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Journal of Special Education Technology

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A Comparison of iPad-Assisted and Flash ª The Author(s) 2020
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Card-Assisted Instruction for Learners DOI: 10.1177/0162643420979935
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With Autism

Davaa Ulzii1 , Susan Kabot1, and Christine Reeve1

Abstract
Using electronic tablets to present flash cards for teaching skills is becoming common among practitioners. However, no
published study compared the effectiveness of the electronic tablet-based flash cards to paper flash cards for teaching
receptive labeling skills. The purpose of this study was to compare the efficacy of the iPad-based and paper flash cards for
teaching receptive labeling to learners with autism. An adapted alternating treatments design was used. Participants included one
preschool student with autism and one elementary school student with autism. Findings indicated that iPad-assisted instruction
resulted in a slightly faster acquisition and slightly lower levels of prompts for both participants. No differences were found in the
generalization and maintenance of the skills between the two instructional mediums. Mixed results were found for challenging
behaviors associated with each intervention. Implications and suggestions for future research are discussed.

Keywords
autism, applied behavior analysis, iPad, flash card, receptive labeling skill

As of 2016, approximately one out of 54 eight-year-old chil-
dren were diagnosed with autism spectrum disorder (ASD)
across multiple areas of the United States (Maenner et al.,
2020). Studies (Kover et al., 2013; Volden et al., 2011; Weis-
mer et al., 2010) found that children with ASD have weaker
receptive language skills compared to typically developing
children. When comparing the early language patterns of chil-
dren with ASD to language patterns of children with develop-
mental delay using a groups-comparison design, Weismer et al.
(2010) found that the children with ASD scored higher on
expressive language skills compared to the receptive language
skills. Volden et al. (2011) examined syntactic and semantic
language skills in preschool children with ASD using the Pre-
school Language Scale, Fourth Edition, and found that overall,
expressive communication was stronger than the auditory com-
prehension skills among the participants. Moreover, Kover
et al. (2013) assessed the characterization of the receptive lan-
guage skills of boys with ASD using the cross-sectional devel-
opmental trajectories approach. Kover et al. found that relative
to their chronological age, school-aged boys with ASD showed
a delay in their receptive language skills. Aside from the group
differences found between children with ASD, developmental
delay, or typically developing children, studies (e.g., Kover
et al., 2013; Weismer et al., 2010) also find individual varia-
bility among participants.
Listener behavior is determined by whether a speaker’s ver-
bal behavior evokes a specific nonverbal response from the
listener, such as performing an action. If the understanding is
a nonverbal response, it is considered as listener behavior and
termed as receptive language or receptive labeling (Sundberg,
2008). Demonstrating comprehension of speech is the most
complex skill in the listener repertoire, and it is logical to
assume that understanding the other person’s speech is also
required for other verbal operants, such as mand, tact, and
intraverbal (Sundberg, 2008). Accordingly, most programs
devote a part of the early intervention curriculum for develop-
ing receptive language skills (Grow & LeBlanc, 2013).
Electronic Tablet-Assisted Interventions
for Improving Communication
Technology-based intervention, such as computer-assisted
interventions have been used to teach various skills to learners
with ASD (Knight et al., 2013). Within the past decade, the use
of electronic tablets for education activities became increas-
ingly popular in homes and schools. Consequently, the effec-
tiveness of the tablets for teaching skills has been a focus of
1
Nova Southeastern University, Fort Lauderdale, FL, USA
Corresponding Author:
Davaa Ulzii, Abraham S Fischler College of Education and School of Criminal
Justice, 3301 College Avenue, Fort Lauderdale, FL 33314, USA.
Email: du96@nova.edu
2 Journal of Special Education Technology XX(X)
many studies. The effectiveness of the electronic tablets for
improving expressive communication skills has been exempli-
fied in the studies by Dennis (2016), Kagohara et al. (2012),
and Xin and Leonerd (2015). Dennis (2016) examined the
effects of an iPad-based application and extended instruction
on the expressive vocabulary, definitions, and generalization
skills of preschool children using repeated acquisition design.
The study found that all six participants increased their expres-
sive verb vocabulary. Dennis (2016) stated that all participants
appeared to enjoy the iPad-based instruction and did not show
resistance.
Moreover, Kagohara et al. (2012) examined teaching picture
naming skills using an iPad-based speech-generating device for
two adolescents using multiple probes across participants
design. Kagohara et al. found that picture naming using the
speech-generating device increased accurate picture naming
in both participants. Similarly, Xin and Leonard (2015) found
that the use of the iPad application, SonoFlex, increased the
