751436

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BMOXXX10.1177/0145445517751436Behavior ModificationShillingsburg et al.

Original Article
Behavior Modification
1­–19
Rapport Building and © The Author(s) 2018
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DOI: 10.1177/0145445517751436
https://doi.org/10.1177/0145445517751436
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Instruction: Moving
From Child-Led Play to
Intensive Teaching

M. Alice Shillingsburg1,2,3,
Bethany Hansen1,2, and Melinda Wright2

Abstract
Discrete trial instruction (DTI) is effective for teaching skills to children with
autism spectrum disorder (ASD). Although effective, instructional settings
can become aversive resulting in avoidant and escape-related behaviors.
Given the significant social impairments associated with ASD, interventions
that promote social approach and reduce avoidance are warranted. Rapport
building or “pairing” the therapist and teaching setting with highly preferred
activities prior to instruction can reduce problematic behaviors during
subsequent instruction. However, the path from child-led play to DTI is
not well established. Instructional fading may assist in bridging this gap.
Four participants with ASD who were beginning an intensive behavioral
intervention program were included in the current study. Participants
progressed through nine stages of pairing and instructional fading with
minimal problem behavior and high percentages of in-seat and close
proximity to the therapist. Guidelines for incorporating rapport building
strategies prior to intensive teaching with children with ASD are proposed.

1Emory University School of Medicine, Atlanta, GA, USA

2Marcus Autism Center, Atlanta, GA, USA
3May Institute, Randolph, MA, USA

Corresponding Author:
M. Alice Shillingsburg, May Institute, 41 Pacella Park Dr., Randolph, MA 02368, USA.
Email: ashillingsburg@mayinstitute.org
2 Behavior Modification 00(0)

Keywords
autism, discrete trial instruction, escape extinction, instructional fading,
pairing, rapport

Individuals with autism spectrum disorder (ASD) often receive intensive

comprehensive interventions for 25 to 40 hr per week for 2 or more years
(Dawson & Burner, 2011). Given the deficits experienced by many individu-
als with ASD, time in intervention is spent learning skills which can be dif-
ficult to acquire but are critical for social and daily functioning. Research
suggests that both discrete trial instruction (Smith, 2001) and naturalistic
developmental behavioral interventions (Schreibman et al., 2015) are effec-
tive at improving language, cognitive skills, and adaptive behaviors (Warren
et al., 2011), and it is often recommended that comprehensive approaches
include both naturalistic and more structured procedures (Granpeesheh,
Tarbox, & Dixon, 2009). It is safe to assume that children receiving intensive
behavioral interventions spend much of their time in instruction. Although
effective at improving necessary skills, intensive instructional sessions may
engender some problems. For example, it has been noted that instructional
settings can become aversive, resulting in avoidant and escape-related behav-
iors (Geiger, Carr, & LeBlanc, 2010).
Effective interventions to reduce problem behaviors during instruction
have been identified (e.g., escape extinction, differential reinforcement of
compliance); however, it has been noted that avoidant and resistant behaviors
may persist despite these interventions, albeit, in a more muted manner
(Anderson, Taras, & O’Malley Cannon, 1996). One possible explanation is
the motivating operation that initially evoked the problem behavior, aversive
task demands, remains (Carbone, Morgenstern, Zecchin-Tirri, & Kolberg,
2007). Use of escape extinction and differential reinforcement of compliance
entails requiring the child to sit and comply with instruction while noncom-
pliance and attempts to escape instruction are ignored. Through this process,
it is possible that the instructional setting and therapist becomes associated
with demands. Although compliance may be achieved, responding is likely at
least partially reinforced by breaks from demands and, ultimately, escape
from the therapist.
An added element to consider is the social impairment that is central to
ASD. Widely recognized as the characteristic feature of the disorder, social
deficits are often at the forefront of most treatment plans for children with
ASD. Interventions that promote social approach, communicative initiations
such as mands (Sundberg & Michael, 2001), and joint attention (e.g., Kasari,
Freeman, & Paparella, 2006) are prioritized. Therefore, practitioners must
Shillingsburg et al. 3

