Journal of Autism and Developmental Disorders (2018) 48:1957–1970

https://doi.org/10.1007/s10803-017-3455-z

ORIGINAL PAPER

An Evaluation of Behavioral Skills Training for Teaching

Caregivers How to Support Social Skill Development in
Their Child with Autism Spectrum Disorder
1 2 2 2,3 2 1
Mahfuz Hassan · Andrea Simpson · Katey Danaher · James Haesen · Tanya Makela · Kendra Thomson

Published online: 6 January 2018

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract
Limited research has explored how to best train caregivers to support their child with autism spectrum disorder (ASD)
despite caregivers being well suited to promote generalization and maintenance of their child’s skills in the natural
environ-ment. Children with ASD have been shown to benefit from social skill training, which is not always conducted in
the natural context. This research examined the efficacy of behavioral skills training (BST) with, and without in situ
training (IST), for teaching caregivers how to also use BST to support their child’s context -specific social skills. Although
caregivers met mastery criterion within BST sessions, their skills did not generalize to the natural environment until IST
was introduced. The implications of the findings are discussed.

Keywords Caregiver training · Behavioral skills training (BST) · In situ training (IST) · Autism spectrum disorder
(ASD) · Social skills · Applied behavior analysis (ABA)

Introduction 2010; Williams White et al. 2007). However, some studies

The diagnostic criteria for autism spectrum disorder (ASD)
are deficits in social interaction and communication in con-
junction with restrictive, repetitive patterns of behavior,
interests, or activities that are present during early develop-
ment (American Psychiatric Association 2013). Deficits in
social interaction and communication can include: nonver-bal
communication such as eye contact and body language,
developing and maintaining friendships, as well as social-
emotional reciprocity including conversation skills and emo-
tions (Church et al. 2000; Daniel and Billingsley 2010; Tan-
aka and Sung 2016). Evaluations of group based social skills
training for children with ASD have shown some positive
results (National Autism Center 2015; Reichow and Volkmar
*\ Kendra Thomson
\ kthomson@brocku.ca
1
\ Department of Applied Disability Studies, Brock University,
1812 Sir Isaac Brock Way, St. Catharines, ON L2S 3A1,
Canada
2
\ Lake Ridge Community Support Services, 900 Hopkins
Street, Whitby, ON L1N 6A9, Canada
3
\ Present Address: Monarch House, Oakville, ON, Canada
indicate only moderate effect sizes (Gates et al. 2017) and
the impact on some constructs, such as social reciprocity,
may be inconclusive (Keonig et al. 2009).
Another limitation of social skills training for children with
ASD is a lack of maintenance and generalization of skills
from contrived training settings to the natural environ-ment
(Rao et al. 2008; Williams White et al. 2007). Gresham et al.
(2001) suggest that social skills training take place in a
naturalistic setting and there is some evidence of enhanced
maintenance and generalization when children are trained
within natural environments versus contrived settings (Bell-ini
et al. 2007). One way to address this limitation may be to train
caregivers how to support their child’s social skills in
ecologically valid environments to maximize generalization
opportunities. Further evaluation of caregiver training strate-
gies is highly warranted, especially to determine if involv-ing
caregivers in child social skills training maximizes child
outcomes.
Behavioral skills training (BST), which is comprised of
instructions, modelling, rehearsal and feedback (Milten-berger
2008a; Parsons et al. 2012 , 2013), has been suc-cessfully
utilized to teach a variety of skills across diverse populations.
Examples include: teaching children gun safety (Miltenberger
et al. 2004), teaching staff to implement