expressive communication skills in all three participants with
ASD.
By contrast, Fletcher-Watson et al. (2016) found that iPad
intervention did not improve social communication skills in
children when using a groups comparison design. Despite the
results, Fletcher-Watson et al. noted that researchers should
continue to investigate tablet-based interventions considering
that the iPad intervention used in their study engaged children
and was perceived positively by the parents. Likewise,
Rodrı́guez and Cumming (2017) found no differences when
using a group comparison design to investigate the effects of
a iPad-based Language Builder application on expressive and
receptive vocabulary skills of students with language-based
disabilities. However, Rodrı́guez and Cumming (2017) noted
that the treatment group using the iPad-based intervention
made significant gains in their sentence formation skills.
Also, Dennis et al. (2016) found no significant differences in
the outcomes of expressive and receptive vocabulary skills.
The study used teacher-facilitated intervention and iPad-
facilitated intervention for teaching verbs to five at-risk pre-
school children. The results of the study indicated that all five
students learned the target verbs during two interventions.
Although Dennis et al. (2016) utilized an adapted alternating
treatments design (AATD; Sindelar et al., 1985) to compare the
teacher-facilitated and iPad-facilitated interventions, several
variables differed between the conditions, such as presentation
of a stimulus following an incorrect response and overall
teacher attention and involvement during instruction.
Teaching Receptive Labeling Skills Using Electronic
Tablets
Thus far a relatively few studies examined the effectiveness of
electronic tablets for improving receptive labeling skills in
individuals with disabilities. Chai et al. (2015) evaluated the
effectiveness of the iPad application, Touch Sound, for recep-
tive identification of the initial phonemes using a multiple
probes across behaviors and across participants design. Chai
et al. found that phoneme awareness skills increased in all three
participants.
In the same way, Lorah and Karnes (2016) evaluated the
effectiveness of the iPad-based app, Language Builder, for the
acquisition of the listener responding skills in two children with
ASD using a multiple baseline across responses design. Also,
the research included a generalization assessment where the
same target picture-identification tasks were presented on
paper picture cards. Both participants gained skills to recep-
tively identify the target items and the identification skills gen-
eralized to the paper-based picture cards. Lorah and Karnes
recommended future research use a multiple-probe design to
eliminate the potential overexposure to target and nontarget
items. The researchers also suggested that replication of this
study should be conducted in a more natural setting (i.e., home
or classroom) and to determine if the environmental factors
influenced the learner’s acquisition.
On the other hand, Ganz et al. (2015) found mixed results
when examining the effectiveness of the tablet-based picture
exchange communication systems on the receptive identifica-
tion skills of one preschool student with ASD using a multiple
baseline across target words design. The participant’s ability to
receptively identify an object improved for two of the target
words but did not show improvement for one of the target
words.
Also, Chebli et al. (2017) found mixed results when evalu-
ating the generalization of the skills following the instruction of
one-word concepts using a tablet-based application using mul-
tiple probes across concepts design. The results of the study
showed that three of the five participants demonstrated general-
ization for at least two of the concepts. The other two partici-
pants did not demonstrate any generalization skills. Chebli
et al. (2017) stated the participants who did not show any gen-
eralization also needed a more significant number of prompts
to sit down and stay on task compared to the other participants.
For future studies, Chebli et al. recommended examining
whether some level of off-task behavior is an indicator for
children not benefitting from a tablet-based instruction.
Effects of Electronic Tablet-Based
Interventions on Behaviors
Several studies suggest that the use of electronic tablets or high
tech devices may affect behavioral outcomes. Neely et al.
(2013) studied the effects of an iPad on challenging behaviors
with two children who had a prior history of engaging in chal-
lenging behaviors during instruction. The study utilized an
alternating treatments design to compare the effects of the
traditional paper/pencil/flashcard instruction and iPad-based
instruction. The results showed that for both participants, chal-
lenging behaviors decreased, and academic engagement
increased during the iPad instruction phase of the study com-
pared to the instruction phase delivered via traditional
materials.
Lee et al. (2015) compared the therapist-implemented and
iPad-assisted interventions for teaching skills to two children
Ulzii et al.
with ASD using an alternating treatments design. To demon-
strate the effects of the two mediums, the researchers used the
same pictures for both therapist-implemented intervention and
the iPad-based intervention. The results showed that for one of
the participants, there were no differences in the outcome
between the two interventions. For the other participant, there
were more occurrences of on-task behavior and correct