balance the need to work on very difficult skills in an intensive and persistent
manner, while also prioritizing the need to promote these social skills (i.e.,
social orientation and approach). Given that highly demanding instructional
sessions can actually result in avoidant behaviors, these two objectives may
seem to be counter to one another in that treatments designed to address the
first concern may inadvertently exacerbate the second concern.
Recently, the role of building rapport in addressing problematic behavior
and treating the core symptoms of ASD has been emphasized. Although
building rapport, also referred to as pairing, has long been suggested as an
important component of interventions for children with ASD (Barbera,
2007; Sundberg & Partington, 1998; Taylor & Fisher, 2010; Weiss, 2001), it
has received only sparing research attention. One of the first studies to
examine the effects of pairing on the interactions between children with
ASD and a therapist showed that two preschoolers exhibited more social
initiations toward the therapist and fewer problematic behaviors during ses-
sions with the therapist who spent time pairing (i.e., building rapport) com-
pared with a therapist who did not (Shillingsburg, Bowen, & Shapiro, 2014).
Kelly, Axe, Allen, and Maguire (2015) studied the effects of presession pair-
ing on problematic behavior and responding to instructions in three school-
aged children with ASD. All of the participants showed reductions in
problem behaviors and better academic responding in instructional sessions
that had been preceded by a pairing session compared with those sessions
that had not.
The relationship between adults with disabilities and their therapists has
also been examined as to its effect on compliance and indices of happiness
(McLaughlin & Carr, 2005; Parsons, Bentley, Solari, & Reid, 2016). In a
recent study (Parsons et al., 2016), the “familiarity” of staff is described as an
important variable, suggesting that preferred staff members are those with
whom the individual has formed a good relationship. They examined a
“familiarization intervention” which consisted of several steps. First, the
inexperienced staff member only interacted with the individual within the
context of a preferred activity with a familiar staff member present. Next, the
inexperienced staff member phased into the work session with the adult client
by initially observing work sessions and then alternating with the familiar
staff member in presenting instructions. Over the course of a few sessions,
the inexperienced staff member gradually conducted more work with the
individual as the familiar staff member phased out. This process sounds strik-
ingly similar to recommendations for building rapport (i.e., pairing) by ini-
tially engaging with the client in a preferred activity. However, it also includes
an added element of gradually fading in the therapist. If the unfamiliar thera-
pist is experienced as less preferred, this fading in process could help mitigate
4 Behavior Modification 00(0)

the level of aversiveness experienced. The results of this study showed that
the adult residents exhibited better compliance and higher ratings on happi-
ness indices with “familiarized” staff.
In addition to the empirical support for rapport building and presession
pairing on client behavior, guidelines delineating what therapist behaviors
should be exhibited during pairing have also recently been developed
(Lugo, King, Lamphere, & McArdle, 2017). These behaviors include oper-
ationalized aspects of play and engagement, such as creating new opportu-
nities to play with toys, praising, imitating, and reflecting the child’s
behavior. The development of guidelines such as these is critical in dis-
seminating specific procedures that can be employed by practitioners.
However, another gap exists. Although pairing can be an effective strategy
to prevent avoidant and problematic behaviors prior to the introduction of
more structured instructional sessions, the path from child-led play to inten-
sive teaching is not well established. One option is to conduct a pairing
session prior to every instructional session as implemented in Kelly et al.
(2015). In this study, every 5-min instructional session was preceded with a
2- to 4-min pairing session. Although 2 to 4 min is quite brief, it adds up to
30% to 40% of time with the therapist spent in pairing rather than instruc-
tion. In the Shillingsburg et al. (2014) study, a phase of pairing was con-
ducted and then withdrawn, maximizing instruction time. However, the
likelihood that the effects of pairing would diminish over time is quite high.
It may be beneficial to determine if it is possible to gradually fade pairing
out and increase instruction over time.
Demand fading, which involves phasing in task demands and response
requirements, has repeatedly been shown to reduce problematic behaviors
during demand presentation (Pace, Iwata, Cowdery, Andree, & McIntyre,
1993; Piazza, Moes, & Fisher, 1996; Ringdahl et al., 2002). Not surprisingly,
the gradual introduction of demands within the contexts of pairing or rapport
building has also been recommended clinically for some time (Weiss, 2001).
The process described in the “familiarization intervention” presents one
model by which to do this with adults (Parsons et al., 2016). However, a simi-
lar process to employ with children receiving intensive behavioral interven-
tion has not been described, and the results on child behaviors have not been
shown experimentally.
The purpose of the current study was to evaluate a pairing and instruc-
tional fading protocol with children with ASD who are beginning an inten-
sive behavioral intervention program. We propose guidelines for moving
from child-led, rapport building sessions to intensive teaching sessions with
a focus on minimizing problematic behaviors and simultaneously promoting
social initiations that are critical to interventions for children with ASD.
Shillingsburg et al. 5

