Naturalistic Developmental

Behavioral Interventions for

Autism Spectrum Disorder
edited by

Yvonne Bruinsma, Ph.D., BCBA-D

In STEPPS and In STEPPS Academy
Irvine, CA

Mendy B. Minjarez, Ph.D.

Seattle Children’s Hospital Autism Center
and University of Washington School of Medicine
Seattle, WA

Laura Schreibman, Ph.D.

University of California, San Diego
La Jolla, CA

and

Aubyn C. Stahmer, Ph.D., BCBA-D

University of California, Davis MIND Institute
Sacramento, CA

Baltimore • London • Sydney

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Library of Congress Cataloging-in-Publication Data

Names: Bruinsma, Yvonne, editor.
Title: Naturalistic developmental behavioral interventions for autism
spectrum disorder / edited by Yvonne Bruinsma, Ph.D., BCBA-D, In STEPPS
Academy, Irvine, CA, Mendy B. Minjarez, Ph.D., Seattle Children’s Hospital Autism Center and
University of Washington School of Medicine, Seattle, WA, Laura Schreibman, Ph.D., University
of California, San Diego, CA, and Aubyn C. Stahmer, Ph.D., University of California, Davis MIND
Institute, Sacramento, CA.
Description: Baltimore, Maryland: Paul H. Brookes Publishing Co., [2020] |
Includes bibliographical references and index.
Identifiers: LCCN 2019001591 (print) | LCCN 2019011481 (ebook) | ISBN
9781681253398 (epub) | ISBN 9781681253404 (pdf) | ISBN 9781681252049
(paperback)
Subjects: LCSH: Autistic children—Behavior modification. | Autistic
children—Education. | BISAC: EDUCATION / Special Education / Mental
Disabilities. | EDUCATION / Special Education / Social Disabilities.
Classification: LCC RJ506.A9 (ebook) | LCC RJ506.A9 N38 2019 (print) | DDC
618.92/85882—dc23
LC record available at https://lccn.loc.gov/2019001591

British Library Cataloguing in Publication data are available from the British Library.

Version 1.0
Contents

About the Editors � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � ix

About the Contributors� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � xi
Foreword � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � xvii
Acknowledgments � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �xxiii
About the Online Materials � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � xxv

SECTION I Overview
Chapter 1 Understanding NDBI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Laura Schreibman, Allison B. Jobin, and
Geraldine Dawson
ASD Defined � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 4
History of ASD Intervention � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 5
Developmental Science and Its Influence in
ASD Early Intervention � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 7
Integration of Behavioral and
Developmental Sciences � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 8
Examples of NDBI � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �10
Common Elements of Empirically Validated NDBI � � � � � � � � � � � � � �10

Chapter 2 Considering NDBI Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Mendy B. Minjarez, Yvonne Bruinsma, and
Aubyn C. Stahmer
Early Start Denver Model � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �21
Enhanced Milieu Teaching� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 23
Incidental Teaching/Walden Toddler Program � � � � � � � � � � � � � � � � � 25
Joint Attention, Symbolic Play,
Engagement, and Regulation � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 27
Pivotal Response Treatment � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 30
Project ImPACT � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �32

iii
iv Contents

SECTION II Core Concepts and Foundational Principles

Chapter 3 Selecting Meaningful Skills for
Teaching in the Natural Environment . . . . . . . . . . . . . . . . . . . . . . . 45
Grace W. Gengoux, Erin McNerney, and
Mendy B. Minjarez
Goodness of Fit of NDBI Approaches� � � � � � � � � � � � � � � � � � � � � � � � � 46
Functional Skills � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 49
The Natural Environment � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 56
Case Example: Jin � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 66

Chapter 4 Empowering Parents Through

Parent Training and Coaching. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Mendy B. Minjarez, Elizabeth A. Karp,
Aubyn C. Stahmer, and Lauren Brookman-Frazee
Parent-Mediated Interventions and NDBI � � � � � � � � � � � � � � � � � � � � � 77
Psychological Functioning in Parents of
Children With ASD � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 79
Effective Parent Coaching Practices � � � � � � � � � � � � � � � � � � � � � � � � � � 82
Case Example: Gabe � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �91

Chapter 5 Fostering Inclusion With Peers and

in the Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Aubyn C. Stahmer, Connie Wong,
Matthew J. Segall, and Jennifer Reinehr
The Importance of Inclusion � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 99
Inclusion in Practice� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �100
Use of NDBI in Inclusive Settings � � � � � � � � � � � � � � � � � � � � � � � � � � � �102
Practical Suggestions for Incorporating
NDBI Strategies Into Community Programs� � � � � � � � � � � � � � � � � � �106
Common Challenges to Inclusion � � � � � � � � � � � � � � � � � � � � � � � � � � � �111
Case Example: Preschool Program � � � � � � � � � � � � � � � � � � � � � � � � � � �112
Case Example: Adult Program� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �114

SECTION III NDBI Strategies

Chapter 6 Implementing Motivational Strategies . . . . . . . . . . . . . . . . . . . . . 123
Mendy B. Minjarez and Yvonne Bruinsma
NDBI and Motivation � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �124
Measuring Motivation� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 125
Strategies That Enhance Motivation � � � � � � � � � � � � � � � � � � � � � � � � � �126

Chapter 7 Applying Antecedent Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . 151

Jennifer B. Symon, Yvonne Bruinsma, and
Erin McNerney
Preparing to Teach � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �153
Setting Up Opportunities in NDBI � � � � � � � � � � � � � � � � � � � � � � � � � � �164
Case Example: Ty � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �171
 Contents v

Chapter 8 Implementing Instructional Cues and

Prompting Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Kyle M. Frost, Brooke Ingersoll,
Yvonne Bruinsma, and Mendy B. Minjarez
Definitions � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �175
Learning Opportunities Across NDBI Models � � � � � � � � � � � � � � � � �177
Prompting Strategies � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �182
Prompt Fading � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �187
Examples of Prompts for Specific Skills � � � � � � � � � � � � � � � � � � � � � � �187
Case Example: Leah � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �190

Chapter 9 Using Consequence Strategies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193

Allison B. Jobin and Laura Schreibman
Increasing the Strength of a Behavior � � � � � � � � � � � � � � � � � � � � � � � �194
Decreasing the Strength of a Behavior � � � � � � � � � � � � � � � � � � � � � � � �195
Applying the Premack Principle � � � � � � � � � � � � � � � � � � � � � � � � � � � � �196
Promoting Consequence Effectiveness � � � � � � � � � � � � � � � � � � � � � � �196
Using Consequences to Maintain Behavior Change � � � � � � � � � � � �199
Shaping and Chaining � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �201
Using Natural Consequences� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 202
Reinforcing Attempts � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 205
Modeling and Expanding on Child’s Response � � � � � � � � � � � � � � � 205
Imitating the Child’s Response � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 206
Troubleshooting NDBI Consequence Strategies � � � � � � � � � � � � � � � 206

Chapter 10 Guiding Meaningful Goal Development . . . . . . . . . . . . . . . . . . . 213

Grace W. Gengoux, Erin E. Soares, and
Yvonne Bruinsma
Formulating Goals � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �214
Assessment � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �218
Case Example: José� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �221
Considerations for Goal Selection � � � � � � � � � � � � � � � � � � � � � � � � � � � 224
Case Example: Jenna � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 226
Case Example: Kaleb � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 227
Case Example: Ashir � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 227
Developmental Considerations � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 228
Case Example: Alex � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 229
Case Example: Cole � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 229
Case Example: Josephine � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 230
Case Example: Marco � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 230
vi Contents

SECTION IV Applications of NDBI Strategies

Chapter 11 Targeting Communication Skills . . . . . . . . . . . . . . . . . . . . . . . . . . 237
Mendy B. Minjarez, Rachel K. Earl,
Yvonne Bruinsma, and Amy L. Donaldson
Communication Profile of Children With ASD � � � � � � � � � � � � � � � �237
Communication Development in
Typically Developing Children � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 238
Use of NDBI for Targeting Communication � � � � � � � � � � � � � � � � � � �240
Teaching Communication Across
Developmental Levels Using NDBI Strategies � � � � � � � � � � � � � � � � �249

Chapter 12 Improving Social Skills and Play . . . . . . . . . . . . . . . . . . . . . . . . . . 277

Yvonne Bruinsma and Grace W. Gengoux
Social Initiations � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �278
Imitation Skills � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 284
Play � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 286
Teaching Play With Friends � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �297

Chapter 13 Supporting Behavior, Self-Regulation,

and Adaptive Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
Mendy B. Minjarez, Yvonne Bruinsma,
and Rosy Matos Bucio
NDBI and Challenging Behavior � � � � � � � � � � � � � � � � � � � � � � � � � � � �310
Relevant Applied Behavior
Analysis Interventions � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �311
NDBI Strategies for Teaching
Self-Regulation and Adaptive Skills � � � � � � � � � � � � � � � � � � � � � � � � � 322
Promoting Self-Regulation in
Individuals With ASD � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �326
Teaching Adaptive Skills � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �332
Tips for Teaching Self-Regulation and
Adaptive Skills � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 339
Case Example: Jonas � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 341

Chapter 14 Implementing NDBI in Schools . . . . . . . . . . . . . . . . . . . . . . . . . . . 347

Aubyn C. Stahmer, Jessica Suhrheinrich,
and Laura J. Hall
Including NDBI Components in
Group or Academic Settings � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 348
School-Based Activities Most Suited for NDBI � � � � � � � � � � � � � � � � 355
Examples of Activities and Lessons � � � � � � � � � � � � � � � � � � � � � � � � � �357
 Contents vii

Chapter 15 Collecting Data in NDBI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361

Mendy B. Minjarez, Melina Melgarejo,
and Yvonne Bruinsma
General Framework for Data Collection � � � � � � � � � � � � � � � � � � � � � �362
Data Collection Across NDBI Models� � � � � � � � � � � � � � � � � � � � � � � � 363
When and Why Data Are Collected � � � � � � � � � � � � � � � � � � � � � � � � � �369
Types of Data and Measurement Systems � � � � � � � � � � � � � � � � � � � � �375
Data Collection in the Natural Environment � � � � � � � � � � � � � � � � � 383

Chapter 16 Identifying Quality Indicators of

NDBI Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
Aubyn C. Stahmer, Sarah R. Rieth, Brooke Ingersoll,
Yvonne Bruinsma, and Aritz Aranbarri
Quality Indicators Versus Common Features � � � � � � � � � � � � � � � � � �391
Specific Program Elements to Look
for in a Quality NDBI Program � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �391

Chapter 17 Considering Future Directions in NDBI . . . . . . . . . . . . . . . . . . . . 407

Laura Schreibman, Mendy B. Minjarez,
and Yvonne Bruinsma
Research Future Directions � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 408
Dissemination and Implementation:
Future Directions � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �410

Glossary� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �415
Index � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 423
About the Editors

Yvonne Bruinsma, Ph.D., BCBA-D, In STEPPS and In STEPPS Academy, Irvine,

CA. Dr. Bruinsma is CEO and founder of In STEPPS and In STEPPS Academy,
a behavioral health agency and a nonprofit private school for children with autism
in California. She is a Board Certified Behavior Analyst and received her doctorate
in special education, developmental disabilities, and risk studies in 2004. She has
been working with families and teaching others how to work with families by
using Naturalistic Developmental Behavioral Interventions (NDBI) strategies for
over 20 years. Yvonne’s focus is to blend research and reality in the highest quality
treatment in a community setting.

Mendy B. Minjarez, Ph.D., Seattle Children’s Hospital Autism Center and Uni-
versity of Washington School of Medicine, Seattle, WA. Dr. Minjarez is a licensed
psychologist with a background in Applied Behavior Analysis and NDBI. She is
an assistant professor in psychiatry and behavioral sciences at the University of
Washington, the Clinical Director of the Seattle Children’s Hospital Autism Center,
and the Program Director of the Applied Behavior Analysis Early Intervention Pro-
gram at Seattle Children’s Hospital Autism Center. Dr. Minjarez’s clinical work is
focused on diagnosis and treatment of autism spectrum disorder, with a particular
interest in NDBI, parent training, and early childhood. Her research is focused on
dissemination of parent-mediated NDBI, particularly through innovative models,
such as group parent training.

Laura Schreibman, Ph.D., Department of Psychology, University of California,

San Diego, La Jolla, CA. Dr. Schreibman served as Director and Principal Investi-
gator of the Autism Intervention Research Program at the University of California
at San Diego from 1984 until 2012. She is Distinguished Professor Emeritus of
Psychology and Research Professor at the University of California, San Diego. Her
most recent research interests have focused on the development and dissemination
of NDBI strategies, the development of individualized treatment protocols, transla-
tion of empirically based treatments into community settings, analysis of language
and attentional deficits, generalization of behavior change, parent training, and
issues of assessment. She is the author of four books and more than 160 research
reports, articles, and book chapters.

ix
x About the Editors

Aubyn C. Stahmer, Ph.D., BCBA-D, University of California, Davis MIND Insti-

tute, Sacramento, CA. Dr. Stahmer has been using and studying NDBI strategies
with children with autism spectrum disorder and their families in research and
community settings for 30 years. She is an expert in the translation of evidence-
based autism research to community-based practice and delivery. The main goals
of her research include developing ways to help community providers, such as
teachers and therapists, and helping children with autism and their families by
providing high-quality care. She is widely published and a frequent presenter at
annual professional meetings in the field of services to children with autism.
About the Contributors

Aritz Aranbarri, Ph.D., The MIND Institute, University of California (UC) Davis
Medical Center, Sacramento, CA. Dr. Aranbarri is a clinical licensed psychologist spe-
cialized as a developmental neuropsychologist (Early Start Denver Model certified
therapist) and holds a Ph.D. in environmental epidemiology and early neurodevelop-
ment. He received postdoctoral training in Autism Early Intervention Community
Research at the UC Davis MIND Institute mentored by Dr. Aubyn C. Stahmer and
now coordinates autism research at the SJD Barcelona Children’s Hospital.

Lauren Brookman-Frazee, Ph.D., San Diego Department of Psychiatry, University

of California, La Jolla, CA. Dr. Brookman-Frazee is Professor of Psychiatry at the
University of California, San Diego, Associate Director of the Child and Adoles-
cent Services Research Center, and Research Director at the Autism Discovery In-
stitute at Rady Children’s Hospital–San Diego. She specializes in parent-mediated
interventions for children with autism spectrum disorder (ASD) and other develop-
mental and mental health problems. Dr. Brookman-Frazee’s research involves part-
nering with mental health and education system leaders, providers, and families
to develop, test, and implement evidence-based interventions in community and
school-based settings.

Geraldine Dawson, Ph.D., Departments of Psychiatry and Behavioral Sciences,

Pediatrics, and Psychology & Neuroscience, Duke University, Durham, NC.
Dr. Dawson is Professor in the Departments of Psychiatry and Behavioral Sciences,
Pediatrics, and Psychology & Neuroscience at Duke University. She is Past-President
of the International Society for Autism Research and a member of the Interagency
Autism Coordinating Committee. She is Director of the Duke Center for Autism and
Brain Development, an interdisciplinary autism research and treatment center, and
Chair of the Faculty Governance Committee for the Duke Institute for Brain Sciences.
Dr. Dawson is Director of a National Institutes of Health Autism Center of Excellence
Award at Duke focused on understanding early detection, neural bases, and treat-
ment of autism and attention-deficit/hyperactivity disorder. Dr. Dawson has pub-
lished extensively on early detection, brain function, and treatment of autism. With
Sally Rogers, she developed the Early Start Denver Model, a comprehensive early
behavioral intervention for young children with autism. She completed a Ph.D. in
developmental/child clinical psychology from University of Washington and clinical
internship at the University of California, Los Angeles.
xi
xii About the Contributors

Amy L. Donaldson, Ph.D., CCC-SLP, Department of Speech and Hearing Sci-

ences, Portland State University, Portland, OR. Dr. Donaldson is an associate pro-
fessor in the Department of Speech & Hearing Sciences at Portland State University.
Her research focuses broadly on social-communication and perception of social
competence in individuals on the autism spectrum and neurotypical individuals.
Dr. Donaldson examines intervention efficacy, pre- and postprofessional develop-
ment, the influence of context on performance, and the experiences of neurodiver-
gent individuals in different contexts.

Rachel K. Earl, Ph.D., Seattle Children’s Hospital, Seattle, WA. Dr. Earl earned
her Ph.D. in school psychology at the University of Washington. She is currently
a postdoctoral fellow at Seattle Children’s Hospital–Autism Center, specializing in
diagnosis and treatment of ASD.

Kyle M. Frost, M.A., Department of Psychology, Michigan State University (MSU),

East Lansing, MI. Mrs. Frost is a doctoral candidate in clinical psychology at MSU
and a member of the MSU Autism Research Lab. Her research focuses on mea-
suring intervention response and implementation, as well as understanding the
common elements of Naturalistic Developmental Behavioral Interventions (NDBI).

Erin E. Soares, B.S., Palo Alto University, Palo Alto, CA. Ms. Soares is a third-year
Ph.D. student at Palo Alto University (PAU) in the clinical psychology program,
with an emphasis in child and family studies. Prior to attending PAU, Ms. Soares
graduated from Santa Clara University with a B.S. in psychology and child studies.

Grace W. Gengoux, Ph.D., BCBA-D, Division of Child and Adolescent Psychia-

try, Department of Psychiatry, Stanford University School of Medicine, Stanford,
CA. Dr. Gengoux is a clinical psychologist and Board Certified Behavior Analyst
who directs the Autism Intervention Program within the Stanford Autism Center
at Lucile Packard Children’s Hospital. Dr. Gengoux received her Ph.D. in Clinical
Psychology from the University of California Santa Barbara and completed her
clinical internship and postdoctoral fellowship at the Yale Child Study Center.
Her research specifically focuses on the development and evaluation of NDBI for
young children with ASD. Dr. Gengoux’s previous publications have focused on
models for enhancing functional communication and social development and for
providing effective parent training.

Laura J. Hall, Ph.D., Department of Special Education, San Diego State Univer-
sity, San Diego, CA. Dr. Hall is Professor and Chair of Special Education at San
Diego State University. She has been working with individuals with ASD and their
families for over 35 years. The focus of her research and teaching has been on the
transfer of research into practice, or facilitating the implementation of evidence-
based practices by supporting educators and paraeducators. She is the author of
the widely used textbook, Autism Spectrum Disorders: From Theory to Practice (2009,
Pearson).
 About the Contributors xiii

Brooke Ingersoll, Ph.D., BCBA-D, Michigan State University (MSU), East Lansing,
MI. Dr. Ingersoll is an associate professor of clinical psychology at MSU, where she
is the director of the MSU Autism Research Lab. She is also a licensed psychologist
and Board Certified Behavior Analyst. Dr. Ingersoll’s research focuses on the de-
velopment, evaluation, and dissemination of social-communication interventions
for individuals with ASD. She has published multiple peer-reviewed journal arti-
cles and book chapters on ASD and is the coauthor of Teaching Social Communication
to Children with Autism (with A. Dvortcsak; 2010, Guilford Press), an NDBI parent
training curriculum for children with ASD.

Allison B. Jobin, Ph.D., BCBA-D, Child and Adolescent Services Research Center,
Department of Psychiatry, University of California, San Diego, Rady Children’s
Hospital San Diego, San Diego, CA. Dr. Jobin is a licensed clinical psychologist
and Board Certified Behavior Analyst at the Autism Discovery Institute of Rady
Children’s Hospital San Diego and study manager in the Department of Psychiatry
of the University of California, San Diego, and Child and Adolescent Services Re-
search Center. Dr. Jobin has over 15 years of experience in the delivery, supervision,
and evaluation of evidence-based interventions for children with ASD and their
families. She specializes in parent-mediated treatment models and NDBI. Her re-
search focus includes evaluating and improving treatment for children with ASD,
as well as methods for effective implementation in community settings.

Elizabeth A. Karp, M.S., Department of Psychology, University of Washington,

Seattle, WA. Ms. Karp is a doctoral candidate in child psychology at the University
of Washington. She is passionate about identifying ways to provide family-centered
care for families with a child with ASD. She is particularly interested in caregivers’
experiences as they implement interventions with their young children.

Rosy Matos Bucio, Ph.D., BCBA-D, Santa Barbara SELPA, Santa Barbara, CA�
Dr. Matos Bucio is a Board Certified Behavior Analyst who completed her doctoral
training in 2005 at the University of California, Santa Barbara. For over 20 years,
her research and professional practice has focused on using the motivational strat-
egies of NDBI to support individuals with ASD across the life span and dissemi-
nate best practices to families and professionals.

Erin McNerney, Ph.D., BCBA-D, In STEPPS and McNerney & Associates, Irvine,
CA. Dr. McNerney is a licensed clinical psychologist and Board Certified Behav-
ior Analyst Doctoral specializing in ASD, developmental disabilities, and behavior
challenges. She has spent the past 2 decades teaching and implementing Pivotal
Response Treatment (PRT) and providing behavior-based parent training. She cur-
rently provides psychological assessment and therapy to support the mental health
needs of individuals with ASD and their families.

Melina Melgarejo, Ph.D., San Diego State University, San Diego, CA. Dr. Melgarejo
received her Ph.D. in education with an emphasis in special education, disabilities,
xiv About the Contributors

and risk studies from the University of California, Santa Barbara. She is a postdoc-
toral scholar at San Diego State University and the Child and Adolescent Services
Research Center. She is currently involved in research on the multi-level factors
affecting the use of evidence-based practices for children with ASD within schools.

Jennifer Reinehr, Psy.D., TEACCH Center, University of North Carolina at Chapel

Hill, Chapel Hill, NC. Dr. Reinehr is a clinical assistant professor and staff psy-
chologist at the TEACCH Center with the University of North Carolina at Chapel
Hill. She is specialized in diagnostic and developmental assessment of young chil-
dren with ASD. For over 10 years, she has provided clinical oversight for an inte-
grated preschool program for young children with and without ASD. Dr. Reinehr
continues to work toward practical application of evidence-based practices in an
individual’s natural settings.

Sarah R. Rieth, Ph.D., BCBA-D, Child and Adolescent Services Research Center,
Department of Child and Family Development, San Diego State University, San
Diego, CA. Dr. Rieth is Assistant Professor of Child and Family Development at
San Diego State University and an investigator at the Child and Adolescent Ser-
vices Research Center. She received her Ph.D. from the Psychology Department
at UCSD in 2012. Her research focuses on intervention for children with ASD and
their families and the delivery of high-quality intervention in community settings.
Dr. Rieth is a licensed clinical psychologist and specializes in training others and
delivering intervention for children with ASD, ages 12 months to 10 years. Her
current work involves training community providers to deliver parent-mediated
interventions and examining student outcomes from community-based trials of
evidence-based treatment models.

Matthew J. Segall, Ph.D., Emory Autism Center, Emory University School of

Medicine, Atlanta, GA. Dr. Segall is Program Director for Education and Transition
Services at the Emory Autism Center, as well as Assistant Professor of Psychiatry
and Behavioral Sciences in the Emory University School of Medicine. He is a li-
censed psychologist in the State of Georgia. Dr. Segall completed his bachelor’s de-
gree in psychology at the University of Virginia and his doctoral degree in school
psychology at the University of Georgia. His predoctoral internship and postdoc-
toral fellowship were both completed at the Emory Autism Center, while also com-
pleting a fellowship at Georgia State University in the Georgia LEND (Leadership
Education in Neurodevelopmental Disabilities) program. Dr. Segall’s professional
interests include educator and professional training, supporting students in inclu-
sive educational settings, and transition planning.

Jessica Suhrheinrich, Ph.D., Department of Special Education, San Diego State

University, San Diego, CA. Dr. Suhrheinrich is an assistant professor of special
education at San Diego State University and an investigator with the Child and
Adolescent Services Research Center. Broadly, her research aims to improve com-
munity-based services for children with ASD.
 About the Contributors xv

Jennifer B. Symon, Ph.D., BCBA, Special Education and Counseling, California

State University Los Angeles, Los Angeles, CA. Dr. Symon is a professor in the
Division of Special Education and Counseling at California State University, Los
Angeles. She coordinates the programs in ASD and is a Board Certified Behavior
Analyst. Her research interests include interventions for parents, teachers, para-
professionals, and peers who support students with ASD.

Connie Wong, Ph.D., Frank Porter Graham Child Development Institute, Univer-
sity of North Carolina at Chapel Hill, Chapel Hill, NC. Dr. Wong is a research
scientist at the Frank Porter Graham Development Institute at the University of
North Carolina at Chapel Hill and Adjunct Professor in Early Intervention and
Early Childhood Special Education at California State University, Los Angeles. Her
research focuses on young children with or at risk for autism and other develop-
mental delays and their families.
Foreword

The outcomes of children with autism spectrum disorder (ASD) may be about to
change radically for the better in the next decade. If so, a world of promise, rather
than a world of challenges, may open to the approximately 66,000 children who are
born every year in the United States alone who will have autism. This possibility is
within the grasp of this coming generation of autism investigators and clinicians to
attain, in deep collaboration with parents and community providers.
Yet, if we are to succeed in optimizing developmental potential and quality of
life of the next generations of children with ASD, three priority goals need to be
achieved. We need to identify ASD early; we need to translate early detection into
access to evidence-based, effective early treatments; and we need to provide ongo-
ing high-quality supports and solutions to children and families affected by ASD.
The challenges in these domains are considerable but not insurmountable.
Why is early detection critical? By the time we celebrate a baby’s first birthday,
his or her brain has doubled, and synaptic density has quadrupled. Brain matura-
tion guides a baby’s experiences, which in turn deeply influences brain organiza-
tion and continued specialization. By the end of their second year of life, babies
have undergone their period of maximal lifetime neuroplasticity. By 18–24 months,
there may be an emergence of autism symptoms, making possible reliable diagno-
sis by expert clinicians. For treatment to have optimal benefits, there is a need to
capitalize on this early brain malleability, before speech-language and communica-
tion development is severely derailed and problem behaviors become entrenched.
Yet, the median age of autism diagnosis has not changed in consecutive cohorts
followed by Centers for Disease Control and Prevention surveillance efforts. Fifty
percent of children with autism are diagnosed after the age of 4–5 years, and chil-
dren from underserved populations—minorities, low income, rural—are diag-
nosed later still.
What is the solution? Despite some controversy on this topic in the past
5 years, most investigators, as well as science, policy, and advocacy organizations,
believe that populationwide surveillance programs can effectively deploy univer-
sal screening for ASD and related developmental delays and that the screening
process can be made actionable via increased access to diagnostic services.
The promise of early detection can only be delivered if screening programs
are shown to increase access to effective early intervention services. Most stud-
ies of early treatment in autism have shown major benefits in learning and lan-
guage acquisition. Yet, it is likely that the potential benefits of early treatment have

xvii
xviii Foreword

been grossly underestimated. One reason may be the fact that most investiga-
tions have focused on children age 3 years old and older; another reason may be
the fact that most studies have reported on relatively small studies conducted by
research groups rather than on population trends resulting from federally man-
dated birth-to-3 services. More studies are needed of early treatment involving
toddlers if we are to take neuroplasticity seriously, and more “big data” studies
of state-by-state indicators of service access and outcomes are needed if we are
to judge the populationwide effects of the Program for Infants and Toddlers with
Disabilities (Part C) of the Individuals with Disabilities Education Act (IDEA), and
of the now 11-year-old recommendations of the American Academy of Pediatrics.
The promise is clear: Optimize development and learning potential by age 3 years,
and the child’s lifetime prospects are likely to change dramatically; make high-
quality early treatment accessible, and the longtime, financial equation burdens
are alleviated for individual families and for the entire health care and education
systems. Yet, a large number of children with ASD receiving special education in
their school years have not benefited from early treatment, and some who receive
services before the age of 3 may obtain treatments that vary in quality and inten-
sity, indeed services that may fail to maximize what might be achieved otherwise.
What is the solution? You are holding it in your hands. This book compiles
the best promise we have of treatments that work, that leverage the best science
we currently have, and that are scalable to meet the demands of the community at
large. The authors on these pages are some of the leading innovators and experts
in this field. Their commitment to evidence-based practice, to individualized and
personalized treatments, and to the wedding of quality and access is second to
none. Most of all, their commitment is to the families of children with autism and
to the providers who are in the trenches: They need to navigate a labyrinth of
information, some of which is questionable or even predatory, in order to identify
and secure what is best for children. The authors of this book make this task easy
and straightforward. Unhelpful arguments that verge on ideological fights are left
behind; acronyms that create differences when there are none, and that confuse
rather than illuminate, are sidestepped in order to focus instead on principles that
work and have been proven via scientific rigor and on active ingredients that can be
easily identified, studied, and promoted. This book is a victory of common sense:
a consensual framework that will serve as the basis for improvements of treatment
efficacy, effectiveness, and community uptake in what is now the highest priority,
with potentially the highest gains in the field.
Why is the provision of supports and solutions to children and families
affected by ASD so critical? Although early detection and intervention promise
life-changing opportunities for the next generations of children with autism, those
affected by ASD now cannot wait. Families, community providers, and schools
can deploy treatments that work in fostering communication and adaptive skills
and that decrease the risk of problem behavior. Communication skills facilitate
meaningful inclusion and make possible friendships and other relationships, as
well as a world of vocational opportunities. Adaptive skills promote independence,
self-reliance, and self-determination. The management of challenging behavior
decreases the risk of isolation, enhances quality of life, and makes it possible for
a child to learn and adapt to environmental demands. Yet, families are often con-
fused and frustrated with the lack of direction, integration, and helpful navigation
 Foreword xix

through the struggles of the day; providers are often overwhelmed at the very sight
of the plethora of titles sitting on their book shelves that do not necessarily translate
into a concrete plan and approach for their day of therapy and teaching. How are
we to distill from this chaotic state the straightforward principles of treatment and
supports that work, the roadmap to generate learning that generalizes, and the
strategies to promote communication skills that are self-driven and effective across
environments?
The solution, again, is in your hands. This book describes ways to leverage
children’s daily lives as the stage for their learning. Teach skills in isolation, and
the road from skill acquisition to spontaneous skill deployment is a much longer
and winding road. The importance of developmental considerations is extended
to all ages: Not only are the children with ASD growing up, but so are their peers.
And with the passage of developmental stages comes the unfolding of increasingly
more challenging environmental demands. Remove therapy and supports from the
developmental context in which they need to work, and one may witness further
isolation, prompt dependency, and reduced adaptation. Similarly, the reader will
learn about environmental controls and reinforcement management techniques
that foster habit formation, accelerate skill learning, and promote self-motivation
and self-regulation. Fail to consider that, and you may find yourself struggling
with continued disruption, lack of engagement, despondency, and heightened anx-
iety. These are principles of treatment and intervention that should guide our work
with children of all ages, from infancy through adolescence and beyond.
How does this book achieve the sorely needed synthesis? First and foremost, it
represents the culmination of some 50 years of science in early treatment of autism,
a process that has greatly accelerated in the past 10 years. Facts matter, and sci-
ence has produced a great body of evidence justifying the integrative approach
taken by the authors. In this approach, there is great respect for a clinical principle,
enshrined in the language of educational law, that treatments and intervention pro-
grams should be individualized to a child’s profile, addressing the child’s needs
while capitalizing on the child’s assets. This principle unravels many of the ideolog-
ical debates. A treatment devised to promote communication skill acquisition in a
nonverbal 6-year-old at risk of never speaking is unlikely to be beneficial in the case
of a 2-year-old who vocalizes and shows intent to communicate with others, albeit
inconsistently, and vice versa. There is no need to train a child to display a complex
behavior by chaining discrete and disconnected behaviors if the child has the abil-
ity to learn how to learn in more naturalistic settings. In this way, generalization
challenges are reduced; prompts and consequences are inherent in the real world;
and pivotal skills generate more learning, in more settings, and in more contexts.
The authors also leverage behavioral science in ways that do not turn it into a
stereotype. The science of Applied Behavior Analysis (ABA) has generated some of
the most critical advances in the care of individuals with developmental disabili-
ties. Anyone who has worked in a residential facility for individuals with severe
disabilities is quick to appreciate this fact. But ABA is not synonymous to narrow
applications that may have its place for some children but not for others. ABA is a
vast body of science that painstakingly assesses and changes human behavior. At
its core is learning theory with its focus on an individual’s behavior acquisition
and display as a function of environmental conditions. For primates in general, but
certainly for humans, that environment consists of people and their referents in the
xx Foreword

surroundings. Making these connections is central to the acquisition of speech, lan-

guage, and communication. We fail to follow ABA principles at our peril; indeed,
we are all behaviorists in real life, but unfortunately most of us are bad behavior-
ists, often pre-empting the very result we seek to achieve.
By advancing individualized, naturalistic approaches and the basic scientific
tenets of learning theory, there should be no surprise that the individual child, his
or her style of learning, and his or her perceived environment take center stage in
any effective program of treatment and intervention. In between an antecedent
and a response, there is a single child with a specific age and stage of development,
assets and needs, emotional state, capacity for self-regulation, motivations, social
relatedness, interests, fears, and personalized environment. For too long, learning
theorists proceeded in their scientific endeavors by pretending to ignore a child’s
individualized agency: The brain is no black box! Similarly, for too long, develop-
mental scientists proceeded in their scientific endeavors by focusing on sweeping
generalities that were not easily translatable into manualized treatments capable
of singling out active ingredients and of achieving greater fidelity. Why these two
currents of human ideas forged parallel paths for so many decades is as infuriating
as it is counterproductive to any evidence-based synthesis of effective treatment for
young vulnerable children. Thankfully, the authors of this book leave this anach-
ronistic notion behind us all. The behaviorists versus developmentalist confronta-
tion should be relegated to the history of the field, thus erased and eradicated from
its future science and its future scientists.
By moving the nonsensical aside, and by leveraging the best science from
within, this book generates a consensual synthesis, whose name includes the very
words that generated this unsatisfactory state of artificial conflagration in our past:
Naturalistic Developmental Behavioral Interventions. The very name is our best
assurance that research on early treatments will continue to thrive on healthy sci-
entific grounds.
This book is more than a compilation of evidence-based treatment principles; it
is also a recipe for viability and for increased access. In an early intervention world
of scarce resources, to state that a 40-hour regimen of treatment delivered by an
expert clinician is aspired standard of care, as we have learned to believe over the
past 2 decades, is a recipe for frustration. With few exceptions in the country, most
states, where maybe 1–2 hours a week is the reality of treatment, need more viable
solutions. Children need to access effective services when they need them and
where they are. For that to happen, a number of stakeholders need to be involved. It
is the responsibility of investigators and clinicians to use the best implementation
science to generate innovations that can be deployed in the real world, advancing
quality as well as accessibility. Parents need to be engaged in the most important
role in their lives: to promote the development of their children. Parent-mediated
interventions are emerging as both viable and effective: Professional intervention-
ists can use their limited availability to train parents to turn every waking moment
of the child’s life into a learning moment, using routine daily activities as natural-
istic platforms for treatment, with the intensity and emotional engagement needed
to achieve lasting results. Similarly, generalist child development providers and
teachers can promote similar principles in group settings. In this fashion, a new
ecosystem of care becomes possible, in which divisions across contexts and settings
can dissolve thanks to common goals and strategies.
 Foreword xxi

Most important, the involvement of parents and child care providers allows
treatments to be downward extended into toddlerhood and maybe even infancy:
There is no reason to wait until a diagnosis is attained to turn surveillance and
parent education into strategies that promote development—of all children. All
vulnerable children, and certainly those with autism, are likely to benefit from
a robust dosage of facilitation of social and communication engagement. This is
already the approach taken by those trying to counter the effects of intergenera-
tional poverty on a child’s language acquisition. And therein lies one of the great-
est promises in the field: the beneficial effects of child development surveillance
and parental engagement on the outcomes of all children. Perhaps if we were to
deploy these generalist strategies systemically in a communitywide fashion, chil-
dren would reach the age of more individualized and intensive treatments at a
much higher level of readiness to learn.
These may seem like lofty aspirations. Yet, after the publication of this book,
we, as a field, are closer to these goals than ever before. The authors have made a
terrific contribution in our effort to ensure that every child with ASD is afforded
what they need in order to fulfill their promise.

Ami Klin, Ph.D.

Director, Marcus Autism Center
Children’s Healthcare of Atlanta and Emory University School of Medicine
Acknowledgments

This book is the result of the persistence and resolve of a small group of people.
I believe this book may advance our field, and I sincerely hope it is the cohesive
and comprehensive book that we set out to write when we started. It is our pas-
sionate desire for this book to create the start of the resources we need for broader
dissemination and implementation of Naturalistic Developmental Behavioral
Interventions (NDBI).
This book could not have been written without the support and collaboration
from the authors of the different NDBI models. I am grateful for their collaboration
and willingness to come together under one name to help advance our field. I am
incredibly proud to be a part of that movement. While the book covers many NDBI,
it is important to note the book editors were all initially trained in Pivotal Response
Treatment (PRT). Our hope is that by including experts from many methods in
various book chapters and asking additional experts to review our descriptions of
their model, we have represented all of the NDBI respectfully and accurately.
I would like to acknowledge my mentors and teachers who supported me
along the way and helped me grow clinically and academically. I especially thank
my teachers Robert and Lynn Koegel, Paul Smeets, Paul Touchette, and Harry Boel-
ens.
I thank all my friends and the staff at In STEPPS and In STEPPS Academy for
supporting me through this process. I would especially like to thank Danny Open-
den for putting me in touch with Brookes Publishing Co. and, of course, Mendy
Minjarez. Her incredible task-master and organizational skills as well as her clini-
cal expertise and writing skills brought the book to a new level. Gratitude is also
deserved for Grace Gengoux, who went above and beyond in helping us write
some of the chapters.
Finally, I would like to thank my family. My husband, Robert, and my “poor”
kids Niels, Sander, and Fenna Rose, who were so sick of yet another writing retreat.
I have good news for you: No more writing retreats. It is done.

Yvonne Bruinsma, Ph.D., BCBA-D

xxiii
xxiv Acknowledgments

I would like to acknowledge those who have supported me and my career person-
ally, and those who have made this work possible through their contributions to
the field. Personally, I could not have asked for a better colleague, coauthor, and
friend than Yvonne Bruinsma. I am also grateful to my mentors and colleagues for
the knowledge and opportunities they have provided, including Marji Charlop,
Ami Klin, Bob and Lynn Koegel, Tara O’Connor, Bryan King, and Maddie Parsons.
The body of work that has preceded the NDBI framework must be fully acknowl-
edged because it is the foundation for the content of this book, which we believe
will propel the field forward. I have also learned so much from the children and
families that I work with, which I anticipate will continue lifelong; however, my
greatest teachers are my own children, who have taught me that life is messy and
hard but full of humor and joy, which I hope carries over to the rest of my career
and life as well.

Mendy B. Minjarez, Ph.D.

Over many years, I have had the good fortune to work with amazing students,
colleagues, researchers, teachers, and community members of all kinds. Most im-
portant, I have had the good fortune to work with wonderful children and families
who have taught me so much and have showed me the real power of what we do
and what we can accomplish. I want to acknowledge the efforts of all these people
who have worked so hard at getting us to where we are today. I see the develop-
ment of NDBI as the fruit of these efforts.

Laura Schreibman, Ph.D.

Many people have devoted their time and expertise to make this project a reality.
First, thank you to all the amazing NDBI developers willing to support the in-
tegration of their individual evidence-based interventions into a coherent model.
Each reviewed the descriptions of their respective interventions in this book and
supported the concept of NDBI through the original article. Second, thank you to
all my colleagues who helped shape my understanding of NDBI across contexts.
Third, thanks to my research and treatment teams in San Diego and Sacramento,
who bring it all to life. Finally, thank you to all the children, families, teachers,
therapists, and advocates who have supported this work.

Aubyn C. Stahmer, Ph.D., BCBA-D

About the Online Materials

Online materials are available to supplement the knowledge, approaches, and

strategies discussed in Naturalistic Developmental Behavioral Interventions for Autism
Spectrum Disorder�
All readers can access downloadable versions of the datasheets and other
forms for use in clinical settings and the classroom. To access the forms:
1. Visit the Brookes Publishing Download Hub: http://downloads.brookes
publishing.com
2. Register to create an account, or log in with an existing account.
3. Filter or search for the book title.
Course materials are also available to help faculty and instructors integrate Natu-
ralistic Developmental Behavioral Interventions for Autism Spectrum Disorder into their
course. These resources include:
• Sample syllabi for various disciplines to guide instructors on how this
book can be integrated into their course
• Customizable PowerPoints that summarize Chapters 1–16, for use in
lecture
• A test bank with 160 multiple-choice questions for instructors to use and
adapt in course exams
To access the course materials for this book:
1. Visit the Brookes Publishing Download Hub: http://downloads.brookes
publishing.com
2. Register to create an account with your university email, or log in with an
existing account.
3. Filter or search for the book title.

xxv
I

Overview
1
Understanding NDBI
Laura Schreibman, Allison B. Jobin, and Geraldine Dawson

A
utism spectrum disorder (ASD) affects as many as 1 in 59 children (Baio
et al., 2018). Although this statistic certainly has an impact across ser-
vice systems, the impact is far greater for those individuals and families
affected. While ASD may have been considered a dire prognosis for these children
and families from the 1950s through the 1980s and beyond, the state of affairs is
much brighter today. Research since the 1960s conducted across multiple academic
disciplines has led to the identification and development of treatments for ASD
that are both highly effective and efficient. The development of these effective
intervention strategies, coupled with an ability to diagnose ASD at earlier ages, has
broadened and strengthened the positive effect of treatment efforts. Early interven-
tion by using empirically based treatments has proven to have a substantial impact
on the future functioning of children with ASD, changing the outlook for these
individuals and their families (e.g., Dawson, 2008; Dawson et al., 2012; Rogers &
Dawson, 2010). Although early intervention using these newer strategies has cer-
tainly improved the prognosis for young children with ASD, treatments based on
these same principles have also proven to be effective for individuals throughout
the life span, as well as for individuals with related disorders that share some of
the same features of ASD (e.g., language acquisition delays, behavior problems,
cognitive impairment).
Our goal in writing this book was to describe a scientifically validated set
of interventions, derived primarily from the fields of Applied Behavior Analysis
(ABA) and developmental psychology. These interventions are called Naturalistic
Developmental Behavioral Interventions (NDBI) to reflect the essential combined con-
tributions of these two disciplines. As described in later chapters, there are several
established NDBI utilized with children with ASD and related disorders; although
specific NDBI have differences, they all have general concepts and procedures in
common. This book describes the development of NDBI, identifies and describes

3
4 Overview

the concepts and procedures that unite them, and provides an implementation
guide for practitioners and others who wish to use NDBI with children with ASD.
Section I introduces NDBI and key NDBI models. Section II explains core concepts
and foundational principles common to all NDBI, highlighting topics such as the
selection of meaningful skills, parent empowerment, and inclusion. Section III
dives deeper into specific NDBI strategies, and Section IV offers an implementation-
focused look at NDBI in practice.
This book is a resource for practitioners, educators, and other professionals
who make treatment decisions for children with ASD. Those searching for ASD
treatment are often confused and overwhelmed because there is so much informa-
tion available. Much of what is available via the web or other sources is not likely to
be helpful and can even be harmful. Some proposed treatments have proven to be
dangerous (e.g., certain drug regimens or chelation). Other treatment approaches
elevated through celebrity advocacy, although perhaps the most visible, often lack
evidence for effectiveness. Furthermore, even if a child receives a relatively benign
but not scientifically validated treatment (e.g., equine or dolphin therapy), it still
can be harmful if it is costly or results in the child spending less time in effective
treatment.
There are so many treatments and claims of effectiveness (often patently
false) that the process of identifying effective interventions for a child with ASD
too often becomes a burden for parents and treatment providers. This book offers
a solution by not only identifying proven treatments but also by describing the
basic, important concepts that characterize such treatments to help parents,
teachers, and practitioners decide if interventions meet the standards of estab-
lished NDBI. Although specific NDBI may have different names, such as Pivotal
Response Treatment (or Training) (PRT), Early Start Denver Model, and Project
ImPACT, they all involve the same important core concepts discussed in this
book. Our hope is that by helping parents, teachers, and practitioners determine
whether a treatment meets the standard of research-based practice, we will make
the initially unmanageable, manageable.