responses and fewer occurrences of the challenging behaviors
during the iPad-assisted condition. Furthermore, Lee et al.
found that during the final phase of the study, both participants
preferred the iPad-assisted condition when given an option to
choose between the two conditions.
On the other hand, Vandermeer et al. (2015) found iPad-
based social stories to be an effective strategy for only one
participant of the study but not for the other two participants
for increasing on-task behavior in young children with ASD.
Vandermeer et al. (2015) used the iPad-based application for
social stories, Stories2Learn, to create social stories for model-
ing the on-task behavior. For future studies, Vandermeer et al.
suggested that when recruiting participants, researchers should
gather comprehensive information about the participants, their
learning style (e.g., visual vs. auditory), and emotional state
within the classroom.
In summary, review of the literature on the effectiveness of
the electronic tablets for improving communication skills sug-
gest the following: (a) studies that examined the effectiveness
of the electronic tablet-based interventions for improving com-
munication skills found them to be effective for some learners
and ineffective for other, or do not generalize, (b) learners’
behaviors can interfere with acquisition of the skills, (c) when
given a choice some learners are likely to choose the electronic
tablets over traditional materials or stay on task longer.
These findings, although important, do not address whether
tablet-based flash cards are as effective or more effective than
paper flash cards. Though there is no evidence suggesting
tablet-based pictures are as effective or more effective than
traditional flash cards for teaching receptive labeling skills,
teachers and practitioners have been using computers and
tablets to present flash cards during distance teaching or
telehealth-based services. Therefore, this is a timely question
for practitioners and researchers to examine and find solutions
for the best practice.
Purpose of the Present Study
To the researchers’ knowledge, no published studies compared
the effectiveness of the electronic tablet-based flash cards and
traditional flash cards for teaching receptive labeling skills.
Therefore, the purpose of this study was to compare the effec-
tiveness of the iPad-assisted and flash card-assisted applied
behavior analysis (ABA) interventions on the acquisition, gen-
eralization, and maintenance of the receptive labeling skills,
and the number of prompts and challenging behaviors associ-
ated with each intervention during instructional sessions.
3
Method
Participants and Setting
Participants included two learners with autism. Selection cri-
teria to recruit participants included that they had (a) a medical
diagnosis of an ASD, (b) ABA treatment goals to improve
communication skills, (c) adequate motor skills to interact with
an electronic tablet and flash cards, and (d) an ability to under-
stand and follow spoken directions given in English. Partici-
pants were assigned pseudonyms to protect their anonymity.
Emma was a 3-year-old girl with a medical diagnosis of
ASD and mild hearing loss. Emma wore hearing aids during
the day. Emma received in-home ABA therapy four times a
week and attended public preschool 5 half-days a week in an
inclusive classroom setting. At school, Emma received speech
and language therapy, occupational therapy, physical therapy,
and consultation from a teacher of the hearing impaired on
weekly basis either within the classroom setting or in a 1:1
setting.
Sage was an 11-year-old girl with a medical diagnosis of
ASD. Sage received in-home ABA therapy services five times
a week. Sage attended public school 5 days a week in the
special education classroom setting. At school, Sage received
speech and language therapy, occupational therapy, and phys-
ical therapy weekly in a 1:1 setting.
At the time of the study both participants’ ABA programs
for skill acquisition were guided by the Verbal Behavior Mile-
stones Assessment and Placement Program (VB-MAPP; Sund-
berg, 2008). Emma’s listener responding skills were at Level 2
(18–30 months) of the VB-MAPP. Sage’s listener responding
skills were primarily at Level 2 (18–30 months) of the VB-
MAPP. Sage also received partial scores on some of the skills
at Level 3 (30–48 months) of the VB-MAPP.
Both participants had an individualized educational pro-
gram at school. Both participants were familiar with the use
of the iPad. Emma interacted with an iPad at school during
educational activities. Sage also engaged in iPad-based educa-
tional activities at school and used to listen to children’s music
on the iPad when at home. Both participants’ native language
was English, and they spoke English at home.
The study was conducted in participants’ homes where they
typically received their ABA intervention. The study setting
included a child-sized table and a chair suited for the partici-
pants’ height. The table was positioned against the wall and
within 3 in. (7.62 cm) of the seated child. For both participants,
during the majority of the study sessions, only one parent was
present at home, and no distracting noise or stimuli were pres-
ent in the environment.
Materials
Flash Cards
For teaching receptive labeling of the actions, the researcher
used the Language Builder Verbs and Action Word flash card
set produced by Stages Learning (2018). The Language Builder
4 Journal of Special Education Technology XX(X)