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\1958
discrete-trial teaching (Sarokoff and Sturmey 2004), train-ing
teachers on using natural language paradigm (Gianoumis et al.
2012), training graduate students to implement manu-alized
cognitive behavior therapy (Hassan et al. 2017), and training
caregivers to implement guided compliance (Miles and
Wilder 2009). The components of BST have also been used to
teach a variety of social skills including: increasing vocal
conversation skills such as greetings and maintaining and
ending conversations (Kornacki et al. 2013; Nuernberger et al.
2013); changing the topic of conversation and main-taining
eye contact (Stewart et al. 2007); negotiating and giving
compliments (Hui Shyuan Ng et al. 2016); joining activities
and changing games (Peters et al. 2016); teaching
communication in the form of requesting (Loughrey et al.
2014); and numerous play skills (Leaf et al. 2009).
In situ training (IST) involves practicing a skill in a natu-
ral environment versus a contrived setting. Similar to the
rehearsal component of BST, feedback can be provided
immediately if the skills are not demonstrated correctly or
within a specified time (Hanratty et al. 2016 ; Pan-Skadden et
al. 2009). Although research suggests that for some indi-
viduals BST alone is effective for learning certain skills, for
others an IST component has proven beneficial in meeting
specified mastery criteria (Gunby and Rapp 2014; Milten-
berger 2008b; Pan-Skadden et al. 2009). BST combined with
IST is effective for teaching a variety of safety skills to chil-
dren (Harriage et al. 2016; Himle et al. 2004; Miltenberger et
al. 2009) including gun safety (Miltenberger et al. 2005) and
abduction prevention (Johnson et al. 2006), as well as sexual
abuse prevention in women with developmental disabilities
(Egemo- Helm et al. 2007). Nuernberger et al. (2013)
examined the effects of using BST and IST to teach
conversation skills to young adults with ASD and indicated
that BST with IST was effective (Nuernberger et al. 2013). It
is unclear whether training caregivers to implement BST
necessitates an IST component to effectively support social
skill development in their child with ASD and whether car-
egiver involvement improves child social skills outcomes.
Matson et al. (2009) reviewed literature which indicated
that training parents on behavioral procedures led to positive
treatment effects in the domains of communication, early
intervention, and the treatment of specific fears. Despite the
acknowledgement of the efficacy of training parents on
behavioral procedures there is limited research on the use of
BST for teaching caregivers how to support their child in
social settings. One exception (Stewart et al. 2007) used BST
to train the mother and sister of a child with Asper-ger’s
disorder to use BST to support their son/brother in
conversational skills. The researchers conducted an assess-
ment, provided training, and took direct observations over a
total of 13 h. After training both the mother and sister were
able to use BST to teach conversational skills to their
son/brother which led to improved conversational skills. The
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Journal of Autism and Developmental Disorders (2018) 48:1957–1970
mother continued using BST up to 3 months later to help
improve her son’s conversational skills. She had not gener-
alized using BST to teach her son new skills although she
indicated she would be confident in doing so. This training
package did not involve IST as treatment integrity (i.e.,
BST implementation accuracy) remained above 80% for
most tri-als. Although some research indicates that IST can
lead to more effective outcomes than BST alone (i.e.
instruction, modelling, practice, feedback), IST may not be
feasible in all clinical environments. Due to time and
resource constraints in community and/or treatment
settings IST is not always a viable option when training
caregivers (Hanratty et al. 2016; Miltenberger et al. 2009).
Current Research
BST has demonstrated effectiveness for teaching a variety of
skills to diverse populations and there is preliminary support
for using BST to teach social skills to children with ASD in
natural settings (e.g., Stewart et al. 2007). We hypoth-esized
that BST would be efficacious for training caregivers how to
also use BST to support their children’s social skill
development in an ecological valid setting (i.e., uncontrived
free play sessions with their child and other children) . To
evaluate, we added a BST component for caregivers to a pre-
existing children’s social skills group to address previous
recommendations to promote maintenance and generaliza-tion
of child outcomes by training individuals in the child’s
environment (Bellini et al. 2007; Gresham et al. 2001). Using
a concurrent multiple probe design, Study 1 evalu-ated
whether two brief BST sessions (one individual and one
group) would be sufficient for training caregivers how to also
implement BST to support their child’s social skills within
free -play sessions with unplanned social situations. In Study
2 we hypothesized that the addition of IST would lead to
improved caregiver BST implementation accuracy and
generalization with their child. We also hypothesized that
caregivers would find the training to be acceptable. This
research attempts to address the need for feasible and effica-
cious social skills training for children with ASD through
evaluation of a previously validated training model applied to
caregivers. Results may inform how to capitalize on
opportunities for generalization and maintenance of child
social skills in the natural environment.
Method
This research was conducted in partnership with an agency
that provides treatment, education, and consultation ser-vices
to support individuals with intellectual disabilities and ASD.
Caregivers referred to the agency were asked to choose a
priority for their child from four available treatment
Journal of Autism and Developmental Disorders (2018) 48:1957–1970\ 1959

domains: (1) communication, (2) emotional regulation, (3)
daily living, and (4) social skills. Caregivers who signed their
child up for the social skills group were invited to par-ticipate
in the current research. Their children were at the top of a
waitlist for service based on their child’s biological age (6–8),
verbal ability (had to be verbal), and indicated need for social
skill development. Children’s developmental ages were not
assessed. The researchers and agency clini-cians designed a
BST protocol for caregivers to accompany
a pre-existing 8-week child social skills program. Partici-
pant recruitment for Study 1 commenced once approval
was received from the Research Ethics Board of the
affiliated university. After the completion of Study 1,
recruitment for Study 2 commenced.
Participants
Study 1 included four female caregivers of children diag-
nosed with ASD (ages 6–8) enrolled in an 8-week social skills
group at the community agency. Caregivers were sent a letter
of invitation from the agency and were asked to con-tact the
researchers if they were interested in participating in a study
examining the effects of a caregiver training model for
supporting social skill development in their children with
ASD. Caregivers were enrolled in the research on a first
come, first served basis. Those who were unable to partici-
pate in the research but were interested in the training were
provided the option of participating in a group-based train-ing
session. Caregivers were asked to attend each week of their
child’s social skills group (two caregivers missed 1 week
during baseline), no participants withdrew from the study, and
no participant data were excluded from the study.
Four of the five caregivers who received invitations con-
sented to participate in the study. The fifth caregiver was
unable to participate due to time restrictions, although par-
ticipated in the group training for interest. Pseudonyms for
the participants in Study 1 were: Amanda, Barbara, Cath-
erine, and Daisy (see participant characteristics in Table 1).
Four additional female caregivers of children diagnosed
with ASD (ages 6–8) were invited to participate in Study 2
using the same procedure described above. Caregivers missed
several sessions (M = 3, range 0–4) in Study 2 due to weather
restrictions and illness. Pseudonyms for caregiv-ers in Study 2
were: Ellen, Felicia, Grace, and Hannah. Only one caregiver
per child received training in both Study 1 and 2, and were all
mothers except Ellen who was a grandmother (see Table 2 for
participant characteristics).
Settings and Materials
Training sessions with caregivers took place in a quiet room,
while their child participated in the normally- scheduled social
skills group in a separate room. All data collection and IST
sessions took place in the room where children par-ticipated
in the social skills group and materials to facilitate social
interactions during free-play sessions with peers were
available (e.g., toys, games, Lego, action figures, etc.).
Experimental Design and Procedure
Study 1 evaluated caregiver training in a concurrent multi-
ple probe design across four participants. This type of sin-
gle case design is appropriate for assessing the efficacy of
an intervention with irreversible changes in behavior (i.e.,

