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
Mahfuz Hassan1 · Andrea Simpson2 · Katey Danaher2 · James Haesen2,3 · Tanya Makela2 · Kendra Thomson1

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

13
Vol.:(0123456789)

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
13
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

13

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)
Felicia 4 Sessions (3–6)
Grace 6 Sessions (1–2, 5–6, 9–10)
13
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)
2 Sessions (7–8) 2 Sessions (13–14) 1 Session (17)
3 Sessions (11–13) 2 Sessions (14–16) 1 Session (17)
Journal of Autism and Developmental Disorders (2018) 48:1957–1970 1961
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
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.
13

1962 Journal of Autism and Developmental Disorders (2018) 48:1957–1970

Interrater Reliability procedural integrity of the trainer behavior from a checklist

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).
of 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 integrity
of behavioural skills training
sessions
Introduction
 1. The trainer introduces themselves and reviews participant’s rights in research and study details
 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

13
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

13

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 1965

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
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).

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

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 1967
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
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.
References
American Psychiatric Association. (2013). Diagnostic and statistical
manual of mental disorders (5th edn; DSM–5). Washington, DC:
Author.
Baer, D. M., Wolf, M. M., & Risley, T. R. (1968). Some current dimen-
sions of applied behavior analysis. Journal of Applied Behavior
Analysis, 1, 91–97.
Baer, D. M., Wolf, M. M., & Risley, T. R. (1987). Some still-current
dimensions of applied behavior analysis. Journal of Applied
Behavior Analysis, 20, 313–327.
Bellini, S., Peters, J. K., Benner, L., & Hopf, A. (2007). A meta-anal-
ysis of school-based social skills interventions for children with
autism spectrum disorders. Remedial and Special Education,
23(3), 153–162.
Church, C., Alisanski, S., & Amanullah, S. (2000). The social, behav-
ioral, and academic experiences of children with Asperger syn-
drome. Focus on Autism and Other Developmental Disabilities,
15(1), 12–20.
Daniel, L. S., & Billingsley, B. S. (2010). What boys with an autism
spectrum disorder say about establishing and maintaining friend-
ships. Focus on Autism and Other Developmental Disabilities,
25(4), 220–229.
Dunn, M. E., Burbine, T., Bowers, C. A., & Tantleff-Dunn, S. (2001).
Moderators of stress in parents of children with autism. Commu-
nity Mental Health Journal, 37(1), 39–52.
Egemo-Helm, K. R., Miltenberger, R. G., Knudson, P., Findstrom, N.,
Jostad, C., & Johnson, B. (2007). An evaluation of in situ training
Journal of Autism and Developmental Disorders (2018) 48:1957–1970 1969
to teach sexual abuse prevention skills to women with mental
retardation. Behavioral Interventions, 22(2), 99–119.
Gates, J. A., Kang, E., & Lerner, M. D. (2017). Efficacy of group social
skills interventions for youth with autism spectrum disorder: A
systematic review and meta-analysis. Clinical Psychology Review,
52, 164–181.
Gianoumis, S., Seiverling, L., & Sturmey, P. (2012). The effects of
behavior skills training on correct teacher implementation of
Natural Language Paradigm teaching skills and child behavior.
Behavioral Interventions, 27(2), 57–74.
Gresham, F. M., Sugai, G., & Horner, R. H. (2001). Interpreting out-
comes of social skills training for students with high-incidence
disabilities. Exceptional Children, 67(3), 331–344.
Gunby, K. V., & Rapp, J. T. (2014). The use of behavioral skills training
and in situ feedback to protect children with autism from abduc-
tion lures. Journal of Applied Behavior Analysis, 47, 856–860.
Hanratty, L. A., Miltenberger, R. G., & Florentino, S. R. (2016). Evalu-
ating the effectiveness of a teaching package utilizing behavioral
skills training and in situ training to teach sun safety in a preschool
classroom. Journal of Behavior Education, 25, 310–323.
Harriage, B., Blair, K. C., & Miltenberger, R. (2016). An evaluation of
a parent implemented in situ pedestrian safety skills intervention
for individuals with autism. Journal of Autism and Developmental
Disorders, 46(6), 2017–2027.
Hassan, M., Thomson, K. M., Khan, M., Riosa, B. P., & Weiss, J. A.
(2017). Behavioral skills training for graduate students providing
cognitive behavior therapy to children with autism spectrum dis-
order. Behavior Analysis: Research and Practice, 17(2), 155–165.
Himle, M. B., Miltenberger, R. G., Flessner, C., & Gatheridge, B.
(2004). Teaching safety skills to children to prevent gun play.
Journal of Applied Behavior Analysis, 37, 1–9.
Horner, R. D., & Baer, D. M. (1978). Multiple probe-technique: A
variation on the multiple baseline. Journal of Applied Behavior
Analysis, 11, 189–196.
Hui Shyuan Ng, A., Schulze, K., Rudrud, E., & Leaf, J. J. (2016).
Using the teaching interactions procedure to teach social skills to
children with autism and intellectual disability. American Journal
On Intellectual & Developmental Disabilities, 121(6), 501–519.