Verbs and Action Word flash cards were printed on a photo Table 1. Targets for Receptive Labeling by Participants and Experi-
paper, which was 12.7 cm in width and 8.89 cm in height. The mental Sets.
cards include photographic images of people from diverse ages, Participant Flash Card iPad Control
gender, and ethnicities engaging in everyday activities in many
different settings. Emma Actions
For teaching receptive labeling of the functional sight
Shaking hands Raising hand Drying hands
words, the researcher created paper flash cards. The words Buttoning Dressing Hanging
selected for the experimental sets were printed on a white paper Yawning Barking Calling
using a bold 88-point Calibri font in black. These flash cards Folding Cutting Peeling
were 12.4 cm in width and 8.8 cm in height and were Pointing Painting Writing
laminated. Sweeping Breaking Tearing
Smelling Tickling Skiing
Stirring Standing Blowing
iPad-Based Cards Pulling Throwing Dripping
Riding Clapping Carrying
In this study, the researchers used an iPad with a screen size of
9.7 in. (24.63 cm). For the iPad-assisted instruction, the Sage Sight Words
researchers used the Language Builder Pro app (Version
Girl Boy Candy
1.3.0) developed by the Stages App (2016). The Language Little Push Coat
Builder Pro app has a function that allows the user to upload Deli Off Movie
images. The researcher uploaded the images of the Language Hot Food Music
Builder’s Verbs and Action card pictures and sight words to the Close Dairy Slow
Language Builder Pro app and created an account for each Drink Men Snack
participant. To control the effects of the variables other than Pickles Soda Caution
the experimental variables, the additional features of the app Enter Chocolate Soup
Volume Cold Straw
(i.e., instructional commands, within-stimulus prompting, Out Danger Water
audio, or visual reinforcement) were turned off either by deac-
tivating the feature or setting it on the maximum number of
trials required prior to activation.
treatment goals. Next, the researchers conducted a logical anal-
ysis of those words by their practicality, initial sounds, number
Reinforcers of letters and syllables. Based on the results of the logical
analysis, the researchers selected a pool of 30 words for each
To differentially reinforce the participants’ independent correct
participant and divided the words into three equal experimental
responses during the instructional phase, the researcher identi-
sets as shown in Table 1: (a) flash card set, (b) iPad set, and (c)
fied reinforcers for each participant using the multiple-stimulus
control set.
presentation without a replacement item (MSWO; DeLeon &
Due to the participants’ individual needs, the instructional
Iwata, 1996) procedure prior to the study. For each participant,
sets varied by the participant. For Emma, receptive labeling of
the top three reinforcers were identified.
action words was chosen as instructional targets. For Sage,
receptive labeling of the functional sight words was chosen
Experimental Design as instructional targets.
Academic skills, such as picture naming and sight word read-
ing, are nonreversible behaviors (Gast, 2014). Thus, with
respect to nonreversibility of the receptive labeling of the Dependent Variables
actions and sight words, an AATD was used to compare the This study measured the outcomes on each learner’s skill
effectiveness of the instructional mediums for teaching recep- acquisition, generalization, maintenance, and frequency of the
tive labeling skills. Separate sets of target behaviors of equal prompts and challenging behaviors associated with each
difficulty were assigned to each intervention. Also, a control instructional medium.
set, on which no instruction occurred, was used for assessing A criterion for skill acquisition was defined as learner pro-
participants’ skills at baseline and at the end of the instructional viding 100% independent correct responses for two consecu-
phase to detect whether history influenced the participants’ tive sessions. Participant’s responses for each trial were
responses (Sindelar et al., 1985). recorded using score keys during the discrete trial instructional
In this study, to identify instructional sets of equal difficulty, (DTI) session.
the researchers used a combination of the approaches recom- Stimulus generalization of the skill was defined as the
mended by Wolery et al. (2014). First, the researchers selected occurrence of the taught behavior when presented with a sti-
possible target words that have high utility across the partici- mulus variation of the mastered stimulus. Stimulus generaliza-
pant’s environment and consistent with the participant’s ABA tion was assessed in two ways: (a) by presenting a stimulus
Ulzii et al.
variation of the taught stimulus on the same medium, and (b)
identical stimulus presented on the other medium.
Response maintenance was defined by the occurrence of the
taught response during the follow-up session 4 weeks postin-
tervention. The researcher tested the occurrence of the taught
response once using the stimulus presented during instructional
sessions.
The challenging behavior was defined as participants enga-
ging in behaviors not related to the task, such as getting up and
attempting to walk away from the table. Challenging behaviors
were recorded using the event recording method from the
moment the instructional session began, and till the instruc-
tional session ended.
A response prompt was defined as an additional antecedent
stimulus provided by the instructor to occasion the correct
response, such as pointing to the correct stimulus, modeling,
and providing physical guidance. Prompting was recorded
using score keys whenever the least-to-most prompting step
was required to occasion the correct response during each trial
within the instructional session.
Independent Variables