ASD DEFINED
Before diving in to the more complicated topics that follow in this book, perhaps
it is best to establish a common understanding of what we mean by autism spec-
trum disorder (ASD). Autism was first identified as a specific disorder by Leo
Kanner in 1943. Kanner described a group of children who exhibited a set of
features unlike those of any other known pediatric disorder. These features in-
cluded severe social deficits, such as failure to bond with parents, social avoid-
ance of others, failure to establish eye contact, failure to acquire language or
particular pathological features of language if it did develop, lack of appropriate
interaction or interest in toys or other features of the environment, and the pres-
ence of repetitive, nonpurposeful behaviors. He also believed that these children
possessed normal or above-normal intelligence. Kanner named this disorder
early infantile autism to describe the fact that the symptoms were exhibited very
early in life and involved a severe withdrawal. Since 1943, much has changed in
terms of understanding of the disorder, including requisite diagnostic features
(Schreibman, 2005).
 Understanding NDBI 5

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth

Edition (DSM-5; American Psychiatric Association, 2013), the following diagnostic
criteria for ASD have been established:
1. Persistent deficits in social-communication and social interaction such as
abnormal social approach, reduced sharing of emotions or affect, and failure to
initiate or respond to the social initiations of others
2. Persistent deficits in verbal and nonverbal behaviors used for social interac-
tion, such as failure to develop speech, inadequate eye contact, failure to use or
understand gestures for social purposes, failure to develop and maintain social
relationships, and absence of interest in, or sharing with, peers
3. Presence of restricted, repetitive patterns of behavior, interest, or activities
(including stereotyped or repetitive motor movements or use of objects; inflex-
ibility to changes in routines; and highly restricted, fixated interests that are
abnormal in intensity of focus)
4. Hyper- or hyporeactivity of the sensory environment
Also, whereas Kanner did not associate autism with cognitive impairment, a sig-
nificant number of these individuals do experience cognitive impairment. (See the
DSM-5 and Autism Speaks at http://www.autismspeaks.org for a more detailed
and comprehensive description of ASD.)

HISTORY OF ASD INTERVENTION

To fully appreciate where the field of ASD intervention is now, it is important to
look back at where the field began and how it has progressed. Prior to the early
1960s, educators widely assumed that children with ASD could not learn. The early
work of Charles Ferster and Marian DeMyer (1961, 1962) demonstrated that children
with ASD could learn a simple task if their responses reliably resulted in a positive
effect. The task was pressing a lever for candy in the presence of a stimulus, and
the positive effect was delivery of candy. Although this was not a particularly func-
tional curriculum, it did demonstrate that the principles of learning could be used
effectively to teach children with ASD. This early work was followed by a substan-
tial increase in the study of operant learning approaches to teach a variety of skills.
Examples of these skills include language (Lovaas, Berberich, Perloff, & Schaeffer,
1996; Risley & Wolf, 1967), social skills (Ragland, Kerr, & Strain, 1978; Strain, Kerr,
& Ragland, 1979), play (Koegel, Firestone, Kramme, & Dunlap, 1974; Lifter, Sulzer-
Azaroff, Anderson, & Cowdery, 1993; Stahmer, 1999; Stahmer & Schreibman, 1992),
adaptive skills (Ayllon & Azrin, 1968; Baker, 2004), and academic skills (McGee,
Krantz, & McClannahan, 1986; McGee & McCoy, 1981), as well as skills to reduce
the occurrence of interfering or challenging behaviors (Carr & Durand, 1985; Iwata,
Dorsey, Slifer, Bauman, & Richman, 1982; Schreibman & Carr, 1978).
This work reflected the new field of ABA, which studies the laws governing
how the environment affects behavior. Once researchers had determined these
laws, they began to study how to alter the environment to change others’ behavior
for the better. For example, the principle of positive reinforcement (i.e., a behavior
followed by a positive event will become stronger) is not only well established but
is used by everyone (e.g., saying “please” to request a treat will become a stronger
6 Overview

response if the treat follows saying the word). The field of ABA has established
many of these laws and continues to refine understanding of how to improve the
life of others. It offers specific experimental methodologies to investigate and prove
the effects of procedures aimed at changing behavior.
The application of behavioral principles to teach new skills and reduce behav-
ioral challenges for children with ASD took a huge leap forward through the work
of Ivar Lovaas; Lovaas and his colleagues developed an intensive and comprehen-
sive intervention program that focused on many of these skills (Lovaas, 1987, 2002).
Although Lovaas’s successes, and those of other behavioral researchers, propelled
behavioral treatment into the forefront, his 1987 treatment study had the most pro-
found impact. In that study, Lovaas provided intensive (i.e., up to 40 hours per
week) behavioral intervention to a group of young children with ASD. In contrast
to a control group of children who did not receive the treatment at such intensity,
the children in the experimental group showed significant gains in IQ score and
success in typical school placements. This work greatly altered the expectations
of treatment, especially early treatment, for ASD. The field began to realize that
tremendous progress, potentially leading to limited ongoing need for services and
supports, might be possible for almost half of children with ASD if they receive
excellent treatment early enough and with enough intensity. This work, and subse-
quent studies demonstrating efficacy of early intervention, led to two main trends
in ASD treatment.
First, parents, understandably very encouraged by these findings, began advo-
cating for their children to receive early intensive behavioral intervention, which
led to changes in educational practices and policies. Second, discrete trial training
(DTT), the behavioral approach used in Lovaas’s (1987) study, became increasingly
popular. In brief, DTT involves one system of implementation of operant methodol-
ogy. In this type of intervention, teaching is conducted via successive discrete tri-
als, with each trial consisting of an antecedent (a cue to indicate when a response
should be emitted), a response or behavior, and a consequence (an event following
the response). We call this the three-term contingency and abbreviate it A-B-C.
In DTT, educators break skills down into smaller, separate components and
teach them one at a time using discrete training trials until the complete skill is
acquired. For example, if a teacher wanted to teach a child to put on a pair of pants
when told to put on pants, he or she might first teach the child to point to a pair
of pants when told to put on pants. Once the child reliably points to the pants, the
teacher would teach the next component of the skill by requiring the child to point
to and then pick up the pants. Once that is mastered, the child would be required
to put one leg in the pants and so forth until the child could perform the entire skill
when told to put on pants. Thus, the teacher broke the complex skill of putting on
pants down into smaller steps and taught them separately.
Although DTT became increasingly popular with parents and other treatment
providers, intervention research in the late 1980s found that highly structured
intervention such as DTT had some limitations (Schreibman, 2005). These limita-
tions included 1) failure to generalize newly learned skills across multiple contexts,
2) occurrence of escape/avoidance-motivated challenging behaviors, 3) lack of
spontaneity in responding, and 4) overdependence on prompts. These limitations,
plus the successes of behavioral interventions, led many ASD treatment research-
ers from different disciplines to focus their efforts on addressing these identified
 Understanding NDBI 7

limitations and otherwise improving and expanding treatment effectiveness.

Advances in the developmental sciences—particularly those in the area of promot-
ing early communication skills, social engagement, and affective engagement—set
the stage for advancing early intervention methods beyond the highly structured
format of DTT. The marriage of ABA principles and principles derived from devel-
opmental science has proven to be particularly important and relevant because the
ability to diagnose ASD in children at earlier ages has led to an increased number
of children receiving early intervention.

DEVELOPMENTAL SCIENCE AND ITS

INFLUENCE IN ASD EARLY INTERVENTION
In the late 1980s and 1990s, researchers started to think that ASD could be best un-
derstood by explaining how the developmental trajectory of children with the di-
agnosis deviated from that of typically developing children. This perspective was
fueled by the emergence of the field of developmental psychopathology (Cicchetti,
1989), which allowed for the scientific study of atypical development. Researchers
realized that typical and atypical development are mutually informative and that
their understanding of ASD would be enhanced by studying the basic processes
that caused development to diverge from typical pathways. This led to a search
for the earliest fundamental developmental processes that could explain the core
symptoms of ASD. At this time, there was also greater emphasis on longitudinal
studies and perspectives. The result was formative work that helped define the
core distinguishing early characteristics of ASD.
Studies comparing preschool-age children with and without ASD were espe-
cially useful in shedding light on some of the early deficits that distinguished chil-
dren with ASD. Such deficits were found in the areas of social orienting (Dawson,
Meltzoff, Osterling, Rinaldi, & Brown, 1998), imitation (Dawson & Adams, 1984;
Rogers, Bennetto, McEvoy, & Pennington, 1996), joint attention (Mundy, Sigman,
Ungerer, & Sherman, 1986), affective reciprocity (Dawson, Hill, Spencer, Galpert,
& Watson, 1990; Yirmiya, Kasari, Sigman, & Mundy, 1989), and responses to emo-
tional cues (Sigman, Kasari, Kwon, & Yirmiya, 1992). Studies of home videotapes
showed that young infants who later developed ASD did not orient to name,
point, show, or make eye contact, demonstrating the earliest symptoms of ASD by
10–12 months of age (Werner, Dawson, Osterling, & Dinno, 2000).
These findings began to shape both the strategies used in early interven-
tion and the targets of intervention. For example, theories of typical development
emphasized the active role of the child in constructing both the social and non-
social world. Researchers found that even young infants learn by forming ideas
or hypotheses and then testing these ideas through playing with objects, inter-
acting with people, and using social interaction to test those hypotheses (Saffran,
Aslin, & Newport, 1996). Thus, researchers focused intervention methods more
on children’s initiation and spontaneity rather than on their response to cues and
prompts. Likewise, research on typically developing infants and young children
showed that learning is promoted when that learning occurs in the context of an
affectively rich social environment, such as social play involving smiling and eye
contact (Kuhl, 2007). Research on young children with ASD demonstrated that
the disorder is associated with deficits in affective sharing and social motivation
8 Overview

(Dawson et al., 1990). Thus, ASD treatments began using strategies to promote
affective engagement (e.g., Prizant et al., 2003; Rogers & DiLalla, 1991), or using
social emotion to act on and respond to the world. Studies of typically developing
infants found that early emerging skills, such as joint attention and imitation, were
critical for setting the stage for a wide range of later skills. As a result, early inter-
vention began targeting skills that were fundamental precursors to the develop-
ment of language, including joint attention (Mundy, Sigman, & Kasari, 1990).
As the theoretical frameworks and research findings from the fields of devel-
opmental psychology and developmental psychopathology were incorporated into
early intervention models, it became clear that they could be readily integrated
with the strategies of ABA. This integrated approach improved children’s motiva-
tion to learn, speed of acquisition of skills, and ability to generalize newly acquired
skills to novel environments. NDBI were the result of this integration of develop-
mental and ABA principles.

INTEGRATION OF BEHAVIORAL AND DEVELOPMENTAL SCIENCES

Despite their distinct theoretical foundations, methodologies, and implications
for intervention, the fields of behavioral and developmental science came together
with the emergence of NDBI (see Schreibman et al., 2015). These interventions in-
corporated components of both fields, demonstrating that integrating behavioral
and developmental sciences had a profound effect. The merging of these two fields
led to interventions that are informed by the strengths of each perspective and
that better serve the younger ASD population in particular. NDBI essentially are
research-based interventions that incorporate well-established behavioral inter-
ventions to affect developmentally important and appropriate behavior change.
Thus, NDBI ensure that the treatment strategies employed remain guided by un-
derstanding of child development.
The core elements of NDBI fall into three general areas: the nature of the teach-
ing targets, contexts in which the interventions are delivered, and instructional
strategies (see Schreibman et al., 2015).

Nature of Teaching Targets

The teaching targets selected in NDBI typically come from a broad range of devel-
opmental domains, including language and communication, play, social interac-
tion, cognition, and motor skills. The skills are selected based on the cascading
effect (i.e., flow or progression from lower level skills toward higher level skills)
and the foundational role they play in later development, especially in regard to the
core social deficits of ASD. These skills include imitation; shared and reciprocal en-
gagement; joint attention; and functional communication via the use of gestures,
facial expressions, and words, among others. Moreover, various domains are tar-
geted concurrently during learning episodes, in contrast to more highly structured
methods that may teach each domain separately. This distinction reflects a devel-
opmental systems approach, whereby different skills are integrated from the start
to promote generalization. Generalization is the use of skills across various people,
places, and materials with the ultimate goal of promoting long-lasting and func-
tional use of learned skills in real-world settings. For example, a young child who
learns new words while playing kitchen with a therapist would also practice those
 Understanding NDBI 9

same words during dinnertime at home or during another daily routine. During
these activities, the therapist or parent would also incorporate other developmental
skills, such as gesture use, imitation, shared engagement, or joint attention.

Contexts of Treatment Delivery

The empirical literature has provided evidence that children’s experiences affect
neurobiological development (Dawson et al., 2012; Knudsen, 2004) and that expe-
riences have a cascading effect on development (e.g., Thelen & Smith, 1994). The
contexts in which early learning occurs need to allow children to experience the
natural contingencies of their own behavior (Gibson, 1973). For example, asking
an adult for help reaching a toy leads to acquiring the toy. Increasing evidence is
emerging that learning is enhanced when it is embedded in activities that contain
emotionally meaningful social interactions, compared to situations in which in-
struction occurs without meaningful social engagement (Topál, Gergely, Miklósi,
Erdohegyi, & Csibra, 2008). Spelke, Bernier, and Skerry (2013) argued that provid-
ing children the opportunity to learn within a socially engaged context sets the
stage for them to learn about the social landscape around them. For example, an
educator can teach a child about different pieces of furniture by teaching the labels
chair or table separately, but learning is improved if a social partner teaches the
child while playing house. The child could sit a doll in the chair or put a dish on
the table for his or her mother so that the child learns the pieces of furniture within
the context of the natural environment.
In NDBI, these concepts are brought to fruition through child-initiated and
motivation-based (i.e., following the child’s preferences) interactions. These inter-
ventions take place during enjoyable play routines and familiar daily routines
using a variety of materials. Teaching usually looks and feels like the everyday
interactions that are central to toddler experiences. In fact, first-time observers
of these approaches have said they do not look like therapy. Parent and family
involvement is also common to NDBI because it broadens the context in which
teaching occurs and increases the frequency of learning opportunities. Learning
opportunities include imitating facial expressions and actions, identifying body
parts during bath time with mom or dad, or building shared engagement and
social initiations during a game of Peekaboo or chase with the child’s therapist.
Skill acquisition has been shown to be more effective in engaged contexts such as
these (Dawson et al., 2010; Delprato, 2001). Thus, specific characteristics of learning
contexts, including the activities, materials, and quality and emotional valence of
the adult–child interaction, contribute toward optimal learning and generalization
of newly developing skills.

Instructional Strategies
Finally, NDBI have in common the use of development-enhancing strategies, which
are described in more detail in other chapters. These strategies promote learning
and motivation within ecologically valid contexts and routines. At first, the child
may learn through highly predictable and salient response–reinforcer sequences.
For example, he or she may get to push a car down a steep ramp after making
brief eye contact with the play partner. This might later be expanded to following
instructions around the vehicle-based activity or even taking turns and sharing
10 Overview

enjoyment around that theme with the therapist. By incorporating behavioral

strategies, such as modeling, shaping, chaining, prompting, and differential
reinforcement, the therapist, teacher, or parent supports the child throughout these
activities in the development of expressive communication, receptive language un-
derstanding, early cooperative play, and shared engagement. The rewarding value
of these child-centered, everyday activities maximizes motivation. Research has
also demonstrated a decrease in maladaptive behaviors as they are replaced with
more functional, adaptive skills (e.g., Carr & Durand, 1985).
These skills are relevant for older individuals as well. Although this feature
of NDBI is most commonly utilized in early intervention, researchers and prac-
titioners realize the importance of skills such as imitation and joint attention as
foundations for many more advanced skills. For example, joint attention skills are
an important component of successful social interaction. Thus, they are good skills
for older individuals learning social skills. These skills need to be taught at any age
if the individual has not already acquired them. Another key feature of NDBI is
that the components can be adapted for any age and any skill area.

EXAMPLES OF NDBI
While developing interventions for ASD, several clinical research laboratories inde-
pendently realized the need for more naturalistic treatments that would greatly ex-
pand on the earlier work of Hart and Risley (1968) and increased focus on strategies
that would enhance child motivation and improve generalization of learned skills.
Thus, these laboratories established distinct NDBI that had several commonalities.
Examples include incidental teaching (IT; Hart & Risley, 1968, 1975; McGee, Morrier,
& Daly, 1999), Pivotal Response Treatment (Koegel & Koegel, 2006; Koegel et al.,
1989; Schreibman & Koegel, 2005), the Early Start Denver Model (ESDM; Dawson et
al., 2012; Dawson et al., 2010; Rogers & Dawson, 2010; Rogers, Dawson, & Vismara,
2012), Enhanced Milieu Teaching (EMT; Kaiser & Hester, 1994), Project ImPACT
(Improving Parents as Communication Teachers; Ingersoll & Wainer, 2013a, 2013b),
and Joint Attention, Symbolic Play, Engagement, and Regulation (JASPER; Kaale,
Fagerland, Martinsen, & Smith, 2014; Kaale, Smith, & Sponheim, 2012; Kasari,
Gulsrud, Wong, Kwon, & Locke, 2010; Kasari, Kaiser, et al., 2014; Kasari, Lawton,
et al., 2014; Kasari, Paparella, Freeman, & Jahromi, 2008). Although this list is not
exhaustive, it includes many of the models with the most research, each of which
is discussed in greater detail in Chapter 2. Some of the intervention models are
comprehensive (i.e., they target a broad range of functioning across multiple devel-
opmental domains), whereas others are focused interventions that address specific
areas of behavior or development (e.g., social-communication only). The emphasis
throughout this book, however, is on the commonalities among these NDBI.

COMMON ELEMENTS OF EMPIRICALLY VALIDATED NDBI

As noted previously, all NDBI share common elements that distinguish them from
other forms of intervention (see Schreibman et al., 2015). Thus, when a practitioner
or parent wishes to determine whether a specific intervention qualifies as one of
the NDBI, he or she can look for these common elements (see Box 1.1). (The com-
mon elements are covered in more detail in subsequent sections of this book.)
 Understanding NDBI 11

Ready, Set, Implement!

BOX 1.1: What are the common elements of empirically validated NDBI?
Core Components
• Are based on the well-established principles developed via the science
of ABA
• Use developmentally based intervention strategies and sequences to
guide goal development that is individualized to each child
Common Procedural Elements
• Have an intervention manual or manuals that clearly specify the
procedures of the intervention
• Include procedures for assessing treatment fidelity
• Involve ongoing measurement of progress during treatment
Common Instructional Strategies
• Specify how the environment should be arranged to ensure that the child
must initiate or interact with an adult in order to gain access to desired
materials, favored activities, or familiar routines
• Utilize natural reinforcement and other motivation-enhancing procedures
• Use prompting and prompt fading during acquisition of new skills
• Use balanced turns within teaching routines
• Use modeling
• Utilize adult imitation of the child’s language, play, or body movements
• Work to broaden the attentional focus of the child
• Involve some form of child-initiated teaching episodes

Core Components of NDBI

This section discusses foundational tenets underlying all NDBI, presented along a
continuum of emphasis/degree across NDBI.
• All evidence-based NDBI are based on the well-established principles devel-
oped via the science of ABA.
As might be expected from ABA-based strategies, NDBI all involve the three-
part contingency of antecedent → behavior (response) → consequence, which
helps the child understand when to respond and ensures that the intervention
provides feedback to the child. Although more recent strategies for ASD inter-
vention, such as NDBI, differ in various forms from earlier behavioral inter-
ventions, the basic tenets of NDBI are the same as those of their original ABA
roots. For example, Skinner’s (1953) work on motivation and Stokes and Baer’s
(1977) seminal work on enhancing generalization of intervention effects are
well represented in NDBI strategies. Skinner described the contingent applica-
tion of rewarding events as seminal to the process of acquiring new behaviors.
12 Overview

Motivation to respond is enhanced when rewarding events can be anticipated.

NDBI utilize strategies that promise these rewards (reinforcers) for responding
and thus increase the child’s motivation to respond. Stokes and Baer (1977) de-
scribed how generalization of acquired behaviors may be enhanced by utiliz-
ing a specific set of teaching strategies. To illustrate, a generalization-enhancing
strategy is to use multiple examples of materials during training. Thus, when
teaching a child the concept of a car, the teacher would utilize cars of various
colors, shapes, and sizes to ensure the child learns the general concept of car
instead of learning car means a red object of medium size on a specific table.
NDBI employ strategies to ensure that the child’s teaching environment con-
tains a variety of stimuli.
• Having a base in developmental science, NDBI use developmentally based
intervention strategies and sequences to guide goal development that is indi-
vidualized to each child.
Some NDBI are associated with a specific developmental assessment and cur-
riculum (e.g., ESDM; Rogers & Dawson, 2010). In almost all NDBI, goals are
developed with the use of standardized assessment, observation, and develop-
mental checklists, which serve to guide the clinician in determining individu-
alized treatment targets across behavior domains. Strategies for assessment
and goal development are outlined in detail in later chapters.

Common Procedural Elements

Common procedural elements are procedures that consistently accompany use of
NDBI and should be incorporated throughout implementation of the intervention
approaches. Those elements are as follows:
• NDBI have an intervention manual or manuals that clearly specify the proce-
dures of the intervention.
Research has shown that accurate implementation of an intervention requires
adherence to clearly stated procedures (Durlak & DuPre, 2008; Fixsen, Naoom,
Blasé, Friedman, & Wallace, 2005; Greenberg, Domitrovich, Graczyk, & Zins,
2005). Manualization helps with consistency of implementation and with train-
ing of treatment providers (e.g., clinicians, parents). Some manuals for NDBI
are published and thus readily available to the public, whereas others are
available primarily in research settings. Of course, clearly described proce-
dures and manualization of intervention are important in ensuring accuracy
of implementation, but manuals alone are unlikely to lead to proficiency. Addi-
tional training, including coaching and feedback, will be required (Bush, 1984;
Cornett & Knight, 2009).
• NDBI include procedures for treatment fidelity.
Treatment fidelity refers to the degree to which an intervention is being applied
correctly, as it was designed (i.e., Gresham, 1989; Rabin, Brownson, Haire-Joshu,
Kreuter, & Weaver, 2008; Schoenwald et al., 2011). That is, it indicates that treat-
ment providers are implementing NDBI accurately. This is essential because the
evidence base shows that the intervention is effective when implemented ac-
cording to the manual, but it is unknown how effective the intervention might
 Understanding NDBI 13

be if it is not accurately applied. Thus, the accuracy of treatment implementa-

tion is likely a mediating factor in child outcome, with better outcome likely as-
sociated with more accurate treatment implementation (Durlak & DuPre, 2008;
Gresham, MacMillan, Beebe-Frankenberger, & Bocian, 2000; Stahmer & Gist,
2001). NDBI provide specific assessment procedures and mastery criteria to
allow trainers to assess the level of implementation accuracy by practitioners.
• Ongoing measurement of progress during treatment is an essential feature of
good treatment and thus a feature of all NDBI.
Effective practice must be systematically and objectively verified through ap-
propriate data collection (Simpson, 2005a, 2005b). Data must be collected to track
child progress not only to ensure overall treatment effectiveness but also to
allow for alterations in treatment procedures or treatment targets if necessary.
Although all NDBI have specified procedures for tracking treatment progress,
different NDBI emphasize different methods appropriate for their intervention.
Data collection methods may include trial-by-trial recording of child responses
to each learning opportunity, interval recording of progress during a treatment
session, probes of specific behavior, or the use of curriculum-based assess-
ments to examine progress at specific time periods (e.g., monthly, quarterly).
Data collection is an essential feature of any intervention based on ABA and
should be linked to the child’s treatment goals. If necessary, it should be used
to alter intervention to better serve the child’s needs.

Common Instructional Strategies

Although NDBI vary in terminology and emphasis on each of these strategies, all
NDBI share common instructional strategies that comprise the intervention ap-
plication itself. These strategies are the individual component parts that make up
the interventions.
• NDBI specify how the environment should be arranged to ensure that the
child must initiate or interact with an adult in order to gain access to desired
materials, favored activities, or familiar routines.
Environmental arrangement refers to how the adult structures the environ-
ment to facilitate and encourage child initiation of skills and learning of new
target skills. Preferred materials may be visible but placed out of reach to en-
courage the child to initiate a request for the material (e.g., incidental teaching);
in other interventions, a variety of toys or activities are placed in a room and the
child is asked what he or she wants (e.g., PRT). Other types of environmental
arrangement 1) control access to materials until the child initiates; 2) playfully
obstruct where the child initiates to continue the activity; 3) introduce materials
that require assistance so that the child must interact with the adult; 4) create ex-
pectant waiting, in which the adult looks at the child and waits for an initiative
response; or 5) violate a routine, in which the adult changes a familiar sequence
of events so that the child must correct the sequence. Some NDBI are quite
specific on methods to structure the environment to promote child initiation,
whereas others are less specific, dictating that the adult simply must gain the
child’s attention while controlling toy access. Adults do not need to arrange the
child’s environment in specific ways in NDBI. The variety of ways to promote
14 Overview

interaction with the child can be used extensively in the child’s natural environ-
ment. Thus, if the child is playing in a community park where different objects
are present, the treatment provider can use NDBI to promote initiation and in-
teraction, allowing all of the child’s environments to be potentially therapeutic.
• NDBI utilize natural reinforcement and other motivation-enhancing procedures.
NDBI give the child a good deal of control over a teaching episode, and the child’s
choice of stimuli or activities allows for the use of natural reinforcement as a
consequence. Reinforcement refers to the strengthening of a behavior and mak-
ing that behavior more likely to occur, as a result of what happens immediately
following that behavior. A natural reinforcer is one that is directly related to the
child’s response. For example, if the child wishes to play with a car, access to the
car would be contingent on a related response from the child, such as saying
“car.” This is in contrast to an indirect or unrelated reinforcer, which is not re-
lated to the response. The previous example would exhibit an indirect reinforcer
if the child says “car” and the adult reinforces the child with a piece of candy.
Candy and saying “car” are not related, whereas saying “car” and gaining access
to a car are related. A related motivation-enhancing procedure involves the use
of loose reinforcement contingencies, also referred to as reinforcing attempts
or loose shaping. This strategy involves allowing for more variability around a
correct response such that the child may receive reinforcement for reasonable
attempts to respond correctly. Thus, the child receives reinforcement for trying.
Overall this procedure typically leads to more reinforcement and thus higher
motivation. Different NDBI vary in terms of how closely the child’s response
must be to the target response in order for a reinforcer to be delivered.
Another strategy used to keep the overall reinforcement level, and thus
the child’s motivation, high is interspersal of maintenance tasks. A mainte-
nance task is a skill the child has already mastered (i.e., an easy task). When
teaching a new skill, the adult will expect some maintenance (i.e., easier) tasks
among acquisition (i.e., new, more difficult) tasks. To illustrate, a child is learn-
ing to say the phrase “I want the ball” (i.e., acquisition task). It is new, so it may
be challenging at times. To increase the child’s motivation while decreasing
frustration, the adult would intersperse trials where the child is asked only
to label the ball, a skill already mastered (i.e., maintenance task). This practice
also serves to maintain learned skills through presentation of mastered skills
while helping the child acquire more advanced skills. Several NDBI specifi-
cally require this strategy, whereas others achieve this effect via loose shaping
by reinforcing a mastered or maintenance task as an attempt. Some NDBI also
require the use of both procedures (e.g., PRT).
• All NDBI use prompting and prompt fading during acquisition of new skills.
Prompting involves presenting a cue (i.e., visual, verbal, auditory, physical) be-
tween an instruction (also referred to as a discriminative stimulus [SD]) and the
target behavior being taught in order to evoke the desired response and thus
set the context for reinforcement. Prompt stimuli are used to support behaviors
not yet in the child’s repertoire or not yet under the control of the SD so they
can occur and be reinforced. Again, some NDBI are very specific about how
prompts should be used, whereas others are less specific. However, all NDBI
require the systematic use of adult prompts to promote new skills.
 Understanding NDBI 15

• NDBI use balanced turns within teaching routines.

This strategy (also known as turn taking, shared control, or reciprocal interac-
tions) involves back-and-forth exchanges in activities or with objects between
the child and the adult. Such interactions serve to increase and support the
social reciprocity found in many typical social interactions. In addition, this
strategy increases maintenance of social interactions as well as allows the
adult to control access to materials. Because turn taking involves the back-and-
forth structure that has been associated with early learning (Harris & Waugh,
2002), its inclusion in NDBI has intuitive merit. However, despite its inclusion
in NDBI, its empirical validation as an individual component awaits more re-
search. Not all NDBI emphasize turn taking to the same degree. Some require
it as a specific, programmed component of their NDBI, and others emphasize
that turn taking occurs within the context of building longer interactions and
thus is not specifically programmed.
• NDBI use modeling.
In modeling, the adult demonstrates a behavior that follows the child’s focus
of interest and typically demonstrates the target skill the child should per-
form. Modeling is often used as a prompt strategy, specifically by the adult
to evoke and support the child’s imitation of a modeled action or language.
Across NDBI, modeling is used in various ways. Some NDBI use it primarily
as a prompt strategy, and others also incorporate it as a general strategy for
promoting engagement and enhancing the learning environment outside of
specific embedded teaching trials.
• NDBI utilize adult imitation of the child’s language, play, or body movements.
This strategy is used to increase the child’s responsivity to, and imitation of, an
adult, as well as to promote continuation of the interaction. Research indicates
that children with or without ASD respond with increased attentiveness when
being systematically imitated by the adult (Dawson & Adams, 1984; Ingersoll
2010; Ingersoll & Schreibman, 2006). Again, different NDBI place different
emphasis on reciprocal imitation as a specific component strategy, with some
models using this strategy to systematically generate a context for embedding
teaching trials (as in reciprocal imitation training) and others using it as a gen-
eral strategy to enhance engagement and enrich the learning environment.
• NDBI work to broaden the attentional focus of the child.
Early research identified an attentional deficit in many children with ASD,
wherein a child’s behavior might only be affected by a small portion of a com-
pound stimulus (e.g., Lovaas, Schreibman, Koegel, & Rehm, 1971). This atten-
tion phenomenon is called stimulus overselectivity to denote that the level
of selective attention is excessive. For example, one child whose father wore
glasses could not identify his father when the father removed the glasses.
The child used only a very small portion (glasses) of the compound stimulus
(father, made up of many component features) to identify him. It is easy to see
how such restricted stimulus control might interfere with learning. More re-
cent research has shown that overselectivity is highly related to developmental
level and is not specific to ASD (Ploog, 2010; Reed, Stahmer, Suhrheinrich, &
16 Overview

Schreibman, 2013). In many cases, it can be modified (e.g., Koegel & Schreibman,
1977), and teaching with multiple examples seems to be key. Because NDBI
emphasize teaching in natural and varied contexts with a variety of materi-
als, this natural occurrence of multiple examples may likely help broaden, or
normalize, the child’s attentional focus (Dawson et al., 2012; Rieth, Stahmer,
Suhrheinrich, & Schreibman, 2014).
• One of the most critical features of NDBI is that all NDBI involve some form of
child-initiated teaching episodes.
This strategy may be called child choice or following the child’s lead. It seeks
to take advantage of increased motivation by presenting something highly de-
sired to a child or providing an instruction or opportunity to respond within
the context of a child-preferred activity or familiar routine. The child indicates
interest in an object or activity by speaking, pointing to, reaching for, or sponta-
neously engaging in the desired activity, and the clinician provides a teaching
opportunity within the activity. Because the child chooses the object or activity
involved in the teaching interaction, the child’s successful achievement of his or
her goal is the positive consequence for the child’s use of the target skill set up
by the adult. The degree to which the child must initiate a teaching episode var-
ies across NDBI, with some models focusing primarily on child initiations (e.g.,
incidental teaching) and other models balancing child initiations with adult-
initiated teaching episodes (e.g., PRT, Project ImPACT).

CONCLUSION
ASD has historically been the focus of intense interest and intervention strategies.
The development of treatments based on the science of ABA provided the first
successful treatment for ASD. These behavioral interventions initially focused on
a discrete trial model of implementation wherein skills were broken down into
smaller components and taught via a successive series of discrete trials. Although
effective, and indeed a substantial change for ASD intervention, subsequent re-
search identified some important limitations of DTT treatments. In response to
these limitations, behavioral treatments expanded and became more naturalistic.
This included teaching in the child’s everyday environments, teaching skills likely
to be maintained in the child’s everyday environment, and using the child’s moti-
vation. In addition, the ASD field changed as younger children began being diag-
nosed and the importance of developmental science became apparent when early
social and other behavioral deficits became the focus of treatment. Thus, the fields
of behavioral psychology and developmental psychology have joined to inform a
set of interventions called NDBI.
NDBI are composed of a number of specific interventions that include required
components and procedures. Thus, the concept of NDBI provides for parsimony of
distinct intervention models (e.g., PRT, ESDM, JASPER) and allows for a clearer
appreciation and understanding by families, professionals, insurance carriers, and
others. It is essential that researchers and clinicians self-identify their particular
intervention as one of the NDBI. To be identified as such, however, requires that
the intervention has strong empirical support and incorporates the requirements
described in this chapter.
 Understanding NDBI 17

Chapter 2 provides a short overview of NDBI models. Sections II–IV offer

more specifics of NDBI concepts, requirements, and intervention procedures. This
book focuses in detail on how NDBI are implemented and evaluated as treatment
strategies for individuals with ASD and other developmental disabilities.

REFERENCES
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Washington, DC: Author.
Ayllon, T., & Azrin, N. (1968). The token economy: A motivational system for therapy and rehabili-
tation. New York, NY: Appleton Century-Crofts.
Baio, J., Wiggins, L., Christensen, D. L., Maenner, M. J., Daniels, J., Warren, Z., . . . Dowling,
N. F. (2018). Prevalence of autism spectrum disorder among children aged 8 years—
Autism and Developmental Disabilities Monitoring Network, 11 sites, United States, 2014.
Morbidity and Mortality Weekly Report Surveillance Summaries, 67(6), 1–23.
Baker, B. L. & Brightman, A. (2004). Steps to independence: Teaching everyday skills to children
with special needs, Fourth Edition. Baltimore, MD: Paul H. Brookes Publishing Co.
Bush, R. N. (1984). Effective staff development. In Making our schools more effective: Proceedings
of three state conferences. San Francisco, CA: Far West Laboratories.
Carr, E. G., & Durand, V. M. (1985). Reducing behavior problems through functional com-
munication training. Journal of Applied Behavior Analysis, 18, 111–126.
Cicchetti, D. (1989). Developmental psychopathology: Some thoughts on its evolution.
Development and Psychopathology, 1, 1–4
Cornett, J., & Knight, J. (2009). Research on coaching. In J. Knight (Ed.), Coaching: Approaches
and perspectives (pp. 192–216). Thousand Oaks, CA: Corwin Press.
Dawson, G. (2008). Early behavioral intervention, brain plasticity, and the prevention of
autism spectrum disorder. Development and Psychopathology, 20, 775–803.
Dawson, G., & Adams, A. (1984). Imitation and social responsiveness in autistic children.
Journal of Abnormal Child Psychology, 12, 209–225.
Dawson, G., Hill, D., Spencer, A., Galpert, L., & Watson, L. (1990). Affective exchanges
between young autistic children and their mothers. Journal of Abnormal Child Psychology,
18, 335–345.
Dawson, G., Jones, E. J., Merkle, K., Venema, K., Lowy, R., Faja, S., . . . Webb, S. J. (2012). Early
behavioral intervention is associated with normalized brain activity in young children
with autism. Journal of the Academy of Child Adolescent Psychiatry, 51, 1550–1559.
Dawson, G., Meltzoff, A. N., Osterling, J., Rinaldi, J., & Brown, E. (1998). Children with
autism fail to orient to naturally occurring social stimuli. Journal of Autism and Develop-
mental Disorders, 28, 479–485.
Dawson, G., Rogers, S., Munson, J., Smith, M., Winter, J., Greenson, J., . . . Varley, M. S. (2010).
Randomized, controlled trial of an intervention for toddlers with autism: The Early Start
Denver Model. Pediatrics, 125, 17–23.
Delprato, D. J. (2001). Comparisons of discrete-trial and normalized behavioral language
intervention for young children with autism. Journal of Autism and Developmental Disor-
ders, 31, 315–325.
Durlak, J. A., & DuPre, E. P. (2008). Implementation matters: A review of research on the
influence of implementation on program outcomes and the factors affecting the imple-
mentation. American Journal of Community Psychology, 41, 327–350.
Ferster, C. B., & DeMyer, M. K. (1961). The development of performance in autistic children
in an automatically controlled environment. Journal of Chronic Diseases, 13, 312–345.
Ferster, C. B., & DeMyer, M. K. (1962). A method for the experimental analysis of the behavior
of autistic children. American Journal of Orthopsychiatry, 32, 89–98.
Fixsen, D. L., Naoom, S. F., Blasé, K. A., Friedman, R. M., & Wallace, F. (2005). Implementation
research: A synthesis of the literature. Tampa: University of South Florida, Louis de la Parte
Florida Mental Health Institute, The National Implementation Research Network.
Gibson, E. J. (1973). Principles of perceptual learning and development. New York, NY: Appleton-
Century-Crofts.
18 Overview

Greenberg, M. T., Domitrovich, C. E., Graczyk, P. A., & Zins, J. E. (2005). The study of imple-
mentation in school-based preventive interventions: Theory, research, and practice. Pro-
motion of Mental Health and Prevention of Mental and Behavioral Disorder, 3, 1–62.
Gresham, F. M. (1989). Assessment of treatment integrity in school consultation and pre-
referral intervention. School Psychology Review, 18, 37–50.
Gresham, F., MacMillan, D. L., Beebe-Frankenberger, M. B., & Bocian, K. M. (2000). Treat-
ment integrity in learning disabilities intervention research: Do we really know how
treatments are implemented? Learning Disabilities Research and Practice, 15, 198–205.
Harris, A. W., & Waugh, R. M. (2002). Dyadic synchrony: Its structure and function in chil-
dren’s development. Developmental Review, 22, 555–592.
Hart, B. M., & Risley, T. R. (1968). Establishing use of descriptive adjectives in the spontane-
ous speech of disadvantaged preschool children. Journal of Applied Behavior Analysis, 1,
109–120.
Hart, B., & Risley, T. R. (1975). Incidental teaching of language in preschool. Journal of Applied
Behavior Analysis, 8, 411–420.
Ingersoll, B. (2010). Brief report: Pilot randomized controlled trial of reciprocal imitation
training for teaching elicited and spontaneous imitation to children with autism. Journal
of Autism and Developmental Disorders, 40, 1154–1160.
Ingersoll, B., & Schreibman, L. (2006). Teaching reciprocal imitation skills to young children
with autism using a naturalistic behavioral approach: Effects on language, pretend play,
and joint attention. Journal of Autism and Developmental Disorders, 36, 487–505.
Ingersoll, B., & Wainer, A. (2013a). Initial efficacy of Project ImPACT: A parent-mediated
social communication intervention for young children with ASD. Journal of Autism and
Developmental Disorders, 43, 2943–2952.
Ingersoll, B., & Wainer, A. (2013b). Pilot study of a school-based parent training program for
preschoolers with ASD. Autism—International Journal of Research and Practice, 17, 434–448.
Iwata, B. A., Dorsey, M. E, Slifer, K. J., Bauman, K. E., & Richman, G. S. (1982). Toward a func-
tional analysis of self-injury. Analysis and Intervention in Developmental Disabilities, 2, 3–20.
Kaale, A., Fagerland, M. W., Martinsen, E. W., & Smith, L. (2014). Preschool-based social
communication treatment for children with autism: 12-month follow-up of a randomized
trial. Journal of the American Academy of Child and Adolescent Psychiatry, 53, 188–198.
Kaale, A., Smith, L., & Sponheim, E. (2012). A randomized controlled trial of preschool
based joint attention intervention for children with autism. Journal of Child Psychology and
Psychiatry, 53, 97–105.
Kaiser, A. P., & Hester, P. P. (1994). Generalized effects of enhanced milieu teaching. Journal
of Speech, Language, and Hearing Research, 37, 1320–1340.
Kanner L. (1943). Autistic disturbances of affective contact. Nervous Child, 2, 217–250.
Kasari, C., Gulsrud, A., Wong, C., Kwon, S., & Locke, J. (2010). Randomized controlled
caregiver mediated joint engagement intervention for toddlers with autism. Journal of
Autism and Developmental Disorders, 40, 1045–1056.
Kasari, C., Kaiser, A., Goods, K., Nietfeld, J., Mathy, P., Landa, R., . . . Almirall, D. (2014).
Communication interventions for minimally verbal children with autism: A sequential
multiple assignment randomized trial. Journal of the American Academy of Child and Adoles-
cent Psychiatry, 53, 635–646.
Kasari, C., Lawton, K., Shih, W., Landa, R., Lord, C., Orlich, F., . . . Senturk, D. (2014).
Caregiver-mediated intervention for low-resourced preschoolers with autism: An RCT.
Pediatrics, 134, e72–e79.
Kasari, C., Paparella, T., Freeman, S. N., & Jahromi, L. (2008). Language outcome in autism:
Randomized comparison of joint attention and play interventions. Journal of Consulting
and Clinical Psychology, 76, 125–137.
Knudsen, E. I. (2004). Sensitive periods in the development of the brain and behavior. Journal
of Cognitive Neuroscience, 16, 1412–1425.
Koegel, R. L., Firestone, P. B., Kramme, K. W., & Dunlap, G. (1974). Increasing spontaneous
play by suppressing self-stimulation in autistic children. Journal of Applied Behavior
Analysis, 7, 521–528.
Koegel, R. L., & Koegel, L. K. (2006). Pivotal response treatments for autism: Communication,
social & academic development. Baltimore, MD: Paul H. Brookes Publishing Co.
 Understanding NDBI 19