Table 1  Participant Caregiver name Age Ethnicity Income Education Confirmation of

characteristics in Study 1 child’s diagnosis

Amanda 37 Caucasian $0–$50,000 Trade, technical or vocational training ADOS

Barbara 49 Chinese $0–$50,000 Trade, technical or vocational training ADOS
Catherine 42 Metis $0–$50,000 High school graduate ADOS
Daisy 54 Caucasian $0–$50,000 Bachelor’s degree ADOS
ADOS autism diagnostic observation schedule

Table 2  Participant characteristics in Study 2

Caregiver name Age Ethnicity Income Education Confirmation of
child’s diagnosis

Ellen 68 Caucasian $0–$50,000 High school graduate ADOS

Felicia 33 Caucasian $100,000–$150,000 Trade, technical or vocational training Prefer not to disclose
Grace 35 Caucasian $100,000–$150,00 Some college credit, no degree ADOS
Hannah 42 Caucasian $50,000–$100,000 Bachelor’s degree CARS
ADOS autism diagnostic observation schedule, CARS childhood autism rating scale

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\1960
learning) and controls for practice effects (Horner and Baer
1978) . The design consisted of six phases: baseline assess-
ment, individual BST session, post-individual BST assess-
ment, group -based BST session, post group- BST assess-
ment, and a 1-month follow-up assessment. After stable
baseline data was obtained the first caregiver received the
individual BST session (50-min) while the other partici-
pants remained in baseline. Subsequent caregivers received
the individual training sessions in a staggered fashion on
separate weeks during the 8-week social skills group. The
staggering of the intervention across participants allows for
effects of the training to be observed while attempting to
rule out other variables (Morgan and Morgan 2009). All
four caregivers also received a group training on Week 7
of the child social skills group. The flow of participants
through the phases is summarized in Table 3.
Study 2 assessed caregiver training within a concurrent
multiple probe design across three participants. The design
consisted of five phases: baseline assessment, individual
BST, post -individual BST assessment, IST, and a 2
-month follow-up assessment. Study 2 followed the same
format as Study 1 except caregivers received IST if they
did not maintain 100% implementation of BST steps in the
post-individual training assessment phase and there was no
group training component. The flow of participants is
summarized in Table 4.
Baseline Assessment
Caregivers were invited to join a free-play portion of their
child’s social skills group with other children present. The
researchers provided the following instructions to the car-
egiver: “Please support your child in this social setting as you
normally would for 5 min. I will let you know when the 5 min
are up. If you are in the middle of something, please wrap up
as naturally and quickly as possible.” Only one
Table 3  Participant flow in
Caregivers Baseline
Study 1
Amanda 3 Sessions (1–3)
Barbara 3 Sessions (3–5)
Catherine 7 Sessions (1–7)
Daisy 6 Sessions (2–6, 9)
Table 4  Participant flow in
Caregivers Baseline
Study 2
Ellen 4 Sessions (1–4)
Journal of Autism and Developmental Disorders (2018) 48:1957–1970
caregiver went into the room at a time to prevent potential
confounding variables such as observational learning and to
minimize disruption to the social skills group. All caregiv-ers
were assessed within the same session and the order in which
caregivers entered the social skills room was rand-omized for
all phases. Each caregiver had two 5-min data collection
sessions during the social skills group each week.
Individual Behavioral Skills Training Intervention
The caregiver with the most stable baseline received indi-
vidual BST after three data points were obtained. In Study
1 Amanda received training first despite having a slightly
ascending baseline due to Barbara and Daisy both missing
the first session and not having more than three data points
and Catherine had a higher ascending baseline. Barbara
received training next followed by Catherine and Daisy
based on the stability of their baseline assessments. In
Study 2 Ellen had the most stable baseline and received the
indi-vidual BST session first. Felicia received individual
BST next as her baseline was both more stable and had
fewer missing data points than Grace.
The individual BST session was consistent across Study 1
and 2 ranging from 50 to 60 min. A graduate student trainer,
under the supervision of a Board Certified Behavior Ana-lyst
(BCBA)™, attempted to teach caregivers using a BST model
how to also use BST to teach social skills to their child with
ASD. Parents received instructions on how and why to use
BST to teach social skills with a reference sheet to follow
along with. The trainer then modelled appropriate and
inappropriate examples of using BST to support social skills
with another trainer. The caregiver was then given an
opportunity to rehearse three examples that they identified as
important social skill targets for their child. Rehearsal was
followed by feedback on performance with specific praise and
corrective feedback from the trainer. All training was
Post-individual BST Post-group BST 1-month
Follow-up
10 Sessions (4–13) 3 Sessions (14–16) 1 Session (17)
8 Sessions (6–13) 3 Sessions (14–15) 1 Session (17)
5 Sessions (8–10, 12–13) 3 Sessions (14, 16) 1 Session (17)
4 Sessions (10–13) 3 Sessions (14–16) 1 Session (17)
Post-individual BST Post-group BST 1-month
Follow-up
4 Sessions (5–8) 8 Sessions (9–16) 1 Session (17)
 Felicia 4 Sessions (3–6) 2 Sessions (7–8) 2 Sessions (13–14) 1 Session (17)
Grace 6 Sessions (1–2, 5–6, 9–10) 3 Sessions (11–13) 2 Sessions (14–16) 1 Session (17)