Independent variables for this study were flash card-assisted
intervention for receptive labeling and iPad-assisted interven-
tion for receptive labeling. Instructions for receptive labeling
skills were provided using the steps of DTI which consisted of:
(a) presentation of the three target stimuli, (b) verbal instruction
to touch the target stimulus for that specific trial, (c) partici-
pant’s response, and (d) delivery of a reinforcer or prompt
depending participant’s response. Except for the instructional
mediums (i.e., paper flash cards and iPad-based flash cards), all
other aspects of the two interventions were the same (i.e.,
therapist, instructional setting, teaching method, number of
trials for each session, an array of stimuli presented, prompts,
reinforcers).
Procedures
All phases of the study were conducted in the same manner.
The study took place at the participants’ child-sized table,
which was positioned against the wall. The researcher sat next
to the participant, no more than 6 in. (15.24 cm) away from the
student. The iPad or flash cards were placed immediately in
front of the student on the table within 3 in. (7.62 cm) of the
student.
Baseline Phase
During the baseline phase, the researchers tested participants’
performance on each word using flash cards twice and using
iPad twice. This was done to ensure that participants cannot
receptively identify the target stimulus regardless of the
medium it was presented on. The researchers wanted to demon-
strate that potential novelty effects of the iPad did not influence
participants’ performance during the baseline phase as the
5
previous study (Neely et al., 2013) found that iPad-assisted
intervention resulted in more academic engagement compared
to the traditional materials. A total of four baseline data points
were collected for each word in all three experimental sets. The
researcher did not test each word three times on each instruc-
tional medium to prevent possible facilitative effects (i.e.,
improved performance) due to repeated testing (Cooper
et al., 2007; Gast, 2014). During the baseline phase, partici-
pants were reinforced by social praise for attending to the task
and to encourage responding and demonstrating their optimal
performance during the instructional phase as recommended by
Gast (2014).
Instructional Phase
As suggested by Wolery et al. (2014), all aspects of the two
interventions (i.e., therapist, the number of an array of items
presented, prompts, reinforcers, number of trials for each ses-
sion, and the setting) were the same except for the instructional
mediums used.
Using the steps of the DTI, the researcher presented three
target stimuli simultaneously during each trial of the instruc-
tional sessions. The steps of the DTI included: (a) presentation
of the three target stimuli, (b) researcher delivering the discri-
minative stimulus, which was a verbal instruction (i.e., Touch)
to select the target stimulus for that trial, (c) If the participant
responded correctly within 5 seconds of the discriminative sti-
mulus, the researcher delivered a small amount of the prede-
termined reinforcer (i.e., a preferred snack item) with social
praise (e.g., “Nice job!”). Alternatively, if the participant
responded incorrectly or did not respond within 5 seconds of
the delivery of the discriminative stimulus, the therapist deliv-
ered the prompt using the least-to-most prompting hierarchy.
The researchers chose the least-to-most prompting strategy
as it was reported that both participants had a tendency to avoid
or sensitive to physical prompts or touch. The steps of the least-
to-most prompting strategy were: (a) pointing to the correct
stimulus within 3 in. (7.62 cm) of the correct stimulus, (b)
pointing to the correct stimulus within 1 in. (2.54 cm) of the
correct stimulus, and (c) gently guiding the student with hand-
over-hand prompt to occasion the correct response.
Following each trial, the position of the pictures or sight
words were changed within the same array. Each picture or
sight word was targeted for instruction five times during each
session by rotating the discriminative stimulus across trials and
each instructional session consisted of 15 trials. A criterion for
mastery was 100% independent correct responding for two
consecutive sessions. When the participant demonstrated a
mastery of a target stimulus, the acquired target was removed
from the array to be tested for generalization, and a new target
word was added.
Both interventions were provided on the same days with at
least a 1 hr gap between the two instructional sessions. The
order of the iPad-assisted and flash card-assisted instructional
sessions was selected randomly. If one of the instructional
mediums was selected as the first session of the day for 2 days
6 Journal of Special Education Technology XX(X)
in a row, on the third day, the other instructional medium was
selected as the first session to counterbalance the treatment
sequence effects. The participants attended the research ses-
sions on average three to four times a week, and the instruc-
tional phase of the study lasted for 4 weeks.
Generalization Probe
Stimulus generalization of the skill was assessed by assessing
participants’ ability to receptively label variations (i.e., stimu-
lus examples) of the trained stimulus. The researcher assessed
the skills by (a) presenting different variations of the trained
stimulus on the same instructional medium and (b) presenting
the trained stimulus on the other instructional medium. For
example, if the action word “pulling” was taught using flash
card-assisted instruction, the generalization of the skill was
tested by presenting (a) two different pictures of the “pulling”
action involving different people in different settings on flash
cards, and by presenting (b) same picture of the “pulling”
action used during flash card-assisted instruction on the iPad.
Final Probe