Koegel, R. L., & Schreibman, L. (1977). Teaching autistic children to respond to simultane-
ous multiple cues. Journal of Experimental Child Psychology, 24, 299–311.
Koegel, R. L., Schreibman, L., Good, A. B., Cerniglia, L., Murphy, C., & Koegel, L. K. (1989).
How to teach pivotal behaviors to autistic children. Santa Barbara: University of California.
Kuhl, P. K. (2007). Is speech learning “gated” by the social brain? Developmental Science, 10,
110–120.
Lifter, K., Sulzer-Azaroff, B., Anderson, S. R., & Cowdery, G. E. (1993). Teaching play activi-
ties to preschool children with disabilities: The importance of developmental consider-
ations. Journal of Early Intervention, 17, 139–159.
Lovaas, O. I. (1987). Behavioral treatment and normal educational and intellectual function-
ing in young autistic children. Journal of Consulting and Clinical Psychology, 55, 3–9.
Lovaas, O. I. (2002). Teaching individuals with developmental delays: Basic teaching techniques.
Austin, TX: PRO-ED.
Lovaas, O. I., Berberich, J. P., Perloff, B. F., & Schaeffer, B. (1966). Acquisition of imitative
speech in schizophrenic children. Science, 151, 705–707.
Lovaas, O. I., Schreibman, L., Koegel, R. L., & Rehm, R. (1971). Selective responding by autis-
tic children to multiple sensory input. Journal of Abnormal Psychology, 77, 211–222.
McGee, G. G., Krantz, P. J., & McClannahan, L. E. (1986). An extension of incidental teaching
to reading instruction for autistic children. Journal of Applied Behavior Analysis, 19, 147–157.
McGee, G. G., & McCoy, J. F. (1981). Training procedures for acquisition and retention of
reading in retarded youth. Applied Research in Mental Retardation, 2, 263–276.
McGee, G. G., Morrier, M. J., & Daly, T. (1999). An incidental teaching approach to early
intervention for toddlers with autism. Journal of the Association for Persons with Severe Hand-
icaps, 24, 133–146.
Mundy, P., Sigman, M., & Kasari, C. (1990). A longitudinal study of joint attention and lan-
guage development in autistic children. Journal of Autism and Developmental Disorders, 20,
115–128.
Mundy, P., Sigman, M., Ungerer, J., & Sherman, T. (1986). Defining the social deficits of
autism: The contribution of non-verbal communication measures. Journal of Child Psychol-
ogy and Psychiatry and Allied Disciplines, 27, 657–669.
Ploog, B. O. (2010). Stimulus overselectivity four decades later: A review of the literature and
its implications for current research in autism spectrum disorder. Journal of Autism and
Developmental Disorders, 40, 1332–1349.
Prizant, B., Wetherby, A., Rubin, E., & Laurent, A. (2003). The SCERTS Model: A transactional,
family-centered approach to enhancing communication and socioemotional abilities of
children with autism spectrum disorder. Infants & Young Children, 16, 296–316.
Rabin, B. A., Brownson, R. C., Haire-Joshu, D., Kreuter, M. W., & Weaver, N. L. (2008). A
glossary for dissemination and implementation research in health. Journal of Public Health
Management Practice, 14, 117–123.
Ragland, E. U., Kerr, M. M., & Strain, P. S. (1978). Behavior of withdrawn autistic children:
Effects of peer social interactions. Behavior Modification, 2, 565–578.
Reed, S. R., Stahmer, A. C., Suhrheinrich, J., & Schreibman, L. (2013). Stimulus overselec-
tivity in typical development: Implications for teaching children with autism. Journal of
Autism and Developmental Disorders, 43, 1249–1257.
Rieth, S. R., Stahmer, A. C., Suhrheinrich, J., & Schreibman, L. (2014). Examining of the
prevalence of stimulus overselectivity in children with ASD. Journal of Applied Behavior
Analysis, 48, 71–84.
Risley, T., & Wolf, M. (1967). Establishing functional speech in echolalic children. Behaviour
Research and Therapy, 5, 71–88.
Rogers, S. J., Bennetto, L., McEvoy, R., & Pennington, B. F. (1996). Imitation and pantomime
in high-functioning adolescents with autism spectrum disorders. Child Development, 67,
2060–2073.
Rogers, S. J., & Dawson, G. (2010). Early Start Denver Model for young children with autism:
Promoting language, learning and engagement. New York, NY: Guilford Press.
Rogers, S. J., Dawson, G., & Vismara, L. (2012). An early start for your child with autism:
Using everyday activities to help kids connect, communicate, and learn. New York, NY: Guilford
Press.
20 Overview

Rogers, S. J., & DiLalla, D. (1991). A comparative study of the effects of a developmentally
based preschool curriculum on young children with autism and young children with
other disorders of behavior and development. Topics in Early Childhood Special Education,
11, 29–47.
Saffran, J. R., Aslin, R. N., & Newport, E. L. (1996). Statistical learning by 8-month-old
infants. Science, 274, 1926–1928.
Schoenwald, S. K., Garland, A. F., Chapman, J. E., Frazier, S. L., Sheidow, A. J., & Southam-
Gerow, M. A. (2011). Toward the effective and efficient measurement of implementation
fidelity. Administration and Policy in Mental Health and Mental Health Services Research, 38,
32–43.
Schreibman, L. (2005). The science and fiction of autism. Cambridge, MA: Harvard University
Press.
Schreibman, L., & Carr, E. G. (1978). Elimination of echolalic responding to questions
through the training of a generalized verbal response. Journal of Applied Behavior Analysis,
11, 453–463.
Schreibman, L., Dawson, G., Stahmer, A. C., Landa, R., Rogers, S. J., McGee, G. C., . . .
Halladay, A. (2015). Naturalistic developmental behavioral interventions: Empirically
validated treatments for autism spectrum disorder. Journal of Autism and Developmental
Disorders, 45, 2411–2428.
Schreibman, L., & Koegel, R. L. (2005). Training for parents of children with autism: Pivotal
responses, generalization, and individualization of interventions. In E. D. Hibbs & P. S.
Jensen (Eds.), Psychosocial treatment for child and adolescent disorders: Empirically based strate-
gies for clinical practice (2nd ed., pp. 605–631). Washington, DC: American Psychological
Association.
Sigman, M. D., Kasari, C., Kwon, J. H., & Yirmiya, N. (1992). Responses to the negative emo-
tions of others by autistic, mentally retarded, and normal children. Child Development, 63,
796–807.
Simpson, R. L. (2005a). Evidence-based practices and students with autism spectrum disor-
ders. Focus on Autism and Other Developmental Disabilities, 20, 140–149.
Simpson, R. L. (2005b). Finding effective intervention and personnel preparation practices
for students with autism spectrum disorders. Exceptional Children, 70, 135–144.
Skinner, B. F. (1953). Science and human behavior. New York, NY: Macmillan.
Spelke, E., Bernier, E. P., & Skerry, A. E. (2013). Core social cognition. In Navigating the
social world: What infants, children, and other species can teach us (pp. 11–16). Oxford, United
Kingdom: Oxford University Press.
Stahmer, A. C. (1999). Using pivotal response training to facilitate appropriate play in chil-
dren with autism spectrum disorders. Child Language Teaching and Therapy, 15, 29–40.
Stahmer, A. C., & Gist, K. (2001). Enhancing parent training through additional support
services. Journal of Positive Behavior Interventions, 3, 75–82.
Stahmer, A. C., & Schreibman, L. (1992). Teaching children with autism appropriate play
in unsupervised environments using a self-management treatment package. Journal of
Applied Behavior Analysis, 25, 447–459.
Stokes, T. F., & Baer, D. M. (1977). An implicit technology of generalization. Journal of Applied
Behavior Analysis, 10, 349–367.
Strain, P. S., Kerr, M. M., & Ragland, E. U. (1979). Effects of peer-mediated social interactions
and prompting/reinforcement procedures on the social behavior of autistic children. Jour-
nal of Autism and Developmental Disorders, 9, 41–54.
Thelen, E., & Smith, L. (1994). A dynamic systems approach to the development of cognition and
action. Boston, MA: MIT Press.
Topál, J., Gergely, G., Miklósi, A., Erdohegyi, A., & Csibra, G. (2008). Infants’ perseverative
search errors are induced by pragmatic misinterpretation. Science, 321, 1831–1834.
Werner, E., Dawson, G., Osterling, J., & Dinno, N. (2000). Brief report: Recognition of autism
spectrum disorder before one year of age: A retrospective study based on home video-
tapes. Journal of Autism and Developmental Disorders, 30, 157–162.
Yirmiya, N., Kasari, C., Sigman, M., & Mundy, P. (1989). Facial expressions of affect in autis-
tic, mentally retarded and normal children. Journal of Child Psychology and Psychiatry and
Allied Disciplines, 30, 725–735.
2
Considering NDBI Models
Mendy B. Minjarez, Yvonne Bruinsma, and Aubyn C. Stahmer

C
hapter 1 clarifies what constitutes Naturalistic Developmental Behavioral
Interventions (NDBI) and provides conceptual history and background.
This chapter presents key NDBI models with a condensed synopsis of
the empirical support and a short overview of the characteristics of each model.
Each included NDBI model meets two criteria: 1) a manual or enough literature
was available to adequately describe the model, and 2) the model itself or its core
components were considered evidence-based practices (Wong et al., 2015) or estab-
lished interventions (National Autism Center, 2015) or they had other strong evi-
dence (e.g., Kasari, Gulsrud, Paparella, Hellemann, & Berry, 2015). This chapter
is not necessarily an exhaustive review of all NDBI models or all models that use
NDBI components; rather, it is a representative sample of models that met the two
criteria. Indeed, there are a number of additional models that use strategies con-
sistent with NDBI; for example, the Social Communication, Emotional Regulation,
and Transactional Support (SCERTS) Model (Prizant, Wetherby, Rubin, Laurent, &
Rydell, 2006; Rubin, Prizant, Laurent, & Wetherby, 2013); Developmentally Appro-
priate Treatment for Autism (Project DATA; Sandall et al., 2011; Schwartz, Ashmun,
McBride, Scott, & Sandall, 2017; Schwartz, Thomas, McBride, & Sandall, 2013);
Social ABCs (Brian, Smith, Zwaigenbaum, Roberts, & Bryson, 2016; Brian, Smith,
Zwaigenbaum, & Bryson, 2017); and Learning Experiences: An Alternative Pro-
gram for Preschoolers and Parents (LEAP; Strain & Bovey, 2011; Strain & Hoyson,
2000). The example models included here are presented in alphabetical order.

EARLY START DENVER MODEL

A key NBDI model meeting the criteria is the Early Start Denver Model (ESDM).
ESDM is a comprehensive treatment model for children with autism spectrum dis-
order (ASD) younger than age 5 and their families. Developed in the 1980s, the

21
22 Overview

original Denver model (Rogers, Herbison, Lewis, Pantone, & Reis, 1986) continues
to shape the current model in several important ways. These include the multi-
disciplinary team approach, the use of sensory social routines, the involvement
of parents as stakeholders, and the use of a developmental curriculum to identify
skill deficits. The Denver model also includes the idea of interpersonal develop-
ment in ASD (Rogers & Pennington, 1991), which describes the ASD skill deficits
in a developmental framework and emphasizes the lack of affective sharing and
imitation in children with ASD. Some of the same theories inform the social moti-
vation hypothesis of ASD (Dawson et al., 2004; Dawson et al., 2002), which is also
important to ESDM. This hypothesis suggests that the social reward system in the
brain is compromised, resulting in children with ASD receiving limited reinforce-
ment from social engagement. The focus on this idea leads ESDM to specifically
target social engagement and motivation and to continually increase the salience
of social rewards within interactions. These ideas were integrated with the science
of learning via the incorporation of Pivotal Response Treatment (PRT; e.g., Koegel
et al., 1999). PRT principles, discussed in greater detail later in the chapter, support
initiative, spontaneity, and social motivation through an emphasis on natural rein-
forcers within social interactions. The resulting NDBI model was coined the ESDM
in recognition of the extension of the work down to toddler-age children.

Empirical Support
The ESDM is supported by a number of empirical studies that demonstrate efficacy.
In 2010, Dawson and colleagues conducted a randomized controlled trial, which
provided the most methodologically rigorous support of ESDM. This study fol-
lowed 48 toddlers (age range 10–30 months at intake) over 2 years. The children
were randomly assigned to the intervention or control group. Families received
training and delivered 5 or more hours of intervention per week. In addition, each
child in the ESDM treatment group received 20 hours of ESDM from a clinician.
Data from this study indicated that children in the treatment condition demon-
strated significant gains in IQ score, adaptive behavior, and communication skills
and experienced reductions in ASD symptoms. These treatment gains were also
correlated with more normalized electroencephalogram (EEG) activity (Dawson
et al., 2012), suggesting that ESDM did in fact change neural pathways in ways
that affected social attention and engagement. Furthermore, data from a follow-up
study assessing the same groups of children 2 years post treatment suggested that
the ESDM treatment group not only maintained initial treatment gains in multiple
domains of functioning but also improved core ASD symptoms (Estes et al., 2015).
This finding is especially interesting because the ESDM treatment group did not
demonstrate reduced core ASD symptoms immediately following treatment, thus
indicating a possible long-term benefit to this type of early intervention.
A number of additional studies reported strong outcomes for ESDM as a parent-
mediated intervention. These include outcomes for a short-term, low-intensity parent
education program for toddlers (Rogers et al., 2012) and infants (Rogers et al., 2014),
outcomes of ESDM implementation in a child care setting (Vivanti et al., 2014), and
outcomes following an intensive 4-day workshop in ESDM for community practitio-
ners (Vismara, Young, & Rogers, 2013). Please see Ryberg (2015) for a comprehensive
review and discussion of research related to the ESDM model.
 Considering NDBI Models 23

Core Components
As outlined previously, ESDM is a multidisciplinary intervention that draws strate-
gies and frameworks from multiple models. The core teaching strategies are a com-
bination of general Applied Behavior Analysis (ABA), PRT, and the original Denver
model. These strategies complement each other because they address different facets
of a comprehensive model. ABA teaching strategies include using the antecedent-
behavior-consequence (A-B-C) format for teaching, prompting, shaping, and chain-
ing. Challenging behaviors that do not decrease as communication increases are
addressed using functional behavioral assessment and teaching replacement
behaviors. PRT techniques address the social motivation component by reinforcing
attempts, alternating easy and difficult tasks (i.e., interspersal of maintenance and
acquisition tasks), using natural reinforcers, using turn taking, using clear prompts,
incorporating child-selected activities, and following the child’s lead. Teaching strat-
egies from the original Denver model add the relationship component, focusing on
affective sharing and relationship building. These strategies include adults provid-
ing sensitive and responsive interaction; using positive affect; and regulating and
optimizing the child’s readiness for learning in terms of affect, attention, and arousal.
Teaching is conducted within joint activity routines that include following
a child into an activity, setting up a theme or action with the child, varying the
theme, and finally, closing the activity together (e.g., putting away the toys) and
making the transition to a new one. In addition, the interdisciplinary focus leads to
incorporation of specific communication teaching strategies, often used by licensed
speech and language therapists. These strategies include providing many and var-
ied language and play opportunities and supporting transitions. Teaching goals
are derived from the ESDM curriculum tool, which guides the developmentally
appropriate content of the intervention.

Relationship to Other NDBI

The ESDM is an excellent example of a comprehensive treatment model that truly
balances the behavioral and developmental principles that are the hallmark of
NDBI. The ESDM has published a manual, and highly qualified trainers provide
ongoing workshops to promote high-quality community implementation as much
as possible. It has methods for measuring treatment fidelity, as well as parent
coaching methods, and includes methods for collecting ongoing data to evaluate
and monitor child progress. In addition, a curriculum checklist is used to identify
developmentally appropriate goals across areas of development. It uses all of the
teaching strategies identified as central to NDBI models.

ENHANCED MILIEU TEACHING

Initially developed as an intervention program for young children with intellectual
disability and language delays (Hancock & Kaiser, 2006; Kaiser, Hancock, & Trent,
2007), Enhanced Milieu Teaching (EMT) has also been applied extensively to children
with ASD who are preverbal (Kasari, Kaiser, et al., 2014) or have some foundational
language skills (Hancock & Kaiser, 2002; Kaiser & Robert, 2013). Like other NDBI,
EMT is a blended approach that combines strategies from ABA (incidental teach-
ing [IT], natural language paradigm, and milieu teaching; Hancock & Kaiser, 2012)
24 Overview

with developmentally based strategies such as responsiveness, modeling, and

expansions (Kaiser & Hampton, 2017). It has been described in the literature as a
contemporary ABA model (Corsello, 2005; Ogletree, Oren, & Fischer, 2007; Prizant,
Wetherby, & Rydell, 2000) as well as a developmental pragmatic communication
approach (Hancock & Kaiser, 2012).
EMT strategies are infused into daily routines, including play and daily liv-
ing sequences, with a special focus on teaching the child to initiate communica-
tion and play skills. EMT can be implemented by therapists (Hancock & Kaiser,
2002), parents (Kaiser, Hancock, & Nietfeld, 2000; Roberts & Kaiser, 2012; Wright &
Kaiser, 2016), and educators (Kaiser & Hester, 1994) in a range of settings, includ-
ing classrooms (Kaiser & Hester, 1994). Although the intervention may be less
intensive compared to traditional ASD treatment programs, the parent education
emphasis ensures a high number of overall treatment hours and provides par-
ents with skills that they can continue to implement over time. EMT research has
explored a combination of interventions by therapists and parents at the same time
(Kaiser & Roberts, 2013; Roberts & Kaiser, 2012, 2015). This approach was the result
of research suggesting that, although the use of trained therapists resulted in faster
language acquisition for some children, parent implementation of EMT resulted
in better generalization to the home environment (Kaiser et al., 2000). In general,
communication interventions implemented by therapists and parents show the
largest effects on spoken language (Hampton & Kaiser, 2016).

Empirical Support
A substantial body of literature suggests strong evidence for the effectiveness of EMT
with a variety of providers, populations, ages, and skill levels (Hampton, Kaiser, &
Roberts, 2017; Hancock & Kaiser, 2006, 2012; Kaiser, Hancock, et al., 2007; Kaiser &
Roberts, 2013; Kaiser, Scherer, Frey, & Roberts, 2017; Roberts & Kaiser, 2015; Wright
& Kaiser, 2016). In addition, several studies have demonstrated that skills acquired
during EMT generalize to other settings and communicative partners (Hancock
& Kaiser, 2002; Kaiser et al., 2000; Kaiser & Roberts, 2013). Research also supports
reductions in problem behaviors associated with communication gains in the con-
text of EMT intervention for preschoolers (Curtis, Roberts, Estabrook, & Kaiser, 2017;
Hancock, Kaiser, & Delaney, 2002). EMT has also been combined with Joint Attention,
Symbolic Play, Engagement, and Regulation (JASPER) and speech-generating devices
(Almirall et al., 2016; Kasari et al., 2014; Olive et al., 2007) to specifically support the
development of joint attention, communication, and play skills of children who are
preverbal. In addition, specific EMT components enjoy strong empirical support from
a variety of sources. These include, but are not limited to, following the child’s lead
(e.g., Kern et al., 1998), turn taking (Ingersoll & Dvortcsak, 2010), imitation (Ingersoll
& Dvortcsak, 2010; Rogers, Dawson, & Vismara, 2012), contingent responsiveness (e.g.,
Tamis-LeMonda & Bornstein, 2002), expansions or recasts of child language (e.g.,
Camarata, Nelson, & Camarata, 1994; Cleave, Becker, Curran, Van Horne, & Fey, 2015),
reinforcement, time delays (Halle, Marshall, & Spradlin, 1979), and prompting.

Core Components
EMT consists of four components: environmental arrangements, responsive inter-
action, specific language modeling and expansions, and milieu teaching prompts
 Considering NDBI Models 25

(Hampton & Kaiser, 2016). Environmental arrangements are ways in which adults
optimize the child’s surroundings to create learning opportunities. Adults may
give children choices between or among play materials that provide opportunities
for interaction and learning. They typically exclude from the environment materi-
als that invite independent play. They preselect materials that can easily be adapted
into routines and use them to establish and then extend play schemes.
Responsive interaction in EMT refers to the ability of the parent or therapist to
connect with the child emotionally. Following the child’s lead, mirroring nonverbal
actions (sometimes referred to as synchronization; Harrist & Waugh, 2002), and
turn taking are examples of responsive interactions that provide the context and
the interaction in which teaching is optimized.
Communication skills are a core focus of EMT. Adults model and expand on
language and use specific prompting to reinforce and shape verbal behavior. They
sometimes use visual supports to assist children with ASD and echolalia. Finally,
EMT takes special care to ensure children can develop independent language and
do not become prompt dependent or prompt resistant (Hancock & Kaiser, 2012).

Relationship to Other NDBI

EMT is a packaged intervention similar to other NDBI, firmly rooted in ABA and
developmental frameworks. EMT is primarily used in the research setting and has
been adequately described in book chapters; however, an instructional manual is
not yet available to the wider public. In an environment optimized for learning,
therapists implementing EMT use reinforcement contingencies, prompting and
fading strategies, and shared control strategies. Therapists model appropriate lan-
guage targets and mirror child actions and behaviors to ensure synchronous inter-
actions and affective engagement. Data are collected throughout the program, both
on child target behaviors and treatment fidelity. Parents learn EMT strategies and
are stakeholders in the treatment.

INCIDENTAL TEACHING/WALDEN TODDLER PROGRAM

The original pioneering work on IT was conducted by Todd Risley and Betty Hart
(Hart & Risley, 1968, 1975). The initial focus of IT was on reducing language delays
in preschoolers from disadvantaged backgrounds and preschoolers who experi-
enced delays (e.g., Hart & Risley, 1975) but was quickly expanded to other skill defi-
cits and populations. Gail McGee and colleagues (McGee, Morrier, & Daly, 1999)
subsequently utilized IT as the foundation for their Walden Toddler Program at
Emory University. We use the Walden Toddler Program to illustrate IT as an NDBI
model because it is a comprehensive and well-described example. However, IT is a
more general group of teaching strategies that is not synonymous with the Walden
Toddler Program only.
The Walden Toddler Program is a full inclusion preschool program for stu-
dents with ASD. Students receive instruction for 4 hours per day. In addition, fami-
lies receive weekly parent training (up to 4 hours) and commit to at least 10 hours per
week of home implementation. At school, IT episodes are interspersed throughout
all activities, and the environment is arranged to optimize the possibility of child
initiations, a core feature of IT. Although IT is often generally described as an inter-
vention focused on the development of verbal communication, the Walden Toddler
26 Overview

Program specifically notes targeting a variety of developmentally appropriate skills

(e.g., toy play, daily living skills, gross motor skills) (McGee et al., 1999). In addition,
like other NDBI, it places a particular emphasis on the social connection between the
child with ASD and others: social responsiveness to adults, social tolerance of peers,
and peer imitation and (parallel) play.

Empirical Support
IT as a general strategy has broad and substantial empirical support, especially in
the improvement of expressive and receptive communication. IT has been success-
fully used to target early language development (Haring, Neetz, Lovinger, & Peck,
1987; McGee et al., 1999), as well as specific language abilities, such as use of adjec-
tives (Hart & Risley, 1968), preposition use (McGee, Krantz, & McClannahan, 1985),
and receptive labeling (McGee, Krantz, Mason, & McClannahan, 1983). IT has also
shown success for increasing spontaneous speech (Charlop-Christy & Carpenter,
2000) and has been used to address social pragmatic skills, such as social phrases
(McGee & Daly, 2007) and child initiations (Ryan, Hemmes, Sturmey, Jacobs, &
Grommet, 2008). Research has also addressed the use of IT to target broader social
behaviors, such as reciprocal interactions with peers (McGee, Almeida, Sulzer-
Azaroff, & Feldman, 1992) and assertiveness (McGee, Krantz, & McClannahan,
1984). Research on IT has also been extended to academic skills, such as sight read-
ing, with good success (McGee, Krantz, & McClannahan, 1986).
The Walden Toddler Program, developed by McGee and colleagues at Emory
University, was originally funded as a model demonstration grant by the U.S.
Department of Education. Although much empirical support exists for IT, only one
study reported empirical support for the Walden Toddler Model specifically. In
this seminal study, 28 children with ASD received an average of 30 hours per week
of IT through a combination of center-based and in-home intervention (McGee
et al., 1999). Prior to starting the Walden Toddler Program, 36% of the participat-
ing children had some form of expressive communication, which was primar-
ily stereotyped. After participating in the Walden Toddler Program, 82% of the
children were functionally using meaningful expressive verbalizations.

Core Components
The Walden Toddler Program has a number of core principles that drive decision
making in the design and implementation of intervention. These principles are
aligned with best practices in intervention for children with ASD and are shared
with other NDBI. Some examples include focus on parent involvement, inclusion
with typically developing peers, and use of specific strategies to increase child
motivation and engagement (McGee et al., 1999). In addition, the Walden Toddler
Model developed a distinctive curriculum with input from professionals from a
variety of disciplines. Another unique component to this program is the organiza-
tion of the preschool classroom into specific teaching zones that are conducive to
ongoing learning related to specific sets of goals per zone. Teachers are deployed
by zone and ensure opportunities for learning are presented when the child shows
interest. In addition to this initiation-based learning, children receive short bursts
of more intensive one-on-one teaching, thus ensuring enough trials are completed
to maintain intervention intensity.
 Considering NDBI Models 27

The Walden Toddler Program employs core IT strategies that focus on reme-
diating the lack of initiations in children with ASD. During all teachable moments,
IT specifies the following steps: 1) the adult establishes the environmental arrange-
ment, 2) the adult waits for the child to initiate engagement for the teachable
moment, 3) the adult prompts the response if necessary, 4) the adult reinforces
the child’s correct response with access to the desired item or activity, and 5) the
adult fades the prompting level or support as the child gains mastery. McGee and
colleagues referred to these steps as “wait-ask-say-show-do.” In addition, IT incor-
porates a variety of ABA teaching strategies, some of which were mentioned pre-
viously, including the use of natural reinforcement, errorless learning, shaping,
prompting sequences, and modeling.

Relationship to Other NDBI

Consistent with other NDBI models, IT is firmly rooted in the principles of ABA
while delivering intervention in the natural environment using a developmental
framework. The Walden Toddler Model has been replicated several times, but a
published instructional manual is not yet available, hindering broader implemen-
tation. IT models, such as the Walden Toddler Model, utilize data for ongoing clini-
cal evaluation, have methods for assessing treatment integrity, and use most of
the NDBI teaching strategies, with somewhat more focus on behavioral strategies.
IT was one of the earliest interventions to emerge with a focus on enhancing moti-
vation and skill generalization through teaching in the natural environment using
natural reinforcers. The most unique feature of IT in comparison to its fellow NDBI
models is its emphasis on child-initiated teaching interactions.

JOINT ATTENTION, SYMBOLIC

PLAY, ENGAGEMENT, AND REGULATION
JASPER is a targeted social-communication intervention for very young chil-
dren with ASD and older prelinguistic individuals with ASD (Kasrai, Freeman,
& Paparella, 2006; Kasari, Paparella, Freeman, & Jahromi, 2008). Developed by
Connie Kasari at the University of California, Los Angeles, JASPER is likely the
NDBI model most firmly rooted in developmental strategies. JASPER focuses par-
ticularly on the foundations of social-communication, especially joint attention
and play (Kasari et al., 2008). JASPER targets increasing all social-communication
behaviors but especially the spontaneous use of joint attention initiation (e.g., co-
ordinated joint looking, showing and giving objects to share interest, and point-
ing to show or request). It utilizes toy play not only as a context for teaching but
also as an important intervention goal. In addition, JASPER highlights the need for
regulation as an important prerequisite for learning. JASPER uses a combination
of active strategies to promote engagement (e.g., imitating and modeling language,
play and affect) and matches the child’s skill level and frequency of communica-
tion behaviors, strategies that leave room for child spontaneous initiation of social,
communication, and play behaviors.

Empirical Support
A series of randomized controlled trials have emerged in the literature support-
ing the use of JASPER with very young children with ASD (Kasari et al., 2006;
28 Overview

Kasari et al., 2005; Kasari, Gulsrud, Wong, Kwon, & Locke, 2010). To date, empirical
evidence supports that JASPER is useful for teaching joint attention, symbolic play,
language, and engagement to children ranging from 12 months to 8 years of age
(Kasari et al., 2006; Kasari et al., 2015; Kasari, Kaiser, et al., 2014). Its application ex-
tends beyond clinicians, to parents, teachers, paraprofessionals, and other primary
caregivers (Gulsrud, Hellemann, Shire, & Kasari, 2015; Kasari et al., 2010).
Randomized controlled trials of JASPER have demonstrated its effects across
several areas of development. For example, in an early randomized controlled trial,
Kasari, Freeman, and Paparella (2006) demonstrated that children who received a
joint attention–focused intervention had significant increases in showing behaviors,
initiation, and response to joint attention compared to controls and that children
who received a symbolic play intervention had more diverse symbolic play and
higher play levels than controls. These findings have been replicated (Kasari et al.,
2010) and also extended to demonstrate increases in expressive language skills fol-
lowing joint attention and symbolic play interventions (Kasari et al., 2008). JASPER
has also used speech-generating devices in conjunction with other treatments, such
as EMT to target communication skills in minimally verbal children with ASD
(Kasari et al., 2014). These findings support the use of this combination of interven-
tions with older children (ages 5–8 years) who are minimally verbal because partici-
pants gained spontaneous communicative utterances, novel words, and comments.
Several studies have also examined the effectiveness of teaching caregiv-
ers to implement JASPER with good success (Kasari et al., 2015), including with
families who were considered “low-resourced,” such as those living in poverty
(Kasari, Lawton, et al., 2014). Another study evaluated implementation of JASPER
in a preschool program and demonstrated that play diversity improved and also
generalized from the treatment setting to the classroom (Goods, Ishijimi, Chang, &
Kasari, 2013). These studies suggest strong potential for successful dissemination
of JASPER to settings and populations that have been traditionally harder to reach,
such as classroom settings and families who are low-resourced.

Core Components
JASPER places a primary emphasis on remediating the foundational social-
communicative behaviors that are absent or severely compromised in children
with ASD. To accomplish this, JASPER focuses on four interrelated core compo-
nents: 1) joint attention, 2) symbolic play, 3) engagement, and 4) regulation (Kasari
et al., 2015).
Joint attention (i.e., the coordination of attention between objects and people
for purposes of sharing) can manifest in many ways (e.g., coordinating eye contact
between a person and object, pointing to share, commenting; Kasari et al., 2010;
Kasari et al., 2008). The techniques of JASPER not only emphasize bids of joint
attention through modeling but also directly teach children how to demonstrate
joint attention behaviors during play routines. Consistent with research in neu-
rotypical children, as children with ASD learn to engage in joint attention, their
engagement, communication, and learning improve (Charman et al., 2005; Mundy,
Sigman, & Kasari, 1990).
In terms of symbolic play, JASPER emphasizes improving the diversity and
complexity of each child’s play abilities, using functional play to build up to
symbolic exchanges. The play aspect of JASPER is formulaic. Although it may
 Considering NDBI Models 29

appear like simple play on the surface, the intervention taking place to target
play includes a range of complex strategies and targets. Although the main focus
in the intervention is object play, sometimes play without toys is recommended.
Described as person-engaged play, this skill can be targeted with children who
lack object play skills and can also be alternated with object play to provide peri-
ods of less demanding play that can be alternated with more difficult toy play. The
focus on play has a twofold purpose in the JASPER model. The intervention targets
play as the venue for learning socialization and language, but it also targets teach-
ing play skills.
Language and verbal communication goals are not targeted with the same inten-
sity and core focus in JASPER as they are in other NDBI models; however, language
is nonetheless directly and indirectly targeted during play interactions. Techniques
used to scaffold language development in JASPER include the adult responding to
all of the child’s functional communication attempts, the adult modeling language at
the child’s level plus one step above (similar to ESDM), and the adult providing some
direct prompting for language, although this is used sparingly. Language goals are
typically focused on requesting and use of language for joint attention.
JASPER targets engagement by using scaffolding to help the child move from
inattentive and/or solitary focus on objects to states of sustained joint engagement
with others. Related to this is regulation, which emphasizes techniques to reduce
self-stimulatory behaviors that interfere with the direct development of the other
three core components.
Indispensable to JASPER is the inclusion of caregiver training (e.g., parents,
teachers) to ensure generalization and maintenance. The key caregivers or inter-
ventionists implementing JASPER must learn how to effectively use environmental
arrangements to promote engagement, effectively use modeling and imitation, and
expand language and play behaviors.
Basic elements of each intervention session include adults 1) adjusting the
environment (i.e., activities, routines, toy choices) to match the child’s interests
2) responding to the child’s communication bids (all are treated as functional); 3) mod-
eling joint attention, expressive communication, and symbolic play; 3) expanding the
child’s joint attention, language, and play behaviors; 4) pacing adult language and
play behavior to mirror the child’s; and 5) using prompting procedures (using the
least-to-most method) to evoke episodes of joint attention, language, and play. The
therapist uses general strategies common with other NDBI, including environmen-
tal arrangements, following the child’s lead, imitation of the child’s actions on toys
and language, and prompting strategies to scaffold targeted behaviors.
JASPER is promoted as complimentary to other behaviorally based ASD inter-
ventions (e.g., Kasari et al., 2014), as well as easily incorporated into inclusive and
special education classroom settings (e.g., Goods et al., 2013). JASPER also empha-
sizes parent involvement and implementation across daily routines and activities.
Developmentally appropriate toys and activities must be used during intervention
sessions.

Relationship to Other NDBI

Unlike most NDBIs, JASPER does not identify itself as a comprehensive treatment
model but rather a focused intervention specifically designed to improve social-
communication, play, and engagement. In fact, in several studies, it has been used
30 Overview

in conjunction with EMT or discrete trial teaching to enhance learning (e.g., Kasari
et al., 2014). Gains in these areas are not collateral; they are the direct result of
precise intervention implementation. Its evidence base suggests strong support for
teaching joint attention and engagement skills early on because it predicts later
language use. Project ImPACT (discussed later) is one of the few other models that
focuses on specific strategies for teaching joint attention through parent education,
making these two models unique from other NDBI. Finally, the fact that JASPER
has more than 15 years of research and numerous clinical trials validating its treat-
ment effectiveness merits recognition.
JASPER draws on the ABA literature for many of its teaching strategies but
clearly has a developmental focus. For example, JASPER’s building blocks include
child-centered intervention (i.e., following the child’s lead), teaching in the natural
environment with developmentally appropriate toys, natural reinforcement, fam-
ily involvement, and learning opportunities across daily routines and activities.
JASPER uses ongoing data collection to measure child progress and has individu-
alized goals. An internal manual is currently in press for wider dissemination,
which will include treatment fidelity measures.

PIVOTAL RESPONSE TREATMENT

Pivotal Response Treatment (PRT), also called Pivotal Response Training, is
grounded in the same combination of ABA and developmental theory as other
NDBI models. It focuses on embedding behaviorally based, contingent teaching
trials in natural interactions, activities, and routines rather than working in a struc-
tured format, as in discrete trial teaching. In PRT, parents, caregivers, educators,
and therapists learn to embed these teaching trials across as many of the child’s
waking hours as possible. As such, this model emphasizes ongoing embedded
teaching trials, as opposed to targeted therapy sessions. PRT rests on the premise
that certain “pivotal” areas can be targeted that will result in widespread gains in
untargeted areas (Koegel et al., 1999), such as reductions in challenging behavior
(Koegel, Koegel, & Surratt, 1992) and improvements in initiation behaviors (Koegel,
Koegel, Shoshan, & McNerney, 1999). The primary pivotal area is motivation, and
the PRT principles heavily focus on the application of behavioral teaching prin-
ciples while maintaining child motivation. Motivation is often cited as a core deficit
in ASD (Dawson, Webb, & McPartland, 2005; Rogers & Dawson, 2010); therefore,
targeting this area is considered critical in remediating the core deficits and en-
gaging children in meaningful learning opportunities (Rogers & Dawson, 2010).
Other pivotal areas discussed in the literature include broadening attentional
focus through varied cues and teaching materials (Reith, Stahmer, Suhrheinrich, &
Schreibman, 2015; Schreibman & Koegel, 1982, 2005), teaching initiation behaviors,
and learning self-management skills (Genc & Vuran, 2013).
PRT has seven components, which are designed to target motivation and
maintain strong treatment fidelity (e.g., clear prompts, contingent and immedi-
ate reinforcement). PRT places equal emphasis on maintaining motivation and
engagement and embedding teaching trials such that the pace and difficulty level
of teaching are constantly individualized based on a child’s skills and motivation.
In addition, instructional cues and materials are varied to help children broaden
their attention and generalize learning from the outset (Schreibman & Koegel,
1982, 2005). PRT historically has been taught to parents as the primary agents
 Considering NDBI Models 31

of intervention (e.g., Koegel, Bimbela, & Schreibman, 1996); however, alternative

models of PRT have been developed, such as classroom PRT (CPRT; Suhrheinrich,
Stahmer, & Schreibman, 2007). Parent education in PRT is typically conducted dur-
ing sessions with a therapist and parent–child dyad over a number of sessions
that has ranged in the literature from 10 sessions to treatment that is ongoing over
years. Short-term and group models of PRT have also emerged and are gaining
popularity due to their ease of dissemination compared to models that require
more clinician support (e.g., Hardan et al., 2015; Minjarez, Williams, Mercier, &
Hardan, 2011).

Empirical Support
PRT is considered an established intervention (National Autism Center, 2015) and
an evidence-based practice (Wong et al., 2015). Empirical support for PRT has pri-
marily been derived from single-case design studies demonstrating its efficacy
in teaching a range of social, communication, and play behaviors (Cadogan &
McCrimmon, 2015). For example, PRT has been associated with improvements in
question asking (Koegel, Camarata, Valdez-Menchaca, & Koegel, 1998), increased
number and length of utterances (Koegel, Carter, & Koegel, 2003), spontaneous lan-
guage (Koegel et al., 2003), vocabulary, and functional communicative utterances
(Hardan et al., 2015; Minjarez et al., 2011; Symon, 2005). In the social realm, PRT has
demonstrated efficacy in targeting peer interactions (Boudreau, Corkum, Meko, &
Smith, 2015; Koegel, Kuriakose, Singh, & Koegel, 2012), social initiations (Koegel
et al., 1999; Pierce & Schreibman, 1997), conversation skills (Genc & Vuran, 2013),
and engagement. Play skills have also been successfully targeted (e.g., Stahmer,
1995; Stahmer, Ingersoll, & Carter, 2003). PRT also has support as an intervention
for reducing challenging behaviors (Koegel et al., 1992; Koegel, Stiebel, & Koegel,
1998) and repetitive behaviors (Koegel & Koegel, 1990). This is primarily done
through a combination of functional communication training using PRT strategies
and other behavior analytic methods, such as manipulation of antecedents and
extinction.
Various individuals have learned to implement PRT techniques. The majority
of PRT studies have focused on parent education models and have demonstrated
that parents can successfully learn these strategies and have a positive impact
on their child’s treatment goals (Hardan et al., 2015; Koegel et al., 1996; Koegel,
Symon, & Kern Koegel, 2002; Minjarez et al., 2011). Research has also supported that
parents experience positive impact as a result of this training, including improve-
ments in stress and empowerment (e.g., Minjarez et al., 2013). Paraprofessionals,
including those who work in schools and in-home child care providers, have also
been trained successfully (Kim, Koegel, & Koegel, 2017; Koegel, Kim, & Koegel,
2014; Symon, 2005). One study even demonstrated that parents who were trained
by PRT clinicians could then successfully train their own paraprofessionals, such
as child care providers (Symon, 2005).
Classroom PRT has increasing empirical support as well for targeting a range
of social, communication, and academic skills (Stahmer, Suhrheinrich, & Rieth,
2016; Suhrheinrich, 2015; Suhrheinrich, Stahmer, & Schreibman, 2007) by training
teachers to embed PRT strategies in the classroom. Peers have also successfully
learned PRT, primarily to target social-communication and play behaviors, often in
classroom settings (e.g., Harper, Symon, & Frea, 2008; Pierce & Schreibman, 1997).
32 Overview

Brief and group-based models of PRT have also emerged. Several studies have
demonstrated efficacy of short-terms models, including workshops (e.g., Bryson
et al., 2007) and short courses of therapy (e.g., Coolican, Smith, & Bryson, 2010;
Smith et al., 2010). A short-term group model of PRT has also emerged in the lit-
erature, showing efficacy of this model, which was associated with parent acquisi-
tion of PRT skills and meaningful changes in child verbal communication skills
(Gengoux et al., 2015; Hardan et al., 2015; Minjarez et al., 2011).