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Journal of Autism and Developmental Disorders (2018) 48:1957–1970\
provided by the first author and a supervising BCBA™.
The only difference in Study 2 was that the reference sheet
was given to caregivers ahead of time in attempt to reduce
the training time. Mastery criteria was set at 100%
accuracy in implementing the steps of BST across the three
exam-ples chosen by the caregiver and roleplayed with the
trainer and another trainer role-playing a child. The social
validity questionnaires were given to caregivers at the end
of the individual training to fill out without the researcher
present. Post-individual training data collection sessions
were iden-tical to baseline assessment sessions (in the
natural socials skills group environment).
Group-Based Behavioral Skills Training
Since caregivers’ BST accuracy did not generalize to post-
individual sessions with their children in Study 1, a group
BST session was introduced to all caregivers (and those car-
egivers who were interested in the training but could not par-
ticipate in the research) on Week 7 of the 8 -week program.
Caregivers were briefly reminded of each of the components
of BST. Two trainers modelled common examples that were
chosen by the caregivers in their individual sessions and
discussed with the group. Trainers facilitated roleplays in
which caregivers practiced using BST while alternating roles
of both caregiver and child and provided each other with
feedback. Each caregiver had an opportunity to rehearse and
provide feedback to everyone in the group and have their
rehearsals observed by a trainer who also provided feed-back.
The session took 50 min and was also supervised by a
BCBA™. Post-group training data collection sessions were
identical to baseline and post-individual training assessment.
In-Situ Training (IST)
In Study 2 caregivers received IST instead of group training
during the free play component of their child’s social skills
group. The trainer confirmed the social skills that caregiv-ers
planned on targeting with their child. Once the goal was
clarified, the trainer demonstrated how to prompt the goal
with another child in the social skills group using BST and
then asked if they had any questions. The caregiver then
attempted to find an opportunity to use BST (for the goal they
had in mind or another skill that came up naturally) and were
provided feedback on their implementation of BST. The IST
sessions were supervised by a BCBA™.
Follow-Up Assessment
To assess maintenance of caregiver BST implementation,
Study 1 provided an opportunity for caregivers and their
children to attend a “party” with all the children and caregiv-
ers involved in the social skills group program (regardless
1961
of participation in the study) 1 month after the group ended.
Children had access to the same activities as in group free-
play sessions (i.e., board games, Lego, action figures, video
games, etc.) to help facilitate social interactions with their
peers. Caregivers were told to “Please support your child in
this social setting as you normally would.” All caregiv-ers
were present throughout the follow- up session and data were
taken at random 5- min intervals for each caregiver. Follow-
up assessment in Study 2 was identical to Study 1, but
occurred 2 months after the social skills group ended and
caregivers were present in the room individually instead of as
a group during data collection.
Primary Outcome Measure (Caregiver
BST Implementation Accuracy)
Accuracy of caregiver implementation of BST to support their
child’s context-specific social skills in the group envi-ronment
was recorded across phases. Trained observers live coded
caregiver implementation of the following BST steps:
(1) ability to provide instructions to their child on how to
perform a relevant social skill, (2) modelling that social skill
for their child, (3) allowing their child to perform or rehearse
the social skill, and (4) providing praise and/or corrective
feedback to their child about the performance of the social
skill. In each session caregiver accuracy in the implementa-
tion of these steps were then averaged as a percent correct.
Secondary Outcome Measure (Child Social
Skill Success After Caregiver Prompt)
The same trained observers also recorded live whether the
children successfully performed the caregiver-prompted social
skills that were specific to the child and the situation. Success
was defined as the child performing the skill without the need
for corrective feedback from the caregiver.
Social Validity Questionnaire
Each caregiver was asked to complete an anonymous social
validity questionnaire after receiving the individual BST
session and again after receiving the IST. The question-naire
was adapted from the Treatment Acceptability Rating Form-
Revised (TARF-R; Reimers et al. 1991), which used
a 5-point Likert-type scale (“5” = agree, “3” = neutral, “1”
= disagree). Caregivers were asked to report on their prior
knowledge in supporting their child’s social skills, con-
fidence in supporting their child in social skills after the
training, and thoughts about the training (BST), including
whether they would recommend it to other caregivers. In
Study 2, the questionnaire was administered after the IST
phase.
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\1962 Journal of Autism and Developmental Disorders (2018) 48:1957–1970