At the conclusion of the instructional phase, the researcher
assessed participants’ ability to receptively label action words
and sight words from all three experimental sets (i.e., flash
card, iPad, and control set) using paper flash cards. The final
probe was conducted in the same setting and environmental
arrangement as the instructional phase of the study.
Follow-Up Probe
Response maintenance refers to the continued occurrence of
the taught behavior when all, or part of the intervention has
been terminated (Cooper et al., 2007). The words mastered
during the instructional phase of the study were tested for
maintenance at 4 weeks postintervention. The researcher
probed the maintenance of the skills using flash cards. The
researcher conducted the maintenance probes for each partici-
pant in the same setting as the instructional phase of the study.
Data Recording and Analysis
Data Recording
The data were collected on paper data sheets developed by the
researchers. Trial-by-trial data was collected for the acquisi-
tion, prompts, generalization, and maintenance of the skills
using score keys. A count of the challenging behaviors that
occurred during instructional sessions were recorded using
event recording method.
Reliability Measures
To ensure the accuracy of the measurement, interobserver
agreement (IOA), and procedural fidelity data were collected
for each participant during each phase of the study.
IOA. The ABA therapist who worked with each participant
observed 100% of the sessions during the baseline, instruc-
tional phase, generalization probes, and final probe. The thera-
pists were blind to the hypotheses of the study and were trained
in data collection procedures. Three therapists had a master’s
degree; one was a Board Certified Behavior Analyst (BCBA),
and two were pursuing a BCBA certification. One therapist was
a special education teacher, and another therapist had a bache-
lor’s degree in psychology. The second observer recorded IOA
data simultaneously with the researcher during 30% of the
sessions.
Trial-by-trial IOA for participants’ response to an instruc-
tional stimulus and a number of prompts used during the instruc-
tional phase of the study was calculated for each participant.
The mean IOA for instructional trials across interventions
was 97.2% (range: 93%–100%).
The mean IOA for the number of prompts used across two
conditions for both participants was 98.6% (range: 93%–100%).
Also, a total count IOA data was calculated for occurrences
of the challenging behaviors for each participant during the
instructional phase of the study. The mean IOA for the number
of challenging behaviors during instructional sessions was
100% for both participants.
Procedural fidelity. Fidelity data were collected for 31% of the
sessions of the study for Sage and for 21% of the sessions for
Emma. The steps of the procedural fidelity for the instructional
phase included (a) instructional setting is arranged as described
in the design, (b) therapist gaining the learner’s attention before
delivering the instruction, (c) waiting the appropriate time
delay before providing a prompt, (d) providing the appropriate
prompt, and (e) providing the predetermined reinforcement.
The procedural fidelity data were calculated by dividing the
number of observed behaviors by the number of opportunities,
multiplied by 100 (Gast, 2014). The review of the procedural
fidelity data indicated that the researcher achieved 100% accu-
racy in implementing the conditions of the study.
Analysis of Data
The effectiveness of the two instructional mediums was exam-
ined using a combination of visual analysis and the percentage
of the nonoverlapping data values (PND; Scruggs & Mastro-
pieri, 1998). Visual analysis of the data allows the examiner to
evaluate the behavior change without imposing a predeter-
mined arbitrary level of significance (Cooper et al., 2007). The
visual analysis of the data was conducted to analyze the acqui-
sition, generalization, and maintenance of the skills for each
intervention, and frequency of prompts and challenging beha-
viors associated with each intervention,
Also, PND point values were calculated to examine the effec-
tiveness of the instructional mediums. PND was determined by
(a) a range of data point values in the first condition; (b) the
number of data points in the second condition, (c) counting the
number of points from the second condition that falls outside of
the range of values of the first condition, and (d) dividing the data
Ulzii et al.
Figure 1. Cumulative number of words mastered over sessions by participants.
points that fall outside of the range of the value of a first condition
by the total number of data points in the second condition and
multiplying it by 100 (Scruggs & Mastropieri, 1998). Though the
nonoverlap methods provide valuable information, it should not
replace the visual analysis and should be used as a supplement
for interpreting the visual analysis (Rakap et al., 2014).
Results
Emma
During the baseline phase, Emma receptively labeled zero
action words out of the 30 target action words. Visual
7
examination of the data graph showed a steady baseline level
at zero value, which changed to an increasing trend during the
instructional phase. As shown in Figure 1, by the end of the
instructional phase, Emma had mastered receptively labeling
16 out of the 20 action words from the instructional sets. Emma
identified nine action words on the iPad-based pictures and
seven action words on flash card-based pictures. The data val-
ues for iPad-assisted instruction demonstrated a steady increas-
ing trend. During the final probe session, Emma receptively
labeled four of the 10 action words from the control set inde-
pendently (see Figure 1). The calculation of the PND showed
that for Emma, the PND score was 84.6 for both interventions.
8 Journal of Special Education Technology XX(X)