Core Components
In PRT, the adult providing the intervention is encouraged to embed as many
teaching trials as possible in his or her natural interactions with the child while
also balancing the need to maintain motivation and engagement. A teaching trial
consists of a four-part sequence, in which the adult 1) follows the child’s lead and
gains shared control over the identified reinforcer, 2) gives a cue and/or prompt to
evoke the target behavior, 3) waits until a behavior is evoked, and 4) provides rein-
forcement contingent on the behavior. This sequence follows the typical behavior
analytic A-B-C format.
There are seven core components of PRT, which are primarily behavior ana-
lytic in nature but also focus on enhancing motivation during teaching interactions:
1) child attention and clear prompts, 2) task variation (interspersal of maintenance
and acquisition tasks), 3) following the child’s lead and gaining shared control,
4) immediate and contingent reinforcement, 5) natural reinforcement, 6) reinforc-
ing attempts (i.e., a loose shaping contingency), and 7) broadening children’s atten-
tion through varying the instructional cue and materials used to teach each goal.

Relationship to Other NDBI

As with all NDBI, by definition, PRT combines behavior analytic teaching method-
ology with developmental principles and embeds teaching in the natural context.
PRT balances motivation and engagement with embedding of contingent learning
trials with about equal focus. When using PRT, the adult must constantly gauge the
child’s motivation in order to modify the pacing and difficulty level of demands
being placed. Like other NDBI, motivation and engagement are core areas of focus
and are considered a prerequisite for embedding trials; however, PRT has more
focus on the number of trials and encourages as many trials as possible during the
child’s waking hours. In contrast, some NDBI models have decreased emphasis on
explicit demands and focus more on sustained engagement (e.g., JASPER).

PROJECT ImPACT
Project ImPACT (Improving Parents as Communication Teachers) was developed
by Brooke Ingersoll and Anna Dvortcsak as a short-term parent education program
focused on teaching social-communication to children with ASD. The program
was published in 2010 as a manual and practitioner’s guide and can easily be imple-
mented by most practitioners with a background in ABA and an understanding of
developmental principles (Ingersoll & Dvortcsak, 2010). A parent trainer must meet
treatment fidelity standards, which are clearly described and included in the pub-
lished manual. Parent trainers should be able to use the program’s techniques flu-
ently, as well as be able to provide constructive feedback to a parent in the moment.
 Considering NDBI Models 33

This parent training program is appropriate for children with ASD and social-
communication delays between the ages of 18 months and 6 years. Written by a
speech therapist and a psychologist who is also a Board Certified Behavior Analyst
(BCBA), Project ImPACT is a practical and user-friendly program. The focus on
parents as providers of intervention is well supported by decades of research and
is especially important in terms of sustainability of intervention gains.

Empirical Support
To date, two publications show strong empirical support for this parent educa-
tion program, and many of its components are supported in literature reviews of
targeted behavioral interventions (e.g., Kasari et al., 2006). In a multiple baseline
design study across eight participating dyads, all parents improved in their use
of the techniques during the parent education intervention and met treatment fi-
delity after 6 weeks (Ingersoll & Wainer, 2013a). Sessions in this study were once
per week. In addition, the data showed a significant positive correlation between
parent treatment fidelity and child spontaneous language, suggesting that if the
parent improved in his or her use of the techniques, correlated gains in child spon-
taneous language were observed.
In a more methodologically rigorous study (Stadnick, Stahmer, & Brookman-
Frazee, 2015), researchers compared child and parent outcomes between inter-
vention and control groups for 30 dyads in community settings. Children in the
intervention group showed significantly greater gains in communication when
compared to the control group. In addition, as in the first study, a positive rela-
tionship was found between parent treatment fidelity and improvement in child
communication skills. In contrast, some data suggested that parents with very high
stress levels may not benefit from this intervention as much because their children
progressed less. Findings of this nature require further study to better understand
the nature of these outcomes.
Project ImPACT has also been implemented in preschool settings (Ingersoll &
Wainer, 2013b), where teachers implemented the intervention with parent–child
dyads. Findings demonstrated that parents significantly improved their use of
treatment strategies from pre- to postintervention, and children increased their
rate of language during a home-based parent–child interaction. Both parents and
teachers rated the intervention positively in terms of feasibility and effectiveness,
supporting the use of Project ImPACT in preschool settings. Because teachers con-
ducted the parent training, these findings also support that highly trained NDBI
therapists are not required to implement intervention.
Other methods of training in Project ImPACT have been explored, including
a protocol that uses a combination of web-based instruction, brief workshops, and
remote consultation to teach community providers (Wainer, Pickard, & Ingersoll,
2017). Results from this study demonstrated feasibility of this protocol for dis-
semination of Project ImPACT in community settings. Telehealth has also been
explored as a dissemination strategy (Ingersoll & Berger, 2015; Ingersoll, Wainer,
Berger, Pickard, & Bonter, 2016; Pickard, Wainer, Bailey, & Ingersoll, 2016), with
results indicating that parents showed gains in targeted intervention skills and
children showed correlated gains in social-communication skills. In one study, self-
directed and therapist-directed online modules were randomly assigned to parents
(Ingersoll & Berger, 2015). Although both groups successfully learned the strategies
34 Overview

and reported high levels of satisfaction with treatment, engagement was higher in
the therapist-assisted version, suggesting that parents can benefit from a minimal
amount of clinician support when receiving services via online training modules.
As with several other interventions outlined in this chapter, strong evidence
is readily available for the individual teaching strategies used in Project ImPACT.
Examples of these include following the child’s lead (e.g., Kern et al., 1998), prompt-
ing and reinforcement strategies, environmental arrangements (e.g., McGee et al.,
1999), and a focus on joint attention (e.g., Kasari et al., 2006).

Core Components
Project ImPACT is a short-term parent education program that can be implemented
in an individual or group format. The individual format consists of two weekly
sessions over 12 weeks, or 24 sessions total. The group format alternates between
group sessions (six 2-hour groups) and individual practice sessions (6 hours total).
The program has both child and parent goals. Child goals revolve around four
core child skill deficits: 1) social engagement, 2) language/communication, 3) social
imitation, and 4) play. Parent trainers help parents to identify and select interven-
tion targets and set goals using a brief curriculum checklist. Parents learn specific
teaching strategies that build on each other. The early teaching techniques target
the parent’s active engagement and general responsiveness to the child, for exam-
ple, by following the child’s lead, reading the child’s cues (verbal or nonverbal),
and responding to the child’s behavior as if it were meaningful. The later teaching
techniques include the prompting and reinforcing components that are intention-
ally embedded to teach specific skills. Examples of these include environmental
arrangements, shared control, reinforcement of target behaviors, and communica-
tion temptations to evoke joint attention and verbal behaviors.

Relationship to Other NDBI

Project ImPACT shares many of the same ABA strategies (e.g., environmental ar-
rangements, shared control, natural reinforcement, prompting, turn taking, imi-
tation) and the developmental framework with other NDBI. In fact, the manual
indicates that strategies are drawn from several of the NDBI discussed. In addi-
tion, it has a well-developed manual, including a parent workbook and teaching
material on DVD (Ingersoll & Dvortcsak, 2010). Project ImPACT also meets all of
the other procedural NDBI characteristics in that it uses data collection to evaluate
ongoing progress and has detailed treatment fidelity procedures for both parent
implementation and the parent trainer. Project ImPACT is unique in its singular
focus on parent education. Parent training programs such as these may also be a
cost-effective addition to other NDBI and could certainly function as an early first
step for those children newly diagnosed with ASD.

CONCLUSION
NDBI go by many names or brands, but as the summaries of the models demon-
strate, they share many core characteristics and all rely on the core combination
of ABA and developmental principles. These relationships are also highlighted
in Table 2.1, which summarizes the roles that various treatment components play
in each model. As emphasized in Chapter 1, the NDBI framework is not another
 Table 2.1. Summary of NDBI models and their relationship to the NDBI framework

NDBI common elements IT JASPER PRT EMT ESDM Project ImPACT

Core components

ABA Yes Yes Yes Yes Yes Yes

Developmental theory Implicit Yes Implicit Yes Yes Yes

Common procedural elements

Manualized Not publicly Not publicly Yes Not publicly Yes Yes
available available available
Treatment fidelity Not publicly Not publicly Yes Not publicly Yes Yes
available available available
Ongoing measurement Yes Yes Yes Yes Yes Yes

Instructional strategies

Use of three-part contingency Yes Yes Yes Yes Yes Yes

Arranging the environment Yes Yes Yes Yes Yes Yes
Shared control and natural Yes Yes Yes Yes Yes Yes
reinforcement
Prompting and prompt fading Yes Yes Yes Yes Yes Yes
Balanced turns Yes Yes Yes Yes Yes Yes
Modeling Yes Yes Yes Yes Yes Yes
Imitation of child No Yes No Yes Yes Yes
Broadening of attentional focus Not specifically Yes Yes Not specifically Yes Yes
Use of child initiations Yes Yes Yes Yes Yes Yes

Literature

Manual citation or seminal McGee, Morrier, Kasari, Paparella, Koegel and Kaiser and Rogers and Ingersoll and
article describing the model and Daly (1999) Freeman, and Koegel (2006) Hampton (2017) Dawson (2010) Dvortcsak
Jahromi (2008) (2010)
Key: ABA, Applied Behavior Analysis; ESDM, Early Start Denver Model; JASPER, Joint Attention, Symbolic Play, Engagement, and Regulation; PRT, Pivotal Response Treatment;
IT, Incidental Teaching; EMT, Enhanced Milieu Teaching.

35
36 Overview

rebranding of intervention strategies being used in the treatment of ASD. Rather,

the goal is to cut across brands and propose a set of empirically supported practices
that treatment providers can draw on to develop individualized treatment plans to
target the core deficits in ASD across a broad range of ages. This may be similar to
a “technical eclectic” approach to community treatment (Odom, Hume, Boyd, &
Stabel, 2012), in which evidence-based intervention strategies are selected purpose-
fully for each program. In a technical eclectic approach, teaching strategies should
be empirically supported for targeting specific skills, even if they have not been
studied as a package or a comprehensive treatment model (CTM), and should be
combined to target a range of developmentally appropriate individualized goals.
A set of similar key treatment strategies have been used across different NDBI
brands (e.g., ESDM, EMT, PRT), and it may be helpful to think of NDBI generally
as a technical eclectic approach that focuses on key evidence-based strategies from
principles of ABA and developmental theory. As such, the goal of this book is to
describe and define the active ingredients common to NDBI that can be used to
select both individualized treatment strategies and appropriate child goals.
One challenge of adopting a technical eclectic approach is that manualized
materials for selecting intervention strategies and targets are not readily available,
whereas the individual treatment “brands” (e.g., ESDM) are more well operational-
ized. As such, clinicians may be tempted to adopt brands because they have a road
map to follow, whereas adopting a technical eclectic approach may require draw-
ing on a range of available materials that may require a higher level of expertise
and training. We hope this book will help clinicians develop comprehensive pro-
gramming knowledge based on a range of NDBI strategies rather than just based
on individual brands.
Generally speaking, all NDBI share three overarching guiding principles,
which are highlighted throughout the remaining chapters in this book: 1) teaching
functional skills in the natural environment in developmental order, 2) parents as
key stakeholders, and 3) inclusion in the least restrictive environment with typi-
cally developing peers in the community.
The remainder of this book focuses on the practical use of NDBI principles
in developing high-quality intervention programming for children with ASD.
Although it considers the models discussed in this chapter where appropriate, it
focuses on describing treatment components and their application to specific tar-
get behaviors in treatment, as opposed to on what brand the component can be
ascribed to. Recommendations and strategies described can be used with any of the
branded interventions or as part of a technical eclectic approach. The three guid-
ing principles outlined previously and the 13 characteristics of NDBI interventions
outlined in Chapter 1 are integrated into this discussion as well. However, the
focus ultimately turns to the practical application: designing and implementing
high-quality technical eclectic treatment plans.

REFERENCES
Almirall, D., DiStefano, C., Chang, Y., Shire, S., Kaiser, A., Lu, X., . . . Kasari, C. (2016). Lon-
gitudinal effects of adaptive interventions with a speech-generating device in minimally
verbal children with ASD. Journal of Clinical Child and Adolescent Psychology, 45(4), 442–456.
Boudreau, A. M., Corkum, P., Meko, K., & Smith, I. M. (2015). Peer-mediated pivotal response
treatment for young children with autism spectrum disorders: A systematic review. Cana-
dian Journal of School Psychology, 30(3), 218–235.
 Considering NDBI Models 37

Brian, J. A., Smith, I. M., Zwaigenbaum, L., & Bryson, S. E. (2017). Cross-site randomized
control trial of the Social ABCs caregiver-mediated intervention for toddlers with autism
spectrum disorder. Autism Research, 10(10), 1700–1711.
Brian, J. A., Smith, I. M., Zwaigenbaum, L., Roberts, W., & Bryson, S. E. (2016). The Social
ABCs caregiver-mediated intervention for toddlers with autism spectrum disorder: Fea-
sibility, acceptability, and evidence of promise from a multisite study. Autism Research,
9(8), 899–912.
Bryson, S. E., Koegel, L. K., Koegel, R. L., Openden, D., Smith, I. M., & Nefdt, N. (2007).
Large scale dissemination and community implementation of pivotal response treat-
ment: Program description and preliminary data. Research and Practice for Persons with
Severe Disabilities, 32(2), 142–153.
Cadogan, S., & McCrimmon, A. W. (2015). Pivotal response treatment for children with
autism spectrum disorder: A systematic review of research quality. Developmental Neuro-
rehabilitation, 18(2), 137–144.
Camarata, S. M., Nelson, K. E., & Camarata, M. N. (1994). Comparison of conversational-
recasting and imitative procedures for training grammatical structures in children with
specific language impairment. Journal of Speech and Hearing Research, 37(6), 1414–1423.
Charlop-Christy, M., & Carpenter, M. H. (2000). Modified incidental teaching sessions:
A procedure for parents to increase spontaneous speech in their children with autism.
Journal of Positive Behavior Interventions, 2(2), 98–112.
Charman, T., Taylore, E., Drew, A., Cockerill, H., Brown, J., & Baird, G. (2005). Outcome at
7 years of children diagnosed with autism at 2: Predictive validity of assessments con-
ducted at 2 and 3 years of age and pattern of symptom change over time. Journal of Child
Psychology and Psychiatry, 46, 500–513.
Cleave, P. L., Becker, S. D., Curran, M. K., Van Horne, A. J. O., & Fey, M. E. (2015). The efficacy
of recasts in language intervention: A systematic review and meta-analysis. American
Journal of Speech-Language Pathology, 24(2), 237–255.
Coolican, J., Smith, I. M., & Bryson, S. E. (2010). Brief parent training in pivotal response
treatment for preschoolers with autism. Journal of Child Psychology and Psychiatry, 51(12),
1321–1330.
Corsello, C. M. (2005). Early intervention in autism. Infants and Young Children, 18(2), 74–85.
Curtis, P. R., Roberts, M. Y., Estabrook, R., & Kaiser, A. P. (2017). The longitudinal effects
of early language intervention on children’s problem behaviors. Child Development, 90(2),
576–592.
Dawson, G., Jones, E. J. H., Merkle, K., Venema, K., Lowy, R., Faja, S., . . . Webb, S. J. (2012).
Early behavioral intervention is associated with normalized brain activity in young chil-
dren with autism. Journal of the American Academy of Child and Adolescent Psychiatry, 51(11),
1150–1159.
Dawson, G., Rogers, S., Munson, J., Smith, M., Winter, J., Greenson, J., . . .Varley, J. (2010).
Randomized, controlled trial of an intervention for toddlers with autism: The Early Start
Denver Model. Pediatrics, 125(1), 17–23.
Dawson, G., Toth, K., Abbott, R., Osterling, J., Munson, J., Estes, A., & Liaw, J. (2004). Early
social attention impairments in autism: Social orienting, joint attention, and attention to
distress. Developmental Psychology, 40(2), 271–283.
Dawson, G., Webb, S. J., & McPartland, J. (2005). Understanding the nature of face process-
ing impairment in autism: Insights from behavioral and electrophysiological studies.
Developmental Neuropsychology, 27(3), 403–424.
Dawson, G., Webb, S., Schellenberg, G. D., Dager, S., Friedman, S., Aylward, E., & Richards,
T. (2002). Defining the broader phenotype of autism: Genetic, brain, and behavioral per-
spectives. Development and Psychopathology, 14(3), 581–611.
Estes, A., Munson, J., Rogers, S. J., Greenson, J., Winter, J., & Dawson, G. (2015). Long-term
outcomes of early intervention in 6-year-old children with autism spectrum disorder.
Journal of the American Academy of Child and Adolescent Psychiatry, 54(7), 580–587.
Genc, G. B., & Vuran, S. (2013). Examination of studies targeting social skills with pivotal
response treatment. Kuram Ve Uygulamada Eğitim Bilimleri, 13(3), 1730–1742.
Gengoux, G. W., Berquist, K. L., Salzman, E., Schapp, S., Phillips, J. M., Frazier, T. W., . . . Hardan,
A. Y. (2015). Pivotal response treatment parent training for autism: Findings from a 3-month
follow-up evaluation. Journal of Autism and Developmental Disorders, 45(9), 2889–2898.
38 Overview

Goods, K. S., Ishijima, E., Chang, Y., & Kasari, C. (2013). Preschool based JASPER interven-
tion in minimally verbal children with autism: Pilot RCT. Journal of Autism and Develop-
mental Disorders, 43(5), 1050–1056.
Gulsrud, A. C., Hellemann, G., Shire, S., & Kasari, C. (2015). Isolating active ingredients in
a parent-mediated social communication intervention for toddlers with autism spectrum
disorder. Journal of Child Psychology and Psychiatry, 57(5), 606–613.
Halle, J. W., Marshall, A. M., & Spradlin, J. E. (1979). Time delay: A technique to increase
language use and facilitate generalization in retarded children. Journal of Applied Behavior
Analysis, 12(3), 431–439.
Hampton, L. H., & Kaiser, A. P. (2016). Early intervention effects on spoken-language out-
comes or children with autism: A systematic review and meta-analysis. Journal of Intel-
lectual and Developmental Disabilities, 60(5), 444–463.
Hampton, L. H., Kaiser, A. P., & Roberts, M. Y. (2017). One-year language outcomes in tod-
dlers with language delays: An RCT follow-up. Pediatrics, 140(5), e20163646. doi:10.1542/
peds.2016-3646
Hancock, T. B., & Kaiser, A. P. (2002). The effects of trainer-implemented enhanced milieu
teaching on the social communication of children with autism. Topics in Early Childhood
Special Education, 22(1), 39–54.
Hancock, T. B., & Kaiser, A. P. (2006). Enhanced milieu teaching. In S. F. Warren & M. E. Fey
(Series Eds.) & R. J. McCauley & M. E. Fey (Vol. Eds.), Communication and language interven-
tion series: Treatment of language disorders in children (pp. 203–236). Baltimore, MD: Paul H.
Brookes Publishing Co.
Hancock, T. B., & Kaiser, A.P. (2012). Implementing enhanced milieu teaching with children
who have autism spectrum disorders. In M. E. Fey & A. G. Kamhi (Series Eds.) & P. A. Pre-
lock & R. J. McCauley (Vol. Eds.), Communication and language intervention series: Treatment
of autism spectrum disorders: Evidence-based intervention strategies for communication and social
interaction (pp. 163–187). Baltimore, MD: Paul H. Brookes Publishing Co.
Hancock, T. B., Kaiser, A. P., & Delaney, E. M. (2002). Teaching parents of preschoolers at
high risk: Strategies to support language and positive behavior. Topics in Early Childhood
Special Education, 22(4), 191–212.
Hardan, A. Y., Gengoux, G. W., Berquist, K. L., Libove, R. A., Ardel, C. M., Phillips, J., . . .
Minjarez, M. B. (2015). A randomized controlled trial of pivotal response treatment group
for parents of children with autism. Journal of Child Psychology and Psychiatry, 56(8), 884–892.
Haring, T. G., Neetz, J. A., Lovinger, L., & Peck, C. (1987). Effects of four modified incidental
teaching procedures to create opportunities for communication. Journal of The Association
for Persons with Severe Handicaps, 12(3), 218–226.
Harper, C. B., Symon, J. G., & Frea, W. D. (2008). Recess is time-in: Using peers to improve social
skills of children with autism. Journal of Autism and Developmental Disorders, 38(5), 815–826.
Harrist, A. W., & Waugh, R. M. (2002). Dyadic synchrony: Its structure and function in chil-
dren’s development. Developmental Review, 22, 555–592.
Hart, B. M., & Risley, T. R. (1968). Establishing use of descriptive adjectives in the spontane-
ous speech of disadvantaged preschool children. Journal of Applied Behavior Analysis, 1(2),
109–120.
Hart, B., & Risley, T. R. (1975). Incidental teaching of language in the preschool. Journal of
Applied Behavior Analysis, 8(4), 411–420.
Ingersoll, B., & Berger, N. I. (2015). Parent engagement with a telehealth-based parent-
mediated intervention program for children with autism spectrum disorders: Predictors
of program use and parent outcomes. Journal of Medical Internet Research, 17(10), e227.
Ingersoll, B., & Dvortcsak, A. (2010). Teaching social communication to children with autism:
A manual for parents. New York, NY: Guilford Press.
Ingersoll, B., & Wainer, A. (2013a). Initial efficacy of Project ImPACT: A parent-mediated
social communication intervention for young children with ASD. Journal of Autism and
Developmental Disorders, 43(12), 2943–2952.
Ingersoll, B. R., & Wainer, A. L. (2013b). Pilot study of a school-based parent training pro-
gram for preschoolers with ASD. Autism, 17(4), 434–448.
Ingersoll, B., Wainer, A. L., Berger, N. I., Pickard, K. E., & Bonter, N. (2016). Comparison of a
self-directed and therapist-assisted telehealth parent-mediated intervention for children
with ASD: A pilot RCT. Journal of Autism and Developmental Disorders, 46(7), 2275–2284.
 Considering NDBI Models 39

Kaiser, A. P., & Hampton, L. H. (2017). Enhanced milieu teaching. In M. E. Fey & A. G.
Kamhi (Series Eds.) & R. J. McCauley, M. E. Fey, & R. B. Gilliam (Vol. Eds.), Communi-
cation and language intervention series: Treatment of language disorders in children (2nd ed.,
pp. 87–120). Baltimore, MD: Paul H. Brookes Publishing Co.
Kaiser, A. P., Hancock, T. B., & Nietfeld, J. P. (2000). The effects of parent-implemented
enhanced milieu teaching on the social communication of children who have autism.
Early Education and Development, 11(4), 423–446.
Kaiser, A. P., Hancock, T. B., & Trent, J. A. (2007). Teaching parents communication strate-
gies. Early Childhood Services: An Interdisciplinary Journal of Effectiveness, 1(2), 107–136.
Kaiser, A. P., & Hester, P. P. (1994). Generalized effects of enhanced milieu teaching. Journal
of Speech & Hearing Research, 37(6), 1320–1340. doi:10.1044/jshr.3706.1320
Kaiser, A. P., & Roberts, M. Y. (2013). Parent-implemented enhanced milieu teaching with
preschool children who have intellectual disabilities. Journal of Speech, Language, and Hear-
ing Research, 56(1), 295–309.
Kaiser, A., Scherer, N., Frey, J., & Roberts, M. (2017). The effects of enhanced milieu teaching
with phonological emphasis on the speech and language skills of young children with
cleft palate: A pilot study. American Journal of Speech-Language Pathology, 26(3), 806–818.
Kasari, C., Freeman, S., & Paparella, T. (2006). Joint attention and symbolic play in young
children with autism: A randomized controlled intervention study. Journal of Child Psy-
chology and Psychiatry, 47(6), 611–620.
Kasari, C., Freeman, S., Paparella, T., Wong, C., Kwon, S., & Gulsrud, A. (2005). Early intervention
on core deficits in autism. Clinical Neuropsychiatry: Journal of Treatment Evaluation, 2(6), 380–388.
Kasari, C., Gulsrud, A., Paparella, T., Hellemann, G., & Berry, K. (2015). Randomized com-
parative efficacy study of parent-mediated interventions for toddlers with autism. Journal
of Consulting and Clinical Psychology, 83(3), 554–563.
Kasari, C., Gulsrud, A. C., Wong, C., Kwon, S., & Locke, J. (2010). Randomized controlled
caregiver mediated joint engagement intervention for toddlers with autism. Journal of
Autism and Developmental Disorders, 40(9), 1045–1056.
Kasari, C., Kaiser, A., Goods, K., Nietfeld, J., Mathy, P., Landa, R., . . . Almirall, S. (2014).
Communication interventions for minimally verbal children with autism: A sequential
multiple assignment randomized trial. Journal of the American Academy of Child & Adoles-
cent Psychiatry, 53(6), 635–646.
Kasari, C., Lawton, K., Shih, W., Barker, T. V., Landa, R., Lord, C., . . . Senturk, D. (2014).
Caregiver-mediated intervention for low-resourced preschoolers with autism: An RCT.
Pediatrics, 134(1), e72–e79.
Kasari, C., Paparella, T., Freeman, S., & Jahromi, L. B. (2008). Language outcome in autism:
Randomized comparison of joint attention and play interventions. Journal of Consulting
and Clinical Psychology, 76(1), 125–137.
Kern, L., Vorndran, C. M., Hilt, A., Ringdahl, J. E., Adelman, B. E., & Dunlap, G. (1998).
Choice as an intervention to improve behavior: A review of the literature. Journal of Behav-
ioral Education, 8(2), 151–169.
Kim, S., Koegel, R. L., & Koegel, L. K. (2017). Training paraprofessionals to target socializa-
tion in students with ASD: Fidelity of implementation and social validity. Journal of Posi-
tive Behavior Interventions, 19(2), 102–114.
Koegel, L. K., Camarata, S. M., Valdez-Menchaca, M., & Koegel, R. L. (1998). Setting gener-
alization of question-asking by children with autism. American Journal on Mental Retarda-
tion, 102(4), 346–357.
Koegel, L. K., Carter, C. M., & Koegel, R. L. (2003). Teaching children with autism self-
initiations as a pivotal response. Topics in Language Disorders, 23(2), 134–145.
Koegel, L. K., Koegel, R. L., Harrower, J. K., & Carter, C. M. (1999). Pivotal response interven-
tion I: Overview of approach. Journal of The Association for Persons with Severe Handicaps,
24(3), 174–185.
Koegel, L. K., Koegel, R. L., Shoshan, Y., & McNerney, E. (1999). Pivotal response interven-
tion II: Preliminary long-term outcomes data. Journal of The Association for Persons with
Severe Handicaps, 24(3), 186–198.
Koegel, L. K., Kuriakose, S., Singh, A. K., & Koegel, R. L. (2012). Improving generalization
of peer socialization gains in inclusive school settings using initiations training. Behavior
Modification, 36(3), 361–377.
40 Overview

Koegel, L. K., Stiebel, D., & Koegel, R. L. (1998). Reducing aggression in children with autism
toward infant or toddler siblings. Journal of The Association for Persons with Severe Handi-
caps, 23(2), 111–118.
Koegel, R. L., Bimbela, A., & Schreibman, L. (1996). Collateral effects of parent training on
family interactions. Journal of Autism and Developmental Disorders, 26(3), 347–359.
Koegel, R. L., Kim, S., & Koegel, L. K. (2014). Training paraprofessionals to improve socializa-
tion in students with ASD. Journal of Autism and Developmental Disorders, 44(9), 2197–2208.
Koegel, R. L., & Koegel, L. K. (1990). Extended reductions in stereotypic behavior of students
with autism through a self-management treatment package. Journal of Applied Behavior
Analysis, 23(1), 119–127.
Koegel, R. L., & Koegel, L. K. (2006). Pivotal response treatment for autism: Communication,
social, and academic development. Baltimore, MD: Paul H. Brookes Publishing Co.
Koegel, R. L., Koegel, L. K., & Surratt, A. (1992). Language intervention and disruptive
behavior in preschool children with autism. Journal of Autism and Developmental Disorders,
22(2), 141–153.
Koegel, R. L., Symon, J. B., & Kern Koegel, L. (2002). Parent education for families of children
with autism living in geographically distant areas. Journal of Positive Behavior Interventions,
4(2), 88–103.
McGee, G. G., Almeida, M. C., Sulzer-Azaroff, B., & Feldman, R. S. (1992). Promoting recip-
rocal interactions via peer incidental teaching. Journal of Applied Behavior Analysis, 25(1),
117–126.
McGee, G. G., & Daly, T. (2007). Incidental teaching of age-appropriate social phrases to
children with autism. Research and Practice for Persons with Severe Disabilities, 12(2), 112–123.
McGee, G. G., Krantz, P. J., Mason, D., & McClannahan, L. E. (1983). A modified incidental
teaching procedures for autistic youth: Acquisition and generalization of receptive object
labels. Journal of Applied Behavior Analysis, 161(3), 329–338.
McGee, G. G., Krantz, P. J., & McClannahan, L. E. (1984). Conversational skills for autistic
adolescents: Teaching assertiveness in naturalistic game settings. Journal of Autism and
Developmental Disorders, 14(3), 319–330.
McGee, G. G., Krantz, P. J., & McClannahan, L. E. (1985). The facilitative effects of incidental
teaching on preposition use by autistic children. Journal of Applied Behavior Analysis, 18(1),
17–31.
McGee, G. G., Krantz, P. J., & McClannahan, L. E. (1986). An extension of incidental teaching
procedures to reading instruction for autistic children. Journal of Applied Behavior Analysis,
191(2), 147–157.
McGee, G. G., Morrier, M. J., & Daly, T. (1999). An incidental teaching approach to early
intervention for toddlers with autism. Journal of The Association for Persons with Severe
Handicaps, 24(3), 133–146.
Minjarez, M. B., Mercier, E. M., Williams, S. E., & Hardan, A. Y. (2013). Impact of pivotal
response training group therapy on stress and empowerment in parents of children with
autism. Journal of Positive Behavior Interventions, 15(2), 71–78.
Minjarez, M. B., Williams, S. E., Mercier, E. M., & Hardan, A. Y. (2011). Pivotal response
group treatment program for parents of children with autism. Journal of Autism and Devel-
opmental Disorders, 41(1), 92–101.
Mundy, P., Sigman, M., & Kasari, C. (1990). A longitudinal study of joint attention and lan-
guage development in autistic children. Journal of Autism and Developmental Disorders, 20,
115–128.
National Autism Center. (2015). National Standards Project, Phase II. Randolph, MA: Author.
Odom, S., Hume, K., Boyd, B., & Stabel, A. (2012). Moving beyond the intensive behavior
treatment versus eclectic dichotomy: Evidence-based and individualized programs for
learners with ASD. Behavior Modification, 36(3), 270–297.
Ogletree, M. L., Oren, T., & Fischer, M. A. (2007). Examining effective intervention prac-
tices for communication impairment in autism spectrum disorder. Exceptionality, 15(4),
233–247.
Olive, M. L., de la Cruz, B., Davis, T. N., Chan, J. M., Lang, R. B., O’Reilly, M. F., & Dickson,
S. M. (2007). The effects of enhanced milieu teaching and a voice output communication
aid on the requesting of three children with autism. Journal of Autism and Developmental
Disorders, 37, 1505–1513.
 Considering NDBI Models 41

Pickard, K. E., Wainer, A. L., Bailey, K. M., & Ingersoll, B. R. (2016). A mixed-method evalua-
tion of the feasibility and acceptability of a telehealth-based parent-mediated intervention
for children with autism spectrum disorder. Autism, 20(7), 845–855.
Pierce, K., & Schreibman, L. (1997). Multiple peer use of pivotal response training social
behaviors of classmates with autism: Results from trained and untrained peers. Journal of
Applied Behavior Analysis, 30(1), 157–160.
Prizant, B. M., Wetherby, A. M., Rubin, E., Laurent, A. C., & Rydell, P. J. (2006). The SCERTS
Model: A comprehensive educational approach for children with autism spectrum disorders. Vol. II.
Baltimore, MD: Paul H. Brookes Publishing Co.
Prizant, B. M., Wetherby, A. M., & Rydell, P. J. (2000). Communication intervention issues
for young children with autism spectrum disorders. In S. F. Warren & J. Reichle (Series
Eds.) & A. M. Wetherby & B. M. Prizant (Vol. Eds.), Communication and language inter-
vention series: Vol. 9. Autism spectrum disorders: A transactional developmental perspective
(pp. 193–224). Baltimore, MD: Paul H. Brookes Publishing Co.
Rieth, S. R., Stahmer, A. C., Suhrheinrich, J., & Schreibman, L. (2015). Examination of the
prevalence of stimulus overselectivity in children with ASD. Journal of Applied Behavior
Analysis, 48(1), 71–84.
Roberts, M., & Kaiser, A. (2012). Assessing the effects of a parent-implemented language
intervention for children with language impairments using empirical benchmarks:
A pilot study. Journal of Speech, Language, and Hearing Research, 55(6), 1655–1670.
Roberts, M. Y., & Kaiser, A. P. (2015). Early intervention for toddlers with language delays:
A randomized controlled trial. Pediatrics, 134(4), 686–693. doi:10.1542/peds.2014-2134
Rogers, S. J., & Dawson, G. (2010). Early Start Denver Model for young children with autism: Pro-
moting language, learning, and engagement. New York, NY: Guilford Press.
Rogers, S. J., Dawson, G., & Vismara, L. A. (2012). An early start for your child with autism: Using
everyday activities to help kids connect, communicate, and learn. New York, NY: Guilford Press.
Rogers, S. J., Estes, A., Lord, C., Vismara, L., Winter, J., Fitzpatrick, A., . . . Dawson, G. (2012).
Effects of a brief Early Start Denver Model (ESDM)–based parent intervention on toddlers
at risk for autism spectrum disorders: A randomized controlled trial. Journal of the Ameri-
can Academy of Child and Adolescent Psychiatry, 51(10), 1052–1065.
Rogers, S. J., Herbison, J., Lewis, H., Pantone, J., & Reis, K. (1986). An approach for enhanc-
ing the symbolic, communicative and interpersonal functioning of young children with
autism and severe emotional handicaps. Journal of the Division of Early Childhood, 10, 135–148.
Rogers, S. J., & Pennington, B. F. (1991). A theoretical approach to the deficits in infantile
autism. Development and Psychopathology, 3(2), 137–162.
Rogers, S. J., Vismara, L., Wagner, A. L., McCormick, C., Young, G., & Ozonoff, S. (2014). Autism
treatment in the first year of life: A pilot study of infant start, a parent-implemented interven-
tion for symptomatic infants. Journal of Autism and Developmental Disorders, 44(12), 2981–2995.
Rubin, E., Prizant, B. M., Laurent, A. C., & Wetherby, A. M. (2013). Social Communica-
tion, Emotional Regulation, and Transactional Support (SCERTS). In S. Goldstein & J. A.
Naglieri (Eds.), Interventions for autism spectrum disorders: Translating science into practice
(pp. 107–127). New York, NY: Springer.
Ryan, C. S., Hemmes, N. S., Sturmey, P., Jacobs, J. D., & Grommet, E. K. (2008). Effects of a
brief staff training procedure on instructors’ use of incidental teaching and students’ fre-
quency of initiation toward instructors. Research in Autism Spectrum Disorders, 2(1), 28–45.
Ryberg, K. H. (2015). Evidence for the implementation of the Early Start Denver Model for
young children with autism spectrum disorder. Journal of the American Psychiatric Nurses
Association, 21(5) 327–337.
Sandall, S. R., Ashmun, J. W., Schwartz, I. S., Davis, C. A., Williams, P., Leon-Guerrero, R., . . .
McBride, B. J. (2011). Differential response to a school-based program for young children
with ASD. Topics in Early Childhood Special Education, 31(3), 166–177.
Schreibman, L., & Koegel, R. L. (1982). Multiple-cue responding in autistic children. Advances
in Child Behavioral Analysis & Therapy, 281–299.
Schreibman, L., & Koegel, R. L. (2005). Training for parents of children with autism: Piv-
otal responses, generalization, and individualization of interventions. In E. D. Hibbs
& P. S. Jensen (Eds.), Psychosocial treatments for child and adolescent disorders: Empirically
based strategies for clinical practice (pp. 605–631). Washington, DC: American Psychological
Association.
42 Overview

Schwartz, I., Ashmun, J., McBride, B., Scott, C., & Sandall, S. R. (2017). The DATA Model for
teaching preschoolers with autism: Blending approaches to meet individual needs. Baltimore, MD:
Paul H. Brookes Publishing Co.
Schwartz, I., Thomas, C. J., McBride, B., & Sandall, S. (2013). A school-based preschool pro-
gram for children with ASD: A quasi-experimental assessment of child change in Project
DATA. School Mental Health, 5(4), 221–232.
Smith, I. M., Koegel, K., Koegel, L. K., Openden, D. A., Fossum, K. L., & Bryson, S. E. (2010).
Effectiveness of a novel community-based early intervention model for children with
autistic spectrum disorder. American Journal on Intellectual and Developmental Disabilities,
115(6), 504–523.
Stadnick, N. A., Stahmer, A., & Brookman-Frazee, L. (2015). Preliminary effectiveness of
Project ImPACT: A parent-mediated intervention for children with autism spectrum dis-
order delivered in a community program. Journal of Autism and Developmental Disorders,
45(7), 2092–2104.
Stahmer, A. C. (1995). Teaching symbolic play skills to children with autism using pivotal
response training. Journal of Autism and Developmental Disorders, 25(2), 123–141.
Stahmer, A. C., Ingersoll, B., & Carter, C. (2003). Behavioral approaches to promoting play.
Autism, 7(4), 401–413.
Stahmer, A. C., Suhrheinrich, J., & Reith, S. (2016). A pilot examination of the adapted pro-
tocol for classroom pivotal response teaching. Journal of the American Academy of Special
Education Professionals, 119–139.
Strain, P. S., & Bovey, E. H. (2011). Randomized, controlled trial of the LEAP model of early
intervention for young children with autism spectrum disorders. Topics in Early Childhood
Special Education, 31(3), 133–154.
Strain, P. S., & Hoyson, M. (2000). The need for longitudinal, intensive social skill interven-
tion: LEAP follow-up outcomes for children with autism. Topics in Early Childhood Special
Education, 20(2), 116–122.
Suhrheinrich, J. (2015). A sustainable model for training teachers to use pivotal response
training. Autism, 19(6), 713–723.
Suhrheinrich, J., Stahmer, A. C., & Schreibman, L. (2007). A preliminary assessment of
teachers’ implementation of pivotal response training. The Journal of Speech and Language
Pathology—Applied Behavior Analysis, 2(1), 1–13.
Symon, J. B. (2005). Expanding interventions for children with autism: Parents as trainers.
Journal of Positive Behavior Interventions, 7(3), 159–173.
Tamis-LeMonda, C. S., & Bornstein, M. H. (2002). Maternal responsiveness and early lan-
guage acquisition. Advances in Child Development and Behavior, 29, 89–127.
Vismara, L. A., Young, G. S., & Rogers, S. J. (2013). Community dissemination of the Early
Start Denver Model: Implications for science and practice. Topics in Early Childhood Special
Education, 32(4), 223–233.
Vivanti, G., Paynter, J., Duncan, E., Fothergill, H., Dissanayake, C., Rogers, S. J., & The Vic-
torian ASELCC Team. (2014). Effectiveness and feasibility of the Early Start Denver Model
implemented in a group-based community childcare setting. Journal of Autism and Devel-
opmental Disorders, 44, 3140–3153.
Wainer, A. L., Pickard, K., & Ingersoll, B. R. (2017). Using web-based instruction, brief work-
shops, and remote consultation to teach community-based providers a parent-mediated
intervention. Journal of Child and Family Studies, 26(6), 1592–1602.
Wright, C. A., & Kaiser, A. P. (2016). Teaching parents enhanced milieu teaching with words
and signs using Teach-Model-Coach-Review. Topics in Early Childhood Special Education,
36(4), 192–204. doi:10.1177/0271121415621027
Wong, C., Odom, S. L., Hume, K. A., Cox, A. W., Fettig, A., Kucharczyk, S., . . . Schultz, T. R.
(2015). Evidence-based practices for children, youth, and young adults with autism spec-
trum disorder: A comprehensive review. Journal of Autism and Developmental Disorders,
45(7), 1951–1966.
II

Core Concepts and

Foundational Principles
3
Selecting Meaningful Skills for
Teaching in the Natural Environment
Grace W. Gengoux, Erin McNerney, and Mendy B. Minjarez

T
he emphasis on teaching meaningful skills in natural contexts is a foun-
dational element of Naturalistic Developmental Behavioral Interventions
(NDBI; Schreibman et al., 2015). Given the core social-communication deficits
in autism spectrum disorder (ASD), both naturalistic behavioral and developmen-
tal approaches have historically emphasized teaching of social-communication
skills (Ingersoll, 2010). Furthermore, the National Research Council’s (2001) report
asserted that personal independence and social responsibility should be priorities
for educating children with ASD, just as they are for all children. Yet, when decid-
ing which skills to prioritize, therapists and families are faced with an exhaustive
list of possible target behaviors, which often makes the task daunting. In NDBI
treatment planning, skill areas are prioritized based on which skills will have the
greatest impact on later independence and quality of life for the individual and
family and are taught in a developmentally appropriate sequence.
Meaningfulness of the skill is the first important consideration when selecting
treatment targets. To determine if a skill is meaningful, therapists should consider
the following: Is this skill functional? That is, will it help the child participate more
fully in his or her school, home, or community activities? Is this a skill that will
improve the child’s and family’s quality of life? Of all potential skills, improve-
ment in functional skills is likely to have the greatest impact on an individual’s
long-term independence and self-determination. In fact, research has suggested
that an individual’s performance of functional daily living and social skills is a
stronger predictor of responsibility and independence with life tasks than the indi-
vidual’s cognitive ability (Kao, Kramer, Liljenquist, & Coster, 2015). Another impor-
tant advantage of teaching a functional behavior is that it is more likely to result
in immediate natural reinforcement from the environment. This frequent and
natural reinforcement means that functional skills are easier to learn, maintain,
45
46 Core Concepts and Foundational Principles

and generalize (Koegel & Koegel, 2012; Williams, Koegel, & Egel, 1981). Functional
skills are discussed in more detail later in this chapter.
Developmental sequence must also be considered when developing treatment
goals that are functional. The child’s present level of functioning in a particular
domain must be evaluated before choosing a skill that represents the next devel-
opmental step (Rogers & Dawson, 2010). All NDBI take developmental sequence of
skill acquisition into account and therefore focus on certain foundational abilities
known to be precursors to other critical functional skills. In typically develop-
ing children, several early-emerging social-communication skills, such as joint
attention (Bates, Camaioni, & Volterra, 1975; Baldwin, 1991; Mundy & Crowson,
1997; Mundy & Sigman, 1989; Mundy, Sigman, & Kasari, 1990), play skills (Shore,
O’Connell, & Bates, 1984; Sigman & Ruskin, 1999), and imitation (Uzgiris, 1981)
have been associated with the later emergence of more advanced social and cog-
nitive skills. Given that these skills are often deficient in children with ASD, they
are widely considered to be developmentally sound targets for early intervention
efforts (Charman & Stone, 2008). A skill may also be considered foundational if
acquisition of that behavior is known to produce a cascading effect across broader
developmental domains. For instance, skills such as functional communication
and initiations are common intervention priorities because these skills have the
potential for widespread effects for the individual and for interactions with impor-
tant stakeholders (Koegel, Koegel, Harrower, & Carter, 1999).
This chapter reviews the NDBI approach to selection of functional skills and
suggests several priorities in selecting meaningful treatment targets, such as the
importance of considering goodness of fit with family values and routines. It also
discusses why the natural environment is the ideal place for teaching to occur and
examines how parents and providers can effectively contextualize learning oppor-
tunities across settings.