Interrater Reliability procedural integrity of the trainer behavior from a checklist of

Two trained observers recorded caregiver and child behav-
ior live during free play sessions of the social skills group.
Observers were required to achieve at least 80% agreement
with each other and a video scoring key on training videos
prior to commencing scoring in data collection sessions. A
primary observer scored all data live (during free-play ses-
sions over the 8-week social skills group) and a secondary
observer double coded a random sample of 30% of
sessions for reliability. Intraclass correlation coefficient
(ICC) esti-mates and their 95% confidence intervals (CIs)
were calcu-lated between the observers using SPSS
statistical package version 24 (SPSS, Inc., Chicago, IL).
training items across all of the caregiver training sessions
(Table 5). The checklist identified 14 steps for the trainer to
follow such as reminding caregivers of their rights in research,
providing them with a written handout and ration-ale for using
components of BST to support social skills, modelling how to
use BST for caregiver identified examples, rehearsing three
examples with caregivers, and providing feedback to
caregivers about their performance.
Results
Study 1

Procedural Integrity of Behavioral Skills
Training Sessions
To ensure consistency of the training across caregivers, a
BCBA™ observed all training sessions to calculate the
All four caregivers demonstrated 100% accuracy of BST
implementation during role plays with trainers for three
different social skills within a 50-min individual BST
training. Caregivers minimally generalized correct BST
implementation with their child in post-individual training

Table 5  Procedural
Introduction
integrity of behavioural
1. The trainer introduces themselves and reviews participant’s rights in research and study details
skills training sessions
2. The trainer provides the caregiver with the reference sheet
3. The trainer provides the caregiver an overview of what BST is, how it is currently used with their child
in the social skills groups and how it may be helpful for the caregiver
4. The trainer and caregiver discuss three social skills targets that can be targeted with BST
Instructions and modelling
5. The trainer verbally reviews instructions
(a) Ensuring the child is attending
(b) Using appropriate language
(c) Ensuring understanding
6. The trainer verbally goes over modelling
(a) Why to model
(b) How to model
7. The trainer models/acts out how to use instructions and how to model social skills
(a) Models appropriate examples
(b) Models inappropriate examples
(c) Discusses the differences with the caregiver
8. The trainer and caregiver rehearse examples from Step 4 (instructions and modelling only)
9. The trainer provides feedback (during or after) and reinforces attempts
Rehearsal and feedback
10. The trainer verbally goes over rehearsal
(a) Importance of rehearsal
(b) How to provide opportunities for their child to practice
(c) How to provide effective feedback
(d) Providing praise for appropriate attempts
11. The trainer models an example of using BST in its entirety
12. The trainer and caregiver rehearse all three examples from Step 4 until mastery (full BST)
13. The trainer provides feedback (during or after) and reinforces attempts
Social validity questionnaire
14. The trainer will provide the caregiver the social validity questionnaire to the caregiver

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Journal of Autism and Developmental Disorders (2018) 48:1957–1970\ 1963

assessment which occurred in the natural social skills
group setting (M = 5% increase from baseline). Following
an addi-tional group-BST training session caregivers had
minimal improvements compared to post-individual BST
(M = 8% increase from baseline).
Figure 1 presents the percentage correct BST steps
implemented by caregivers (depicted by the line graph)
and their child’s social skill success after caregiver
prompts (depicted by the bar graph) during each phase
of the experiment. Amanda had an immediate increase in
BST implementation accuracy from baseline to post-
individual BST (25% before to 75% after the training), and
returned to near baseline levels in Session 5. Amanda also
demonstrated an immediate increase in correct BST imple-
mentation post group-BST (0% before to 50% after train-
ing), but returned to baseline levels in Session 15. Amanda
had 0% implementation accuracy in follow-up. Her child’s
social skill success was variable across all phases, but

Fig. 1  Caregiver BST imple-

mentation accuracy (line graph)
and children’s social skill
performance (bar graphs) across
phases (baseline, individual
training, post-individual train-
ing, post-group training, and
follow-up) in Study 1

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\1964 Journal of Autism and Developmental Disorders (2018) 48:1957–1970