Johnson, B. M., Miltenberger, R. G., Knudson, P., Egemo-Helm, K.,
Kelso, P., Jostad, C., & Langley, L. (2006). A preliminary evalu-
ation of two behavioral skills training procedures for teaching
abduction-prevention skills to school children. Journal of Applied
Behavior Analaysis, 39, 25–34.
Keonig, K., De Los Reyes, A., Cicchetti, D., Scahill, L., & Klin, A.
(2009). Group intervention to promote social skills in school-age
children with pervasive developmental disorders: Reconsidering
efficacy. Journal of Autism and Developmental Disorders, 39(8),
1163–1172.
Kornacki, L. T., Ringdahl, J. E., Sjostrom, A., & Nuernberger, J. E.
(2013). A component analysis of a behavioral skills training pack-
age used to teach conversation skills to young adults with autism
spectrum and other developmental disorders. Research in Autism
Spectrum Disorders, 7(11), 1370–1376.
Leaf, J. B., Taubman, M., Bloomfield, S., Palos-Rafuse, L., Leaf, R.,
McEachin, J., & Oppenheim, M. L. (2009). Increasing social skills
and pro-social behavior for three children diagnosed with autism
through the use of a teaching package. Research in Autism Spec-
trum Disorders, 3(1), 275–289.
Loughrey, T. O., Contreras, B. P., Majdalany, L. M., Rudy, N., Sinn, S.,
Teague, P., Marshall, G., McGreevy, P., & Harvey, A. C. (2014).
Caregivers as interventionists and trainers: Teaching mands to
children with developmental disabilities. Analysis of Verbal
Behavior, 30(2), 128–140.
Matson, M. L., Mahan, S., & Matson, J. L. (2009). Parent training: A
review of methods for children with autism spectrum disorders.
Research in Autism Spectrum Disorders, 3(4), 868–875.
Miles, N. I., & Wilder, D. A. (2009). The effects of behavioral skills
training on caregiver implementation of guided compliance. Jour-
nal of Applied Behavior Analysis, 42, 405–410.
Miltenberger, R., Gross, A., Knudson, P., Jostad, C., & Breitwieser, C.
B. (2009). Evaluating behavioral skills training with and without
simulated in situ training for teaching safety skills to children.
Education and Treatment of Children, 32(1), 63–75.
Miltenberger, R. G. (2008a). Behavior modification: Principles and
procedures (4th edn.). Belmont, CA: Thomson Wadsworth.
Miltenberger, R. G. (2008b). Teaching safety skills to children: Preven-
tion of firearm injury as an exemplar of best practice in assess-
ment, training and generalization of safety skills. Behavior Analy-
sis in Practice, 1(1), 30–36.
Miltenberger, R. G., Flessner, C., Gatheridge, B., Johnson, B., Sat-
terlund, M., & Egemo, K. (2004). Evaluation of behavioral skills
training to prevent gun play in children. Journal of Applied Behav-
ior Analysis, 37, 513–516.
Miltenberger, R. G., Gatheridge, B. J., Satterlund, M., Egemo-Helm, K.
R., Johnson, B. M., Jostad, C., … Flessner, C. A. (2005). Teach-
ing safety skills to children to prevent gun play: An evaluation
of in situ training. Journal of Applied Behavior Analysis, 38,
395–398.
Morgan, D. L., & Morgan, R. K. (2009). Single-case research methods
for the behavioral and health sciences. Los Angeles, CA: Sage
publications.
National Autism Center. (2015). National Standards Report. Retrieved
from http://www.nationalautismcenter.org/resources/.
Nock, M. K., & Kazdin, A. E. (2001). Parent expectancies for child
therapy: Assessment and relation to participation in treatment.
Journal of Child and Family Studies, 10(2), 155–180.
Nuernberger, J. E., Ringdahl, J. E., Vargo, K. K., Crumpecker, A. C.,
& Gunnarsson, K. F. (2013). Using a behavioral skills training
package to teach conversation skills to young adults with autism
spectrum disorders. Research in Autism Spectrum Disorders, 7(2),
411–417.
O’Neill, R. E. (1990). Establishing verbal repertoires: Toward the
application of general case analysis and programming. The Analy-
sis of Verbal Behavior, 8, 113–126.
Pan-Skadden, J., Wilder, D. A., Sparling, J., Severtson, E., Donald-
son, J., Postma, N., Beavers, G., & Neidert, P. (2009). The use of
behavioral skills training and in-situ training to teach children to
solicit help when lost: A preliminary investigation. Education and
Treatment of Children, 32(3), 359–370.
Parsons, M., Rollyson, J., & Reid, D. (2012). Evidence-based staff
training: A guide for practitioners. Behavior Analysis in Practice,
5(2), 2–11.
Parsons, M. B., Rollyson, J. H., & Reid, D. H. (2013). Teaching
practitioners to conduct behavioral skills training: A pyramidal
approach for training multiple human service staff. Behavior
Analysis in Practice, 6(2), 4–17.
Peters, B. B., Tullis, C. A., & Gallagher, P. A. (2016). Effects of a
group teaching interaction procedure on the social skills of stu-
dents with autism spectrum disorders. Education & Training in
Autism & Developmental Disabilities, 51(4), 421–433.
Rao, P. A., Beidel, D. C., & Murray, M. J. (2008). Social skills inter-
ventions for children with asperger’s syndrome or high-function-
ing autism: A review and recommendations. Journal of Autism
and Developmental Disorders, 38(2), 353.
Reichow, B., & Volkmar, F. R. (2010). Social skills interventions for
individuals with autism: Evaluation for evidence-based practices
within a best evidence synthesis framework. Journal of Autism
and Developmental Disorders, 40(2), 149–166.
Reimers, T. M., Wacker, D. P., & Cooper, L. J. (1991). Evaluation of
the acceptability of treatments for children’s behavioral difficul-
ties: Ratings by parents receiving services in an outpatient clinic.
Child & Family Behavior Therapy, 13(2), 53–71.
13