Method
Participants, Settings, Materials
Participants included two 4-year-old males, Andy and Matthew, and two
3-year-old males, Logan and Curtis. All participants were previously diag-
nosed with ASD and were admitted to a behavioral intervention clinic to
address social communication and adaptive skills deficits. Prior to admission,
the Verbal Behavior Milestones Assessment and Placement Program
(VB-MAPP; Sundberg, 2008) was conducted. Andy scored a 0 in the mand,
tact, listener, and echoic domains. He imitated a few motor movements but
not consistently, emitted simple matching skills with identical items, and
played with cause and effect toys (i.e., pop-up toy). Matthew exhibited a
strong echoic and motor imitation repertoire (score of 10 on both), vocally
manded for approximately 15 different items, emitted tacts for 50 items
(score of 7), and could follow simple one-step instructions (score of 8). Logan
scored a zero in the mand, tact, echoic, and imitation domains. He oriented to
others when spoken to but did not engage in any other listener behavior. He
emitted simple matching skills with identical items and played with cause
and effect toys. Curtis scored a zero in the tact and echoic domains. Although
he did not use vocal communication, Curtis was able to exchange a few pic-
ture cards to request preferred items. He imitated a few motor movements,
though not consistently. He could not match any items and showed little
engagement with toys. Results of the VB-MAPP indicated that all partici-
pants displayed barriers in the areas of behavior problems and/or instruc-
tional control.
Sessions were conducted in an individual therapy room containing a child-
sized table and chair and therapist’s chair. Materials included data sheets and
timers for data collection, general instructional materials, and various toys,
activities, and preferred snacks. In addition, a video system included in the
session rooms was utilized for recording sessions and scoring interobserver
agreement (IOA).

Experimental Design and Response Measurement

A nonconcurrent multiple baseline design across participants was utilized.
The primary dependent variables for each participant included problematic
behaviors, which were individually identified for each participant (i.e.,
aggression, disruption, crying, self-injurious behavior, spitting, and elope-
ment), and percentage of session in-seat or percentage of session in close
proximity to the therapist (within 2 feet). See Table 1 for operational
definitions.
6 Behavior Modification 00(0)

Table 1. Operational Definitions.

Behavior Definition
Aggression Any instance in which the participant pushed, bit, or grabbed a
therapist or hit or kicked a therapist from a distance of 6 in.
or greater
Disruption Any instance in which the participant threw (greater than 1
feet from body), tore, or swiped materials or reinforcers as
well as any instance in which his hand or foot made contact
with a surface at a distance of 6 in. or greater
Crying Any instance in which the participant raised his voice above
conversational level for longer than 3 s and at least one tear
was visible
Self-injurious Any instance in which the participant’s open or closed hand
behavior made contact with his head from a distance of 3 in. or greater
Spitting Any instance in which saliva was expelled past the lips and
contacted another surface area or individual
Elopement Any instance in which the participant touched the door knob in
an attempt to exit the session room
Time in-seat Any time in which the participant’s buttocks came in contact
with the seat of his chair
Close proximity Any instance in which the participant was within 2 feet of the
to therapist therapist

A second observer independently collected data in-vivo and from

r­ andomly selected video recordings. Total count IOA was obtained for prob-
lem behavior. Total duration IOA was obtained for the durations recorded by
each observer for in-seat, proximity to therapist, and crying. IOA was calcu-
lated by dividing the smaller quantity by the larger quantity and multiplying
by 100. IOA was collected for 15% of Andy’s sessions, 20% of Curtis’s
sessions, 21% of Logan’s sessions, and 20% of Matthew’s sessions. For
Andy, average IOA for problem behavior was 99.72% (range = 87.50%-
100%) and for duration in-seat was 99.75% (range = 97.20%-100%). For
Curtis, average IOA for duration in close proximity to therapist was 99.76%
(range = 95.90%-100%) and for problem behavior was 95.41% (range =
0%-100%). Low occurrences of the behavior account for the low percentage
of IOA obtained during a few sessions. For two sessions, one observer
scored two elopements and the other observer scored no elopements result-
ing in 0% agreement. For all other sessions for Curtis, IOA was 80% or
greater. For Logan, average IOA for problem behavior was 99.60% (range =
83.33%-100%), for close proximity to therapist was 98.34% (range =
Shillingsburg et al. 7