tended to be higher when Amanda implemented more steps
of BST correctly (e.g., Session 8 and 14).
Barbara started the program 1-week late. As such, her
baseline assessment was delayed, but was stable at 0%
implementation accuracy for three consecutive sessions.
She had an immediate increase in BST implementation
accuracy from baseline to post-individual BST (0–75%).
She returned to 0% implementation accuracy on Session 7
and remained variable at higher levels than baseline but
lower than the initial probe after the individual BST ses-
sion. Barbara demonstrated a small increase in correct BST
implementation after group training but returned to 0% a
session later and remained at 0% at follow-up. Bar-bara’s
child’s social skill success was variable but tended to be
higher when Barbara implemented more steps of BST
correctly across all phases (e.g., Session 6, 9 and 11).
Catherine’s baseline data was variable before becoming
stable at 0% BST implementation accuracy (i.e., 4 sessions in
a row) and stayed at 0% for most of the sessions after the
individual BST, with one instance where she implemented
75% of BST steps correctly on Session 13. Catherine did not
show any increase in BST implementation accuracy after
group training and remained at 0% at follow-up. Dur-ing both
sessions where she had implemented 75% of BST steps,
however her child was successful for 100% social skills that
were prompted (i.e., Session 3 and 13).
Daisy missed 1 week during baseline but remained sta-
ble in her implementation of BST after her absence. There
was a slight increase in her BST implementation post-indi-
vidual training, however BST implementation accuracy
was variable. Post group-BST, Daisy showed more stable
responding but was not using 100% of the BST steps. Dur-
ing follow-up, Daisy scored 25% of BST steps with no
child success. Daisy’s child consistently performed more
social skills correctly when Daisy used a more steps of
BST correctly (e.g., Session 13–16).
All caregivers completed the social validity questionnaire
after the individual BST session. Table 6 summarizes the
mean scores on each of the nine questions. All caregivers
indicated that they would use BST to help their child develop
social skills and indicated that evaluating strategies for car-
egivers how to provide social support to children with ASD is
important. No caregivers found their prior knowledge
sufficient to support social skills (0%) and 75% of caregiv-ers
agreed (25% somewhat agreed) that the training helped them
gain knowledge in supporting their child’s social skill
development and that what they learned would help them as a
caregiver to support their child’s social skills.
Interrater Reliability and Procedural Integrity
of Behavior Skills Training Sessions
Average interrater reliability across participants was
excellent for both the primary outcome measure of car-
egiver BST implementation accuracy (ICC = 0.90 with
95% CI = 0.78–0.96) and for the secondary outcome
measure, child social skills data (ICC = 0.95 with 95% CI
= 0.87–0.98). Procedural integrity of the trainer behavior
was 100% across all sessions and participants.
Study 2
Overall, caregivers’ BST implementation accuracy improved
after individual BST (M = 42% increase from baseline), yet
similar to Study 1, caregivers did not implement all steps of
BST and did so variably. When IST was introduced it lead to
more stable accurate use of BST (M = 73% increase from
baseline) and a corresponding improvement in children’s

Table 6  Mean caregiver social validity ratings (N = 4) in Study 1

Statement Mean
score (out
of 5)

Importance of intervention
Evaluating strategies for caregivers how to provide social support to children with ASD is important 5
I found my prior knowledge of how to support my child in social skills sufficient 3.75
I have learned important skills by participating in this study 4.75
Perceptions of BST
I found that the training (BST) helped me gain knowledge in supporting my child in social skills 4.75
I found the trainer knowledgeable and helpful to my learning of supporting my child in social skills 4.75
I feel confident that I can support my child in obtaining their social skills goals 4
I think that what I have learned will help me as a caregiver to support my child in social skills 4.75
I would recommend BST to other caregivers who have children with ASD 4.5
I will/do use BST to help my child develop social skills regularly 5

13
Journal of Autism and Developmental Disorders (2018) 48:1957–1970\
social skills. One participant’s data was not included in the
final analysis as the training protocol had to be
significantly modified to meet the caregiver’s
comprehension needs (e.g., reading textual prompts versus
independent rehearsal of BST implementation).
As shown in Fig. 2, Ellen had an immediate increase in
BST implementation accuracy from baseline to post-
individual BST (0% before to 87.5% after the training),
and quickly returned to near baseline levels in the natural
environment (Session 7). Throughout IST Ellen imple-
mented BST steps more accurately than in baseline, with
two instances of 100%, non -consecutively (Sessions 10
and 12). Ellen was unable to attend the follow-up session
Fig. 2  Caregiver BST imple-
mentation accuracy (line graph)
and children’s social skills
performance (bar graphs) across
phases (baseline, post-individ-
ual training, in situ training, and
follow-up) in Study 2
1965
so no data is reported. Ellen’s child was successful 100%
of the time when she used more than 25% of BST steps.
Felicia had an immediate increase in BST implementa-
tion accuracy from baseline to post -individual BST (25%
before to 75% after training), which declined in Session 8.
She was unable to attend multiple sessions and entered IST
when she returned in Session 13, where she scored 100%
on two consecutive sessions, reaching mastery criteria.
During follow-up Felicia maintained relatively high BST
implementation accuracy at 75% and her child’s social
skills success was variable but he was successful 100% of
the time when he did respond (e.g., Sessions 13 and 17).
13
\1966 Journal of Autism and Developmental Disorders (2018) 48:1957–1970

Grace’s baseline data was stable outside of one outlying
data point in Session 9 and several missed sessions. Grace had
an immediate increase in BST implementation accuracy from
baseline to post-individual BST (0% before to 100%
immediately after training) and maintained 100% imple-
mentation accuracy for two sessions with a slight decrease to
87.5% in Session 13. Given the slight decrease, Grace entered
IST in which she scored 100% in two consecutive sessions,
reaching mastery criteria. During follow-up Grace maintained
high BST implementation accuracy (87.5%). Her child was
successful in responding in almost all instances of Grace
using multiple steps of BST (except Session 15).
All caregivers completed the social validity questionnaire
after the individual BST session. Given that the question-
naires were anonymous the results of a fourth caregiver whose
results are not presented are included. Table 7 sum-marizes
the mean scores on each of the nine questions. All
four caregivers agreed that they would continue to use BST to
help their children develop their social skills and that eval-
uating strategies for caregivers how to provide social support
to children with ASD is important. No caregivers agreed that
their prior knowledge was sufficient to support social skills
(0%) and 100% of caregivers agreed that the training helped
them gain knowledge in supporting their child’s social skills.
Table 8 summarizes the mean scores on the same nine ques-
tions pertaining to the IST component.
Interrater Reliability and Procedural Integrity
of Behavior Skills Training Sessions
Average interrater reliability across all participants was
excellent for caregiver BST implementation accuracy (ICC
= 0.93 with 95% CI = 0.78–0.98) and good for child social
skills data (ICC = 0.87 with 95% CI = 0.57–0.96).