GOODNESS OF FIT OF NDBI APPROACHES

When developing treatment plans for targeting functional skills in the natural en-
vironment, practitioners must consider the goodness of fit of treatment approaches
and specific strategies. Goodness of fit, or contextual fit, means that the treatment
plan works well for stakeholders in the natural environment (home, school, commu-
nity), which improves the likelihood of its long-term use (Albin, Lucyshyn, Horner,
& Flannery, 1996). The idea is to avoid the problem of elegantly designed interven-
tions that are minimally effective because they are never actually implemented.
NDBI are flexible and designed to adapt to fit the environment. The selected in-
tervention strategies must be viewed as important, useful, acceptable, and feasible
by the team members responsible for implementing them in order for the imple-
mentation to be delivered consistently and with a high degree of fidelity (Odom,
McConnell, & Chandler, 1994; Snell, 2003; Stormont, Lewis, & Smith, 2005). Team
members will be motivated to implement strategies when they see the short- and
long-term meaning and value in teaching a skill. Parents, too, will be more likely to
implement those teaching strategies that are consistent with their values, personal-
ity, and daily routines. Understanding family culture and beliefs about effective
parenting is therefore critical to providing individualized and ecologically valid
treatment (see Box 3.1 for definition) in the natural environment (Guler, de Vries,
Seris, Shabalala, & Franz, 2017; Rodriguez & Olswang, 2003).
 Selecting Meaningful Skills 47

BOX 3.1: Ecological validity

In research, ecological validity is the extent to which research findings can
be generalized to everyday real life. Intervention studies with strong ecological
validity are conducted in a fashion that mimics real life as much as possible.
In a clinical setting, this term refers to whether interventions are feasible in
the natural environment and whether context-specific barriers have been
accounted for, such as parental involvement and cultural factors.

Programs with a good fit demonstrate alignment with an individual’s needs,

respect values and skills of implementers, recognize environmental constraints,
and ultimately are likely to result in higher consumer satisfaction. For instance,
a parent who is socially shy may struggle with the task of initiating contact with
parents of a potential peer, indicating that particular strategy has poor goodness
of fit with parent personality. Yet, that same parent may be willing to sign up on
a list of parents requesting to have their children participate in a peer buddy pro-
gram at school, indicating this approach has a better goodness of fit with parent
personality. For a family that rarely eats dinner together, it would be unreasonable
for a clinician to suggest practicing social conversation during mealtimes, but he or
she could be more successful by suggesting that the practice occur during car rides
when the family is together. If a family routinely spends time together watching
television or movies, the clinician could suggest spending a few minutes practicing
social conversation by having family members share their opinions and ask each
other questions about what they watched, practicing turn taking and staying on
topic. See Box 3.2 for more on assessing ecological and social validity of programs.

Role of Culture in Goodness of Fit of Interventions

Clinicians begin to learn about the family’s culture and values as part of the as-
sessment process and should continue to incorporate input from parents regarding

Ready, Set, Implement!

BOX 3.2: Assessing validity
To assess the ecological and social validity of a program, select a client’s
current program. Review with the family members their daily and weekly
routines. Confirm their current top three treatment priorities, and ask them in
which routines they can most easily implement strategies and which routines
they find most challenging. Use this opportunity to make sure your strategies
match their needs, values, and skill levels. Brainstorm with family members
three ways they can try a particularly challenging strategy throughout their
week. Check back in 2 weeks to see how practice is going, and brainstorm
modifications as needed.
48 Core Concepts and Foundational Principles

treatment priorities throughout the treatment relationship. Therapists can enhance

goodness of fit of interventions by empowering parents to take an active role in
deciding which intervention strategies to prioritize, based on which will fit best
within existing family routines (Brookman-Frazee, 2004). Evidence suggests that
acceptability of different types of intervention strategies will vary according to
family cultural factors (Mandell & Novak, 2005).
When working with culturally diverse families, it is important to keep in mind
that values endorsed by European American families may be different from those
endorsed in other cultures (Bernier, Mao, & Yen, 2010). For instance, in many collectiv-
ist cultures, the involvement of extended family is a core value (Jung, 1998; Schwartz,
1990). When appropriate, incorporating siblings and extended family into treatment
can show respect for this cultural priority (Santarelli, Koegel, Casas, & Koegel, 2001).
Likewise, social conformity (Daley, 2004) and respect for authority (Rodriguez &
Olswang, 2003) are highly important in some cultures. Discipline practices, which
might at first seem overly strict to a provider whose culture of origin values individu-
alism, could actually be a sign of parental concern, caring, or involvement in some
cultures (Chao, 1994). Although the child-directed nature of many NDBI is likely to
appeal to families from cultures that value individual autonomy, it may appear to
conflict with the value of respect for authority. A clinician who recognizes the valid-
ity of multiple perspectives can respond to family preferences in a respectful and col-
laborative manner. For instance, a therapist might prioritize teaching the child how
to use polite language with his or her grandparents and how to comply with adult
instructions, knowing that these behaviors are important to the family.

Role of Culture in Parent–Professional Collaboration

When considering goodness of fit of treatment approaches, practitioners should
keep in mind that the relationship between professionals and parents will vary ac-
cording to several important cultural factors (Bernier et al., 2010). Cultural sensitiv-
ity plays an important role in the parent–clinician partnership (Brookman-Frazee,
2004). For instance, some families place high value on expert input. These families
may expect therapists and educators to be primary providers of care and may feel
that treatment is most useful if clear guidance and recommendations are provided
early in the treatment relationship. In contrast, other families may appreciate an
egalitarian relationship with professionals, may expect to participate actively in
treatment decisions, and may respond best to a less directive partnership model of
care. Regardless of cultural norms, parents from diverse backgrounds will be more
likely to obtain care if they perceive providers to be culturally competent (Bernier
et al., 2010).
Practitioners should demonstrate curiosity in learning about each family’s cul-
tural background and values and should work collaboratively to balance implemen-
tation of evidence-based practices in a way that is congruent with family values.
The more practitioners take the time to learn about a parent’s perspective, the more
effective the collaboration can be. When practitioners incorporate family values
and preferences in treatment decisions and the overall parent training approach,
the resulting treatment plan will be acceptable to these critical stakeholders and is
more likely to be sustained. Effective strategies for parent–professional collabora-
tion to enhance parent empowerment are discussed in detail in Chapter 4.
 Selecting Meaningful Skills 49

Goodness of fit of treatment approaches should not be confused with social

validity of goals and target behaviors, which is discussed in detail next. Both must
be considered in order to develop NDBI treatment plans that will function opti-
mally in the natural environment.

FUNCTIONAL SKILLS
A functional skill is one that, by its very name, is necessary for daily living. A func-
tional skill is useful to the particular individual within his or her routines, advances
the individual toward a more typical developmental trajectory, and ultimately
serves as a building block toward independence. Furthermore, functional skills
should be meaningful for the individual and should lead to self-determination
through ability to meet one’s own needs. A functional skill should also have social
validity (Schwartz & Baer, 1991) (see Box 3.3 for definition), fit within the family’s
routine, and be consistent with family cultural values. All NDBI focus on functional
skills (Schreibman et al., 2015), ensuring children or adults learn skills they will use
on a frequent basis and that are meaningful to them, promote their independence,
and improve their social functioning in the community (National Research Coun-
cil, 2001; Rogers & Dawson, 2010). The rationale for prioritizing functional skills is
consistent with developmental theory, which emphasizes the importance of build-
ing skills that are consistent with an individual’s current developmental function-
ing and that improve prognosis by forming a foundation for the development of
more complex skills. The emphasis on skills that are socially valid, are relevant
to long-term independence, and enhance personal responsibility also has strong
historical support from the behavioral treatment literature (Bosch & Fuqua, 2001;
Rosales-Ruiz & Baer, 1997).
By prioritizing functional skills, clinicians ensure that the same skills that are
useful in daily routines are also useful in community contexts. For instance, pri-
oritize teaching communication behaviors that will be widely understood in the
broader community (e.g., words and conventional gestures rather than specialized
sign language; Ingersoll & Dvortcsak, 2010). That is not to say that clinicians will not
teach specific signs; however, they should consider the context and environment of
each individual to ensure that the individual will be understood by those around
him or her. It would similarly be preferable to teach asking for or labeling actual
preferred objects and activities rather than teaching naming of flashcards (Koegel &
Koegel, 2012; Rogers & Dawson, 2010) because a child is more likely to use this skill
in real-life settings to interact with individuals in his or her environment.

BOX 3.3: Social validity

Social validity refers to the social importance and acceptability of treatment
goals or target behaviors, intervention procedures, and treatment outcomes
(Hayes, Barlow, & Nelson-Gray, 1999; Wolf, 1978). A well-rounded view of
social validity takes into account the acceptability from the perspective of the
client, the treatment provider, and the community or society; however, the
client and family views are often most emphasized.
50 Core Concepts and Foundational Principles

Functional Skills Lead to Increased Independence

A skill can be considered functional for a few key reasons. First, functional skills
are useful to the individual in daily life, and demonstration of these skills allows
the individual to be more independent. Functional communication has long been
a priority in treatment research for this reason. The better a child’s functional com-
munication skills, the more he or she will be able to gain access to typical learning
environments and function independently. For example, a parent or provider could
teach a 2-year-old child with ASD to say “please” and “thank you” because many
typically developing children this age learn these words, and these words are often
culturally appropriate and important to parents. However, if the child with ASD
shows delayed expressive language development, more meaningful (functional)
goals might include labeling common objects in the environment that are used in
family routines and that the child may want to obtain or comment on. Although
a 2-year-old who says “please” and “thank you” is definitely polite, he or she may
continue to lack meaningful skills for making more specific requests, which will
also interfere with gaining natural reinforcement.
In a similar way, consistent performance of adaptive or daily living skills, such
as self-feeding, dressing, toileting, cooking, using public transportation, and so
forth, contributes directly to increased independence. Even individuals with ASD
who are intellectually able often have substantial deficits in adaptive skills; there-
fore, the overall goal of many intervention programs is to increase individual self-
sufficiency (Kanne et al., 2011). In a longitudinal study of individuals with average
cognitive ability, adaptive daily living and social skills were more strongly associ-
ated with positive outcome and adult independence than intelligence (Farley et al.,
2009). That is, adaptive and social skills may be even more critical for long-term
positive outcomes in ASD than academic progress and should be emphasized in
treatment across the life span. For instance, for a school-age child with ASD, it
could be appropriate to prioritize self-care routines (e.g., brushing teeth, dressing,
bathing), which allow that individual a more typical level of personal privacy and
self-sufficiency. For a teen with ASD, it could be appropriate to prioritize safety
skills (e.g., crossing a street, dialing 911, appropriate Internet use), which might
open opportunities for greater independence in the community. Likewise, priori-
tizing meaningful and functional social skills (e.g., how to enter a social situation,
appropriate social behavior for the lunchroom at work) increases access to develop-
mentally appropriate social opportunities and decreases the likelihood of stigma
and social isolation.

Functional Skills Can Be Pivotal

A skill may also be considered functional because of its foundational role as a pre-
cursor to the development of other critical skills. When selecting a skill to target,
consider the cascading effects it may have on other skill areas, as well as how its
emergence may affect the systems (e.g., family, classroom, community) in which
the individual participates (Dunlap & Fox, 1996). This concept is similar to that
of pivotal behaviors from Pivotal Response Treatment (PRT; Koegel et al., 1999).
In this way, functional communication skills are not only important for inde-
pendence but are also another one of the most important predictors of positive
 Selecting Meaningful Skills 51

long-term outcome in ASD (Fossum, Williams, Garon, Bryson, & Smith, 2018).
Furthermore, several other prelinguistic behaviors, such as joint attention (Bates,
Camaioni, & Volterra, 1975), play skills (Sigman & McGovern, 2005; Sigman &
Ruskin, 1999), and imitation (Uzgiris, 1981), have been identified as key precursors
to language acquisition in both typically developing children and children with
ASD (Baldwin, 1991; Mundy & Crowson, 1997; Mundy & Sigman, 1989; Mundy,
Sigman, & Kasari, 1990; Sigman & McGovern, 2005). Therefore, before moving to
teaching spoken language, clinicians should choose treatment targets that provide
children with a solid foundation for social-communication.
As an example, joint attention is widely acknowledged to play a critical role in
social-communication development because so many skills are learned from inter-
actions with others. In the area of language, when a child is learning a new word,
the ability to follow another person’s gaze or gesture gives critical information
about which item in the environment corresponds with the word spoken. Embed-
ding the teaching of joint attention within naturally reinforcing activities can make
this skill more functional for a child with ASD who shows initial impairment in this
skill. For instance, a clinician could arrange the teaching environment so that when
the child shifts his or her gaze in response to an adult’s pointing gesture, he or she
experiences clear natural reinforcement (e.g., seeing something exciting, finding a
desired item that had been missing). Understanding how to follow joint attention
can facilitate learning many new skills that involve interaction with others.

Functional Skills Emphasized Across NDBI Models

Due to the pivotal nature of this skill, the NDBI model JASPER (Joint Attention,
Symbolic Play, Engagement, and Regulation) was designed to target joint attention;
other NDBI approaches have also emphasized it (e.g., Bruinsma, 2004; Whalen &
Schreibman, 2003). Interventions systematically targeting joint attention skills have
demonstrated important downstream effects on untargeted language (Kasari,
Paparella, Freeman, & Jahromi, 2008), as well as play and imitation skills (Whalen,
Schreibman, & Ingersoll, 2006). The JASPER approach also emphasizes the impor-
tance of symbolic play, which has been a priority in other NDBI as well (Stahmer,
1995), due to its similar association with social-cognitive development (Shore,
O’Connell, & Bates, 1984). Imitation is another skill prioritized by several NDBI
approaches, including the Early Start Denver Model (ESDM) and Project ImPACT
(Improving Parents as Communication Teachers; Ingersoll & Schreibman, 2006;
Ingersoll, Lewis, & Kroman, 2007). Treatments targeting symbolic play (Kasari
et al., 2008) and imitation (Ingersoll, 2008) have been similarly shown to result in
greater gains in expressive language compared to control groups. These studies
all support the idea that teaching within a developmental framework can lead to
widespread developmental improvements in key skill areas.
Although all NDBI take a functional and developmental approach, each model
may focus on different skills. For example, PRT typically places initial focus on
(social) communication and language, especially requesting behaviors (Koegel &
Koegel, 2012), although PRT may be used to focus on other areas such as social
and play skills (Schreibman, Stahmer, & Pierce, 2006). Enhanced Milieu Teaching
(EMT) targets new language skills, with emphasis on initiations (Kaiser & Trent,
2007). JASPER places less focus on requesting and more on teaching symbolic play
52 Core Concepts and Foundational Principles

and joint attention, as described previously (Kasari, Freeman, & Paparella, 2006).
ESDM typically focuses on a wide range of social-communication and play skills
within the context of dyadic engagement (Rogers & Dawson, 2010). Project ImPACT
similarly focuses on social and communication behaviors, including imitation and
play (Ingersoll & Wainer, 2013; Stadnick, Stahmer, & Brookman-Frazee, 2015).

Assessment of Functional Skills for Goal Setting

Clear understanding of a child’s current developmental level and typical perfor-
mance across skill domains is essential to developing individualized treatment
goals; therefore, assessment of functional skills is a critical first step in any treat-
ment planning process. In addition to published books and manuals, many help-
ful treatment planning and implementation resources are now available online,
including tools for conducting assessments, data collection sheets, tutorials, we-
binars, instructional software programs, and lesson plans developed by a variety
of practitioners and researchers. Selecting what is most appropriate, however, can
remain a challenge. This topic is discussed in more detail in Chapter 10 on goal
development; however, some assessment strategies for assisting with this process
are discussed here.

Standardized Assessments Standardized testing can be a useful way to get

a general idea of where to begin. An advantage of standardized tests for identifi-
cation of target skills is the availability of norms for comparison, including age-
equivalent information across developmental areas. Clinicians can consider several
categories of standardized assessments, each with their own advantages. For in-
stance, developmental tests such as the Mullen Scales of Early Learning (Mullen,
1995) or Bayley Scales of Infant and Toddler Development (Bayley, 2006) can be used
to evaluate a child’s performance level across global developmental domains, such
as expressive and receptive language, early nonverbal cognitive abilities, and gross
and fine motor skills. For older children, cognitive tests (e.g., Wechsler Intelligence
Scale for Children [Wechsler, 2014], Stanford-Binet Intelligence Scales [Roid, 2003],
Kaufman Assessment Battery for Children [Kaufman & Kaufman, 2004]) can be
used to identify global cognitive strengths and weaknesses, as well as specific as-
pects of a child’s mental processing abilities or learning style. Other specialized
tests evaluate social-communication skills specifically, such as the Communication
and Symbolic Behavior Scales (CSBS; Wetherby & Prizant, 2003), and can provide
detailed information about other prelinguistic communication skills, early lan-
guage, as well as both functional and symbolic play skills. Language tests, such
as the Comprehensive Assessment of Spoken Language (CASL; Carrow-Woolfolk,
2016), can identify aspects of speech syntax and pragmatics to be addressed in treat-
ment. Finally, there are several standardized parent interviews or checklists regard-
ing adaptive behavior, such as the Vineland Adaptive Behavior Scales (Vineland;
Sparrow, Cicchetti, & Saulnier, 2016) or Adaptive Behavior Assessment System
(ABAS; Harrison & Oakland, 2015), which can identify broad adaptive domains to
address in treatment (e.g., personal hygiene, community safety skills, leisure skills).
Adaptive measures have the advantage of characterizing actual performance in
natural environments and during daily routines. Because they focus on such prac-
tical skills, item-level analysis of these measures can also yield helpful ideas about
 Selecting Meaningful Skills 53

specific skills for direct teaching. Although standardized assessments are helpful in
giving a general idea of where to begin, they generally do not provide enough detail
for goal writing and are typically not useful for tracking progress toward goals in a
way that can guide treatment planning.

Behavioral Observation Methods Behavioral observation is also routinely

used in NDBI programs. These observations typically consist of a clinician watch-
ing and recording the behavior of a child in one or more contexts (e.g., alone, with
a caregiver, with a peer, at home, at school) in order to collect data relevant to de-
veloping program goals or monitoring of progress. Behavior observations can be
structured or unstructured, depending on the information desired. Following a
structured protocol with a standard set of prompts and materials is helpful when
the goal is to track progress over time or compare behaviors across children. For
instance, research on PRT has routinely included data from Structured Laboratory
Observations (SLO; Hardan et al., 2015), whereas research on JASPER has routinely
included data from a Structured Play Assessment (Ungerer & Sigman, 1984). As an
alternative, unstructured observations are helpful for assessment of how children
typically function in a particular environment of interest and the extent to which
they show generalization of skills. These assessment methods may be time con-
suming if observational data are not collected in vivo, as video recordings must
then be evaluated for target behaviors at a later date.
In clinical settings, formats and goals of behavioral observation can vary
widely, and the clinician is ultimately responsible for selecting the most appro-
priate context for conducting the observation, the types of supports that may or
may not be provided during the observation, and which target behaviors will be
measured. Unlike standardized assessment protocols, which provide clear guid-
ance on administration and norms for interpreting results, the validity and use-
fulness of behavioral observation data depend on the clinician’s judgment and
expertise. For instance, data regarding the child’s performance must be interpreted
in the context of the clinician’s broader understanding of relevant developmen-
tal milestones. Measures such as the Early Social Communication Scale (ESCS;
Mundy et al., 2013) can be useful because they provide standardized methods for
assessing and recording skills such as joint attention, although this measure is not
norm-referenced. In addition, it is not uncommon for clinicians to develop sets
of semi-structured tasks that are introduced as a way to probe for various skills.
Observations from such interactions can then be recorded using developmental
checklists or curricula, such as those discussed previously.

Use of Published Curricula in Goal Development In order to gain more de-

tailed information and make the process of assessment and goal selection more
systematic, numerous curricula have been created and published for practitioners
and parents to use when creating an NDBI program. For instance, the ESDM ap-
proach uses a curriculum assessment checklist for identification of goals (Rogers
& Dawson, 2010). Project ImPACT also utilizes a social-communication skills
checklist (Ingersol & Dvortcsak, 2010). Other NDBI models provide general guid-
ance regarding the recommended developmental sequence for targeting progres-
sively more complex language (Koegel & Koegel, 2006) or play skills (Ungerer &
Sigman, 1984).
54 Core Concepts and Foundational Principles

In the absence of more available NDBI-specific curricular materials, clinicians

are encouraged to use materials from the fields of special education and ABA, many
of which have the advantage of systematically evaluating skills and directly linking
identified deficits to treatment goals. For example, the recently published Project
DATA (Developmentally Appropriate Treatment for Autism) manual (Schwartz et al.,
2017) is a helpful source for curricular materials relevant to young children with ASD.
In addition, curricular and goal-development materials have been published for early
childhood education that are relevant to both typically developing children and chil-
dren with special needs (e.g., Assessment Evaluation and Programming System for Infants
and Children [AEPS®], Second Edition; Bricker et al., 2002) or are specifically for chil-
dren with disabilities (e.g., The Carolina Curriculum for Infants and Toddlers with
Special Needs; Johnson-Martin, Attermeier, & Hacker, 2004). Progress on curricular
assessments has been shown to correlate with progress on standardized measures
(Bacon et al., 2014) and can be used at more frequent intervals to help guide treatment
planning. Additional materials from the ABA field may also be useful, especially
when systematic information about cognitive and language targets is appropriate.
For instance, assessment tools have been developed specifically for identifying goals
for ABA programs (e.g., Assessment of Basic Language and Learning Skills–Revised;
Partington, 2006; Verbal Behavior Milestones Assessment and Placement Program;
Sundberg, 2008), and a number of manuals have been published to guide ABA treat-
ment implementation (e.g., A Work in Progress; Leaf, McEachin, & Harsh, 1999).
Given that most of these curricular materials have not been standardized and
are designed primarily for young children, a combination of assessment methods
is likely the best approach to developing individualized programming and under-
standing long-term outcomes. Furthermore, as part of the assessment process,
gathering information about the child’s existing preferences and natural environ-
ments (Rogers & Dawson, 2010; Winton, 1990) can aid in individualizing the treat-
ment plan, as discussed next.

Individualization of Functional Treatment Goals

As the field of behavior analysis has begun to incorporate increased understanding
of human development, emphasis on individualization of target skills has risen to
the forefront of focus for many treatment models, especially NDBI. Though it may
initially seem easier to apply the same teaching curriculum to all children, each
child presents with a unique set of strengths and weaknesses, and each family
presents with a unique set of routines, values, and priorities. Without individu-
alization, progress may be less meaningful to the child and family. Because all
individuals with ASD are just that—individuals—treatment programs must be de-
signed specifically to meet each person’s needs. Clinicians must prioritize skills that
will be most functional at a given point in time, taking into consideration that this
may vary by individual (Anderson, 2013). Child, family, and practitioner variables
should all be considered in selecting individualized goals (Stahmer, Schreibman,
& Cunningham, 2011). By using specific child and family characteristics to select
target behaviors, clinicians can improve their effectiveness.
Children with ASD often have difficulty demonstrating age-appropriate
skills, and it may therefore be tempting to pick individualized goals based on
expectations for their chronological age. Because children with ASD often show
 Selecting Meaningful Skills 55

delayed social-communication skills rather than deviant patterns of behavior

(Morgan, Cutrer, Coplin, & Rodrigue, 1989; Snow, Hertzig, & Shapiro, 1987), teach-
ing should instead occur in developmental sequence (Anderson & Romanczyk,
1999). Children may actually acquire skills more readily when they are selected
based on appropriate developmental sequence, rather than chronological age-
based expectations (Lifter, Sulzer-Azaroff, Anderson, & Cowdery, 1993). Providers
can also build on skills already in the child’s existing repertoire. For instance, when
teaching first words, a provider might select the word cup to teach a child already
saying a /k/ sound and might teach the word milk to a child already saying the /m/
sound. Individualization based on child characteristics can include modifications
in what to teach. Teaching an adolescent to tie his or her shoes may seem like a
useful and functional self-help skill; however, it fails to be functional if the child
dislikes and never wears shoes with laces.
Person-centered planning (e.g., Coyne & Fullerton, 2014) is an ongoing collab-
orative process in which stakeholders (e.g., treatment providers, parents, caregiv-
ers, school personnel) partner with the individual with ASD (or any developmental
or medical condition) to develop and actualize that person’s vision for his or her
life and future. Person-centered planning is another important area of focus when
individualizing treatment goals, especially with teens and adults with ASD. In this
approach, the team works together to identify opportunities and implement strate-
gies focused on development of personal relationships, participation in the com-
munity, increased autonomy, and development of skills needed to attain these goals.
Several key principles of person-centered care include valuing individuals, auton-
omy, valuing the life experience of the individual, understanding relationships, and
focusing on necessary environmental supports.
As many more individuals with ASD advance to treatment in various
community settings, NDBI will need to continue to adapt to addressing their
needs. Self-determination and autonomy are important principles to incorpo-
rate into treatment planning, even when individuals require a high level of sup-
port. Selecting treatment targets that are meaningful to the individual must be
addressed as another way to individualize treatment goals. At times, there may
be disagreement between treatment or care providers and individuals with ASD
about appropriateness of a behavior. For example, if an individual with ASD
wants to eat pizza three times per day due to rigid eating patterns but is becom-
ing unhealthy and overweight, it may be more important to set goals to expand
eating habits, rather than if the individual eats pizza a few times per week and
his or her parents feel this is unhealthy. Like all human beings, individuals with
ASD have the right to self-determination and autonomy. These rights must be
balanced with promoting optimal functioning and decreasing risks to well-being
that the individual may not recognize. The use of person-centered planning strat-
egies is one important way to address these key factors in selecting functional
intervention targets.
Individualized goal planning has been shown to be a promising way to enhance
treatment effectiveness (Schreibman & Koegel, 2005; Sherer & Schreibman, 2005). One
way to both individualize programs and increase efficiency is by using a decision tree.
Decision trees are typically visual models that break down a course of action (plan)
and guide next steps based on an individual’s performance over time. Decision trees
are useful because they account for numerous possibilities and provide a framework
56 Core Concepts and Foundational Principles

for assessing the likelihood of different outcomes. For instance, ESDM uses decision
trees to guide providers in deciding how to address nonresponse to initial treatment
efforts, often by targeting alternative skills (Rogers & Dawson, 2010). For example, if
a child is not learning to make word approximations after 3–6 months of treatment,
the decision tree may guide providers to augment the treatment approach by intro-
ducing a Picture Exchange Communication System (PECS) or signs paired with
speech. Likewise, research on the effects of combining JASPER and EMT has sug-
gested that addition of a speech-generating device may be helpful for children who
are nonverbal and initially unresponsive to intervention (Kasari et al., 2014).
Advances in the understanding of specific factors that predict response to NDBI
procedures suggest that personalized treatment selection based on child character-
istics may soon be possible (Stahmer, Schreibman, et al., 2011). In an early study
of predictors, Sherer and Schreibman (2005) conducted a retrospective analysis to
identify potential behavioral profiles for predicting response to PRT. They identi-
fied several child characteristics (interest in toys, verbal self-stimulatory behav-
ior, minimal nonverbal self-stimulatory behavior, and tolerating another person
in proximity) that indeed predicted positive response to PRT in a subsequent pro-
spective study of six children. A follow-up study suggested that toy interest may
be particularly important for positive response to PRT but did not predict response
to a discrete trial treatment (Schreibman, Stahmer, Barlett, & Dufek, 2009). Fos-
sum and colleagues (2018) found a similar profile, including child cognitive ability,
positive affect, and levels of appropriate toy contact, predicted response to PRT
in their larger community-based sample. Hardan and colleagues (2015) reported
greater improvement from PRT in children with stronger visual reception skills at
baseline, whereas Vivanti and colleagues (2016) demonstrated that verbal ability at
treatment entry moderated treatment response in young children receiving ESDM.
Yang and colleagues (2016) completed an uncontrolled trial that found association
between functional magnetic resonance imaging (fMRI) brain response to biologi-
cal motion and positive response to PRT.
Other studies have suggested that parent involvement is a significant predic-
tor of treatment response to NDBI, and high levels of parent stress at baseline may
be associated with poor child response to treatment (Stadnick et al., 2015). A study
of Project ImPACT showed an association between parent use of treatment strat-
egies and child progress on language measures (Ingersoll & Wainer, 2013). In a
study of JASPER, parent involvement, buy-in, and use of strategies were related to
child joint engagement (Gulsrud, Hellemann, Shire, & Kasari, 2016).
As is clear from this growing body of research, identifying predictors of
response to NDBI is a critical area for future study and will allow for greater indi-
vidualization of goal selection and treatment approach. Considerable progress
has been made in identifying child and family factors associated with positive
response to treatment. It is expected that treatment selection will soon be guided
by more sophisticated understanding of factors predicting treatment response so
that eventually treatments can be selected based on child characteristics indicating
high likelihood of a favorable response.

THE NATURAL ENVIRONMENT

The decision about where to teach functional skills provides another opportu-
nity to individualize treatment and maximize the focus on meaningful goals.
 Selecting Meaningful Skills 57

Clinicians should consider a wide range of potential teaching settings; differ-

ent contexts may convey distinct advantages depending on the child and family
needs. When performance in real-life settings is the ultimate goal of any interven-
tion program, it makes sense to prioritize teaching in environments that are natu-
rally a part of the child’s daily routine. Although “natural” often means home or
community—and “unnatural” might mean segregated, clinic, or office settings—
many clinic settings can function as a natural environment if planned accordingly
(e.g., classroom-based NDBI programs that are conducted in clinic settings). In some
circumstances, a child’s rate of learning new skills may be enhanced by teaching
specific skills in a setting that provides additional structure or fewer distractions.
In this case, incorporating naturalistic components into the setting will be criti-
cal to enhance generalization of skills to natural environments as well. Clinicians
should consider how to maximize the effectiveness of the available teaching set-
tings, as well as the likelihood that teaching in those settings will help the child
function across contexts that really matter to the child and family.
On some occasions, teaching in a more structured and decontextualized for-
mat may be warranted, at least temporarily, due to individual needs or particularly
slow rate of learning. For some individuals, learning proceeds at a faster rate in a
highly structured approach than with a completely contextualized and naturalis-
tic approach. The individual can more readily focus on the salient learning cue(s)
and access reinforcement immediately. Skills can also be broken down into smaller
components, and focus can be placed on teaching systematically and incrementally
toward the whole. This approach can also be beneficial for teaching some skills
where natural reinforcement is more difficult to provide, when it may not actually
be reinforcing yet, or when skill fluency is required in order to obtain natural rein-
forcement. The ultimate goal is to work toward a more naturalistic and contextual-
ized framework if possible so that each individual can benefit from its advantages,
particularly maintenance and generalization of skills (see Box 3.4 for definition).
There are a number of reasons, both common sense and empirically sup-
ported, why NDBI emphasize teaching skills in the natural environment. There
is even some evidence that children may present different behaviors in natural
settings than they do in clinics (Stronach & Wetherby, 2014), and because perfor-
mance in the natural environment is the ultimate goal, targeting skills in that
setting often makes the most sense. Although behavioral treatments were first
applied in structured settings with few similarities with the natural environment
(LeBlanc, Esch, Sidener, & Firth, 2006), the earliest studies of naturalistic behavioral
treatments employed teaching in the natural environment as a strategy to increase

BOX 3.4: Skill maintenance and generalization

Skill maintenance: A skill is maintained when the child continues to demon-
strate the skill after additional reinforcement from the teaching phase is
faded.
Skill generalization: The transfer of a skill learned under one set of conditions
to another set of conditions. Typically thought of as transfer across people,
settings, and behaviors.
58 Core Concepts and Foundational Principles

generalization and spontaneous use of skills (e.g., Hart & Risley, 1968). Subsequent
researchers were heavily influenced by Stokes and Baer (1977) and their seminal
work on generalization, which inspired the development of a range of treatment
approaches for implementation in natural settings and by caregivers and teachers
(i.e., natural change agents). Several decades of research now support the effective-
ness of teaching in natural settings, not just for skill acquisition but also in terms of
collateral effects on untargeted behaviors (Hart & Risley, 1980).
Rate of skill acquisition, maintenance, and generalization of skills are impor-
tant features to consider in any treatment. Naturalistic teaching strategies have been
shown to have considerable advantage; they are quite effective at promoting skill
acquisition (Delprato, 2001), and when skills are taught in the natural environment,
they often maintain longer and generalize more quickly (Dufek & Schreibman, 2014;
Ingersoll & Dvortcsak, 2010; Rogers & Dawson, 2010). Natural environment teach-
ing also allows for practice and feedback in the setting where the skills occur, and
the resulting natural reinforcement helps the learned skills generalize more quickly
and maintain over time. The use of natural maintaining contingencies has long
been recognized as a key way to promote generalization (Stokes & Baer, 1977). For
instance, one study demonstrated that children made greater improvement in the
intelligibility of their speech when teaching occurred in natural contexts (Koegel,
Camarata, Koegel, Ben-Tall, & Smith, 1998). Parent training, which can be more
practical and accepted in natural settings, also enhances maintenance and general-
ization (Kaiser, Hancock, & Nietfeld, 2000; Kasari, Gulsrud, Paparella, Hellemann,
& Berry, 2015; Koegel, Koegel, Kellegrew, & Mullen, 1996).
Intervention in a natural setting lends itself to more engagement and involve-
ment with the parent, caregiver, siblings, peers, or other individuals who fre-
quently interact with the individual with ASD. This means that targeting skills
in the natural environment can increase the dosage and intensity of the treat-
ment via involvement of key stakeholders. For example, if a skill is practiced in the
natural environment with the relevant caregivers, those individuals will be more
likely to support the individual with ASD when a clinician is not present, thus
increasing the dosage (Ingersoll & Dvortcsak, 2010; Vismara, Colombi, & Rogers,
2009). Another way to facilitate increased dosage and practice in the natural envi-
ronment is to directly teach intervention strategies to parents and other care-
givers. Research on PRT, for example, supports that teaching parents this NDBI
approach in groups is associated with parent acquisition of PRT skills, increased
parent empowerment, and child language gains (Hardan et al., 2015; Minjarez,
Mercier, Williams, & Harden, 2013; Minjarez, Williams, Mercier, & Hardan, 2011).
This innovative approach simultaneously increases treatment dosage across
numerous children and results in intervention being implemented in their natu-
ral environments.
Thus, the environment matters. Parents and providers should consider teach-
ing across a wide variety of settings for optimal generalization and maintenance
of meaningful skills. Although not every skill must be taught exactly where it will
be used, and not every person in the individual’s life must be involved, a concept
shared by NDBI is that the more natural the setting, and the more stakeholders
who participate and learn support strategies, the better the skill will generalize
to where it must be used, and the more fluidly reinforcement will be obtained to
promote skill maintenance. See Box 3.5 for more on planning for generalization.
 Selecting Meaningful Skills 59

Ready, Set, Implement!

BOX 3.5: Planning for generalization
To plan for generalization from the start, select a current client’s program. Take a
look at each goal and how you have written mastery criteria. How many people
should the client practice the skill with? Should the goal include both adults
and peers? How many settings apply to this goal? How many sessions, days,
or weeks do you want to see the client demonstrate this skill independently
before you consider it mastered? By looking at each goal individually to
answer these questions, you ensure both individualization as well as increased
likelihood the client will generalize (and maintain!) newly learned skills.

Types of Natural Environments

A natural environment is the context in which the individual lives, goes to school,
works, and/or engages in social or extracurricular activities. The natural environ-
ment for a toddler might consist of home, preschool, and any other community
settings that are part of his or her family’s routine. As an individual develops, the
natural environments may change to involve different settings or individuals. For
a teenager, these environments may include home, school, sports practice, com-
munity (e.g., buying goods and services), and social settings or events such as ac-
tivities with peers (e.g., clubs, friends’ houses). For an adult, environments may
shift to include the workplace as well as additional social and community settings
(e.g., gym, bars or restaurants). Also included in the natural environment are fam-
ily members, caregivers, and others who may interact with the child in a teach-
ing, mentorship, or supervisory capacity (e.g., teacher, coach, employer). Although
perhaps not identified as a traditionally natural environment, therapeutic settings
such as a clinic can be included in the natural environment in the event that they
have been set up in a manner that imitates the natural environment (e.g., play-
rooms or classroom settings).

Home Settings The home environment is perhaps the most natural of envi-
ronments and a critical context for practicing and performing many meaningful
skills. For example, very young children are more likely to be comfortable at home
compared to an unfamiliar clinic (which may also remind them of going to the doc-
tor). At home, they can access familiar caregivers and be surrounded by familiar
toys and activities. The home setting also provides access to a wider variety of rou-
tines and activities (kitchen, play spaces, outside areas), which allows for targeting
more skills in the natural context (Ingersoll & Dvortcsak, 2010). It also allows for
frequent switching of activities and the use of daily routines, which is appropriate
for young children who are not expected to attend to one activity for more than a
few minutes at a time.
Teaching at home allows for embedding skills within family routines. Across
NDBI approaches, teaching during daily routines is emphasized as an optimal way
to ensure frequent practice of functional skills. For example, if a parent wishes to
60 Core Concepts and Foundational Principles

increase the frequency of a child’s verbal requests, identification of multiple specific

times during the day when the child can practice is often useful (e.g., asking to be
picked up in the morning, requesting breakfast items, asking to open the door to go
outside, requesting bath toys). With repeated practice, the simple act of engaging in
these daily routines can even start to serve as a reminder to practice the communi-
cation skills. Home-based intervention also gives providers insight into how sug-
gested treatment approaches actually fit into a family’s day-to-day life. For example,
a provider might observe that a parent sometimes has difficulty waiting for the
child to make an appropriate verbal request to go outside when the family is late for
school. The provider could suggest that this communication skill only be prompted
in the afternoon period when the parent has sufficient time to wait for an appropri-
ate response. The social validity of intervention will become quickly clear in the
home setting. If modifications to the treatment goals or approach are necessary to
improve goodness of fit with family cultural norms and values, an observant pro-
fessional working in the home setting can help families make these modifications.
Some behaviors that may be important targets for intervention may occur only
in the home setting. For example, if providers wish to have a meaningful impact
on feeding, sleep, dressing, or other personal hygiene behaviors, intervention in
the home may be the most efficient and appropriate way to address these skills.
Sometimes children exhibit challenging behaviors in the home setting that are not
observed in a clinic or school. Intervention to reduce these challenging behaviors
is therefore most effective in that context in which it most frequently occurs. Inter-
vention in the home setting can also allow for more natural involvement of family
members, and the amount of time they participate can be flexible and match a
specific routine or activity.
There are some occasions where teaching in the home environment may not
be the ideal choice. Parents and providers may find the need to weigh the ben-
efits of teaching at home against practical considerations (shared family space and
living arrangements, family schedules, availability of peers and diverse learning
materials) and consider whether an alternative setting may be beneficial for at least
some of the teaching.

Community Settings Treatment in community settings provides a unique

opportunity to teach skills that will be meaningful to both the child and to the
family. Treatment in community settings may also support inclusion by making
other individuals more aware of the needs of individuals with disabilities and pro-
mote respect and acceptance. Many families of children with ASD feel isolated due
to limited engagement with community activities. Often this can be exacerbated by
a child’s unpredictable or disruptive behavior that can feel even more challenging
to manage outside the home. If a provider can conduct intervention in this setting,
parents can be coached in effective management of these behaviors for future occa-
sions. Helping a family develop behavior supports that allow a successful trip to a
grocery store, restaurant, or religious ceremony can greatly enhance quality of life.
Expectations for behavior also vary across community settings. Because chil-
dren are expected to behave differently depending on whether they are playing in
a park, visiting a library, crossing a street, or eating at a restaurant, practicing skills
across settings allows these nuances to be taught most effectively. For example,
the grocery store may be an effective place for teaching walking next to a parent
 Selecting Meaningful Skills 61

and communicating requests to purchase preferred items, as well as tolerating

denied access to preferred items, waiting (e.g., in line), and handling aversive sen-
sory input. In the park, there might be increased focus on social-communication
and play skills as well as following safety directions and decreasing elopement. At
church, the treatment might focus on skills such as waiting prior to being allowed
to leave the setting, engaging in quiet activities to promote appropriate behaviors,
and conducting context-specific routines such as taking communion. The skills
that are appropriate to each context are broader in scope than those that are taught
in the home setting, thus expanding both the number of settings in which the indi-
vidual can function appropriately and the number of skills being targeted.
Different types of people are also available in community settings, which pro-
vides opportunities for a child to practice a range of social skills and respond to a
range of social cues. If some of the targeted skills involve interaction with peers,
intervention in a community setting, such as a park, may provide access to those
peers with whom the individual can consistently practice skills and receive feed-
back. Furthermore, for development of safety skills, it is critical that children learn
how to interact differently with strangers versus familiar people; these types of
skills are ideal for practice in real-world community settings.
Group-based activities (e.g., teams, camps, other group extracurricular activi-
ties) are settings in which typically developing children commonly participate and,
as such, are desirable settings for individuals with ASD as well. Children enrolled
in extracurricular activities, sports, summer camps, and clubs also have more
opportunities to develop friendships and build social skills, although research
indicates that children with disabilities tend, in general, to participate less than
their typically developing peers in such activities (Solish, Perry, & Minnes, 2015).
When involved, many individuals can show gains in social areas (Brooks, Floyd,
Robins, & Chan, 2015), as well as experience long-term academic and social benefits
(Ashbaugh, Koegel, & Koegel, 2017; Palmer, Elliott, & Cheatham, 2017).
Drawing on the NDBI principles of following the child’s lead and child choice,
often the best strategy is to select activities or clubs related to a child’s specific
interests to keep him or her engaged and increase the chances of meeting com-
patible peers. The key is to select an activity the child will enjoy and be able to
participate in (with support if necessary). Many children do best in group activities
that emphasize individual performance (martial arts, swimming, music lessons)
rather than competitive team sports in which the whole group relies on the child’s
skills, such as soccer and basketball. Team activities also require a great deal of
social judgment, which may be challenging. Self-management (see Chapter 13 on
addressing challenging behavior) can also be used to promote independent use of
important social skills in group contexts.
Camp settings are another natural environment that have been shown to have
therapeutic effects when intervention is applied. Summer camps for children with
ASD or other special needs initially tended to be segregated (Blas, 2007; Hung &
Thelander, 1978). However, intervention has been implemented in inclusive summer
camp settings, with gains noted specifically in social skills (Brookman et al., 2003;
Maich, Hall, van Rhijn, & Quinlan, 2015). Corbett and colleagues (2014) found that
children with ASD who participated in a theater-based inclusive, peer-mediated
summer camp demonstrated gains in social areas, such as face perception and social
cognition.
62 Core Concepts and Foundational Principles

Throughout the life span, participation in group activities can have social and
academic benefits. Palmer and colleagues (2017) found a significant association
between students with disabilities who participated in extracurricular activity and
postsecondary degree completion. Ashbaugh and colleagues (2017) utilized a brief
structured social planning approach with adolescents with ASD and found an
increase in their number of community-based social events, extracurricular activi-
ties, and peer interactions.