91.30%-100%), and for crying was 90.48% (range = 0%-100%). For one
session, one observer scored crying while the other did not. IOA for Logan
for all other sessions was 78.6% or greater. For Matthew, average IOA for
crying was 99.22% (range = 92.17%-100%), for duration in-seat was 99.08%
(range = 95.00%-100%), and for problem behavior was 95.46% (range =
0%-100%). Three sessions yielded lower than ideal percentages of IOA. For
one session, the primary observer scored seven elopements and the second-
ary observer scored no elopements. For a second session, the primary
observer scored three elopements and the secondary observer scored four
elopements. For a third session, the primary observer scored one instance of
spitting and the secondary observer scored two instances of spitting. For all
other sessions, IOA was 80% or greater.

General Procedures
The pairing with instructional fading protocol was designed to initially focus
on pairing the therapist and instructional setting with highly preferred items
and activities to increase social approach and initiations and then gradually
fade in increasingly complex and frequent instructions until a terminal stage
that mimicked an intensive structured teaching session was achieved.
Generally, the goal was to promote spontaneous and voluntary approach to
the therapist, maintain close proximity and/or in-seat behavior, improve com-
pliance with instruction, and minimize problem behavior. The initial stage of
pairing began with access to highly preferred items and activities while
requiring very little response effort from the child (i.e., taking preferred items
from a therapist, tolerating therapist approach to the child). Highly preferred
items were selected based on caregiver report, as well as a free operant pref-
erence assessment. Task demands were selected based on results of the
VB-MAPP and included targets such as simple imitation, matching, receptive
instructions, and mands. The focus of this protocol was not necessarily acqui-
sition of skills. Instead, the goal was to increase attempts to respond or
increase acceptance of therapist prompts without resistance. Across all stages
beginning in Stage 1, vocal models of the names of preferred items were
provided when the item was delivered. If the participant echoed the vocaliza-
tion, immediate access to the item was provided and attempts to transfer the
vocalization to an independent mand response were incorporated into subse-
quent sessions. Criteria to move to the next stage consisted of three consecu-
tive sessions with fewer than three instances of problematic behavior and
80% or greater of close proximity/in-seat behavior.
It is important to note that the protocol was designed to provide general
guidance from child-led pairing to intensive teaching. Therefore, targets,
8 Behavior Modification 00(0)

prompts, and reinforcers were individually selected based on assessment data

(i.e., preference assessments) and other best practices. Sessions were 10 min
in duration. See Table 2 for stage descriptions.

Baseline and posttest. Baseline and posttest conditions were conducted identi-
cally to Stage 9 (i.e., the terminal stage) and consisted of presenting one to
five demands followed by 10- to 15-s reinforcer interval according to a Vari-
able Ratio 3 (VR3) schedule. The purpose of Baseline was to determine the
child’s response to the therapist and instructional setting under demand con-
ditions when reinforcement was provided. Demands were identified based on
the results of the previously completed VB-MAPP assessment and were in
each participant’s current repertoire of skills (i.e., already mastered). If a par-
ticipant’s current repertoire of skills was limited, demands were selected that
the participant was likely to comply with when physically prompted to do so
(e.g., give high five; put block in a bucket; touch a picture card in a single
array). Previously identified preferred items and activities were available on
the table. At the start of the session, the child was given the instruction to
come to the table and was provided 10- to 15-s access to the items once he
was within arm’s reach of the table. If the child did not respond to the instruc-
tion to sit, gentle physical guidance was provided to clarify the instruction
and assist him to the table.
Access to preferred items was granted for 10 to 15 s as long as the child
remained in close proximity to the table. In other words, the child could leave
the table, but the preferred items could not. Once 10 to 15 s had elapsed, the
therapist restricted access to items and activities. Contingent upon an indicat-
ing response suggesting interest in a preferred item (i.e., mand, point, reach),
an instruction was presented. If the response was currently in the child’s rep-
ertoire (based on VB-MAPP), an independent opportunity to respond was
permitted. If not, prompts were immediately provided. If the child complied
with the demand(s) with or without prompting, reinforcement in the form of
access to the items was provided for 10 to 15 s. For Andy and Matthew, if a
correct response did not occur, the experimenter re-presented the demand and
provided a prompt to assist the participant to complete the demand, followed
by immediate delivery of the item indicated for. Data were collected on prob-
lem behavior and in-seat behavior. For Logan and Curtis, if a correct response
did not occur, the experimenter re-presented the demand and provided a
prompt to assist the participant to complete the demand, followed by immedi-
ate delivery of the item indicated for. However, with these participants, the
experimenter discontinued the prompt if the participant resisted the physical
prompt. If the prompt was resisted and, therefore, removed, reinforcers were
also withheld. Contingent upon the next indicating response from
Shillingsburg et al. 9

Table 2. Pairing and Instructional Fading Stages.