14 Flash Card-Assisted
Emma
Instruconal Sessions

Total Number of the Challenging

100 12
iPad-Assisted Instruconal
Percentage of Independent Correct

80 Sessions
10
60
Recepve Labeling

Behaviors
8
40
6
20

0 4
Smulus Variaon 1 Smulus Variaon 2 Idencal Smulus
Presented on the Presented on the Presented on the 2
Same Medium Same Medium Other Medium
0
Smulus Trained on Flash Card Smulus Trained on iPad
Emma Sage

Sage Figure 3. Total number of the challenging behaviors occurred during

instructional sessions by participants.
100
Percentage of Independent Correct

80 behaviors included looking away from the table, fidgeting on

60 the seat by moving side to side, and getting up from the seat.
Recepve Labeling

40

20
0 During the baseline phase, Sage recognized zero of the 30
Smulus Variaon 1 Smulus Variaon 2
Presented on the Same Presented on the Same Presented on the Other
Medium
Smulus Trained on Flash Card
Figure 2. Percentage of independent correct responding during sti-
mulus generalization probes by participants.
Interventions with PND scores of 70 to 90 are considered effec-
tive interventions (Scruggs & Mastropieri, 1998).
In terms of generalization of the skills, Emma was able to
receptively label 100% of the acquired action words on two
additional pictures showing the same action performed by dif-
ferent people in different settings. Also, Emma receptively
labeled 100% of the acquired action words when the pictures
were presented on the other instructional medium (see
Figure 2).
During the maintenance probe 4 weeks postintervention,
Emma demonstrated an ability to receptively label 100% of
the action words acquired during the instructional phase.
Emma needed prompts during 7.2% of the iPad-assisted
instructional trials and 9.2% of the flash card-assisted
instructional trials. The number of prompts used during the
initial flash card-assisted session was higher than the initial
iPad-assisted session. When providing prompts to evoke the
correct response, gestural prompts were sufficient for the
majority of the time. Hand-over-hand prompts were needed
only during the initial teaching sessions. Beginning with the
second teaching session, Emma did not need any hand-over-
hand prompts.
Emma engaged in challenging behaviors six times during
iPad-assisted instructional sessions and 12 times during flash
card-assisted instructional sessions (see Figure 3). Challenging
Sage
Idencal Smulus
functional sight words. By the end of the instructional phase,
Medium Medium Sage mastered receptively labeling 17 of the 20 target func-
Smulus Trained on iPad tional sight words from the instructional sets. As shown in
Figure 1, Sage receptively labeled seven sight words on the
flash cards and 10 sight words on the iPad. Also, during the
final probe session, Sage receptively labeled three out of the 10
words from the control set independently on which no instruc-
tion was provided (see Figure 1). For Sage, the PND score was
87.5 for both interventions, which indicated that both interven-
tions were effective.
Sage was able to receptively label 100% of the sight words
on two stimulus variations of the target words (i.e., the same
words printed in different fonts). Also, Sage demonstrated
100% successful generalization of the words by receptively
labeling the acquired sight words presented on the other
instructional medium (see Figure 2).
During the maintenance probe, Sage was able to receptively
label 100% of the acquired functional sight words correctly.
Also, Sage demonstrated textual response for many of the
taught sight words independently, although no formal data
were collected on this skill.
Sage needed prompts during 5.8% of the iPad-assisted
instructional trials and 7.5% of the flash card-assisted instruc-
tional trials. The initial flash card-assisted instructional session
required the highest number of prompts. Moreover, for Sage,
gestural prompts were sufficient 100% of the time when pro-
viding prompts to evoke the correct response. Hand-over-hand
prompts were used zero times during instructional sessions.
As shown in Figure 3, for Sage, the occurrences of the
challenging behaviors were low during both instructional con-
ditions. Challenging behaviors occurred one time during iPad-
assisted instructional sessions and occurred twice during flash
card-assisted instructional sessions.
Ulzii et al.
Discussion
The findings of the current study indicate that both iPad-
assisted and flash card-assisted instructions resulted in the
acquisition of receptive labeling skills. However, visual anal-
ysis of the data shows that acquisition of the skills during the
iPad-assisted instruction was slightly faster than the flash card-
assisted instruction for both participants. There were no differ-
ences found in the generalization and maintenance of the skills
between the two instructional mediums. Data indicated that
iPad-assisted instruction resulted in a slightly lower levels of
prompts. Lower levels of challenging behaviors were associ-
ated with iPad-assisted instruction for one of the participants
and no differences were observed in the behavioral outcome of
the other participant.
Results of this study support the findings by Lorah & Karnes
(2016), in that intervention provided by the iPad-based app,
Language Builder (a version of the app used in this study),
resulted in rapid acquisition of the skills when teaching recep-
tive labeling to preschool children with ASD. A possible reason
for the similar trends seen during the two instructional condi-
tions in this study could be due to the identical instructional
steps of the DTI used. Studies (e.g., Dib & Sturmey, 2007;
Downs et al., 2007; Lovaas, 1987) showed that DTI to be an
effective method for teaching skills to learners with disabilities.
Notably, the DTI for teaching receptive labeling skills using a
conditional-only model, which implements DTI by presenting
and teaching multiple stimuli from the onset of the intervention
rather than teaching the targets in isolation has been demon-
strated to be more effective (Grow et al., 2011, Grow &
LeBlanc, 2013). Aside from the identical instructional methods
used during instructional sessions, the setting, instructor, rein-
forcers, and intensity of the intervention were the same for both
interventions. Also, carryover effects from one intervention
could have affected the performance on the other instructional
set since receptive labeling skills are nonreversible behavior
(Wolery et al., 2014).
Although no change in performance on the control set is
ideal for demonstrating the functional independence of the
interventions, improved performance on the control set was
observed in this study. A possible explanation for that is includ-
ing words of high utility may have contributed to improved
performance on the control set for both participants. The parti-
cipants attended public school 5 days a week and were likely to
encounter those words outside of the research setting. The
researchers considered the possibility of this effect when
selecting target stimuli for the experimental sets. However, it
is recommended to teach words that are practical and relevant
to the participants’ needs, and consistent with their ABA treat-
ment and educational goals (More & Travers, 2013).
In terms of the generalization and maintenance of the
skills, data from the study showed no differences between
flash card-assisted and iPad-assisted instructions. Once the
skill was mastered, participants were able to generalize it
on variations of the target stimulus presented on the same
instructional medium and an identical stimulus presented on
9
the other medium. Similar results were found by Lorah and
Karnes (2016) in that participants were able to generalize the
