children within the autistic and nor-
mal samples at different levels of performance for the combined tangible
and social reinforcement conditions. It can be seen that the distribution of
scores is quite similar for the two groups. Thus the similar group mean scores
 110 Garretson, Fein, and Waterhouse

Table 11. Distribution of Individual Level of Accuracy

Percentage overall accuracy-Average hit rate
Subjects 10 20 30 40 50 60 70 80 90 100
No. autistic 0 1 0 2 1 4 4 3 6 2
No. normal 1 1 0 1 1 1 2 5 8 3
Cumulative autistic 0 1 1 3 4 8 12 15 21 23
Cumulative normal 1 2 2 3 4 5 7 12 20 23

are not masking differences in sample distributions. Only one of the six con-
ditions (Social Slow~) elicited a significantly poorer performance, resulting
in overall differences that were small. An analysis comparing the pooled vari-
ance between autistic and normal children (calculating the variance o f each
minute's accuracy score in references to each subject's mean performance)
indicated that the individual variability o f the children with autism on a
minute-by-minute basis was not significantly greater than that of normal
children.
Mental age in both normal and autistic children was a strong predictor
of performance. We hypothesized that C P T performance would demonstrate
a deviant, rather than delayed, pattern in autistic children. We expected, there-
fore, that mental age would correlate strongly with indices of C P T accuracy
in normal children but not in children with autism. For normal children PPVT
mental age correlated strongly with hit rate (r 2 = .644, p < .01) as did the
D A D mental age (r 2 = .582, p < .01). For autistic children the D A D men-
tal age correlated more strongly (r 2 = .522, p < .01) with hit rate than did
the P P V T measurement (r 2 = .307, p < .08). This may be somewhat relat-
ed to the nature of the current C P T which is a nonverbal visually mediated
task in which language capabilities may play a minimal facilitatory role es-
pecially for language-impaired children. While the correlation between P P V T
scores and hit rate did not reach significance for the autistic children, the corre-
lations for autistic and normal children were not significantly different. In
other words, mental age as measured by the P P V T is not a significantly weak-
er predictor of overall accuracy for children with autism than for children
without autism. Chronological age did not correlate strongly with hit rate
for the children with autism (r 2 = .0589, p < .395) but it did predict perfor-
mance in children without autism (r 2 = .619, p < .01).

DISCUSSION

The children with autism in the present study were not deficient in most
conditions of the C P T relative to MA-matched normal children, nor were
Sustained Attention in Autistic Children 111

they significantly more variable than normals either as a group or within in-
dividuals. All children followed the major trends expected in a vigilance
paradigm, that is, accuracy deteriorated over time and on more difficult tasks.
The effect of task complexity on the ability to sustain attention could not
be clearly assessed by this study, but task difficulty (slow vs. fast condition)
did not significantly compromise the performance of autistic more than that
of normal children. For all children, performance declined on the fast task.
For all children, mental age measurements were strong predictors of CPT
performance.
There are two aspects of the study design in which order effects must
be considered as confounding variables. First there is the order effect for
the Slow1, Fast, Slow2 sequence of segments within each test session. For
the autistic children in the tangibly reinforced condition, and for the normal
children under both social and tangible conditions, performance in the Slow2
epoch returned to the level it was under the initial Slow1 task, following the
more difficult fast condition. Only for the autistic children in the social rein-
forcement condition did performance in Slow2 continue to deteriorate, and
this indeed, does represent an order effect~ in the sense that the autistic chil-
dren under this motivational condition experienced continual performance
decrement regardless of the difficulty level.
The second possible order effect, which represents a more serious pos-
sible confound, is the fact that sufficient data could be collected for the normal
children only in the first two sessions, and that therefore the social condi-
tion always preceded the tangible condition. It is impossible to rule out this
confound as contributing to the results, but three factors reduce the likeli-
hood. First, for autistic children, who were given the entire planned comple-
ment of sessions (Social, Tangible, Tangible, Social) minute-by-minute
comparison between the two social sessions and the two tangible sessions re-
vealed no differences. Thus, for the children with autism, there were no over-
all order effects over the four sessions. Second, for the normal children, there
were no differences between comparable segments in the social versus the
tangible session; therefore, as far as can be determined, no order effect be-
tween Sessions 1 and 2 appeared. Third, the only significant difference be-
tween the autistic and normal children (Social Slow2) appeared in the first
test session, and therefore, although order effects for the normal children
may account for differences of lack or differences between the groups in suc-
ceeding sessions, they cannot account for the group difference in the first
session.
The socially reinforced Slow2 deficit for the children with autism sug-
gests that an abnormal motivational framework, rather than a basic percep-
tual/arousal deviancy, underlies their sustained attention deficits. The data
suggest that the autistic children were more responsive than normal children
to the changes in reinforcement modalities during the second slow trial. For
 !12 Garretson, Fein, and Waterhouse