Stage Therapist behaviors Access to preferred items

1 Therapist approaches child; Free access at or away from the
engages with preferred items table; new items offered every 30 s
with child; no demands or when indicated for
2 Therapist remains at table; engages Free access at the table; preferred
with preferred items with child; items cannot be removed from
no demands table; new items offered every 30 s
or when indicated for
3 Therapist remains at table; engages Free access at the table when
with preferred items with child seated; preferred items cannot
when seated; no demands with be removed from table; new
the exception of gentle guidance items offered every 30 s or when
to sit as needed indicated for
4 Therapist remains at table; engages Free access at the table when
with preferred items with child; seated; preferred items cannot
one demand per minute following be removed from table; items
an indicating response restricted for demand presentation
5 Therapist remains at table; engages Free access at the table when
with preferred items with child; seated; preferred items cannot
one demand every 30 s following be removed from table; items
an indicating response restricted for demand presentation
6 Therapist remains at table; engages Free access at the table when
with preferred items with seated; preferred items cannot
child; two demands every 30 s be removed from table; items
following an indicating response restricted for demand presentation
7 Therapist remains at table; engages Free access at the table when
with preferred items with seated; preferred items cannot
child; two demands every 15 s be removed from table; items
following an indicating response restricted for demand presentation
8 Therapist remains at table; engages Free access at the table when
with preferred items with child; seated; preferred items cannot
three demands every 15 s be removed from table; items
following an indicating response restricted for demand presentation
9/Baseline Therapist remains at table; engages Preferred items cannot be removed
with preferred items with child; from table; approximately 15 s
one to five demands every 15 s of demands followed by 15-s
following an indicating response reinforcement interval

the participant, the experimenter re-presented the same demand. Thus, the
participant was not physically prompted when resisting, but preferred items
were withheld until compliance (without resistance) was achieved. For these
participants, data were collected on problem behavior and percentage of
10 Behavior Modification 00(0)

session the participant was in close proximity to the therapist. Data on close
proximity rather than in-seat behavior were collected for Logan and Curtis
due to their young age and size (i.e., some preferred activities were easier to
play with when standing). Upon completion of treatment stages, a posttest
was conducted following procedures identical to baseline.

Treatment. Treatment began in Stage 1 for Andy, Logan, and Curtis and
began in Stage 3 for Matthew. Andy, Logan, and Curtis were all very early
Level 1 learners according to the VB-MAPP. They emitted very few vocal-
izations and had minimal to no mand repertoire. Matthew, in contrast, was a
high Level 2 learner and exhibited echoic, mand, tact, and listener responses.
Therefore, the decision to begin in Stage 3 was made given his initial ability
to respond to instructions and high baseline levels of in-seat behavior. Rap-
port building, or pairing, was primarily the focus of Stages 1 to 3, and thera-
pist behaviors during these stages were similar to those described in Lugo
et al. (2017). In Stage 1, items were offered continuously and noncontin-
gently throughout the session. There was no requirement for a participant to
be seated or remain within a certain proximity of the therapist to gain access
to preferred items and activities. Furthermore, preferred items were offered
regardless of problematic behavior. During this stage, the therapist remained
close to the participant (i.e., followed him around). New toys and snacks
were offered every 30 s or when the participant indicated for an item (i.e.,
mand, reach, point). If the participant placed an item down, the therapist
retrieved the item and delivered it to the participant at the next opportunity.
Items were not taken from the child. During Stage 2, preferred items and
activities were offered continuously contingent on the participant being
within arm’s length of the table or therapist. In other words, the therapist no
longer approached the child, and instead waited for the child to approach the
table where the therapist was seated with the preferred items. In Stage 3,
preferred items and activities were offered continuously contingent upon the
child sitting at the table. In both Stages 2 and 3, if the child moved out of the
distance or sitting requirement, the therapist restricted access to activities,
keeping the items at the table. In other words, the child was allowed to leave
the table; however, he was not allowed to take preferred items with him. If the
child returned to the table, access to preferred items was provided.
Beginning in Stage 4, simple instructions were introduced, at a rate of
approximately one per minute. Similar procedures described in the baseline
phase for presenting demands were implemented during instructional fading,
using the current stage’s schedule for presentation of instructions and dura-
tion of reinforcement interval. With each new stage, demands were ­presented
more frequently. See Table 2 for stage descriptions.
Shillingsburg et al. 11

Figure 1. Results for Andy and Matthew. Rate of problem behavior per minute is
shown on the primary axis. Percentage of session in-seat and percentage of session
crying is shown on the secondary axis.