Table 7  Mean caregiver social validity ratings (N = 4) in Study 2

Statement Mean
score (out
of 5)

Importance of intervention
Evaluating strategies for caregivers how to provide social support to children with ASD is important 5
I found my prior knowledge of how to support my child in social skills sufficient 3
I have learned important skills by participating in this study 4.75
Perceptions of BST
I found that the training (BST) helped me gain knowledge in supporting my child in social skills 5
I found the trainer knowledgeable and helpful to my learning of supporting my child in social skills 4.75
I feel confident that I can support my child in obtaining their social skills goals 4
I think that what I have learned will help me as a caregiver to support my child in social skills 4.75
I would recommend BST to other caregivers who have children with ASD 5
I will/do use BST to help my child develop social skills regularly 5

Table 8  Mean caregiver social validity ratings including in situ training (N = 2) in Study 2
Statement Mean
score (out
of 5)

Importance of intervention
Evaluating strategies for caregivers how to provide social support to children with ASD is important 5
I found my prior knowledge of how to support my child in social skills sufficient 2.5
I have learned important skills by participating in this study 5
Perceptions of BST
I found that the training (BST) helped me gain knowledge in supporting my child in social skills 5
I found the trainer knowledgeable and helpful to my learning of supporting my child in social skills 4
I feel confident that I can support my child in obtaining their social skills goals 5
I think that what I have learned will help me as a caregiver to support my child in social skills 5
I would recommend BST to other caregivers who have children with ASD 5
I will/do use BST to help my child develop social skills regularly 5