School Settings The school setting is another core natural environment for
all children. Typically developing children spend around 1,000 hours in school
each year. Under the Individuals with Disabilities Education Improvement Act of
2004 (PL 108-446), children with disabilities in the United States are entitled to
free appropriate public education in school, in the least restrictive environment.
This means that children have a fundamental right to be educated appropriately
in school.
Schools provide many benefits as teaching environments. First, because many
children with ASD benefit from familiarity and routine, the predictable structure
of the daily schedule often helps children know what behaviors will be expected
of them each school day. For instance, the greeting routine or circle time each day
can become familiar to children with ASD and support their participation. Con-
sistent behavioral expectations also often help children with ASD learn appropri-
ate behavior. For instance, disruptive noises or high levels of movement may be
difficult to accommodate in a school setting, and children may learn to reduce
these behaviors in compliance with classroom expectations. Many teachers use
multimodal teaching strategies, including visual and tactile supports, which often
benefit children with ASD, who may have different learning styles. Furthermore,
the fact that many children with ASD enjoy basic academic tasks such letter iden-
tification and counting also helps them enjoy early schooling. The group learning
format may be challenging for children with ASD, but it can also help children
generalize skills learned in an individual context to a more real-life environment.
A meta-analysis completed by Bellini and colleagues (2007) and work by Gresham,
Sugai, and Horner (2001) indicate that social skills intervention in the natural
environment as opposed to pull out settings tends to be more successful. Finally,
schools are an ideal context for enhancing social skills and peer interaction given
the number of hours children spend at school and the ready availability of peers
in this context.
Research supports the application of NDBI in school settings, and NDBI
approaches can be implemented in school contexts in a variety of ways. For pre-
school programming, there are a number of inclusive models for serving young
children with ASD and typically developing peers using NDBI approaches. For
instance, classroom design can be informed by NDBI contextual variables, as
in the Walden Toddler Program (McGee et al., 1999), in which classrooms were
divided into zones arranged to provide opportunities for incidental teaching. In
this context, adults provide instruction and reinforcement in response to child-
initiated teaching episodes. In other models, naturalistic developmental behavioral
supports are provided within the context of an inclusive preschool program. For
example, in the Alexa’s PLAYC (Playful Learning Academy for Young Children)
program, all children are provided developmentally appropriate early childhood
 Selecting Meaningful Skills 63

education within a predictable daily routine, and contextual (e.g., visual supports)
or behavioral (e.g., prompting and reinforcement) strategies can be provided as
needed to support skill acquisition for a child with ASD and can subsequently be
faded to promote independence (Stahmer & Ingersoll, 2004). In another model, the
Project DATA program provides individualized behavioral treatment and parent
training as a supplement to high-quality early childhood education in an inclu-
sive setting (Boulware, Schwartz, Sandall, & McBride, 2006; Schwartz, Sandall,
McBride, & Boulware, 2004; Schwartz, Thomas, McBride, & Sandall, 2013). Research
on ESDM (Vivanti et al., 2014) and JASPER (Goods, Ishijima, Chang, & Kasari, 2013)
also indicates that these approaches can be successfully implemented in preschool
settings. The LEAP program (Learning Experiences: An Alternative Program for
Preschoolers and Parents; Strain & Bovey, 2011) emphasizes peer-mediated inter-
vention approaches to support children with ASD in inclusive preschool settings.
Research is now emerging on application of NDBI strategies in school settings
for elementary school children as well. For instance, Mandell and colleagues (2013)
documented implementation of Strategies for Teaching Based on Autism Research,
a program that combined discrete trial training with PRT and teaching within
functional routines. Stahmer and colleagues (2011) also published a manual outlin-
ing the application of PRT to classroom settings for children in early elementary
school. This research indicated that many teachers can be trained to use evidence-
based NDBI approaches in their classrooms (Stahmer, Suhrheinrich, & Rieth, 2016)
and also identified a number of challenges to embedding these practices within
existing school systems (Suhrheinrich et al., 2013). For instance, direct coaching of
teachers may be required to support sustained implementation of these practices
(Suhrheinrich, 2011). Another promising approach has been to train individuals with
ASD to initiate (Koegel, Kuriakose, Singh, & Koegel, 2012) or use self-management
(de Bruin, Deppeler, Moore, & Diamond, 2013) to enhance performance in school set-
tings without the need for intensive intervention in that setting. Chapter 5 reviews
additional examples of how NDBI approaches have been embedded in inclusive
settings, and Chapter 14 is focused on implementing NDBI in schools.
Many children participate in school programs that have ABA treatment embed-
ded in the classroom. Other school programs may contract with ABA agencies to
provide ABA to specific children in their school on an as-needed basis. Both types
of programs may vary in the degree to which providers use naturalistic behavioral
strategies, but parents knowledgeable about NDBI components can often advocate
for incorporation of naturalistic procedures. For instance, parents can request spe-
cific modifications to the child’s school program to support engagement, motiva-
tion, and generalization, such as incorporation of child interests into assignments,
use of natural reinforcement, or implementation of a self-management program.
A school program that is unwilling to implement evidence-based ABA or
NDBI strategies for a child with ASD can be a significant challenge. The first step
is to make sure that a child’s educational team is in agreement that the identified
deficit areas (e.g., academic skills and/or social behaviors) are important targets
for intervention. For social areas, it is often helpful to make sure there are goals
related to peer interaction written directly in the child’s individualized education
program (IEP). It is also important to identify which adults (teacher, paraprofes-
sional, speech pathologist, behavior therapist) will be directly responsible for treat-
ment implementation in each school context (during class time, lunch, and recess).
64 Core Concepts and Foundational Principles

If professionals across multiple public (e.g., school) and private (e.g., therapy clinic)
agencies are involved in a child’s care, coordination of goals and intervention strat-
egies across providers is especially critical.

Clinic Settings Treatment in a clinic setting will often be a component of a

child’s intervention plan. Clinic-based treatment can convey particular advantages,
especially as a complement to treatment provided in other natural environments.
Clinic settings can be particularly useful when structured practice of skills is nec-
essary because clinicians often have greater control of contextual variables in the
clinic setting. In these settings, it can be more feasible to arrange the environment
in a manner conducive to the child’s learning or to reduce distractions if necessary.
Given the treatment priority of building skills relevant in real-life settings, the
addition of naturalistic components in clinic settings may also enhance meaning-
ful generalization of skills. When clinic settings are used, there are specific strate-
gies that can make these settings more natural and appropriate for intervention.
For young children, clinic-based programs can be natural if they are designed
from a play-based and developmental perspective and set up to mimic the natu-
ral environment. Ensuring availability of developmentally appropriate toys and
materials and arranging rooms to mimic other important natural learning envi-
ronments the child currently has access to or is preparing to participate in can be
useful. For example, a treatment space for a young child might be set up to mimic a
playroom or classroom setting, with spaces for group instruction, individual work-
spaces, child-sized furniture, toys, and books. When possible, access to an outdoor
play area or designated space for gross motor play can be helpful. Environmental
arrangements may also be useful in order to provide the child with opportunities
to request items that are not readily available, the way he or she would have to do
at home or in a classroom. For example, having some materials available just out of
reach (e.g., in a cabinet, on a higher shelf) may motivate a child to use spontaneous
communication.
For older children, inclusion of academic or vocational workspaces is appro-
priate, along with spaces for learning recreational and leisure skills. For instance, a
school-age child might benefit from a desk for completion of academic work; a table
for playing board games, puzzles, or block constructions; a comfortable chair or
couch for socializing or playing handheld games; and access to an outdoor area
or gym for practicing sports. For an individual preparing for a job at a grocery
store, shelves for organizing items for purchase might be appropriate. For an indi-
vidual preparing for a job at a hotel, access to a laundry machine may facilitate
learning important housekeeping skills. A treatment space for an adolescent social
group might be set up to mimic a school lounge with couches, a speaker for play-
ing music, and snack items. Some clinics may also have access to areas such as a
kitchen or can create areas that simulate a bedroom or dining room, which can
increase the ability to practice a wide range of skills necessary for independent liv-
ing. The more the clinic environment mimics other real-life settings relevant to the
individual and family, the more readily skills learned in the clinic can be expected
to generalize in other meaningful environments.
There are some additional factors to consider when providing intervention
in a clinic setting. For example, a clinic or office setting may pose limitations on
the number of individuals who can be present, as well as the types of situations
that can be taught or practiced. Participation in a clinic setting is more difficult
 Selecting Meaningful Skills 65

because someone has to transport the child there and then either drop the child
off or remain present throughout the duration of the session. A parent may be
able and willing to participate in a 2-hour session; however, the child’s siblings
or peers may not be able to do so. For these reasons, treatment programs that
provide intervention across a variety of settings have many advantages. When
possible, plan both home and community sessions, integrated with clinic-based
instruction, to allow a wide range of relevant skills to be taught, practiced, and
generalized.

Social Validity of the Natural Environment

Social validity of treatment context has also been a focus of investigation for
NDBI (Ogilvie & McCrudden, 2017; Kim, Koegel, & Koegel, 2017). Evidence in-
dicates that practicing functional skills across a child’s natural environments is
a critical way to enhance the social validity of treatment efforts. As previously
discussed, social validity should emphasize the client and family’s perspective
on the acceptability of treatment. Clinicians should consider the child’s tempera-
ment, cognitive profile, interests, learning history, and other individual factors,
which may influence how he or she responds to certain teaching contexts. For
instance, a therapist might learn that a child responds particularly well to teach-
ing during physical play and could then tailor the treatment to involve outdoor
activities and highly physical indoor play. Another child might learn best when
his or her surroundings are more calm and quiet, and the therapist could work to
minimize distractions and noise to enhance learning. Research has indicated that
parents may also prefer more naturalistic interventions (Schreibman, Kaneko, &
Koegel, 1991).
For an intervention to be socially valid, it should be practical for stake-
holders to use (Winett, Moore, & Anderson, 1991). NDBI’s emphasis on par-
ent involvement and embedding treatment within daily routines is consistent
with this priority. Treatment providers can be most effective when they seek to
help parents integrate teaching into naturally occurring activities rather than
suggesting parents find time to practice outside their normal daily lives. For
instance, a parent can help teach a child about colors while sorting laundry. In
another example, EMT (Hancock & Kaiser, 2002, 2006) enhances goodness of fit
by establishing treatment routines within existing daily activities (arranging the
environment, teaching to promote language use in functional context). Other
NDBI approaches also encourage practicing skills in the context in which they
are naturally relevant.
A socially valid intervention should also improve family quality of life. When
children learn skills and practice them both at home and in important community
contexts, it can make a real difference for the family. For instance, parents who
teach their child skills that allow them to take the child to a restaurant, grocery
store, or church service will likely feel less isolated and less burdened by the child’s
disability. Providers should therefore work collaboratively with family members to
identify contexts for intervention that may enhance family quality of life. Because
the long-term utility of interventions depends on how well they can be integrated
in family and community contexts, the continued development of practical sys-
tems and tools for enhancing social validity of interventions and enhancing good-
ness of fit with family values is still urgently needed.
66 Core Concepts and Foundational Principles

Case Example: Jin

Jin is a 6-year-old Asian American boy who was diagnosed with ASD just before his
third birthday. Having recently moved to a new city, Jin’s parents began the process
of establishing treatment with a new set of providers. When his parents first dis-
cussed their treatment priorities with the supervising clinician, they expressed want-
ing Jin to learn his numbers, colors, and shapes. When discussing treatment goals
further, the supervisor learned that it was also very embarrassing to the family that
Jin still was not toilet trained. The supervisor wanted to prioritize this goal because
it was important to the family, it would help Jin be more independent, and Jin was
showing signs of being developmentally ready (e.g., disliking being dirty, attempting
to wipe himself, pulling up his own pants, waking up dry in the morning).
After completing an initial assessment, the clinician reviewed treatment priorities
and suggested that, given their role in long-term positive prognosis and prevention of
challenging behavior, several functional communication skills (e.g., describing desired
items and asking for a break) should also be considered a key priority. Together with
the family, the clinician developed a plan to integrate teaching of numbers, colors, and
shapes into the broader functional communication goals to ensure the family members
felt their priorities were being addressed, in addition to those being proposed by the clini-
cian. Although it was not initially on the family’s list of treatment priorities, the clinician
also suggested that the parents add several social goals in anticipation of the struggles
many children with ASD have during peer interactions. Jin’s parents confessed that they
did not have many opportunities to observe him around other children, but they agreed
that these additional goals made sense. Jin’s initial goals by domain are listed in Table 3.1.
The team considered multiple natural contexts for treatment. They identified
home as the best place for practicing toileting skills and as a critical environment for
targeting communication and social goals. They identified the school environment for
practicing asking for a break, as well as a number of social and preacademic skills.
As Jin’s therapists started implementing in-home treatment sessions, the treat-
ment supervisor also started providing parent training during one of the family’s
weekly appointments. Knowing from the intake assessment that Jin’s parents held
many traditional Asian values, including the importance of family, the supervisor was
careful to involve both parents as much as possible and offered to include Jin’s grand-
parents in sessions when they were visiting the family. Although Jin’s parents at first
appeared agreeable to the idea of following Jin’s lead when teaching communication,

Table 3.1. Jin’s initial goals

Natural environment
Domain Functional goal priority for practice

Communication Describe desired items (by number, color, Home, school

or shape)
Ask for a break School
Daily living skills Use the toilet independently Home
Social skills Imitate peer behavior in a group setting School, Aikido class
Initiate appropriate requests for play materials Playdates at home, school
Initiate new activity ideas Park, walks home
 Selecting Meaningful Skills 67

they continued to be very directive in their interactions with Jin, even after a month of
parent training. The supervisor was worried that Jin might lose motivation to commu-
nicate if his parents asked too many questions without reinforcement, but the parents
did not agree with this feedback. They wanted Jin to obey their instructions at home
but were also uncomfortable directly contradicting the supervisor and continued
giving Jin instructions the way they always had.
The therapist decided to ask more about the family’s beliefs about effective par-
enting and learned that Jin’s parents felt strongly that children should show respect to
parents’ authority by obeying their directives. The therapist worked to understand the
family perspective and find a compromise that allowed the parents to take advantage
of Jin’s interests to motivate him to learn while maintaining their role as authority fig-
ures within the family. For example, the parents and therapist were able to generate a
number of examples of teaching contexts and target behaviors in which they could pro-
vide Jin with instructions or ask him questions within motivating activities or his areas
of interest. In this way, the parents were able to maintain their expectations while also
targeting Jin’s motivation to make social-communication responses and follow direc-
tions. As the parents learned more skills, they were able to learn strategies such as
interspersal of maintenance and acquisition tasks and shaping in order to give Jin more
instructions in adult-directed contexts because these also were important to them.
Once the parents and supervisor successfully merged their approaches, the par-
ents learned how to take advantage of incidental opportunities throughout the day for
practicing descriptive language. It was tempting to ask Jin to label or describe (e.g.,
by color) objects all the time, but after the therapists modeled and explained how to
use shared control and natural reinforcement strategies to target functional requests
instead, the parents could see how much more readily Jin responded when these moti-
vational strategies were incorporated. Jin even started using more complex descriptive
language spontaneously. For instance, because Jin loved playing with his train track, his
parents learned how to work collaboratively with Jin to build the track together and how
to guide him to use words to describe exactly how he wanted to build it (e.g., modeling
phrases for him such as “put the curved track next to the bridge” and asking him ques-
tions such as “What order should I put the trains in?”) in the context of reciprocal play.
Because Jin was attending school, his parents and providers considered how
treatment goals could also be addressed in the school setting. His parents advocated
in the IEP meeting to have functional goals emphasized on Jin’s IEP. In addition to
academic goals, his parents advocated for Jin to learn how to appropriately ask for
a break so that he would not be reinforced for using disruptive behavior to escape
difficult tasks. They also asked the school team to prompt him to use descriptive
language to request desired items, as he was practicing at home. The team agreed
to add these goals to his IEP and implemented a plan for coordination between par-
ents and teachers. Jin’s parents initially wanted daily feedback on Jin’s performance
in school. After discussing the feasibility of this with the teacher, they agreed that
a weekly communication log would be more sustainable for the teacher and would
still allow the parents to take Jin on a special outing each weekend to celebrate his
consistent appropriate behavior at school. Jin’s parents started including pictures from
their weekend in the log, which helped Jin describe recent past events when children
shared weekend activity stories during Monday morning circle.
68 Core Concepts and Foundational Principles

The team also considered peer interaction opportunities in treatment planning.

In talking with Jin’s providers about social goals, his parents realized that school
was the main context where Jin had a chance to interact with peers. Jin’s parents
were most concerned that Jin was often alone on the playground. They discussed
this problem in the IEP meeting and came up with several functional goals related to
peer interaction at school, including increasing the duration of peer engagement dur-
ing recess. The team decided that it would be most functional for Jin to practice the
types of tag games children in his class typically played on the playground. Because it
was easier for Jin to follow the pace of the game when he was with a buddy (and this
gave him an opportunity to work on the goal of imitating peers), the teacher was able
to suggest a modification to the rules so that the children played in pairs.
Jin’s parents soon realized that Jin’s chances of developing meaningful rela-
tionships with peers would be stronger if he had opportunities for peer interaction
outside school as well. Because Jin did not have any friends from his neighborhood,
his parents started by asking a cousin to come play for a short time on the weekend.
Jin’s mother prepared several fun activities that she knew both children would enjoy
(making cardboard robots, decorating cookies). Jin practiced the functional skill of
initiating to request items from his cousin whenever he needed more materials for his
project (e.g., glue for his robot, sprinkles for his cookie). The next week, Jin’s mother
set up another playdate by asking a good friend of hers from work who she knew had
a boy, Ian, who was about Jin’s age. To make it extra convenient, Jin’s mother offered
to pick Ian up after school on a day when she knew her colleague had to stay late
for an important meeting. The boys had a good time decorating individual pizzas for
dinner and making paper kites to fly in the driveway. Jin practiced making functional
social initiations to Ian during the two activities (e.g., “Do you want pepperoni or
olives on your pizza?” “How long do you want the string for your kite?”). Ian actually
did not want to leave when his mother came to pick him up, but he complied with the
instruction, and the parents agreed to let the boys play together again soon.
With support from the clinician, Jin’s parents also decided to enroll him in an
Aikido class once per week after school. They thought that he would enjoy this activ-
ity and that it would be a good way for him to practice following instructions and a
class routine. This turned out to be a great activity for Jin to practice imitating peers.
Sometimes he did not understand the teacher’s instructions the first time, but his
father would remind him to look at what the other children were doing, and that gave
Jin clues about what he was supposed to do. The Aikido class was also a place for
Jin’s parents to meet other families in their neighborhood. Jin’s parents made sure
to arrive a few minutes early for class each week and stay a few minutes after class,
making time to chat with the other parents who were there. It turned out that one of
the other boys in Jin’s class, Marc, also lived within walking distance of the studio.
That made it easy to plan to walk home together after class. Over the next couple of
weeks, Jin practiced suggesting new ideas for joint activities during the walk home,
such as stopping for a frozen yogurt or playing at the park for a few minutes. Jin’s par-
ents appreciated how hard Jin was working to practice these new skills and, most of
the time, Marc’s parents agreed to the plan, and Jin’s social initiation was reinforced.
As the families got to know each other, Jin’s mother even suggested the families
meet up on a different day to visit a local train museum (Jin’s favorite activity). Marc’s
family was thrilled because they had wanted to go to that museum for a while.
 Selecting Meaningful Skills 69

CONCLUSION
Treatment teams should consider a variety of factors when selecting and prioritiz-
ing treatment targets to ensure that they will be meaningful to the individual and
those in his or her environment. Furthermore, it is important to think about how
those skills can be taught in the most natural environments in order to maximize
treatment effects and increase generalization and maintenance. Meaningfulness of
the skill, awareness of contextual features, and goodness of fit of interventions, as
well as practicality and logistics regarding where treatment can occur, are all key
factors that must be part of planning an individualized program in NDBI.

REFERENCES
Albin, R. W., Lucyshyn, J. M., Horner, R. H., & Flannery, K. B. (1996). Contextual fit for
behavioral support plans. In L. K. Koegel, R. L. Koegel, & G. Dunlap (Eds.), Positive behav-
ior support: Including people with difficult behavior in the community (pp. 81–120). Baltimore,
MD: Paul H. Brookes Publishing Co.
Anderson, S. R. (2013). The development of self-help skills. In P. F. Gerhardt & D. Crommins
(Eds.), Social skills and adaptive behavior in learners with autism spectrum disorders (pp. 133–158).
Baltimore, MD: Paul H. Brookes Publishing Co.
Anderson, S. R., & Romanczyk, R. G. (1999). Early intervention for young children with
autism: Continuum-based behavioral models. Journal of the Association for Persons with
Severe Handicaps, 24(3), 162–173.
Ashbaugh, K., Koegel, R. L., & Koegel, L. K. (2017). Increasing social integration for college
students with autism spectrum disorder. Behavior Development Bulletin, 22, 183–196.
Bacon, E. C., Dufek, S. A., Schreibman, L., Stahmer, A. C., Pierce, K., & Courchesne, E. (2014).
Measuring outcomes in an early intervention program for toddlers with autism spectrum
disorders. Autism Research and Treatment. Article ID 964704. Retrieved from https://www
.ncbi.nlm.nih.gov/pmc/articles/PMC3966353/
Baldwin, D. A. (1991). Infants’ contribution to the achievement of joint reference. Child Devel-
opment, 62(5), 875–890.
Bates, E., Camaioni, L., & Volterra, V. (1975). The acquisition of performatives prior to speech.
Merrill-Palmer Quarterly, 21, 205–226.
Bayley, N. (2006). Bayley Scales of Infant and Toddler Development–Third Edition. San Antonio,
TX: Harcourt Assessment.
Bellini, S., Peters, J. K., Benner, L., & Hopf, A. (2007). A meta-analysis of school-based social
skills interventions for children with autism spectrum disorders. Remedial and Special Edu-
cation, 28, 153–162.
Bernier, R., Mao, A., & Yen, J. (2010). Psychopathology, families, and culture: Autism. Child
and Adolescent Psychiatry Clinics of North America, 19, 855–867.
Blas, H. I. (2007). A specialized program for children with developmental disabilities from
within a “typical” overnight summer camp: Camp Ramah’s Tikvah program. Child and
Adolescent Clinics of North America, 16, 875–886.
Bosch, S., & Fuqua, R. W. (2001). Behavioral cusps: A model for selecting target behaviors.
Journal of Applied Behavior Analysis, 34, 123–125.
Boulware, G., Schwartz, I. S., Sandall, S. R., & McBride, B. J. (2006). Project DATA for toddlers:
An inclusive approach to very young children with autism spectrum. Topics in Early Child-
hood Special Education, 26, 94–105.
Bretherton, I., Bates, E., Benigni, L., Camaioni, L., & Volterra, V. (1979). Relationships
between cognition, communication, and quality of attachment. In The emergence of symbols:
Cognition and communication in infancy (pp. 223–269). San Francisco, CA: Academic Press.
Bricker, D., Capt, B., Johnson, J., Pretti-Frontszak, K., Waddell, M., & Straka, E. (2002). Assess-
ment, Evaluation, and Programming System for Infants and Children (AEPS®), Second Edition.
Baltimore, MD: Paul H. Brookes Publishing Co.
Brookman, L., Boettcher, M., Klein, E., Openden, D., Koegel, R. L., & Koegel, L. K. (2003).
Facilitating social interactions in a community summer camp setting for children with
autism. Journal of Positive Behavior Interventions, 5, 249–252.
70 Core Concepts and Foundational Principles

Brookman-Frazee, L. (2004). Using parent/clinician partnerships in parent education pro-

grams for children with autism. Journal of Positive Behavior Interventions, 6, 195–213.
Brooks, B. A., Floyd, F., Robins, D. L., & Chan, W. Y. (2015). Extracurricular activities and the
development of social skills in children with intellectual and specific learning disabilities.
Journal of Intellectual Disability Research, 59, 678–687.
Bruinsma, Y., Koegel, R. L., & Koegel, L. K. (2004). Joint attention and children with autism:
A review of the literature. Mental Retardation and Developmental Disabilities Research
Reviews, 10(3), 169–175.
Carrow-Woolfolk, E. (2016). Comprehensive Assessment of Spoken Language, Second Edition.
Torrence, CA: WPS.
Chao, R. K. (1994). Beyond parental control and authoritarian parenting style: Understand-
ing Chinese parenting through the cultural notion of training. Child Development, 65(4),
1111–1119.
Charman, T., & Stone, W. (Eds.). (2008). Social and communication development in autism spec-
trum disorders: Early identification, diagnosis, and intervention. New York, NY: Guilford Press.
Corbett, B. A., Swain, D. M., Coke, C., Simon, D., Newsom, C., Houchins-Juarez, N., . . . Song,
Y. (2014). Improvements in social deficits in autism spectrum disorders using a theatre-
based, peer-mediated intervention. Autism Research, 7, 4–16.
Coyne, P., & Fullerton, A. (2014). Toward a balanced leisure lifestyle for adults with autism
spectrum disorders. In M. Tincani, A. Bondy, M. Tincani, & A. Bondy (Eds.), Autism
spectrum disorders in adolescents and adults: Evidence-based and promising interventions
(pp. 208–233). New York, NY: Guilford Press.
Daley, T. C. (2004). From symptom recognition to diagnosis: Children with autism in urban
India. Social Science and Medicine, 58(7), 1323–1335.
de Bruin, C. L., Deppeler, J. M., Moore, D. W., & Diamond, N. T. (2013). Public school–based
interventions for adolescents and young adults with an autism spectrum disorder:
A meta-analysis. Review of Educational Research, 83(4), 521–550.
Delprato, D. J. (2001). Comparisons of discrete-trial and normalized behavioral intervention
for young children with autism. Journal of Autism and Developmental Disorders, 31, 315–325.
Dufek, S., & Schreibman, L. (2014). Natural environment training. In J. Tarbox, D. R. Dixon,
P. Sturmey, & J. L. Matson (Eds.), Handbook of early intervention for autism spectrum disorders:
Research, policy, and practice (pp. 325–344). New York, NY: Springer.
Dunlap, G., & Fox, L. (1996). Early intervention and serious problem behaviors. In L.
K. Koegel, R. L. Koegel, & G. Dunlap (Eds.), Positive behavior support: Including people
with difficult behavior in the community (pp. 31–50). Baltimore, MD: Paul H. Brookes
Publishing Co.
Farley, M. A., McMahon, W. M., Fombonne, E., Jenson, W. R., Miller, J., Gardner, M., . . .
Coon, H. (2009). Twenty-year outcome for individuals with autism and average or near-
average cognitive abilities. Autism Research, 2, 109–118.
Fossum, K., Williams, L., Garon, N., Bryson, S. E., & Smith, I. M. (2018). Pivotal response
treatment for preschoolers with autism spectrum disorder: Defining a predictor profile.
Autism Research, 11, 153–165.
Goods, K. S., Ishijima, E., Chang, Y., & Kasari, C. (2013). Preschool based JASPER interven-
tion in minimally verbal children with autism: Pilot RCT. Journal of Autism and Develop-
mental Disorders, 43, 1050–1056.
Gresham, F. M., Sugai, G., & Horner, R. H. (2001). Interpreting outcomes of social skills
training for students with high-incidence disabilities. Exceptional Children, 67, 331–344.
Guler, J., de Vries, P. J., Seris, N., Shabalala, N., & Franz, L. (2017). The importance of context
in early autism intervention: A qualitative South African study. Autism, 22, 1005–1017.
Gulsrud, A. C., Hellemann, G., Shire, S., & Kasari, C. (2016). Isolating active ingredients in
a parent-mediated social communication intervention for toddlers with autism spectrum
disorder. Journal of Child Psychology and Psychiatry, 57(5), 606–613.
Hancock, T. B., & Kaiser, A. P. (2002). The effects of trainer-implemented enhanced milieu
teaching on the social communication of children with autism. Topics in Early Childhood
Special Education, 22, 39–54.
Hancock, T. B., & Kaiser, A. P. (2006). Enhanced milieu teaching. In M. E. Fey & A. G. Kamhi
(Series Eds.) & R. J. McCauley & M. E. Fey (Vol. Eds.), Communication and language interven-
tion series: Treatment of language disorders in children (pp. 203–236). Baltimore, MD: Paul H.
Brookes Publishing Co.
 Selecting Meaningful Skills 71

Hardan, A. Y., Gengoux, G. W., Berquist, K. L., Libove, R. A., Ardel, C. M., Phillips, J., . . .
Minjarez, M. B. (2015). A randomised controlled trial of pivotal response treatment group
for parents of children with autism. Journal of Child Psychology and Psychiatry, 56(8), 884–892.
Harrison, P., & Oakland, T. (2015). Adaptive Behavior Assessment System, Third Edition. San
Antonio, TX: Pearson.
Hart, B. M., & Risley, T. R. (1968). Establishing use of descriptive adjectives in the spontane-
ous speech of disadvantaged preschool children. Journal of Applied Behavior Analysis, 1(2),
109–120.
Hart, B., & Risley, T. R. (1980). In vivo language intervention: Unanticipated general effects.
Journal of Applied Behavior Analysis, 13(3), 1308147.
Hayes, S. C., Barlow, D. H., & Nelson-Gray, R. O. (1999). The scientist practitioner: Research and
accountability in the age of managed care (2nd ed.). Boston, MA: Allyn & Bacon.
Hung, D. W., & Thelander, M. J. (1978). Summer camp treatment program for autistic chil-
dren. Exceptional Children, 44, 534–536.
Individuals with Disabilities Education Improvement Act (IDEA) of 2004, PL 108-446, 20
U.S.C. §§ 1400 et seq.
Ingersoll, B. (2008). The role of social imitation in autism: Implications for treatment of imi-
tation deficits. Infants & Young Children, 21(2), 107–119
Ingersoll, B. (2010). Teaching social communication: A comparison of naturalistic behavioral
and development, social pragmatic approaches for children with autism spectrum disor-
ders. Journal of Positive Behavior Interventions, 12(1), 33–43.
Ingersoll, B., & Dvortcsak, A. (2010). Teaching social communication to children with autism: A
practitioner’s guide to parent training. New York, NY: Guilford Press.
Ingersoll, B., Lewis, E., & Kroman, E. (2007). Teaching the imitation and spontaneous use of
descriptive gestures in young children with autism using a naturalistic behavioral inter-
vention. Journal of Autism and Developmental Disorders, 37(8), 1446–1456.
Ingersoll, B., & Schreibman, L. (2006). Teaching reciprocal imitation skills to young children
with autism using a naturalistic behavioral approach: Effects on language, pretend play,
and joint attention. Journal of Autism and Developmental Disorders, 36(4), 487–505.
Ingersoll, B., & Wainer, A. (2013). Initial efficacy of Project ImPACT: A parent-mediated
social communication intervention for young children with ASD. Journal of Autism and
Developmental Disorders, 43, 2943–2952.
Johnson-Martin, N. M., Attermeier, S. M., & Hacker, B. J. (2004). The Carolina Curriculum for
Infants and Toddlers with Special Needs (3rd ed.). Baltimore, MD: Paul H. Brookes Publishing Co.
Jung, M. (1998). Chinese American family therapy: A new model for clinicians. Adolescence,
33(132), 143–158.
Kaiser, A. P., Hancock, T. B., & Nietfeld, J. P. (2000). The effects of parent-implemented
enhanced milieu teaching on the social communication of children who have autism.
Early Education and Development, 11, 423–446.
Kaiser, A. P., & Trent, J. A. (2007). Communication intervention for young children with dis-
abilities: Naturalistic approaches to promoting development. In S. Odom, R. H. Horner, M.
E. Snell, & J. Blacher (Eds.), Handbook of developmental disabilities (pp. 224–245). New York,
NY: Guilford Press.
Kanne, S. M., Gerber, A. J., Quirmbach, L. M., Sparrow, S. S., Cicchetti, D. V., & Saulnier, C.
A. (2011). The role of adaptive behavior in autism spectrum disorders: Implications for
functional outcome. Journal of Autism and Developmental Disorders, 41, 1007–1018.
Kao, Y., Kramer, J. M., Liljenquist, K., & Coster, W. J. (2015). Association between impair-
ment, function, and daily life task management in children and adolescents with autism.
Developmental Medicine and Child Neurology, 57, 68–74.
Kasari, C., Freeman, S., & Paparella, T. (2006). Joint attention and symbolic play in young
children with autism: A randomized controlled intervention study. Journal of Child Psy-
chology and Psychiatry, 47, 611–620.
Kasari, C., Gulsrud, A., Paparella, T., Hellemann, G., & Berry, K. (2015). Randomized com-
parative efficacy study of parent-mediated interventions for toddlers with autism. Journal
of Consulting and Clinical Psychology, 83, 554–563.
Kasari, C., Kaiser A., Goods, K., Nietfeld, J., Mathy, P., Landa, R., . . . Almirall, D. (2014).
Communication interventions for minimally verbal children with autism: A sequential
multiple assignment randomized trial. Journal of the American Academy of Child & Adoles-
cent Psychiatry, 53(6), 635–646.
72 Core Concepts and Foundational Principles

Kasari, C., Paparella, T., Freeman, S., & Jahromi, L. B. (2008). Language outcome in autism:
Randomized comparison of joint attention and play interventions. Journal of Consulting
and Clinical Psychology, 76(1), 125–137.
Kaufman, A. S., & Kaufman, N. L. (2004). Kaufman Assessment Battery for Children, Second
Edition. Circle Pines, MN: American Guidance Service.
Kim, S., Koegel R. L., & Koegel, L. K. (2017). Training paraprofessionals to target socializa-
tion in students with ASD: Fidelity of implementation and social validity. Journal of Posi-
tive Behavior Interventions, 19, 102–114.
Koegel, R. L., Camarata, S., Koegel, L. K., Ben-Tall, A., & Smith, A. E. (1998). Increasing
speech intelligibility in children with autism. Journal of Autism and Developmental Disor-
ders, 28, 241–251.
Koegel, R. L., & Koegel, L. K. (2006). Pivotal Response Treatments for autism. Baltimore, MD:
Paul H. Brookes Publishing Co.
Koegel, R. L., & Koegel, L. K. (2012). The PRT pocket guide: Pivotal Response Treatment for autism
spectrum disorders. Baltimore, MD: Paul H. Brookes Publishing Co.
Koegel, L. K., Koegel, R. L., Harrower, J. K., & Carter, C. M. (1999). Pivotal response interven-
tion I: Overview of approach. Journal of The Association for Persons with Severe Handicaps,
24, 174–185.
Koegel, L. K., Koegel, R. L., Kellegrew, D., & Mullen, K. (1996). Parent education for pre-
vention and reduction of severe problem behaviors. In L. K. Koegel, R. L. Koegel, &
G. Dunlap (Eds.), Positive behavior support: Including people with difficult behavior in the
community (pp. 3–30). Baltimore, MD: Paul H. Brookes Publishing Co.
Koegel, L. K., Kuriakose, S., Singh, A. K., & Koegel, R. L. (2012). Improving generalization
of peer socialization gains in inclusive school settings using initiations training. Behavior
Modification, 36(3), 361–377.
Leaf, R., McEachin, J., & Harsh, J. D. (1999). A work in progress: Behavior management strategies
and a curriculum for intensive behavioral treatment of autism. New York, NY: DRL Books.
LeBlanc, L. A., Esch, J., Sidener, T. M., & Firth, A. M. (2006). Behavioral language inter-
ventions for children with autism: Comparing applied verbal behavior and naturalistic
teaching approaches. The Analysis of Verbal Behavior, 22(1), 49–60.
Lifter, K., Sulzer-Azaroff, B., Anderson, S. R., & Cowdery, G. E. (1993). Teaching play activi-
ties to preschool children with disabilities: The importance of developmental consider-
ations. Journal of Early Intervention, 17, 139–159.
Maich, K., Hall, C. L., van Rhijn, T. M., & Quinlan, L. (2015). Developing social skills of sum-
mer campers with autism spectrum disorder: A case study of camps on TRACKS imple-
mentation in an inclusive day-camp setting. Exceptionality Education International, 25, 27–41.
Mandell, D. S., & Novak, M. (2005). The role of culture in families’ treatment decisions for
children with autism spectrum disorders. Mental Retardation and Developmental Disabilities
Research Reviews, 11, 110–115.
Mandell, D. S., Stahmer, A. C., Shin, S., Xie, M., Reisinger, E., & Marcus, S. C. (2013). The role
of treatment fidelity on outcomes during a randomized field trial of an autism interven-
tion. Autism, 17(3), 281–295.
McGee, G. G., Morrier, M. J., & Daly, T. (1999). An incidental teaching approach to early
intervention for toddlers with autism. Journal of The Association for Persons with Severe
Handicaps, 24(3), 133–146.
Minjarez, M., Mercier, E. M., Williams, S. E., & Hardan, A. Y. (2013). Impact of pivotal
response training group therapy on stress and empowerment in parents of children with
autism. Journal of Positive Behavior Interventions, 15, 71–78.
Minjarez, M., Williams, S. E., Mercier, E. M., & Hardan, A. Y. (2011). Pivotal response group
treatment for parents of children with autism. Journal of Autism and Developmental Dis-
abilities, 41, 92–101.
Morgan, S. B., Cutrer, P. S., Coplin, J. W., & Rodrigue, J. R. (1989). Do autistic children dif-
fer from retarded and normal children in Piagetian sensorimotor functioning? Journal of
Child Psychology and Psychiatry, 30(6), 857–864.
Mullen, E. M. (1995). Mullen Scales of Early Learning: AGS Edition. Circle Pines, MN: American
Guidance Service.
Mundy, P., & Crowson, M. (1997). Joint attention and early social communication: Implica-
tions for research on intervention with autism. Journal of Autism and Developmental Disor-
ders, 27(6), 653–676.
 Selecting Meaningful Skills 73

Mundy, P., Delgado, C., Block, J., Venezia, M., Hogan, A., & Seibert, J. (2003). Early social com-
munication scales (ESCS). Coral Gables, FL: University of Miami.
Mundy, P., & Sigman, M. (1989). The theoretical implications of joint-attention deficits in
autism. Development and Psychopathology, 1(3), 173–183.
Mundy, P., Sigman, M., & Kasari, C. (1990). A longitudinal study of joint attention and lan-
guage development in autistic children. Journal of Autism and Developmental Disorders,
20(1), 115–128.
National Research Council. (2001). Educating children with autism. Washington, DC: National
Academy Press.
Odom, S. L., McConnell, S. R., & Chandler, L. K. (1994). Acceptability and feasibility of
classroom-based social interaction interventions for young children with disabilities.
Exceptional Children, 60, 226–236.
Ogilvie, E., & McCrudden, M. T. (2017). Evaluating the social validity of the Early Start
Denver Model: A convergent mixed methods study. Journal of Autism and Developmental
Disorders, 47, 2899–2910.
Ozonoff, S., Young, G. S., Steinfeld, M. B., Hill, M. M., Cook, I., Hutman, T., . . . Sigman, M.
(2009). How early do parent concerns predict later autism diagnosis? Journal of Develop-
mental and Behavioral Pediatrics, 30(5), 367–375.
Palmer, A. N., Elliott, W., & Cheatham, G. A. (2017). Effects of extracurricular activities
on postsecondary completion for students with disabilities. The Journal of Educational
Research, 110, 151–158.
Partington, J. W. (2006). Assessment of Basic Language and Learning Skills–Revised. New York,
NY: Different Roads.
Rodriguez, B. L., & Olswang, L. B. (2003). Mexican-American and Anglo-American mothers’
beliefs and values about child rearing, education, and language impairment. American
Journal of Speech-Language Pathology, 12, 452–462
Rogers, S. J., & Dawson, G. (2010). Early Start Denver Model for young children with autism: Pro-
moting language, learning, and engagement. New York, NY: Guilford Press.
Roid, G. H. (2003). Stanford Binet intelligence scales. Itasca, IL: Riverside Publishing.
Rosales-Ruiz, J., & Baer, D. M. (1997). Behavioral cusps: A developmental and pragmatic
concept for behavioral analysis. Journal of Applied Behavior Analysis, 30, 533–544.
Santarelli, G., Koegel, R. L., Casas, J. M., & Kern Koegel, L. (2001). Culturally diverse families
participating in behavior therapy parent education programs for children with develop-
mental disabilities. Journal of Positive Behavior Interventions, 3(2), 120–123.
Schreibman, L., Dawson, G., Stahmer, A. C., Landa, R., Rogers, S. J., McGee, G. G., . . .
Halladay, A. (2015). Naturalistic Developmental Behavioral Interventions: Empirically
validated treatments for autism spectrum disorder. Journal of Autism and Developmental
Disorders, 45, 2411–2428.
Schreibman, L., Kaneko, W. M., & Koegel, R. L. (1991). Positive affect of parents of autistic
children: A comparison across two teaching techniques. Behavior Therapy, 22, 479–490.
Schreibman, L., & Koegel, R. L. (2005). Training for parents of children with autism: Pivotal
responses, generalization, and individualization of interventions. In E. D. Hibbs & P. S.
Jensen (Eds.), Psychosocial treatments for child and adolescent disorders: Empirically based strate-
gies for clinical practice (pp. 605–631). Washington, DC: American Psychological Association.
Schreibman, L., Stahmer, A. C., Barlett, V. C., & Dufek, S. (2009). Brief report: Toward refine-
ment of a predictive behavioral profile for treatment outcome in children with autism.
Research in Autism Spectrum Disorders, 3(1), 163–172.
Schreibman, L., Stahmer, A. C., & Pierce, K. L. (2006). Alternative applications of pivotal
response training: Teaching symbolic play and social interaction skills. In L. K. Koegel,
R. L. Koegel, & G. Dunlap (Eds.), Positive behavioral support: Including people with difficult
behavior in the community (pp. 353–371). Baltimore, MD: Paul H. Brookes Publishing Co.
Schwartz, S. H. (1990). Individualism-collectivism: Critique and proposed refinements.
Journal of Cross-Cultural Psychology, 21(2), 139–157.
Schwartz, I. S., Ashmin, J. A., McBride, B., Scott, C., & Sandall, S. R. (2017). The DATA Model
for teaching preschoolers with autism: Blending approaches to meet individual needs. Baltimore,
MD: Paul H. Brookes Publishing Co.
Schwartz, I. S., & Baer, D. M. (1991). Social validity assessments: Is current practice state of
the art? Journal of Applied Behavior Analysis. Special Issue: Social Validity: Multiple Perspec-
tives, 24, 189–204.
74 Core Concepts and Foundational Principles