Results
Results for Andy and Matthew are presented in Figure 1. Results for Logan
and Curtis are presented in Figure 2. Figure 1 displays the rates of problem
behavior per minute and the percentage of session in-seat. In addition, the
percentage of session crying is displayed for Matthew. Figure 2 displays the
rates of problem behavior per minute and the percentage of session in close
proximity to the therapist. In addition, the percentage of session crying is dis-
played for Logan.
The first panel in Figure 1 displays data for Andy. During baseline ses-
sions, rate of problem behavior per minute ranged from 0.7 to 1.3 and the
percentage of session in-seat ranged from 95% to 100%. Fifty-one 10-min
treatment sessions were conducted across 2 weeks. During the posttreatment
sessions, rate of problem behavior was stable at .4 per minute or less.
The second panel in Figure 1 displays data for Matthew. This graph depicts
the rate of problem behavior per minute as well as the percentage of session
crying and in-seat. During baseline sessions, the rate of problem behavior per
12 Behavior Modification 00(0)

Figure 2. Results for Curtis and Logan. Rate of problem behavior per minute is shown
on the primary axis. Percentage of session in close proximity to the therapist and
percentage of session crying is shown on the secondary axis.

minute ranged from 0 to 1.1, the percentage of session crying ranged from
less than 1% to 29%, and the percentage of session in-seat ranged from 86%
to 100%. Sixty-two 10-min treatment sessions were conducted across 2
weeks. During the posttreatment sessions, rate of problem behavior was sta-
ble at 0 per minute and percentage of session crying was stable at 0%.
The first panel in Figure 2 displays data for Curtis. During baseline ses-
sions, rate of problem behavior per minute ranged from 0.1 to 1.6 and was
on an upward trend. The percentage of session in close proximity to the
therapist ranged from 41% to 82% and was on a downward trend. Seventy-
eight 10-min treatment sessions were conducted across 6 weeks. During the
posttreatment sessions, rate of problem behavior was stable at 0 per minute
and percentage of session in close proximity to therapist was stable at
100%.
The second panel in Figure 2 displays data for Logan. During baseline
sessions, the rate of problem behavior per minute ranged from 0 to 0.9
instances per minute. The percentage of session crying ranged from 6% to
Shillingsburg et al. 13

63% and was on an increasing trend. Percentage of session in close proximity

to therapist ranged from 23% to 86.5%. Fifty-four 10-min treatment sessions
were conducted across 6 weeks. During the posttreatment sessions, rate of
problem behavior was stable at .4 per minute or less. Percentage of session in
close proximity to therapist was stable at 80% or greater. Percentage of ses-
sion crying was stable at 1% or less.

Discussion
Overall, results of the study provide support for employing procedures
aimed at building rapport prior to initiating intensive intervention. In the
current study, baseline was designed to mimic an intensive teaching session
and consisted of presenting developmentally appropriate instructions with
correct responses being reinforced on a VR3 schedule of reinforcement.
Responding in baseline varied across participants; however, all of the par-
ticipants exhibited problem behavior and crying and/or elopement from the
table, hypothesized to be motivated by avoidance of the therapist, teaching
environment, and/or instructional demands. Following pairing and instruc-
tional fading, participants showed reductions in problem behavior and cry-
ing (Matthew and Logan) and improvements in close proximity or
maintenance of high percentages of in-seat behavior. The reduction in avoid-
ant behaviors when demands are removed as in Stage 1 is not surprising.
Numerous research studies have shown reductions in problem behavior
when free access to highly preferred stimuli and attention is provided and
demands are removed, as described in the toy play/control conditions in
Functional Analysis methodology (Iwata, Dorsey, Slifer, Bauman, &
Richman, 1982/1994). In addition to abolishing the motivation to engage in
problem behavior, this procedure may be a critical component of interven-
tions for children with ASD as a means of promoting social initiations.
Stages 1 to 3 allowed for social initiations (i.e., pointing, reaching), social
approach (i.e., approaching the therapist), and mands to be reinforced and
social avoidance (i.e., leaving the table) to be ignored. For three of the four
participants, close proximity to the therapist and in-seat behavior was high,
even though these behaviors were not required (i.e., prompted). In other
words, when given the choice to come to the table and play with a therapist,
or wander around the room, the participant chose to come to the table. One
participant, Curtis, did not come to the table more often until Stage 3, when
in-seat was required to access items.
This study extends previous research on pairing strategies (Kelly et al.,
2015; Lugo et al., 2017; Shillingsburg et al., 2014) by providing guidelines
for progressing from pairing to an instructional session by implementing
14 Behavior Modification 00(0)