1970
Sarokoff, R. A., & Sturmey, P. (2004). The effects of behavioral skills
training on staff implementation of discrete-trial teaching. Journal
of Applied Behavior Analysis, 37, 535–538.
Schwartz, I. S., & Baer, D. M. (1991). Social validity assessments:
Is current practice state of the art? Journal of Applied Behavior
Analysis, 24, 189–204.
Stewart, K. K., Carr, J. E., & LeBlanc, L. A. (2007). Evaluation of
family-implemented behavioral skills training for teacher social
skills to a child with Asperger’s disorder. Clinical Case Studies,
6(3), 252–262.
Tanaka, J. W., & Sung, A. (2016). The “eye avoidance” hypothesis of
autism face processing. Journal of Autism and Developmental
Disorders, 46(5), 1538–1552.
13
Journal of Autism and Developmental Disorders (2018) 48:1957–1970
Weiss, J. A., MacMullin, J. A., & Lunsky, Y. (2015). Empowerment
and parent gain as mediators and moderators of distress in mothers
of children with autism spectrum disorders. Journal of Child and
Family Studies, 24(7), 2038–2045.
Weisz, J. R., Donenberg, G. R., Han, S. S., & Weiss, B. (1995). Bridg-
ing the gap between laboratory and clinic in child and adolescent
psychotherapy. Journal of Consulting and Clinical Psychology,
63(5), 688–701.
Williams White, S., Keonig, K., & Scahill, L. (2007). Social skills
development in children with autism spectrum disorders: A review
of the intervention research. Journal of Autism and Developmental
Disorders, 37(10), 1858–1868.