Schwartz, I. S., Sandall, S. R., McBride, B. J., & Boulware, G.-L. (2004). Project DATA (Devel-
opmentally Appropriate Treatment for Autism): An inclusive school based approach to
educating young children with autism. Topics in Early Childhood Special Education, 24(3),
156–168.
Schwartz, I., Thomas, C. J., McBride, B., & Sandall, S. (2013). A school-based preschool pro-
gram for children with ASD: A quasi-experimental assessment of child change in Project
DATA. School Mental Health, 5(4), 221–232.
Sherer, M. R., & Schreibman, L. (2005). Individual behavioral profiles and predictors of
treatment effectiveness for children with autism. Journal of Consulting and Clinical Psychol-
ogy, 73, 525–538.
Shore, C., O’Connell, B., & Bates, E. (1984). First sentences in language and symbolic play.
Developmental Psychology, 20(5), 872–880.
Sigman, M., & McGovern, C. W. (2005). Improvement in cognitive and language skills from
preschool to adolescence in autism. Journal of Autism and Developmental Disorders, 35, 15–23.
Sigman, M., & Ruskin, E. (1999). Continuity and change in the social competence of children
with autism, Down syndrome, and developmental delays. Monographs of the Society for
Research in Child Development, 64(1), v–114.
Snell, M. E. (2003). Applying research to practice: The more pervasive problem? Research and
Practice for Persons with Severe Disabilities, 28, 143–147.
Snow, M. E., Hertzig, M. E., & Shapiro, T. (1987). Expression of emotion in young autistic
children. Journal of the American Academy of Child & Adolescent Psychiatry, 26(6), 836–838.
Solish, A., Perry, A., & Minnes, P. (2015). Participation of children with and without disabili-
ties in social, recreational, and leisure activities. Journal of Applied Research in Intellectual
Disabilities, 23, 226–236.
Sparrow, S. S., Cicchetti, D. V., & Saulnier, C. A. (2016). Vineland Adaptive Behavior Scales, Third
Edition. San Antonio, TX: Pearson.
Stadnick, N. A., Stahmer, A., & Brookman-Frazee, L. (2015). Preliminary effectiveness of
Project ImPACT: A parent mediated intervention for children with autism spectrum dis-
order delivered in a community program. Journal of Autism and Developmental Disorders,
45, 2092–2104.
Stahmer, A. C. (1995). Teaching symbolic play skills to children with autism using pivotal
response training. Journal of Autism and Developmental Disorders, 25, 123–141.
Stahmer, A. C., & Ingersoll, B. (2004). Inclusive programming for toddlers with autism spec-
trum disorders: Outcomes from the Children’s Toddler School. Journal of Positive Behavior
Interventions, 6(2), 67–82.
Stahmer, A. C., Schreibman, L., & Cunningham, A. B. (2011). Toward a technology of
treatment individualization for young children with autism spectrum disorders. Brain
Research, 1380, 229–239.
Stahmer, A. C., Suhrheinrich, J., Reed, S., Schreibman, L., & Bolduc, C. (2011). Classroom piv-
otal response teaching for children with autism. New York, NY: Guilford Press.
Stahmer, A. C., Suhrheinrich, J., & Rieth, S. (2016). A pilot examination of the adapted pro-
tocol for classroom pivotal response teaching. Journal of the American Academy of Special
Education Professionals, 119(4), 119–139.
Stokes, T. F., & Baer, D. M. (1977). An implicit technology of generalization. Journal of Applied
Behavior Analysis, 10, 349–367.
Stormont, M., Lewis, T. J., & Smith, S. C. (2005). Behavior support strategies in early child-
hood settings: Teachers’ importance and feasibility ratings. Journal of Positive Behavior
Interventions, 7, 131–139.
Strain, P. S., & Bovey, E. H. (2011). Randomized, controlled trial of the LEAP model of early
intervention for young children with autism spectrum disorders. Topics in Early Childhood
Special Education, 31(3), 133–154.
Stronach, S., & Wetherby, A. M. (2014). Examining restricted and repetitive behaviors in
young children with autism spectrum disorder during two observational contexts.
Autism, 18, 127–136.
Suhrheinrich, J. (2011). Training teachers to use pivotal response training with children with
autism: Coaching as a critical component. Teacher Education and Special Education, 34(4),
339–349.
 Selecting Meaningful Skills 75

Suhrheinrich, J., Stahmer, A. C., Reed, S., Schreibman, L. L., Reisinger, E., & Mandell, D.
(2013). Implementation challenges in translating pivotal response training into commu-
nity settings. Journal of Autism and Developmental Disorders, 43, 2970–2976.
Sundberg, M. L. (2008). Verbal Behavior Milestones Assessment and Placement Program. Con-
cord, CA: AVB Press.
Ungerer, J., & Sigman, M. (1984). The relation of play and sensori-motor behavior to lan-
guage in the second year. Child Development, 55(4), 1448–1455.
Uzgiris, I. C. (1981). Two functions of imitation during infancy. International Journal of Behav-
ioral Development, 4(1), 1–12.
Vismara, L. A., Colombi, C., & Rogers, S. J. (2009). Can one hour per week of therapy lead to
lasting changes in young children with autism? Autism, 13, 93–115.
Vivanti, G., Dissanayake, C., & the Victorian ASELCC Team. (2016). Outcome for children
receiving the Early Start Denver Model before and after 48 months. Journal of Autism and
Developmental Disorders, 46(7), 2441–2449.
Vivanti, G., Paynter, J., Duncan, E., Fothergill, H., Dissanayake, C., Rogers, S. J., & the Victo-
rian ASELCC Team. (2014). Effectiveness and feasibility of the Early Start Denver Model
implemented in a group-based community childcare setting. Journal of Autism and Devel-
opmental Disorders, 44, 3140–3153.
Wechsler, D. (2014). Wechsler Intelligence Scale for Children–Fifth Edition. Bloomington, MN:
Pearson.
Wetherby, A. M., & Prizant, B. M. (2003). Communication and Symbolic Behavior Scales (CSBS™),
Normed Edition. Baltimore, MD: Paul H. Brookes Publishing Co.
Whalen, C., & Schreibman, L. (2003). Joint attention training for children with autism using
behavior modification procedures. Journal of Child Psychology and Psychiatry, 44(3), 456–468.
Whalen, C., Schreibman, L., & Ingersoll, B. (2006). The collateral effects of joint attention
training on social initiations, positive affect, imitation, and spontaneous speech for young
children with autism. Journal of Autism and Developmental Disorders, 36(5), 655–664.
Williams, J. A., Koegel, R. L., & Egel A. L. (1981). Response–reinforcer relationships and
improved learning in autistic children. Journal of Applied Behavior Analysis, 14, 53–60.
Winett, R. A., Moore, J. F., & Anderson, E. S. (1991). Extending the concept of social validity:
Behavior analysis for disease prevention and health promotion. Journal of Applied Behavior
Analysis, 24, 215–230.
Winton, P. J. (1990). Promoting a normalizing approach to families: Integrating theory with
practice. Topics in Early Childhood Special Education, 10, 90–103.
Wolf, M. M. (1978). Social validity: The case for subjective measurement or how applied
behavior analysis is finding its heart. Journal of Applied Behavior Analysis, 11, 203–214.
Yang, D., Pelphrey, K. A., Sukhodolsky, D. G., Crowley, M. J., Dayan, E., Dvornek, N. C., . . .
Ventola, P. (2016). Brain responses to biological motion predict treatment outcome in young
children with autism. Translational Psychiatry, 6, e948. doi:10.1038/tp.2016.213
4
Empowering Parents
Through Parent Training and Coaching
Mendy B. Minjarez, Elizabeth A. Karp, Aubyn C. Stahmer, and Lauren Brookman-Frazee

R
esearch and clinical guidelines (e.g., National Research Council, 2001;
Wong et al., 2013) support the importance of considering family context and
involving parents and other caregivers in treatment for children with autism
spectrum disorder (ASD). In fact, parents (in this chapter, parents refers to any pri-
mary caregiver) increasingly are considered core agents of intervention delivery,
especially in Naturalistic Developmental Behavioral Interventions (NDBI; e.g.,
Early Start Denver Model [ESDM]; Pivotal Response Treatment [PRT]; Joint Atten-
tion, Symbolic Play, Engagement, and Regulation [JASPER]). This focus on parent
involvement is consistent with the focus in general on involving key stakeholders
in order to optimize successful outcomes (Herschell, Calzada, Eyberg, & McNeil,
2002; Kazdin & Weisz, 2003; Patterson, 1982). Families play a central role in creat-
ing their children’s social world and have the most intimate knowledge of both
their children and the environments in which their children will thrive and grow
(Bernheimer, Gallimore, & Weisner, 1990); therefore, considering parent prefer-
ences and goals (i.e., goodness of fit, as discussed in Chapter 3) enhances the match
between what therapists recommend and the feasibility and/or importance from
the family perspective. When therapists consider the family context, families are
more likely to implement intervention strategies consistently and with strong treat-
ment fidelity (Brookman-Frazee, 2004).

PARENT-MEDIATED INTERVENTIONS AND NDBI

Teaching parents to use NDBI strategies during interactions with their children is
one way to provide a cost-effective means of intervention delivery in the natural
environment by the individuals who spend the most time with them (e.g., Kasari,
Gulsrud, Wong, Kwon, & Locke, 2010; Koegel & Koegel, 2006; Oono, Honey, &

77
78 Core Concepts and Foundational Principles

McConachie, 2013). Most, if not all, NDBI models include some form of parent-
mediated intervention for core ASD symptoms (Schreibman et al., 2015). For some
interventions, parents can be the primary intervention agents (e.g., JASPER, PRT,
Enhanced Milieu Teaching [EMT]), whereas other models include parent train-
ing to enhance clinician-delivered intervention (e.g., Early Start Denver Model
[ESDM]). Both are viable forms of parent delivery of NDBI.
Children make greater improvements with a combination of clinician-
implemented and parent-implemented intervention because ongoing parent
implementation increases the intensity of interventions, whereas clinician involve-
ment can ensure appropriate expertise in program development and maintenance
(Nahmias & Mandell, 2014; Rogers et al., 2012). Although parents should always be
included in program and goal development, providers must consider the family
context, parent resources, stress, and time demands when recommending parent-
mediated interventions. The goal is both to maximize opportunities for interven-
tion for the child and to support family functioning through collaboration between
providers and parents (Stahmer & Pellecchia, 2015).
Parent training and education is the primary way in which NDBI models
involve parents in treatment. As discussed throughout this book, NDBI highlight
intervention in the natural environment and the use of familiar and emotionally
connected relationships as a vehicle for intervention delivery. This makes NDBI
especially well suited for use by family members in the home and community. For
example, strategic arrangement of the environment (e.g., incidental teaching [IT])
is outlined as a key strategy for promoting communication development. Family
members can implement this at home by placing toys in hard-to-open see-through
containers, giving smaller portions at mealtime to encourage multiple opportuni-
ties to request more, or waiting for the child to initiate a request. Providers can teach
parents strategies such as the use of natural reinforcement, prompting, balanced
turns, modeling, adult imitation of child behavior, and following the child’s lead,
and parents can implement these strategies consistently in the context of natural
family routines (Hardan et al., 2015; Ingersoll & Wainer, 2013, Kasari et al., 2014;
Rogers et al., 2014; Wetherby et al., 2014).
Although most parents of children with ASD are not professional interven-
tionists, they can teach their children skills through NDBI, sometimes even with a
relatively small amount of training (Coolican et al., 2010; Hardan et al., 2015; Minjarez,
Williams, Mercier, & Hardan, 2011; Vismara, Colombi, & Rogers, 2009). Research sup-
ports that parents can successfully learn to implement NDBI strategies in the natural
environment, and their children show correlated gains in skills (Coolican et al., 2010;
Hardan et al., 2015; Ingersoll & Wainer, 2013; Kasari et al., 2010; Kasari et al., 2014;
Rogers et al., 2014; Stadnick, Stahmer, & Brookman-Frazee, 2015; Wetherby et al., 2014).
When parents are included in their children’s intervention, their children improve
in targeted areas, for example, joint attention, communication, and engagement with
their parents (Estes et al., 2015; Hardan et al., 2015; Kasari et al., 2010). Because parents
can learn to implement interventions effectively, they should be involved in service-
delivery either as primary or complementary agents of intervention.
Involving parents in ASD interventions is also critically important for help-
ing children generalize and maintain newly learned skills. Because generalization
of skills can be particularly challenging for children with ASD (Mesibov, Shea, &
Schopler, 2005), involving parents or primary caregivers promotes opportunities
for generalization to other contexts and individuals outside of treatment sessions.
 Empowering Parents 79

When parents implement NDBI strategies throughout their daily routines, they
enhance opportunities for generalization of skills and continued learning (Lucyshyn,
Dunlap, & Albin, 2002).
Parent training can occur in a variety of contexts, including in a group
(Hardan et al., 2015; McIntyre, 2008; Minjarez et al., 2011), individually, and through
telemedicine and other Internet-based platforms (Brookman-Frazee, Vismara,
Drahota, Stahmer, & Openden, 2009; Vismara, Young, & Rogers, 2012; Wainer &
Ingersoll, 2013). There are certain benefits to conducting parent training in each of
these formats.

Group Parent Education

In group formats, parents can gain support from one another, which has been
shown to decrease parent stress and increase empowerment (Minjarez, Mercier,
Williams, & Hardan, 2013). One of the most effective ways to reduce parents’ stress
is to increase their informal social support, which is likely to be inherent in group
training models (Benson, 2006; Weiss, 2002). Group formats are beneficial because
they provide a more ecologically valid way to teach important content to a large
group of parents. Group formats have been found to be effective, and parents
can learn interventions with high levels of treatment fidelity from participating
(Hardan et al., 2015; Minjarez et al., 2011).

Individual Parent Education

Parents can also participate in individual parent coaching, which is how most parent
training programs that have been studied are delivered (e.g., Steiner, Koegel, Koegel,
& Ence, 2012). When parents learn how to apply a range of skills to teach a range
of behaviors during coaching sessions, they can continue to apply what they have
learned to different situations across their child’s life span, minimizing dependence
on experts or therapists to give them the information. Individual sessions, combined
with group parent support, are another way to offer both training and support
(Hardan et al., 2015; Stahmer & Gist, 2001). In both group and individual parent train-
ing, sustainment of the intervention can be improved when NDBI are individualized
to focus on the family’s needs (Murray, Ackerman-Spain, Williams, & Ryley, 2011).

Technology-Based Parent-Mediated Intervention

Furthermore, depending on geographic location, parents may be the primary
means of service delivery for their children (Kasari et al., 2010). In fact, an increas-
ing number of NDBI models have begun exploring telemedicine and Internet-based
training for families who live in locations with limited access to services, with ini-
tial evidence in support of these models (e.g., Ingersoll, Wainer, Berger, Pickard, &
Bonter, 2016; Pickard, Wainer, Bailey, & Ingersoll, 2016; Vismara et al., 2009).

PSYCHOLOGICAL FUNCTIONING
IN PARENTS OF CHILDREN WITH ASD
Parent psychological functioning is an important consideration when select-
ing parent-mediated interventions or involving parents in treatment. Research
supports that parent functioning can affect treatment outcomes and can also be
80 Core Concepts and Foundational Principles

influenced by involvement in treatment. Although the research in this area is still

growing, some research has begun to focus on incorporating strategies that may
enhance parent functioning and response to treatment.

Parent Stress
Parents of children with ASD are known to experience high levels of stress—higher
than parents of children who are typically developing and higher than parents
of children with other developmental disorders (Baker-Ericzen, Brookman-Frazee,
& Stahmer, 2006; Dunn, Burbine, Bowers, & Tantleff-Dunn, 2001). Some studies
have also documented that this stress actually increases with time (Dale, Jahoda,
& Knott, 2006) and is chronic (Seltzer et al., 2010). These heightened levels of stress
can have negative effects on parental physical and mental health, putting them at
increased risk for heart disease, sleep disturbances, autoimmune diseases, obesity,
and depression (Motzer & Hertig, 2004).
Once a child is enrolled in treatment, parent stress can, in fact, influence
child outcomes, with lower stress being associated with better outcomes (Plienis,
Robbins, & Dunlap, 1988; Robbins, Dunlap, & Plienis, 1991). The relationship
between parent stress and child growth and development highlights the impor-
tance of addressing parent psychological needs, including stress. One strategy for
addressing this need is through parent involvement in intervention.

Parent Empowerment
Incorporating strategies to promote parent empowerment into parent-implemented
intervention may be one way to mediate or address the stress that parents of children
with ASD face. Family empowerment promotes the development of confidence in ad-
vocating for the family’s needs and acquiring necessary resources and opportunities
for the family (Murray, Handyside, Straka, & Arton-Titus, 2013). As such, empower-
ment may be particularly important to consider in parents of children with ASD
because acquiring appropriate resources (i.e., services) can be extremely challenging,
given the various service systems parents must navigate (e.g., school districts, health
insurance, state resources). Parents may also face challenges with understanding the
many types of available interventions and their research support (Berquist & Char-
lop, 2014). The empowered parent is likely to feel more confident navigating the sys-
tem and discerning which interventions are likely to be most helpful and effective.
Research also supports that parent empowerment is associated with increased suc-
cessful interactions with service providers and more positive coping with daily chal-
lenges (Garland, Haine-Schlagel, Accurso, Baker-Ericzén, & Brookman-Frazee, 2012;
Koren, DeChillo, & Friesen, 1992). Furthermore, when parents perceive their goals as
attainable, they have a stronger sense of hope and a sense that they themselves can
be the agent of that change (Lloyd & Hastings, 2009). Box 4.1 outlines several benefits
to being empowered, which lend support for conducting parent training and parent-
mediated interventions using strategies that promote parent empowerment.
When taking an empowerment approach, coaching focuses on family
strengths rather than deficits, creating an atmosphere of collaboration with a
therapist, and helping both the therapist and the parent to see parents as effective
agents of change in the child’s life (Minjarez et al., 2013; Steiner, 2011). When par-
ents participate in empowerment-focused interventions, they demonstrate greater
 Empowering Parents 81

BOX 4.1: Benefits of empowerment

Empowered parents are more likely to do the following:
• Receive access to resources
• Take an active part in making decisions about their child’s services
• Make changes in their lives
• Have strong feelings of self-efficacy
• Feel as if they are part of a group
• Feel hopeful about their lives and their children’s lives
• Learn to change their own perspectives and think critically about a range
of issues
Sources: Carpenter (1997); Dunst (2002); Lloyd & Hastings (2009); Murray & Curran
(2008); Murray, Curran, & Zellers (2008).

resilience to negative life events, increased confidence, more positive interactions

with their children, and lower levels of depression and stress when compared to
less empowered parents (Brookman-Frazee, 2004; Weiss, Cappadocia, MacMullin,
Viecili, & Lunsky, 2012). In fact, parents have reported that the aspect of NDBI that
they enjoy the most is their participation (Ingersoll & Dvortcsak, 2006).
Furthermore, children’s engagement, responsiveness, and affect also improve
when empowerment-focused interventions are used (Brookman-Frazee, 2004), sug-
gesting that treatment approaches that use strategies to enhance parent empow-
erment may also have a positive impact on child outcomes. Parents who learn
behavioral strategies report that they feel confident in their ability to prevent their
child’s challenging behaviors and that once these behaviors begin, they feel confi-
dent in their ability to stop them (Feldman & Werner, 2002). Furthermore, parents
of children with ASD who perceive that they can change their child’s behavior
report that they use intervention strategies outside of treatment settings (Moore &
Symons, 2011).
Because so much of the context for implementation of NDBI relies on the rela-
tionships between children and adults, it naturally follows that focusing on parent
empowerment may be an important intervention goal. Implementation of NDBI
during play and daily routines using motivational procedures (e.g., following the
child’s lead) relies heavily on the presence of positive adult–child interactions;
therefore, strategies to target adult ability to do so are warranted.

Impact of Parent Involvement on Parental Functioning

In addition to enhancing intensity of treatment for their children and generalization
of treatment gains, parent involvement may have additional positive implications
for the parent and family. Although the literature on parent stress has been incon-
clusive to date, there is some evidence that involvement in intervention for children
with ASD may reduce parent stress, specifically related to parent–child interactions
(Minjarez et al., 2013). Parents who participate in NDBI demonstrated increases
in positive interactions with their children (Koegel, Bimbela, & Schreibman, 1996;
82 Core Concepts and Foundational Principles

McConachie & Diggle, 2006). For example, one study demonstrated that during
interactions, parents were more interested in their children, appeared objectively
happier and less stressed, and used more effective communication styles (Koegel
et al., 1996). Another found that parent involvement in intervention was associated
with improvements in the parent–child relationship, as well as lower levels of de-
pression (McConachie & Diggle, 2006). These findings support parent involvement
in intervention because it may have beneficial effects on parents themselves, as
well as child progress in treatment. Although a majority of findings support this,
there is a subset of parents (perhaps up to one-third) who may not benefit from
parent training if they currently have extremely high levels of stress (Robbins et
al., 1991; Singer, 2002; Stern, 2000; Webster-Stratton & Reid, 2003). Therefore, parent
involvement needs to be individualized based on a family’s needs and capacities at
the time of intervention.

EFFECTIVE PARENT COACHING PRACTICES

High-quality parent participation in treatment, including treatment fidelity, treat-
ment enthusiasm, and confidence in using the intervention, influences child gains
(Gulsrud, Hellemann, Shire, & Kasari, 2015; Kasari et al., 2010). As explored previ-
ously, when parents believe that they can enact change in their child, they will be
more involved in interventions and, as a consequence, their children may make
greater gains (Solish & Perry, 2008). As such, clinicians should know how to help
parents feel engaged and empowered in the treatment process. Yet, as Ingersoll and
Dvortcsak (2010) noted in their Project ImPACT (Improving Parents as Communica-
tion Teachers) parent coaching manual, most clinicians who deliver intervention to
children with ASD are trained to work with children but do not necessarily have for-
mal training in teaching adults. Therefore, clinicians as parent coaches require train-
ing in both how to provide excellent coaching, including knowledge of adult learning
principles, and methods for increasing parent empowerment. This chapter outlines
effective parent training and coaching practices, as described in the NDBI literature.
In recognition of this problem, there has been increasing emphasis in how to
provide effective coaching, including models specific to ASD and developmental
delays (e.g., Amsbary & AFIRM Team, 2017; Hardan et al., 2015; Rush & Sheldon,
2011; Steiner et al., 2012). Some NDBI (e.g., Project ImPACT, ESDM) offer specific
training for clinicians in how to coach parents. The sections that follow summarize
successful strategies and include procedures designed to increase parent collabora-
tion and empowerment. There is growing support for collaborative and responsive
coaching interactions with parents (Barnett, Niec, & Acevedo-Polakovich, 2014;
Brookman-Frazee, 2004). In comparison with directive coaching (i.e., telling the
parent what to do), responsive coaching practices (i.e., reinforcing parent’s use of a
specific strategy) has been associated with parent behavior change in subsequent
sessions (Barnett, Niec, & Acevedo-Polakovich, 2014), quicker mastery of skills, and
higher treatment completion (Barnett et al., 2015). Responsive coaching practices
also have more positive effects on measures of observed parent–child interactions
and child responding and engagement (Brookman-Frazee, 2004).
Haine-Schlagel and colleagues (Haine-Schlagel & Bustos, 2013; Haine-
Schlagel, Martinez, Roesch, Bustos, & Janicki, 2016) developed a set of strategies
interventionists can use to facilitate family engagement in child treatment. These
strategies emphasize delivering the intervention in an empowerment-focused
 Empowering Parents 83

Table 4.1. Examples of Parent and Caregiver Active Participation Toolkit (PACT) engagement
strategies incorporated into NDBI

Engagement Examples of application to

strategy domain Strategies Project ImPACT for toddlers

Alliance Actively listen to the Use partnership language, such as we

Goal: To facilitate caregiver. and us.
an open, honest Convey a sense of caregiver– Talk explicitly about how you will be
dialogue with the therapist partnership. working together, for example, “Let’s
caregiver Communicate positive regard work together on. . . .”
toward the caregiver.
Collaboration Give suggestions, not Ask, “What questions do you have
Goal: To share directions. about using this strategy at home?”
decision making Ask for caregiver input. Ask, “What routines do you think you
with the caregiver Collaboratively plan for could use these strategies in?”
to increase buy-in home practice. Ask, “What goals would you most like
and a positive to work on at home?”
experience
Empowerment Recognize and acknowledge Comment on the caregiver’s expertise
Goal: To help caregiver strengths and on his or her child as a valued partner.
caregivers effort. Identify the caregiver’s strengths as a
develop skills Jointly identify and problem- caregiver.
and confidence solve barriers. Recognize the caregiver’s efforts to
to change their attend and speak up in sessions and
behavior to try out new techniques in sessions
and at home.
Ask, “What will be hard about X?”
Ask, “What’s one idea for how to
handle that?”
Say, “Let’s think about a solution to that
challenge.”

Key: Project ImPACT (Improving Parents as Communication Teachers).

Source: Haine-Schlagel, Martinez, Roesch, Bustos, & Janicki (2016).

way; rather than therapists acting as the experts imparting knowledge on parents,
parents are considered key partners in the intervention (Brookman-Frazee, 2004).
The Parent and Caregiver Active Participation Toolkit (PACT; Haine-Schlagel &
Bustos, 2013; Haine-Schlagel et al., 2016) includes a coordinated set of tools tar-
geting three related domains: Alliance, Collaboration, and Empowerment. These
strategies have recently been incorporated into NDBI, such as Project ImPACT, for
delivery with infants and toddlers at risk for ASD (Brookman-Frazee, Stahmer,
Lewis, Feder, & Reed, 2012; Stahmer et al., 2017). Please see Table 4.1 for a descrip-
tion of the application of the Alliance, Collaboration, and Empowerment strategies
for Project ImPACT for Toddlers.

Setting the Stage for Effective Parent Coaching

The first step in parent coaching is for the parent and therapist to develop a strong
relationship. Rapport between parent and therapist can influence parents’ learning
of treatment strategies and potentially their use of these strategies with their chil-
dren outside clinic sessions. As such, focusing on building strong parent–clinician
partnerships is an important aspect of delivering parent-mediated interventions,
particularly in a community setting when it may be challenging for parents to meet
the competing demands of raising a child with ASD (e.g., employment, attending
84 Core Concepts and Foundational Principles

treatment sessions, caring for siblings). Rapport building can be achieved through
the respect of each family’s ethnic and cultural background, effective communica-
tion, shared decision making, and development of trust in relationships (McGrath,
2005). All parents have valuable and unique perspectives about their children, and
professionals should consider these as such, rather than attempting to classify chil-
dren in a particular way by a label or diagnosis, which may prevent more personal-
ized care (Hodge & Runswich-Cole, 2008).
A number of strategies can be used to promote collaboration and empower-
ment when working with parents, including the following:
• Asking parents what goals they would like to see the child work on.
• Frequently asking parents if they have questions about the treatment plan,
goals, or strategies being taught.
• Asking parents for feedback on the treatment plan, goals, and strategies being
taught.
• Asking parents if they foresee any barriers to implementing the treatment
plan, goals, and strategies they are being asked to use.
• Asking parents to brainstorm examples of how they can implement the treat-
ment plan, goals, and treatment strategies at home, rather than making sug-
gestions to them.
• Asking parents to brainstorm examples of how they can implement the goals
and treatment strategies at home, with a focus on the materials and activities
that are available in the home setting.
Because several of these strategies are focused on brainstorming with parents,
clinicians can develop written materials that parents can use to document their
ideas. For instance, as suggested in the final bullet, if a clinician and parent were
brainstorming how to target three goals—verbal requesting, imitation, and follow-
ing directions at home—they might create a grid, noting ideas; see Table 4.2 for an
example. Helping parents to think explicitly about how they will target goals using
the toys and activities available in the home setting can be very useful.

Table 4.2. Brainstorming with parents about how to target goals at home

Use a grid like this one to help parents write down their ideas about how to target goals at
home with the materials they have available.

Toys available Goal 1: Goal 2: Goal 3:

at home Verbal requesting Imitation Following directions

Trains Requesting pieces Imitating driving the train

Following directions
while building the fast or slow related to where
tracks the train should go
Blocks Requesting pieces Imitating actions, such as Following directions
while building putting a block on or about what to do
under with the blocks
Mr. Potato Head Requesting the body Imitating funny actions with Following directions
parts while building the body parts before about where to put
putting them on the toy the body parts
 Empowering Parents 85

Key Components of Parent Coaching

The following are components to consider when coaching parents and other care-
givers to work with children with ASD. Similar steps have been outlined in several
parent training programs for children with ASD (Brookman-Frazee et al., 2012; In-
gersoll & Dvortcsak, 2010; Steiner et al., 2012), as well as in early intervention parent
coaching (e.g., Rush & Sheldon, 2011). The steps in Behavioral Skills Training (e.g.,
Clayton & Headley, 2019), a standard set of training procedures outlined in the Ap-
plied Behavior Analysis (ABA) literature, are embedded here; however, additional
strategies are added to enhance empowerment and parent-professional collabora-
tion. The PACT strategies discussed previously can be incorporated into each step.
When coaching parents, clinicians should do the following:
• Provide manualized or written content
• Begin each session with a check-in or reflection
• Describe and discuss the technique being taught in the session
• Relate the technique to the child’s individual treatment goals
• Demonstrate or model the technique during direct work with the child—
narrate use of the technique
• Have the parent practice the technique with live coaching
• Engage the parent in reflective discussion of the interaction
• Encourage home practice of the intervention techniques
Each of these components is described in detail in the sections that follow.

Provide Manualized or Written Content Clinicians should provide parents

with written content that they can review before they are taught a given treat-
ment strategy. Although not all NDBI models have manualized parent training
programs, some do, including ESDM, Project ImPACT, PRT, and JASPER. The Proj-
ect ImPACT manual, for example, contains short chapters on each intervention
strategy being taught. Parents have the opportunity to read information before
receiving coaching on each technique in session. If parents do not complete the
reading, the provider can review it with them during the session. Of course, cli-
nicians should consider the family’s literacy level and English proficiency when
providing material. Many NDBI have short handouts (e.g., the refrigerator lists in
ESDM) that can support families’ understanding of the topics. For NDBI that do
not have manualized parent training content, clinicians may wish to explore how
content from related models might apply. For example, the content in ESDM or
Project ImPACT contains information about IT that could be provided to parents if
IT is the primary model being used. Content may need to be adapted in such cases,
which requires clinical expertise. Clinicians who do not feel comfortable with such
adaptations may wish to focus on an NDBI model that does have manualized con-
tent for parents when conducting parent training.

Begin Each Session With a Check In or Reflection At the beginning of each

coaching session, clinicians should schedule time for a check in or brief reflection
session with the parent. Clinicians can use active listening techniques to hear how
86 Core Concepts and Foundational Principles

the parent found the use of the strategies from the previous session and to work
with them to problem-solve challenges. This is an excellent time to recognize par-
ent strengths and efforts, as well as child strengths and successes related to parent
efforts. At the end of the check-in period, clinicians and parents can work together
to choose the topics and goals for the session.

Describe and Discuss the Technique To introduce a new technique, clini-

cians should briefly describe and discuss the technique in a way that relates it to
the parent’s own daily activities and goals for the child. Clinicians should first
label and define the technique. They should ensure parents are learning termi-
nology associated with the technique so they understand feedback that is later
provided during direct coaching. Clinicians can then provide verbal examples to
clarify as needed. It may also be useful to have parents paraphrase the technique
to assess comprehension. Parents can also provide examples of application of the
technique as another strategy for evaluating comprehension.
Providing a rationale for the technique is also important. For example, many
NDBI strategies enhance child motivation. A parent who wishes to focus on
increasing communication skills may not immediately understand how enhancing
child motivation will facilitate progress toward this goal. Providing a rationale will
help parents better understand why a technique is being used, in turn increasing
their buy-in and follow through with that technique. Clinicians should ask parents
questions to ensure they understand the technique and should encourage parents
to ask them questions about how the strategy relates to their child. Providing par-
ents with video examples of a technique during this phase may also be useful.
Many parent training models use video examples as a standard part of the training
package (e.g., Hardan et al., 2015).

Relate the Technique to the Child’s Individual Treatment Goals To relate

techniques to the child’s goals, the clinician can begin by providing examples, and
can also engage the parent in a more active manner by having him or her generate
examples of how the treatment technique relates to the child’s goals. This brain-
storming provides the parent with multiple examples of the application of a treat-
ment technique, a strategy that is likely to enhance generalization of parent skills
(Stokes & Baer, 1977). This can also be a good time to brainstorm what might work
well and what might be challenging about using this specific technique with the
child at home after the therapist leaves.

Demonstrate or Model the Technique During Direct Work With the Child
Once the parent has an understanding of the technique and how it relates to the
child’s goals, the next step is to briefly demonstrate the technique during direct
work with the child. Clinicians may find it useful to narrate for the parent how
they are applying the technique and what effect it is having on the child’s behavior
in the moment. As parent understanding increases, he or she can be asked to iden-
tify the techniques being used with increasing independence. Clinicians should not
outshine parents while demonstrating the technique. This can make parents feel
disheartened with their own interactions with their child. Although modeling strat-
egies for the parent is important, direct coaching is imperative because it provides
parents with an opportunity to practice skills. Therefore, clinicians should not get
stuck at the modeling stage and should move to parent practice as soon as possible.
 Empowering Parents 87

Have the Parent Practice the Technique With Live Coaching Once the par-
ent understands the strategy, he or she can move on to practicing the techniques
with clinician coaching and feedback. Some parents may be hesitant to practice. As
such, clinicians may want to develop a routine around how session time is spent.
For example, the clinician and parent might spend the first 5 minutes checking in,
followed by 10 minutes of new material and demonstration, 20 minutes of parent
direct practice and reflection, 10 minutes of review from the week and questions,
and 5 minutes assigning next week’s homework in a 50-minute session. Encourag-
ing parents to practice skills with their children during sessions is associated with
larger intervention effects than programs without practice, regardless of other pro-
gram content or delivery approaches (Kaminski, Valle, Filene, & Boyle, 2008).
When coaching parents, clinicians can give feedback both as they work with
their child and after a technique has been practiced. Clinicians who will regularly
conduct parent coaching and training may need to explicitly develop their skills for
providing feedback to parents. It can be especially challenging for clinicians to pro-
vide feedback in the moment while parents are working with their child, and this
skill set may require training, practice, and feedback from other clinicians. When
first teaching a parent new skills, clinicians can begin a practice session by telling
the parent what the focus will be and then only practice one skill at a time (e.g.,
“Today while you are practicing, I am primarily going to provide you with feedback
on your use of natural reinforcement”). Coaching should focus on that skill. Feed-
back that is provided while a parent is working needs to be succinct and focused in
order to avoid disrupting the flow of the practice (e.g., “Giving him the ball is appro-
priate use of natural reinforcement,” “He appropriately requested, so go ahead and
reinforce”). Additional examples of succinct feedback can be found in Box 4.2. As
parents gain skills, it will become feasible to focus on several skills within a practice

Ready, Set, Implement!

BOX 4.2: Providing feedback in the moment
Feedback that is provided to parents while they are working with their child
should be brief, succinct, and specific. The coach can say
• You’re doing a good job of imitating your child’s actions.
• Your positive affect right now has him really engaged.
• Great job maintaining control of the reinforcer until she communicates
appropriately for it.
• He pointed to the toy! Go ahead and provide him access.
• He looks less motivated than a minute ago. What do you think we should
do next?
• She is really paying attention to the words you are modeling.
• He is not attending to you. How can you gain his attention right now?
• The way you are looking expectantly makes it so clear that you want him
to ask for a turn.
88 Core Concepts and Foundational Principles

session (e.g., “Today we are going to focus on setting up clear teaching trials, includ-
ing using clear prompts, being contingent, and using natural reinforcement”).
At times, feedback will need to be more elaborate and may lead to discussion
(e.g., if it becomes apparent that the parent does not understand the strategy). In
these instances, the practice session may need to pause so the clinician can deliver
more detailed feedback, clarify terms, or answer parent questions. It is also useful
to provide more detailed feedback following a practice session, which is addressed
in more detail in the next section on reflective discussion following practice. Dur-
ing these discussions, clinicians can summarize what the parent did well and what
he or she might need to work on. It may also be useful to discuss how a parent’s
actions led to a certain child outcome (e.g., “You may have noticed that when you
followed his lead he became much more engaged with you”). In contrast, it may also
be useful to explore what may have happened if the parent had chosen a different
path (e.g., “When you tried to interest him in trains, his motivation seemed to go
down. Following his lead to blocks may have resulted in increased engagement”).
As mentioned previously, parent practice is critical to learning; thus, it is
important not to derail practice sessions by stopping for discussion too often. If
this becomes a challenge, clinicians may want to develop a plan to practice for
a certain period in which only coaching will be provided but no discussion will
occur. The clinician can then take notes to use as discussion points when the prac-
tice session is done.
Several strategies for providing effective feedback are outlined in the litera-
ture (e.g., Brookman-Frazee, 2004; Haine-Schlagel & Martinez, 2014; Ingersoll &
Dvortcsak, 2010). These are described in Tables 4.3 and 4.4. Table 4.3 provides exam-
ples of different types of feedback (e.g., labeling correct vs. incorrect implementation
of the strategy), and Table 4.4 provides information on how to conduct empower-
ment-focused feedback. Parents are more likely to need a higher level of direct feed-
back early on in treatment; however, all parents differ in their learning styles, and
clinicians should work to assess what type of feedback best suits a parent and his
or her skills at a given point in time. For example, some parents may struggle with
the multitasking required to receive feedback in the moment, whereas others may
benefit from this type of feedback because it is directly tied to their behavior.
A parent’s response to corrective feedback should also be considered.
Although some parents have no difficulty hearing constructive feedback about
how to improve their skills, others may feel defensive, insecure, or self-conscious
when such feedback is given. The ratio of positive to constructive comments is
important to consider based on individual parent response to feedback. A ratio as
high as five positive comments to every one corrective comment may be ideal for
enhancing learning (Losada, 1999; Losada & Heaphy, 2004). Clinicians and parent
coaches often use at least a ratio of three positives to one corrective comment.
Rapport with the parent is also an important consideration because parents
may be more comfortable hearing constructive feedback from someone with
whom they have a strong alliance. It may be useful to provide more positive feed-
back early in treatment and choose constructive comments very carefully until a
rapport is established that will foster a parent’s comfort level with receiving more
constructive feedback. One clear advantage of using empowerment-focused feed-
back (see Table 4.4) is the increased likelihood of constructive feedback feeling less
threatening because the parent is involved in evaluating his or her own perfor-
mance and discussing both positives and negatives with the therapist.
 Empowering Parents 89

Table 4.3. Strategies for providing effective feedback during parent coaching

Topic Definition Example

Give behavior- Feedback should be specific, “When you followed Jennifer’s lead
specific related to parent and child
feedback behavior in the moment, and
clear.
Give focused Focus each session or grouping Current technique: “When you gave
feedback of sessions on a single or
small number of techniques.
Focus feedback primarily on
the current technique.
As parents learn more
techniques, review feedback
on previously learned
techniques; however, make
sure to balance this with the
current technique of focus.
Use positive Provide parents with positive
examples examples about correct use
of correct of techniques rather than
application of giving corrective feedback.
techniques.
Use corrective Use of corrective suggestions
suggestions is also important to ensure
when needed. success. Some parents
are more comfortable with
feedback than others; you
may need to adjust your
strategy for giving feedback
accordingly.
from the bubbles to the ball ramp,
that was good use of the following the
child’s lead technique, and she stayed
engaged with you for much longer.”
Charlie his train after he pointed
to it, that was good use of natural
reinforcement.”
Review of techniques: “When you
hold up Charlie’s train, wait for him
to respond, and then give it to him.
You are nicely following his lead,
obtaining shared control, setting up a
teaching trial, and providing natural
reinforcement.”
“Nice following the child’s lead from the
blocks to the markers.”
“Your shared control over the stickers is
very clear.”
“You are being very immediate in
providing reinforcement.”
“Nice use of positive affect to enhance
engagement.”
“Junior seems to have lost interest in the
game. Rather than continuing to try to
play, let’s see what he does to next.”
“Since Junior just earned access to the
puzzle by communicating, let’s give
him a minute to play with it. While he
is playing, it would be a good time for
you to practice narrating what he is
doing to provide language modeling.”