systematic demand fading. Pairing procedures and building rapport have

long been touted as important features of teaching (Barbera, 2007; Sundberg
& Partington, 1998; Taylor & Fisher, 2010; Weiss, 2001); however, few sys-
tematic procedures have been proposed as to what these protocols entail and
how practitioners should move from pairing to intensive teaching. In a survey
of practicing behavior analysts (Love, Carr, Almason, & Petursdottir, 2009),
23% described their programming using the term verbal behavior and 57%
indicated that their program was based on Sundberg and Partington’s (1998)
teaching manual. This suggests that a good portion of practicing behavior
analysts are using pairing procedures and are incorporating instructional fad-
ing to promote responding in teaching sessions as described in this manual. It
is clear that delineated steps and empirical support for the procedures are
needed. The current study aimed to propose a set of guidelines that practitio-
ners can follow when initiating intervention with children with autism. In
addition, we sought to provide a method to track responding and make data-
based decisions for moving through the stages of pairing. Finally, we sought
to provide preliminary empirical support for the use of this protocol with
children with ASD. All of the participants progressed through the stages of
the protocol with few instances of problem behaviors and high levels of close
proximity to the therapist or in-seat behavior. All four participants responded
favorably to Stage 9 (baseline conditions) following pairing and instructional
fading. Importantly, each session was 10 min in duration, and therefore, the
participants completed the protocol in approximately 10.5 hr. For these par-
ticipants, this protocol made up the majority of their programming for the
first 1 to 2 weeks of services. More specifically, intervention sessions were
the only programming conducted. Other activities consisted of daily routines
such as bathroom trips.
We refer to the protocol described in this study as a set of guidelines
because it is important that specific details of any intervention program incor-
porate data from a variety of sources regarding numerous factors. For exam-
ple, the exact schedule of demand fading could potentially be altered
depending on the skill presentation and baseline responding of a particular
client. The initial demands selected should also be highly individualized to
include low effort, easily prompted tasks, which may vary across children.
Furthermore, the stage at which a practitioner begins may also vary. The data
presented in the present study are not sufficient to answer questions related to
these types of clinical choices a practitioner may make. However, one partici-
pant in this study began at Stage 3 and responded to the progression of stages
in a similar manner as those who began at Stage 1. This clinical decision was
made based on Matthew’s skill presentation. It is not known whether that
decision was necessary or had an impact on the progression of the protocol.
Shillingsburg et al. 15

One consideration a practitioner may make is whether to conduct the protocol

at all if no problem behavior and high levels of in-seat behavior are consis-
tently observed in baseline. This is an empirical question. One may argue that
building rapport without introducing demands initially may mitigate negative
responding that may emerge over time with consistent demand presentation.
In addition, a focus on social initiations early on may still be warranted even
if a child does well in an instructional setting, given the characteristic social
impairments observed in this population.
This protocol provides an alternative approach to other effective strategies
such as escape extinction and differential reinforcement of alternative behav-
ior (i.e., requesting a break from instruction) in cases in which problem
behavior is maintained by escape. Escape extinction has been demonstrated
to be an effective strategy for reducing escape-maintained problem behavior
and increasing compliance with demands (Iwata, Pace, Kalsher, Cowdery, &
Cataldo, 1990); however, there are ethical considerations associated with
teaching an individual to tolerate an aversive set of conditions (Geiger et al.,
2010). In addition, escape extinction is associated with an extinction burst in
which problem behavior can increase to a higher level than initially observed
prior to treatment (Lerman, Iwata, & Wallace, 1999), which therapists must
be prepared for and equipped to manage. Implementing escape extinction
with high fidelity can be demanding mentally and physically. In fact, research-
ers have found that treatment integrity is often low when implementing
extinction, which can be detrimental to the overall effectiveness of the treat-
ment (McConnachie & Carr, 1997). Functional communication in the form of
requesting a break may be contraindicated given that ASD is a social disabil-
ity. In other words, it may be beneficial, when possible, to examine alterna-
tives to teaching children to request to get away from a therapist. This is not
to diminish the tremendous value of teaching a functional communication
response, but instead to highlight that identifying strategies for increasing
approach to therapists and the instructional setting while emphasizing the
development and maintenance of positive relationships with others may play
an important role in treatments for children with autism. Despite the possible
advantages of the current protocol, it is important to note that the current
procedures were not compared with any other procedures. Therefore, it is not
possible to say whether this set of procedures is superior to other approaches
or to identify when other approaches may be more beneficial. It is likely that
the best method for a particular client requires careful weighing of a variety
of factors.
There are limitations to the study worth discussion. Not all participants
received the exact same intervention. As noted, Matthew began intervention
in Stage 3 while the others began in Stage 1 and the demands varied across
16 Behavior Modification 00(0)