13
Journal of Autism and Developmental Disorders (2018) 48:1957–1970\
Procedural integrity of the trainer behavior was 100%
across all sessions and participants.
Discussion
Results support existing research indicating that BST with
IST leads to more efficacious and generalized training out-
comes than BST alone (e.g., Miltenberger et al. 2009) and
contribute to limited research evaluating BST for training
caregivers how to support their child’s social skills. Since
it is not always practical or feasible in clinical contexts to
include an IST component due to limited resources, Study
1 assessed whether two brief (50-min) BST sessions (one
individual, one group) were sufficient for caregivers to
achieve mastery criteria in BST implementation accuracy. We
hypothesized that two brief BST sessions would be sufficient
for caregivers to achieve the mastery criteria in a controlled
training environment and that implementation accuracy would
generalize, potentially to a lesser degree, with their child.
Results confirmed that caregivers could demonstrate 100%
accuracy in BST implementation in the controlled training
environment, and only minimal accuracy with their child in a
natural environment. We hypothesized that adding an IST
component in place of the group BST session would increase
caregivers’ implementation accuracy with their child and lead
to a potential improvement in chil-dren’s social skills. Results
of Study 2 demonstrated that caregivers’ BST implementation
accuracy increased after receiving the IST component, and
there was a corresponding increase in children’s social skills.
We also hypothesized that caregivers would find the training
to be a helpful strategy for assisting in their child’s social skill
development, which was confirmed by the outcomes of the
social validity surveys.
These findings contribute to the existing literature in a
few important ways: (1) to the authors’ knowledge, this is
the first quasi-experimental evaluation of BST coupled
with IST to teach caregivers how to support social skills, a
highly relevant clinical need in the ASD population; (2)
the train-ing focused on teaching caregivers how to use
BST to teach skills necessary for the context versus using
BST to teach pre-determined skills only; and (3) BST
alone, and with IST, were feasibly implemented in a
clinical setting with limited disruption, few resources, and
had high social validity rat-ings from all caregivers.
The focus of this evaluation was teaching caregivers how
to apply BST to support their child’s social skills based on
what was appropriate to the context instead of learning how to
apply the steps of BST to teach a few specific skills. This
general case analysis approach (e.g., O’Neil 1990) departs
from previous BST research, yet has important implications
for generalization and maintenance of skills for both car-
egiver and child. Another key strength is that the research
1967
was conducted in collaboration with a clinical agency in an
applied setting, which enhances the ecological validity of
the results given that research conducted in highly con-
trolled conditions may not always be replicated in applied
settings or may have weaker effect sizes (e.g., Weisz et al.
1995). Further, all caregivers reported high social validity;
they reported that teaching their children social skills was
important and found that BST was helpful. Social valid-ity
is an important tenet of behavioral interventions (Baer et
al. 1968, 1987) and an important outcome measure of
research and clinical work (Schwartz and Baer 1991) given
that beliefs about credibility or the importance of a
treatment can influence outcome and mediator adherence
to interven-tions (Nock and Kazdin 2001).
A common limitation of social skills training programs for
children with ASD is lack of generalization and main-tenance
of skills (Rao et al. 2008; Williams White et al. 2007). Since
caregivers are present across more of their child’s
environments than clinicians, they are ideal candi-dates to
facilitate opportunities for children to practice and receive
feedback on their skills in natural contexts, which leads to
increased generalization and maintenance of skills (e.g.,
Bellini et al. 2007). Study 2 demonstrated that BST with IST
lead to increased caregiver BST implementation accuracy
with their child in an ecologically valid setting than after BST
alone, and preliminary data suggest that child responding
corresponded with caregiver BST accuracy. Further research
is needed to fully evaluate the relationship between caregiver
BST accuracy and child success.
This research had several limitations, including lack of
external validity due to the small number of participants
across studies, and how participants were recruited due to
the nature of the service delivery model at the community
agency. A potential limitation of this type of convenience
sampling is that the caregivers and children may have dif-
ferent characteristics than other caregivers and children in
the larger population (e.g., belief that their child can
change, child’s social skill abilities, etc). We did not
measure car-egiver’s beliefs, motivation, and knowledge
about their child’s social skills, which should be
considered in future research.
Replication is needed and future research may consider
evaluating the training model in a randomized controlled trial.
Future research should also examine training caregiv-ers to
use BST for different ages and abilities, such as ver-bal or
non-verbal children. Only one caregiver per child participated
in the training and all caregivers were mothers apart from one
grandmother. If more than one primary car-egiver participated
(e.g., mothers and fathers), it may lead to increased
generalization of child social skills due to sup-port from
multiple caregivers. Although the studies assessed skill
maintenance at 1- and 2-month follow- up, generali-zation
was not assessed outside of the social skills group.
13
\1968
Additionally, Felicia missed multiple sessions in Study 2,
however, this did not seem to negatively impact her ability
to accurately implement BST during IST.
Data were not collected on the number of opportuni-ties
caregivers had to prompt their child during data col-lection
sessions, which may have varied across caregiver/ child
dyads; if children were engaged in activities appropri-ately
with peers, there may have been limited opportunities to
prompt. Caregivers entered the room on a randomized
schedule across all phases in attempt to mitigate this pos-
sibility. Caregiver selection of social skills was also not
controlled for, and some caregivers may have targeted dif-
ferent levels of social skills difficulty. Similarly, child data
was collected only on skills prompted by the caregiver, and
therefore may represent their ability to successfully
perform skills that the caregivers felt were important
versus their overall social skills.
It is possible that caregivers may have demonstrated
higher BST accuracy across Study 1 and 2 if they had been
taught how to discriminate opportunities to prompt their
child’s social skills, which may be an inherent component
of IST. Future research is needed to fully understand what
mechanisms are responsible for change and attempt to con-
trol for extraneous variables such as difficulty of social
skill across participants. Future research should also
examine generalization and maintenance of caregiver BST
imple-mentation across other settings, over time, and in
new skill domains. There may also be merit to assessing
the impact of including a second caregiver to increase
opportunities and to also measure child’s performance.
Evaluating whether teaching caregivers how to use BST
impacts confidence, stress, relationship with their child, and
quality of life may be warranted. Caregivers of children with
ASD may experience higher levels of stress compared to
caregivers of children with other disabilities (Dunn et al.
2001). Given that social skill deficits are a core diagnostic
feature of ASD, improving children’s social skills is a com-
mon goal that may have benefits for their caregivers as well.
For example, caregiver empowerment has been shown to be a
mediator of stress in mothers of children with ASD (Weiss et
al. 2015). Empowering caregivers by training them to support
their child’s social skills may be beneficial for both children
with ASD and their caregivers, as stress lev-els may decrease
given that caregivers found the training to be important,
helpful, and reported increased confidence in their skills.
Future research may aim to address the impact of BST on
these important variables.
These preliminary findings add to the body of research on
BST, ASD, and social skill training. Teaching caregivers to
use BST with a general case analysis approach versus train-
ing a specific set of skills may contribute to caregiver and
child skill maintenance and generalization. Furthermore, this
approach was feasible and appropriate in a clinical treatment
13
Journal of Autism and Developmental Disorders (2018) 48:1957–1970
setting which has limited resources and mandated to make
positive clinical gains for families. There is merit to
teaching caregivers ways to support their child with ASD
in ecologi-cally valid settings, as there will be an ongoing
need for the child to learn new skills across the lifespan.
Further evalua-tions of this nature are highly warranted.
Acknowledgments The project was completed as a portion of the
first author’s Master of Arts thesis. The authors would like to thank
Karen Chartier, the program director at Lake Ridge Community
Support Services, all staff members who helped support the project,
and the caregivers and children who participated in the study.
Author Contributions All authors participated in the conception
of the study and participated in the design and the manuscript
preparation. KT and MH lead the design and interpretation of the
data; AS and JH participated in the acquisition of data. All authors
read and approved the final manuscript.
Compliance with Ethical Standards 
Conflict of interest The authors declare that they have no conflict
of interest.
Ethical Approval All procedures performed in studies involving
human participants were in accordance with the ethical standards of
the insti-tutional and/or national research committee (Tri-Council
standards) and with the 1964 Helsinki declaration and its later
amendments or comparable ethical standards.
Informed Consent Informed consent was obtained from all
individual participants included in the study.
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