the autistic children, the efficacy of social reinforcement declined at a steep-

er rate than that of the tangible reinforcement.
The application of signal detection measures makes it possible to attrib-
ute the Group x Reward changes in hit rate to the children's ability to main-
tain discriminative sensitivity at a higher level for a longer time during the
tangibly reinforced condition. The tangible reinforcement seemed to increase
the autistic child's motivation to perform accurately. It did not indiscriminate-
ly increase all button-pressing, but rather helped the child maintain careful
attention for a longer period of time.
In testing normal children motivational changes are not usually consi-
dered to act in a selective fashion when evaluating a cognitive or attentional
deficit. However, the enhancing or detracting effects of motivation on cog-
nitive processes may not be the same for autistic children as for normal chil-
dren. Although children with autism may cooperate with the general demands
of the experimental situation, they may ignore more specific of more com-
plex task requirements or put out less than maximal mental effort. A deficit
in performance cannot be attributed to a defective cognitive process without
considering the possibility of a defective motivational framework that sup-
ports the performance on a cognitive task. In the CPT task in this research,
the reinforcement not only improved the child's willingness to sit and press
the button, it also seemed to facilitate correct perceptual discrimination. What
might be construed as a primary cognitive defect may relate rather to motiva-
tional deficits (Kinsbourne, 1983) that prevent optimal performance in the
autistic child. For any cognitive research with autistic children then, rein-
forcement strategy should be carefully planned to maximize performance.

Implications for Educational Techniques and Further Research

A defective motivational framework, rather than an intrinsic inability

to sustain attention, may better explain the attentional deficits in the every-
day life of children with autism. However, the generalizability of this research
has yet to be tested thoroughly with a less artificial task. This task was a
simple one, designed to measure the ability to sustain attention on a repeti-
tive task. Its rate and range of stimuli were regular and immediate, never
taxing the child's ability to manage novelty, remember complicated instruc-
tions, process changing rules, solve problems, or perform any other aspect
of higher level cognitive processing. These task demands seem to maximize
the autistic children's capacity for response, even when the task was made
more difficult by its increased rate of presentation. The requirements for sus-
tained task-relevant behavior in everyday living may seem more complex and
less regularly reinforced, generally requiring more motivational investment
on the part of the subject than was necessary to perform this continuous
Sustained Attention in Autistic Children 113

performance task. Often in real life the autistic children's desire to perform
their idiosyncratic behaviors is not challenged competitively by potent rein-
forcers from the environment. It remains to be tested, however, whether other
manipulations of the C P T task would stress autistic children's capacity for
response, for example, changing sensory modality, increasing perceptual
difficulty, varying task complexity, using a verbal rather than a pictorial form,
or including a distraction or contingent cue.
In the classroom, the preference for producing repetitive behavior or
repeating previously learned tasks is usually seen as detrimental for the child's
further development of cognitive skills. However there may be situations in
which this "skill" o f sustaining focused attention could be adaptively trans-
ferred to a productive activity. Perhaps teachers need to be more alert to
that subgroup of children who are "repetitive specialists" and seek to de-
velop educational goals that use that capability in everyday living situations
or workshop activites.
In schools, developing individualized reinforcement programs may be
as important as devising individualized skills programs. Primary education-
al efforts should be focused on shaping idiosyncratic motivating preferences
into patterns that relate in form and structure to those of normal children,
for example, variation in reinforcers (Egel, 1980) are more effective for nor-
mal and autistic children alike.
This research confirms the impression o f many theorists (Cart, 1977;
Dunlap & Egel, 1982; Durand & Crimmins, 1988; Lovaas, 1977) that under-
standing the endogenous motivational framework o f the autistic child
represents a critical research question both for determining the biological
substrates of the syndrome and for framing effective intervention techniques.
The C P T paradigm described in this study, in suggesting that autistic chil-
dren's basic capacity to sustain attention is not deviant in and o f itself but
is responsive to reinforcement effects, offers a baseline for further research
manipulating complexity, reinforcement, and other task variables that might
affect the attentional functioning of children with autism.

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