participants. In addition, for two participants, prompts were withdrawn if

they physically resisted. As noted by Sundberg and Partington (1998), “get-
ting the child to physically go along with your physical prompts” (p. 108) is
a step in promoting cooperation during instruction. Most adults are strong
enough to physically require compliance during instruction with young chil-
dren. However, it can be argued that a child voluntarily cooperating with
instruction is a more desirable outcome. In addition, some caregivers may not
find physically prompting a resistant child to be palatable. Although the two
alternate versions of the protocol introduce limitations to the conclusions that
can be drawn from the results, we highlight that both procedures were effec-
tive and, therefore, offer additional choices that a practitioner can make.
Replicating both versions of the protocol with additional participants is
needed to provide further support for the procedures.
Acquisition of nonmastered instructional tasks was not evaluated in this
study. Clearly an important component to intervention with children with
ASD is acquisition of new skills. Evaluating acquisition of targets pre-
sented during pairing and instructional fading would be beneficial, espe-
cially if additional procedures are needed to promote skill acquisition. The
severity of problem behaviors exhibited during instruction is also an impor-
tant factor to be considered by practitioners. The current procedures may be
contraindicated in the presence of severe behaviors that cause imminent
risk of harm. The participants in the current study exhibited problem behav-
iors that are typically seen in children with developmental disabilities and
severe language delays. However, none of the participants exhibited prob-
lem behavior at a severity that required more specialized attention.
Practitioners should keep this in mind and carefully weigh the appropriate-
ness of this procedure when working with individuals with more severe
behaviors. Readers are referred to Geiger and colleagues (2010) for a
review of other procedures as well as other references that may be useful.
Relatedly, a functional analysis of problem behavior was not conducted.
None of the participants were referred for treatment due to problem behav-
ior and the problem behavior that was exhibited was relatively mild.
However, a functional assessment of problem behavior prior to conducting
these procedures may help practitioners interpret results if the procedures
are not effective. Researchers should also consider incorporating a func-
tional assessment to assist in furthering the understanding of the function of
the behaviors and identifying the behaviors most likely to be improved
from the pairing and instructional fading procedures. If escape is not the
primary function of the problem behaviors, it is possible that this strategy
may not be effective or efficient to implement for reducing these behaviors
or to increase compliance with instructions.
Shillingsburg et al. 17

Although the concept of building an effective therapeutic relationship has

a long history in the field of clinical psychology, only recently has empirical
­evidence been sought to understand its role in interventions for children with
ASD. It is our hope that the guidelines put forth in the current study will aid
­practitioners in incorporating these strategies into interventions with children
they serve.

Ethical Approval
All procedures performed in studies involving human participants were in accordance
with the ethical standards of the institutional and/or national research committee and
with the 1964 Helsinki declaration and its later amendments or comparable ethical
standards. Informed consent was obtained for all individuals in the study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publi-
cation of this article.

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Author Biographies
M. Alice Shillingsburg, PhD, is the vice president of applied verbal behavior at the
May Institute, a national nonprofit organization that serves individuals across the life
span with autism spectrum disorder (ASD) and other developmental disabilities. She
is a licensed psychologist and board certified behavior analyst.
Bethany Hansen, PhD, is a licensed psychologist and board certified behavior ana-
lyst practicing at the Marcus Autism Center. She is an assistant professor in the
Department of Pediatrics at Emory University School of Medicine.
Melinda Wright, MA, is a board certified behavior analyst specializing in skill
development and problem behavior reduction. She is currently a school consultant at
the Marcus Autism Center.