receptive labeling skills when the stimuli taught on an iPad
were presented on two-dimensional paper flash cards.
With regard to prompts, the iPad-assisted instruction
resulted in a slightly lower level of prompts. Notably, during
the initial iPad-assisted instructional session, both participants
needed a significantly lower number of prompts to touch the
correct picture or sight word when compared to the initial flash
card-assisted instructional session. Neither participant needed
hand-over-hand prompts during the iPad-assisted instructional
sessions. This could be due to potentially novel effects of the
iPad, as was seen in studies by Lee et al. (2015). Furthermore,
Sage used to listen to her favorite music on an iPad, which
could make iPads, in general, an object associated with rein-
forcement for Sage.
Emma engaged in fewer challenging behaviors during the
iPad-assisted instructional sessions compared to the flash card-
assisted instructional sessions. However, no differences were
observed for Sage. Sage engaged challenging behaviors rela-
tively a few times during the study. Possible explanations for
this result could be due to Sage’s motivation for learning to
read, as was reported by her parents. She participated in ses-
sions with minimal support and indicated her expectation of the
activity by placing the “read” icon in her visual activity sched-
ule. In addition, as discussed above, iPad, in general may have
been associated with reinforcing activities for Sage.
Another notable finding was that both participants were
engaging in echoic behaviors by repeating the given verbal
stimulus during instructional sessions. Similar results were
seen in a study by Grow and Van Der Hijde (2016). During
the final probe and maintenance probe, both participants
expressively labeled some of the words. Expressive labeling
of the sight words by Sage was significant progress considering
the skills required for textual responding.
The findings of this study suggest that iPad-assisted interven-
tion is a viable alternative to a traditional flash card-assisted
instruction for teaching receptive labeling skills to learners with
ASD. Since technology-based instructions have the potential to
decrease errors that may occur during instruction (Lorah &
Karnes, 2016), electronic tablets and apps can be a useful tool
for implementing interventions for teachers and practitioners. If
used effectively, electronic tablets and apps can eliminate poten-
tial human errors such as the timing of the prompts, interspersing
of the target stimuli, and accurate data collection.
Moreover, iPad-assisted instruction can facilitate within sti-
mulus prompts relatively easily by highlighting the target stimu-
lus or fading the nontarget the stimuli. Though within stimulus
prompts are useful for learners who are aversive to physical
touch, they are used infrequently due to the efforts it requires
to create (Cooper et al., 2007; Grow & LeBlanc, 2013).
Limitations and Future Research
Although the researchers attempted to minimize the common
threats to internal validity by adding a control set, randomly
10
assigning the order of the interventions, and implementing the
interventions in distant temporal order, there were other limita-
tions related to the validity of the study. The study included
only two participants from two different age groups. Therefore,
caution must be implied regarding the generalizability of the
findings of this study to other populations. Also, the general-
ization probe of this study assessed the participants’ stimulus
generalization skills using two-dimensional stimuli only. Prob-
ing the skill generalization using materials in different formats,
real-life objects, and across settings may provide further infor-
mation on the skill generalization. As noted by Chebli et al.
(2017), the ability to generalize words taught on electronic
tablets to a real life objects is not easy for all learners.
Another limitation of this study is the inability to determine
the significance of the learning gained by the participants.
Though iPad-assisted intervention resulted in slightly faster
acquisition for both participants, further analyses of the signif-
icance of this behavior change will provide more information
about the findings of this study.
A possible area of future research would be to evaluate the
effectiveness of the iPad-assisted instruction while turning on
one of the additional features of the iPad or app. Adding only
one of the available features such as within stimulus prompting
to the tablet-based receptive labeling instruction will help
researchers to examine the each variable effectively.
In this study, the researchers used an iPad with a screen size
of 9.7 in. (24.63 cm) since it is used most commonly in an
educational setting. As of 2020, iPads with larger screens are
available on the market. Using an iPad with a larger screen may
produce different results since the size, array, and positioning
of the cards can be different on a larger screen. For example,
the previous study by Mechling and Ayres (2012) found that
compared to a smaller screen, the use of a larger screen (i.e.,
laptop) was associated with a higher percentage of correct
responding in all participants when following the steps of the
fine motor tasks delivered by video modeling.
Conclusion
The current study contributes to the literature by directly com-
paring effects of iPad-based flash cards and paper flash cards
for teaching receptive labeling skills to learners with autism.
Evidence from this study shows that iPad-assisted instruction
for teaching receptive labeling skills are as effective as tradi-
tional flash card assisted instruction. Also, iPad-assisted recep-
tive labeling instruction has the potential to facilitate within
stimulus prompts by highlighting the target stimulus or fading
out the nontarget stimuli relatively easily, which may benefit
learners who are aversive to physical prompts or physical
touch. Aside from delivering instructional commands, prompts,
and reinforcers, most apps can collect data and generate graphs,
which can alleviate challenges related to limited time and
resources for practitioners and families. However, the decision
to use technology to teach skills to learners with ASD should
not be taken lightly and should be made on an individual basis
(Knight et al., 2013).
Journal of Special Education Technology XX(X)
Authors’ note
The authors would like to thank the families that participated in this
study.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, an/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
ORCID iD
Davaa Ulzii https://orcid.org/0000-0003-2656-6507
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Author Biographies
Davaa Ulzii, BCBA, has provided autism, early intervention,
and mental health services for over 10 years, and this study was
completed as partial fulfillment of the requirements for her
doctoral degree. Her research interest includes using technol-
Journal of Special Education Technology XX(X)
ogy effectively for teaching skills to individuals with a disabil-
ity. She is an adjunct faculty at Nova Southeastern University.
Susan Kabot, EdD, CCC-SLP has developed and administered
programs for children and young adults with autism for over 35
years. She teaches courses in autism at Nova Southeastern
University at the undergraduate and graduate levels. She cur-
rently is the Chair of the Florida Developmental Disabilities
Council and serves on the Panel of Professional Advisors for
the Autism Society.
Christine Reeve, PhD, BCBA-D received a doctorate in Clin-
ical Psychology at SUNY Stony Brook. She has worked as a
consultant and trainer for schools for more than 20 years and
adjunct faculty at Nova Southeastern University for the last 10
years.