Table 4.4. Types of feedback to use when coaching parents

Type of feedback Definition When to use Example

Direct feedback Suggest something Use this in the moment to “Sam just asked for
specific, or show help parents succeed in the ball. If you
the parent what their interactions. It may give it to him, that
to do. be more appropriate will reinforce his
for parents who are just communication
beginning parent training. behavior.”
Indirect Indirect suggestions Use this when there is “Sam does not
suggestions require the time for a parent to seem to be paying
parent to make reflect without losing the attention to you right
judgements about child’s attention. It may now. Where is his
the situation and be more appropriate for attention?”
decide on a course parents who are further
of action. along in parent training.
Empowerment- Feedback is framed Use this when there is time “It looks like Jennifer is
focused in terms of choices for a parent to reflect motivated to turn the
feedback parents can make without losing the child’s ball popper on again.
about how to apply attention. This can be What communication
the intervention adapted based on parent behavior would you
strategy in the level of experience. like to prompt her to
moment. use?”
90 Core Concepts and Foundational Principles

Engage the Parent in a Reflective Discussion of the Interaction To increase

parent participation and problem-solving skills, clinicians can ask them how using
the strategies during the session worked for them and their child. After each parent
practice session, clinicians should allow time for a reflective discussion on these
points. They can model reflection by describing what they saw in the interaction
and linking the strategies the parent used to child behavior. They should ask the
parent to consider what went well and what the challenges were. Together the cli-
nician and parent can brainstorm solutions to the challenges. Ideas for questions
that can be asked to promote reflective discussion are outlined in Box 4.3. This re-
flective discussion helps parents have more successful practice at home and during
the next session, as well as understand the techniques more clearly.

Encourage Home Practice of Intervention Techniques The last step in each

parent coaching session focuses on collaborating with the parent to plan for practic-
ing intervention techniques outside of sessions. This will facilitate parent learning
and generalizing of the targeted intervention skill. The clinician can ask the parent
to choose a specific day, time, or activity in which they will practice the technique.
Again, the clinician and parent can take time in this discussion to troubleshoot an-
ticipated challenges and to come up with some solutions. Between-session activi-
ties may also include reading materials for the following weeks or video-recording
or tracking child behaviors. To maximize the benefit of home practice, the inter-
ventionist should follow up with discussion in the subsequent session to provide
further feedback and adjust as needed.

Ready, Set, Implement!

BOX 4.3: Promoting reflective discussion with parents
Try asking parents these questions to promote reflective discussion after
they have practiced working with their child.
• What did you think went well?
• What challenges did you experience?
• Can you think of some examples where your actions enhanced
motivation and engagement?
• Can you think of some examples of where you struggled to enhance
motivation and engagement?
• How did you feel while you were working with your child?
• How do you think your actions influenced your child’s behavior,
performance, or motivation?
• How was it to hear my feedback and try to incorporate it in the moment
while working with your child?
• How do you think it will be to use these skills at home?
• Can you provide me with some examples of how or when you might
practice these skills at home?
 Empowering Parents 91

Case Example: Gabe

Gabe is a 3-year-old boy with a diagnosis of ASD. He was diagnosed at the age of
30 months when his speech had not progressed beyond about 20 single words. He
showed minimal interest in peers and began lining up objects and engaging in hand
flapping. His parents had also started to notice unusual reactions in certain situations,
such as crying and covering his ears when his baby sister cried and hiding under the
table at a birthday party when everyone started to sing Happy Birthday. Gabe loved
cause-and-effect toys such as ball-poppers, musical toys, and car ramps. Although
his interest in peers was minimal, he could be readily engaged by adults with gross
motor games, such as tickles, chase, and spinning him around.
Following his diagnosis, the diagnosing psychologist recommended Applied
Behavior Analysis (ABA) therapy. Gabe’s parents understood that ABA therapy was
an effective treatment method for children with ASD, but also wanted to learn strate-
gies they could use to support their son, especially because Gabe’s mother was at
home with her children full time. They interviewed several ABA treatment agencies
and settled on one that would provide regular weekly hours of direct therapy with
Gabe, as well as several hours of parent coaching each week.
Gabe’s parents met with his treatment providers, and together they developed
his treatment plan. The treatment providers discussed their treatment recommenda-
tions in detail with the parents and asked for their input about the recommendations
being made, as well as their priorities for treatment. Together, they decided on a set
of goals to target during parent training sessions. Goals were focused both on skills
the parents would target with Gabe, as well as intervention skills the parents would
learn. Although Gabe would have a broader range of goals in his overall treatment
program, child goals identified by the team for parent education included increasing
frequency of single-word requests for objects, increasing attention to people and con-
tingent vocalizations during parent–child play routines, increasing imitation of actions,
and increasing hand-holding skills to decrease elopement in public. Parent goals for
treatment included learning how to create naturalistic communication opportunities,
set up sensory social routines, increase imitation, and implement a behavior plan for
teaching hand-holding in public (see Table 4.5).
Because Gabe’s parent training plan was designed to target a range of skills in
various domains of development, his intervention team then developed a plan for
teaching skills to Gabe’s parents sequentially in order to not overwhelm them with
too many goals at one time. First, they learned strategies to target verbally request-
ing objects (e.g., environmental arrangements and shared control), as well as how to
use sensory social routines to promote social engagement. Because these strategies
focus on teaching parents to embed behavioral teaching trials in natural parent–child
interactions, learning them first also laid an important foundation of knowledge about
behavioral teaching trials in general. For example, it highlighted the importance of
shared control and contingent natural reinforcement. Once these skills were mas-
tered, Gabe’s parents began learning strategies for targeting imitation, such as imi-
tating Gabe to peak his interest and then using balanced turns to cue him to imitate
in return and reinforcing him for doing so with ongoing access to preferred materi-
als. While building mastery with these skills, they continued to practice naturalistic
92 Table 4.5. Example NBDI parent training plan

Parent goal or Directive parent Empowerment-based

Child goal treatment strategy Example teaching trials coaching feedback example coaching feedback example

Requesting Environmental Hold up a preferred toy or snack, and “Gabe seems really motivated to put the “Gabe is really engaged
objects arrangements wait for Gabe to verbally request it. balls into the popper again. This would with the ball popper! What
or shared Place Gabe’s favorite toy on a shelf so be a great time to hold them up and strategy would you like to
control to target he has to initiate communication in see if he will verbally request them.” use to gain shared control?”
communication order to request it. “Holding the balls up and waiting for “Do you think Gabe looks
trials Gabe to ask would be a nice, clear motivated enough to do
example of shared control.” some communication trials
“Great job continuing to hold the balls right now?”
until he asks for them. Good shared “You have great shared
control!” control, but he does not
“Remember, we don’t want him to gain seem to be requesting. What
access to the balls until he asks.” do you think we should do
next?”
Increased Sensory-social Pause during a tickle game with hands “He loves the tickles! Now, pause and “He loves tickles! Can you
attention or routines held up expectantly, and wait for eye wait for him to look toward you before think of a way to set up a
vocalizations contact or vocalization before tickling you tickle him again.” sensory-social routine right
during him again. “Pausing after spinning him is a nice wait now?”
parent–child Pick Gabe up, spin him around, and to set up this routine. Now, wait until “Pausing after spinning him
play routines then pause to wait for eye contact he vocalizes before you spin again.” is a nice way to set up this
or vocalization before spinning him routine. When you pause,
again. do you want to work on
attention or vocalizations?”
Imitation of Shared control and First, imitate the child’s actions with “That’s great imitating Gabe. Now would “Can you think of a novel
actions balanced turns plastic animals (e.g., making them be a good time to introduce a novel action you’d like to introduce
walk, climb, jump), then introduce action.” for Gabe to imitate?”
the novel action of making the animal “Nice introducing a novel action. Since “You introduced a novel
eat. Once the child imitates, return to he didn’t imitate you, model it again.” action, but he didn’t imitate
imitating the child as reinforcement. you. What ideas do you
Imitate the child’s actions with toy cars have for helping him
(e.g., driving) before introducing the succeed in imitating?”
novel action of crashing the car. Once
the child imitates, return to allowing
the child to play as he wishes for
reinforcement.
 Increasing Natural Starting with a controlled setting (e.g., “You did a nice job making the “He needs a clear
hand-holding reinforcement home or clinic), practice hand- expectation that he hold hands very understanding of the
in public of hand-holding; holding by setting a time-based goal, clear.” expectation to hold
visual cues prompting Gabe to walk holding “He let go of your hand, so let’s begin hands. How could you
to promote hands, and ending the trial in a the trial again. He did not earn communicate that to him?”
generalization in location where toys or adult attention reinforcement.” “He let go of your hand. What
public are available as natural reinforcement should we do next?”
for correct demonstration of target
behavior. Increase the time goal
over repeated trials. Then, generalize
to the community using similar
reinforcement strategies.

93
94 Core Concepts and Foundational Principles

communication trials and sensory social routines. As they gained fluency with teach-
ing imitation, they also began to spend a portion of their parent training sessions
learning about principles of functional assessment. They then participated in a func-
tional assessment interview to assess elopement in public and began taking A-B-C
data during outings (e.g., to the grocery store or park).
Once the functions of elopement were clearer, the parents participated in a
meeting with the treatment team to develop a behavior intervention plan for elope-
ment. They began by using naturalistic teaching to teach hand-holding in a controlled
setting. For instance, they had Gabe hold hands in the house or in the yard for
increasing periods of time, reinforcing the skill through access to preferred toys or
natural social routines such as tickles and swinging him around. Once Gabe could reli-
ably hold hands in controlled settings, they began generalizing these skills during brief
community outings (e.g., to a convenience store to purchase a snack), using visual
cues to prime him for behavioral expectations and contingencies that were in place
(e.g., first hold hands, then get snack).
Parent training strategies used included individual meetings, parent coaching in
the home setting, and parent coaching in community settings to assist with gener-
alization. New skills were presented using the strategies outlined in this chapter. For
example, when introducing strategies for targeting requesting, social engagement
and imitation, clinicians first reviewed the strategies verbally during an individual
parent meeting and also provided the parents with reading materials. As clinicians
discussed topics, they provided examples in relation to Gabe’s treatment goals. The
clinicians then demonstrated the strategies for Gabe’s parents while narrating their
teaching trials and discussing which treatment strategies were being used. They then
encouraged Gabe’s parents to practice the targeted treatment strategies during direct
interactions with Gabe with clinician coaching in the home or clinic setting. Finally,
once the parents had mastered skills, they were taken on community outings with
clinician support, when appropriate, such as to practice his hand-holding goal.

CONCLUSION
This chapter provided an overview of the role and importance of parents and par-
ent training and coaching in NDBI, as well as offering a number of strategies for ef-
fective empowerment-focused parent coaching. These strategies are not specific to
any one NDBI model and can be applied to any intervention in which parent coach-
ing is a focus. As with child treatment goals, parent goals and coaching methods
must be individualized to meet the needs of each family. Taking treatment fidel-
ity data on parent implementation of intervention strategies (Meadan, Ostrosky,
Zaghlawan, & Yu, 2009) is also useful. Treatment fidelity data can inform the train-
ing and coaching approach and can assist with determining when a parent has
received enough parent training or coaching (i.e., met mastery criteria). Strategies
for taking treatment fidelity data are discussed in Chapter 16 on quality indicators.
The strategies discussed in the present chapter can also be combined with the later
chapters that focus on teaching specific skills (e.g., Chapter 11 on communication)
when training and coaching a parent on the intervention procedure. Regardless of
the NDBI strategies being taught, the empirically supported parent coaching strat-
egies included in this chapter should enhance the effectiveness of a parent training
approach to any NDBI model.
 Empowering Parents 95

REFERENCES
Amsbary, J., & AFIRM Team. (2017). Parent implemented interventions. Chapel Hill: University
of North Carolina, FPG Child Development Center, National Professional Development
Center on Autism Spectrum Disorder. Retrieved from http://afirm.fpg.unc.edu/parent
-implemented-interventions
Baker-Ericzen, M., Brookman-Frazee, L., & Stahmer, A. (2006). Stress levels and adaptability
in parents of toddlers with and without autism spectrum disorders. Research and Practice
for Persons with Severe Disabilities, 30, 194–204.
Barnett, M. L., Niec, L. N., & Acevedo-Polakovich, I. D. (2014). Assessing the key to effective
coaching in parent–child interaction therapy: The therapist-parent interaction coding sys-
tem. Journal of Psychopathology and Behavioral Assessment, 36(2), 211–223.
Barnett, M. L., Niec, L. N., Peer, S. O., Jent, J. F., Weinstein, A., Gisbert, P., & Simpson, G.
(2015). Successful therapist–parent coaching: How in-vivo feedback relates to parent
engagement in parent–child interaction therapy. Journal of Clinical Child & Adolescent Psy-
chology, 46(6), 895–902.
Benson, P. R. (2006). The impact of child symptom severity on depressed mood among par-
ents of children with ASD: The mediating role of stress proliferation. Journal of Autism and
Developmental Disorders, 36(5), 685–695.
Bernheimer, L. P., Gallimore, R., & Weisner, T. S. (1990). Ecocultural theory as a context for
the individual family service plan. Journal of Early Intervention, 14(3), 219–233.
Berquist, K. L., & Charlop, M. H. (2014). Teaching parents of children with autism to evalu-
ate interventions. Journal of Developmental and Physical Disabilities, 26(4), 451–472.
Brookman-Frazee, L. (2004). Using parent/clinician partnerships in parent education pro-
grams for children with autism. Journal of Positive Behavior Interventions, 6(4), 195–213.
Brookman-Frazee, L., Stahmer, A. C., Lewis, K., Feder, J. D., & Reed, S. (2012). Building a
research community collaborative to improve community care for infants and toddlers
at-risk for autism spectrum disorders. Journal of Community Psychology, 40(6), 715–734.
Brookman-Frazee, L., Vismara, L., Drahota, A., Stahmer, A., & Openden, D. (2009). Parent
training interventions for children with autism spectrum disorders. In J. Matson (Ed.),
Applied behavior analysis for children with autism spectrum disorders: A handbook (pp. 237–258).
New York, NY: Springer.
Carpenter, B. (1997). Empowering parents: The use of parent as researcher paradigm in
early intervention. Journal of Child and Family Studies, 6(4), 391–398.
Clayton, M., & Headley, A. (2019). The use of behavioral skills training to improve staff per-
formance of discrete trial training. Behavioral Interventions. Retrieved from https://doi-org
.offcampus.lib.washington.edu/10.1002/bin.1656.
Coolican, J., Smith, I. M., & Bryson, S. E. (2010). Brief parent training in pivotal response
treatment for preschoolers with autism. Journal of Child Psychology and Psychiatry, 51(12),
1321–1330.
Dale, E., Jahoda, A., & Knott, F. (2006). Mothers’ attributions following their child’s diagno-
sis of autistic spectrum disorder: Exploring links with maternal levels of stress, depres-
sion and expectations about their child’s future. Autism, 10(5), 463–479.
Dunn, M. E., Burbine, T., Bowers, C. A., & Tantleff-Dunn, S. (2001). Moderators of stress in
parents of children with autism. Community Mental Health Journal, 37(1), 39–52.
Dunst, C. J. (2002). Family-centered practices birth through high school. The Journal of Special
Education, 36(3), 141–149.
Estes, A., Munson, J., Rogers, S. J., Greenson, J., Winter, J., & Dawson, G. (2015). Long-term
outcomes of early intervention in 6-year-old children with autism spectrum disorder.
Journal of the American Academy of Child and Adolescent Psychiatry, 54(7), 580–587.
Feldman, M. A., & Werner, S. E. (2002). Collateral effects of behavioral parent training on
families of children with developmental disabilities and behavior disorders. Behavioral
Interventions, 17(2), 75–83.
Garland, A., Haine-Schlagel, R., Accurso, E. C., Baker-Ericzén, M. J., & Brookman-
Frazee, L. (2012). Exploring the effect of therapists’ treatment practices on client atten-
dance in community-based care for children. Psychological Services, 9(1), 74–88.
Gulsrud, A. C., Hellemann, G., Shire, S., & Kasari, C. (2015). Isolating active ingredients in
a parent-mediated social communication intervention for toddlers with autism spectrum
disorder. Journal of Child Psychology and Psychiatry, 57(5), 606–613.
96 Core Concepts and Foundational Principles

Haine-Schlagel, R., & Bustos, C. (2013). The Parent and Caregiver Active Participation Toolkit
(PACT): Therapist training manual. San Diego, CA: San Diego State University.
Haine-Schlagel, R., & Martinez, J. I. (2014). Therapist Alliance, Collaboration, and Empowerment
Strategies (ACEs) Observational Coding System. San Diego, CA: San Diego State University.
Haine-Schlagel, R., Martinez, J. I., Roesch, S. C., Bustos, C. E., & Janicki, C. (2016). Random-
ized trial of the parent and caregiver active participation toolkit for child mental health
treatment. Journal of Clinical Child and Adolescent Psychology, 21, 1–11.
Hardan, A. Y., Gengoux, G. W., Berquist, K. L., Libove, R. A., Ardel, C. M., Phillips, J., . . .
Minjarez, M. (2015). A randomized controlled trial of pivotal response treatment group for
parents of children with autism. Journal of Child Psychology and Psychiatry, 56(8), 884–892.
Herschell, A., Calzada, E., Eyberg, S., & McNeil, C. (2002). Parent–child interaction therapy:
New directions in research. Cognitive and Behavioral Practice, 9, 9–16.
Hodge, N., & Runswick-Cole, K. (2008). Problematising parent–professional partnerships in
education. Disability and Society, 23(6), 637–647.
Ingersoll, B., & Dvortcsak, A. (2006). Including parent training in the early childhood spe-
cial education curriculum for children with autism spectrum disorders. Topics in Early
Childhood Special Education, 26(3), 179–187.
Ingersoll, B., & Dvortcsak, A. (2010). Teaching social communication to children with autism: A
manual for parents. New York, NY: Guilford Press.
Ingersoll, B., & Wainer, A. (2013). Initial efficacy of Project ImPACT: A parent mediated
social communication intervention for young children with ASD. Journal of Autism and
Developmental Disorders, 43(12), 2943–2952.
Ingersoll, B., Wainer, A. L., Berger, N. I., Pickard, K. E., & Bonter, N. (2016). Comparison of a
self-directed and therapist-assisted telehealth parent mediated intervention for children
with ASD: A pilot RCT. Journal of Autism and Developmental Disorders, 46(7), 2275–2284.
Kaminski, J. W., Valle, L. A., Filene, J. H., & Boyle, C. L. (2008). A meta-analytic review of
components associated with parent training program effectiveness. Journal of Abnormal
Child Psychology, 36, 567–589.
Kasari, C., Gulsrud, A. C., Wong, C., Kwon, S., & Locke, J. (2010). Randomized controlled
caregiver mediated joint engagement intervention for toddlers with autism. Journal of
Autism and Developmental Disorders, 40(9), 1045–1056.
Kasari, C., Lawton, K., Shih, W., Barker, T. V., Landa, R., Lord, C., . . . Senturk, D. (2014).
Caregiver-mediated intervention for low-resourced preschoolers with autism: An RCT.
Pediatrics, 134(1), e72–e79.
Kazdin, A., & Weisz, J. (2003). Evidence-based psychotherapies for children and adolescents.
New York, NY: Guilford Press.
Koegel, R. L., Bimbela, A., & Schreibman, L. (1996). Collateral effects of parent training on
family interactions. Journal of Autism and Developmental Disorders, 26(3), 347–359.
Koegel, R. L., & Koegel, L. K. (2006). Pivotal Response Treatments for autism: Communication,
social, and academic development. Baltimore, MD: Paul H. Brookes Publishing Co.
Koren, P. E., DeChillo, N., & Friesen, B. J. (1992). Measuring empowerment in families whose
children have emotional disabilities: A brief questionnaire. Rehabilitation Psychology, 37(4),
305–321.
Lloyd, T. J., & Hastings, R. P. (2009). Hope as a psychological resilience factor in mothers and
fathers of children with intellectual disabilities. Journal of Intellectual Disability Research,
53(12), 957–968.
Losada, M. (1999). The complex dynamics of high performance teams. Mathematical and
Computer Modelling, 30(9), 179–192.
Losada, M., & Heaphy, E. (2004). The role of positivity and connectivity in the performance of
business teams: A nonlinear dynamics model. American Behavioral Scientist, 47(6), 740–765.
Lucyshyn, J. M., Dunlap, G., & Albin, R. W. (2002). Families and positive behavior support:
Addressing problem behavior in family contexts. Baltimore, MD: Paul H. Brookes Pub-
lishing Co.
McConachie, H., & Diggle, T. (2006). Parent implemented early intervention for young chil-
dren with autism spectrum disorder: A systematic review. Journal of Evaluation in Clinical
Practice, 13(1), 120–129.
McGrath, J. M. (2005). Partnerships with families: A foundation to support them in difficult
times. The Journal of Perinatal and Neonatal Nursing, 19(2), 94–96.
 Empowering Parents 97

McIntyre, L. L. (2008). Adapting Webster-Stratton’s Incredible Years parent training for chil-
dren with developmental delay: Findings from a treatment group only study. Journal of
Intellectual Disability Research, 52, 1176–1192.
Meadan, H., Ostrosky, M. M., Zaghlawan, H. Y., & Yu, S. (2009). Promoting the social and
communicative behavior of young children with autism spectrum disorders: A review of
parent-implemented intervention studies. Topics in Early Childhood Special Education, 29(2),
90–104.
Mesibov, G. B., Shea, V., & Schopler, E. (2005). The TEACCH approach to autism spectrum disor-
ders. New York, NY: Springer.
Minjarez, M. B., Mercier, E. M., Williams, S. E., & Hardan, A. Y. (2013). Impact of elicit group
therapy on stress and empowerment in parents of children with autism. Journal of Positive
Behavior Interventions, 15(2), 71–78.
Minjarez, M. B., Williams, S. E., Mercier, E. M., & Hardan, A. Y. (2011). Pivotal response
group treatment program for parents of children with autism. Journal of Autism and Devel-
opmental Disorders, 41(1), 92–101.
Moore, T. R., & Symons, F. J. (2011). Adherence to treatment in a behavioral intervention
curriculum for parents of children with autism spectrum disorder. Behavior Modification,
35(6), 570–594.
Motzer, S. A., & Hertig, V. (2004). Stress, stress response, and health. Nursing Clinics of North
America, 39(1), 1–17.
Murray, M. M., Ackerman-Spain, K., Williams, E. U., & Ryley, A T. (2011). Knowledge is
power: Empowering the autism community through parent-professional training. School
Community Journal, 21(1), 19–36.
Murray, M. M., & Curran, E. M. (2008). Learning together with parents of children with dis-
abilities: Bringing parent-professional partnership education to a new level. Teach Educa-
tion and Special Education, 31(1), 59–63.
Murray, M. M., Curran, E., & Zellers, D. (2008). Building parent/professional partnerships:
An innovative approach for teacher education. The Teacher Educator, 43(2), 87–108.
Murray, M. M., Handyside, L. M., Straka, L. A., & Arton-Titus, T. V. (2013). Parent empower-
ment: Connecting with preservice special education teachers. School Community Journal,
23(1), 145–168.
Nahmias, A. S., & Mandell, D. S. (2014). A meta-analysis comparing parent- and clinician-
implemented early interventions for children with autism spectrum disorders. Paper presented at
the International Meeting for Autism Research, Atlanta, GA, May 2014.
National Research Council. (2001). Educating children with autism. Washington, DC: National
Academy Press.
Oono, I. P., Honey, E. J., & McConachie, H. (2013). Parent-mediated early intervention for
young children with autism spectrum disorders (ASD). Evidence-Based Child Health: A
Cochrane Review Journal, 8, 2380–2479.
Patterson, G. (1982). Coercive family process. Eugene, OR: Castilia.
Pickard, K. E., Wainer, A. L., Bailey, K. M., & Ingersoll, B. R. (2016). A mixed-method evalua-
tion of the feasibility and acceptability of a telehealth-based parent-mediated intervention
for children with autism spectrum disorder. Autism, 20(7), 845–855.
Plienis, A. J., Robbins, F. R., & Dunlap, G. (1988). Parent adjustment and family stress as
factors in behavioral parent training for young autistic children. Journal of the Multihandi-
capped Person, 1(1), 31–52.
Robbins, F. R., Dunlap, G., & Plienis, A. J. (1991). Family characteristics, family training, and
the progress of young children with autism. Journal of Early Intervention, 15(2), 173–184.
Rogers, S. J., Estes, A., Lord, C., Vismara, L., Winter, J., Fitzpatrick, A., . . . Dawson, G. (2012).
Effects of a brief Early Start Denver model (ESDM)–based parent intervention on toddlers
at risk for autism spectrum disorders: A randomized controlled trial. Journal of the Ameri-
can Academy of Child and Adolescent Psychiatry, 51(10), 1052–1065.
Rogers, S. J., Vismara, L., Wagner, A. L., McCormick, C., Young, G., & Ozonoff, S. (2014).
Autism treatment in the first year of life: A pilot study of infant start, a parent imple-
mented intervention for symptomatic infants. Journal of Autism and Developmental Disor-
ders, 44(12), 2981–2995.
Rush, D. D., & Sheldon, M. L. (2011). The early childhood coaching handbook. Baltimore, MD:
Paul H. Brookes Publishing Co.
98 Core Concepts and Foundational Principles

Schreibman, L., Dawson, G., Stahmer, A. C., Landa, R., Rogers, S. J., McGee, G. G., . . . Halla-
day, A. (2015). Naturalistic developmental behavioral interventions: Empirically validated
treatments for autism spectrum disorder. Journal of Autism and Developmental Disorders,
45(8), 2411–2428.
Seltzer, M. M., Greenberg, J. S., Hong, J., Smith, L. E., Almeida, D. M., Coe, C., & Stawski, R.
S. (2010). Maternal cortisol levels and behavior problems in adolescents and adults with
ASD. Journal of Autism and Developmental Disorders, 40(4), 457–469.
Singer, G. (2002). Suggestions for a pragmatic program of research on families and disabil-
ity. The Journal of Special Education, 36(3), 150–156.
Solish, A., & Perry, A. (2008). Parents’ involvement in their children’s behavioral interven-
tion programs: Parent and therapist perspectives. Research in Autism Spectrum Disorders,
2(4), 728–738.
Stadnick, N. A., Stahmer, A., & Brookman-Frazee, L. (2015). Preliminary effectiveness of Project
ImPACT: A parent-mediated intervention for children with autism spectrum disorder deliv-
ered in a community program. Journal of Autism and Developmental Disorders, 45(7), 2092–2104.
Stahmer, A. C., Brookman-Frazee, L., Rieth, S. R., Stoner, J. T., Feder, J. D., Searcy, K., &
Wang, T. (2017). Parent perceptions of an adapted evidence-based practice for toddlers
with autism in a community setting. Autism, 21(2), 217–230.
Stahmer, A. C., & Gist, K. (2001). The effects of an accelerated parent education program on
technique mastery and child outcome. Journal of Positive Behavior Interventions, 3, 75–82.
Stahmer, A., & Pellecchia, M. (2015). Moving towards a more ecologically valid model of
parent-implemented interventions in autism. Autism, 19(3), 259–261.
Steiner, A. M. (2011). A strength-based approach to parent education for children with
autism. Journal of Positive Behavior Interventions, 13(3), 178–190.
Steiner, A. M., Koegel, L. K., Koegel, B. L., & Ence, W. A. (2012). Issues and theoretical con-
structs regarding parent education for autism spectrum disorders. Journal of Autism and
Developmental Disorders, 42(6), 1218–1227.
Stern, J. (2000). Parent training. In J. White & A. Freeman (Eds.), Cognitive-behavioral group
therapy: For specific problems and populations (pp. 331–360). Washington, DC: American Psy-
chological Association.
Stokes, T. F., & Baer, D. M. (1977). An implicit technology of generalization. Journal of Applied
Behavior Analysis, 10(2), 349–367.
Vismara, L. A., Colombi, C., & Rogers, S. (2009). Can one hour per week of therapy lead to
lasting change in young children with autism? Autism, 13(1), 93–115.
Vismara, L. A., Young, G. S., & Rogers, S. J. (2012). Telehealth for expanding the reach of
early autism training to parents. Autism Research and Treatment. Retrieved from https://
www.ncbi.nlm.nih.gov/pmc/articles/PMC3512210/
Vismara, L., Young, G., Stahmer, A., Griffith, E., & Rogers, S. (2009). Dissemination of
evidence-based practice: Can we train therapists from a distance? Journal of Autism and
Developmental Disorders, 39, 1636–1651.
Wainer, A. L., & Ingersoll, B. R. (2013). Disseminating ASD interventions: A pilot study of
a distance learning program for parents and professionals. Journal of Autism and Develop-
mental Disorders, 43(1), 11–24.
Webster-Stratton, C., & Reid, M. (2003). The Incredible Years parents, teachers, and children
training series: A multifaceted treatment approach for young children with conduct prob-
lems. In A. E. Kazdin & J. R. Weiss (Eds.), Evidence-based psychotherapies for children and
adolescents (pp. 224–240). New York, NY: Guilford Press.
Weiss, J. A., Cappadocia, M. C., MacMullin, J. A., Viecili, M., & Lunsky, Y. (2012). The impact
of child problem behaviors of children with ASD on parent mental health: The mediating
role of acceptance and empowerment. Autism, 16(3), 261–274.
Weiss, M. J. (2002). Hardiness and social support as predictors of stress in mothers of typical
children, children with autism, and children with mental retardation. Autism, 6(1), 115–130.
Wetherby, A. M., Guthrie, W., Woods, J., Schatschneider, C., Holland, R. D., Mordan, L., &
Lord, C. (2014). Parent-implemented social intervention for toddlers with autism: An RCT.
Pediatrics, 134(6), 1084–1093.
Wong, C., Odom, S. L., Hume, K., Cox, A. W., Fettig, A., Kucharczyk, S., . . . Schultz, T. R.
(2013). Evidence-based practices for children, youth, and young adults with autism spectrum disor-
der. Chapel Hill: The University of North Carolina, Frank Porter Graham Child Develop-
ment Institute, Autism Evidence Based Practice Review Group.
5
Fostering Inclusion With
Peers and in the Community
Aubyn C. Stahmer, Connie Wong, Matthew J. Segall, and Jennifer Reinehr

A
ccording to the Centers for Disease Control and Prevention (CDC; 2018),
inclusion means “including people with disabilities in everyday activi-
ties and encouraging them to have roles similar to their peers that do not
have disabilities.” Inclusive education involves adjusting curricula, assessment
practices, systems, teaching styles, and the physical environment to allow all indi-
viduals to participate equally. The United Nations (n.d.) supports the right of all
students, including those with autism spectrum disorder (ASD), to have access to
inclusive quality free education in their community with the necessary support to
enable them to reach their potential. Effective inclusion involves more than simple
integration, which may simply include placing individuals with ASD in situations
with individuals who are neurotypical. Communities, schools, and agencies must
make changes to enable the individual to participate fully in all activities rather
than expecting the person with ASD to conform to the environment (Pellicano,
Bölte, & Stahmer, 2018). This chapter discusses the need for inclusion, the evidence
base for using inclusive strategies, and how Naturalistic Developmental Behavioral
Interventions (NDBI) can successfully support individuals with ASD in inclusive
environments.

THE IMPORTANCE OF INCLUSION

Both the Individuals with Disabilities Education Improvement Act (IDEA) of 2004
(PL 108-446) and the No Child Left Behind Act (NCLB) of 2001 (PL 107-110) man-
dated that children with disabilities, including children with ASD, be educated in
the least restrictive environment (LRE), which means alongside typically devel-
oping peers whenever possible. This ensures that children with special learning
needs, including those with individualized education programs (IEPs) and 504

99
100 Core Concepts and Foundational Principles

BOX 5.1: What is inclusion?

• Inclusion is not a place.
• Inclusion is the belief that everyone is a member of the community,
regardless of skills, talents, or diagnosis.
• Inclusion involves more than simple integration.
• Inclusion involves providing the support needed for everyone to
participate fully in the community.

plans, are not isolated. Inclusive practices are increasingly recognized as best prac-
tice for children with ASD (DiSalvo & Oswald, 2002). See Box 5.1. This is important
because the challenges seen in ASD are primarily related to social interaction and
social skills with friends at school and at work. With these policies in place, the
number of students with ASD participating in general education has been increas-
ing each year (Leach, 2010). There are, unfortunately, no inclusion mandates for
adults with ASD. The Americans with Disabilities Act (ADA) of 1990 (PL 101-336)
mandated supports and accommodations for individuals with disabilities from
government agencies at work sites and college campuses, which may encourage
some inclusion.
Most ASD advocacy organizations support the idea of inclusive practices and
helping individuals with ASD meet any challenges they face in social situations.
For example, the Autistic Self-Advocacy Network (ASAN; n.d.) position statement
on inclusion said, “Every person is worthy of inclusion and respect, whatever
his or her support needs may be.” The Autism Society of America and Autism
Research Foundation both advocate for supported inclusion for the whole life span
and link inclusion to improved quality of life (Biggs & Carter, 2016; Hong, Bishop-
Fitzpatrick, Smith, Greenberg, & Mailick, 2016).

INCLUSION IN PRACTICE
Most research about inclusion comes from studies of preschool and elementary
age children, and the most often measured outcomes for children with ASD in
inclusive settings are social (Freeman, 2003). Inclusion leads to increases in social
engagement and social support, as well as increases in the number of friendships
that students with ASD report (Harrower & Dunlap, 2001). Furthermore, involve-
ment in community and leisure activities are positively associated with quality
of life because these activities provide opportunities for individuals with ASD
to socialize with others and develop friendships (Biggs & Carter, 2016; Chiang &
Wineman, 2014).
Inclusion can also be beneficial for the typically developing children in a
school program. Inclusive early childhood environments encourage positive inter-
actions and learning for all children, including those without disabilities (Hestenes
& Carroll, 2000). Typically developing children may learn how to get along with
others, improve their social skills, and exhibit fewer disruptive behaviors (Daly,
1991; Strain & Cordisco, 1994). Children in inclusive programs also have higher lev-
els of acceptance of peers with disabilities after participation (Diamond, Hestenes,
 Fostering Inclusion With Peers and in the Community 101

Carpenter, & Innes, 1997). Typically developing toddlers who spend the day in an
ASD inclusion program perform well compared to their peers and do not show any
increases in stereotyped or aggressive behavior (Stahmer & Carter, 2005). In school
classrooms, researchers have found no differences in the amount of instruction
time or differences in learning for typically developing students when students
with severe disabilities are enrolled in general education classrooms. Also, there
may be some academic benefits in math and reading when students are educated
with their peers with special needs (see review by Bui, Quirk, Almazon, & Valenti,
2010).
Although inclusion provides clear benefits for children with ASD and their
typically developing peers, inclusion alone is not enough to increase social inte-
gration (Chamberlain, Kasari, & Rotheram-Fuller, 2007). Inclusion is more com-
plex in older grades, probably because games and social interactions become more
complex (Rotherham-Fuller, Kasari, Chamberlain, & Locke, 2010). In high school,
students in inclusive settings often report feeling lonelier than their peers and
say they would like more meaningful relationships (Locke, Ishijima, Kasari, &
London, 2010). Children and youth with ASD report lower scores on quality-of-
life measures than their peers, especially in areas related to socialization (Ikeda,
Hinckson, & Krägeloh, 2014). The reality is that inclusion is more than just being
in the same place as other people. Simply placing individuals with ASD in class-
rooms or workplaces with typically developing peers without systematic supports
has limited benefit (Harrower & Dunlap, 2001). That is, students with ASD need
help learning to make friends, getting involved in social activities, and succeeding
in a busy classroom. As such, evidence-based strategies such as NDBI are key to
helping individuals with ASD succeed in inclusive settings.
One of the main goals of NDBI is to help families and providers use evidence-
based strategies in the natural environment, ensuring that people with ASD can
learn to use their skills in new places and over time. See Box 5.2. Of course, one
of the most natural environments for everyone, no matter the age or diagnosis, is
in the community with peers. This includes attending school and being educated
alongside typically developing students. NDBI help students do well in many envi-
ronments by building social and communication skills across contexts. NDBI work
well in inclusive settings at school (e.g., Crosland & Dunlap, 2012; Koegel, Matos-
Freden, Lang, & Koegel, 2012), for playdates (Koegel, Werner, Vismara, & Koegel,
2005), and at summer camp (Brookman et al., 2003). Many studies used behavioral
strategies to help children in inclusive settings (see Harrower & Dunlap, 2001, for
a review). The National Standards Project for ASD said evidence-based techniques
such as NDBI work well in general education settings (e.g., National Autism Cen-
ter, 2015). Most data for NDBI are for children younger than age 14, and there have
been limited studies with older adolescents and adults (Wong et al., 2015).

BOX 5.2
Because one of the main goals of NDBI is to use evidence-based strategies
in the natural environment, these strategies are well-suited for supporting
individuals with ASD in inclusive settings.
102 Core Concepts and Foundational Principles

USE OF NDBI IN INCLUSIVE SETTINGS

A variety of NDBI strategies are used with success in inclusive settings. Some
programs, especially in preschool settings, have developed comprehensive pro-
grams using NDBI to support students with ASD in settings that include typically
developing peers. In addition, multiple focused interventions, such as modeling,
peer-mediated interventions, self-management and self-monitoring, and structured
playgroups use NDBI strategies to support inclusion in multiple school and com-
munity settings for individuals with ASD from childhood through adulthood. This
section describes models that incorporate NDBI to successfully include individuals
with ASD.

Comprehensive Preschool Programs

Some preschool programs are specifically designed to serve children with ASD
alongside their typically developing peers, and these programs often use NDBI
strategies. A review of comprehensive treatment programs for children with ASD
looked at four inclusive programs, and all used some type of NDBI strategy. These
programs included the Walden School (McGee, Morrier, & Daly, 1999), the Learning
Experiences: An Alternative Program for Preschoolers and Parents (LEAP) program
(Strain & Bovey, 2011), Project DATA (Developmentally Appropriate Treatment for
Autism; Schwartz, Sandall, McBride, & Boulware, 2004), and Alexa’s PLAYC (Play-
ful Learning Academy for Young Children, formerly the Toddler School; Stahmer,
Akshoomoff, & Cunningham, 2011; Stahmer & Ingersoll, 2004). Each of these pro-
grams reports positive outcomes; only LEAP has comparison data from a random-
ized trial, whereas the other program results are from quasi-experimental designs.
The Walden Early Childhood Program uses incidental teaching (IT) exclu-
sively. Children are in a structured environment for about 20 hours per week,
and parents receive education during weekly home visits. The Walden Early Child-
hood Program has excellent child outcomes in language and social behaviors; in
a study by McGee and colleagues (1999), 82% of the 28 children with ASD used
spoken words at program exit, and 71% played closer to other children at exit.
Project DATA was developed in collaboration with public schools and uses nat-
uralistic behavioral strategies during classroom routines in the context of a quality-
of-life curriculum. Children also receive instruction in a smaller group setting and
regular home visits, and their families also receive parent education. Outcomes
for both toddlers and preschoolers show positive change in social-communication,
social skills, and core ASD deficits (Boulware, Schwartz, Sandall, & McBride, 2006;
Schwartz, Thomas, McBride, & Sandall, 2013).
In a study of 102 toddlers with ASD in Alexa’s PLAYC, 31% functioned in the
typically developing range by age 3 (Stahmer et al., 2011). Alexa’s PLAYC serves
children for 20 hours per week and uses a combination of NDBI (similar to those
described in Project ImPACT in Chapter 2), environmental arrangements, visual
supports, and bimonthly home visits that include parent coaching in NDBI. An
early study of the program (Stahmer & Ingersoll, 2004) found 80% of toddlers
exiting the program at 36 months had improved spoken language skills and
decreased severity of ASD behaviors. A majority of children who went to Alexa’s
PLAYC enrolled in general education classroom placements by elementary school
(Akshoomoff, Stahmer, Corsello, & Mahrer, 2010).
 Fostering Inclusion With Peers and in the Community 103

Programs using the LEAP model also embed evidence-based NDBI strategies
(IT) into ongoing classroom activities and use a structured method of peer-mediated
instruction in which typically developing classroom peers are a large part of the
intervention. In LEAP, peers learn the best ways to interact with their peers with
ASD and to encourage ongoing interaction. The program includes parent coaching
to address behavior concerns at home and in the community. LEAP has a strong
history of research documenting improvements in intellectual development and
language (Strain & Hoyson, 2000) as well as for social engagement (Strain, Kohler,
& Goldstein, 1996).
LEAP is one of the only evidence-based inclusion programs to have large-scale
replication. A trial comparing LEAP in 28 classrooms had positive results in com-
parison to “treatment as usual” preschools programs (Strain & Bovey, 2011). They
found that almost 2 years of coaching were needed for classrooms to meet all the
steps needed in the LEAP model and that just providing manualized materials
without coaching did not produce consistent use of most of the strategies. This
is important because the use of the correct strategies was related to all child out-
comes. In addition, long-term outcomes of the LEAP model show that children
continue to improve their development over time (Strain & Hoyson, 2000).

Focused Interventions Across the Life Span

Unlike the preschool inclusive programs for young children with ASD, there are
no clearly defined, comprehensive treatment models with strong research support
for including school-age children, adolescents, or adults with ASD in general ed-
ucation, university, or community settings. The lack of evidence-based inclusive
programs for older individuals with ASD can partially be attributed to the fact
that educational, job, and community programs often have policies and standards
that may not work for a comprehensive treatment model. For example, an educa-
tional aide may not be able to assist a student with test-taking in a college course
due to concerns about cheating. In addition, inclusive settings for older individuals
often consist of typically developing individuals with only one person with ASD.
Instead of restructuring an entire program or activity for an individual with ASD,
evidence-based focused intervention practices are used to support the individual
with ASD without disrupting the program.
Focused intervention practices are strategies that address targeted skills or
goals and can be used easily in an existing program. A review of the ASD inter-
vention literature identified five NDBI practices that are very useful for inclusive
education: comprehensive NDBI (including Pivotal Response Treatment [PRT]),
modeling, peer-mediated interventions, self-management and self-monitoring,
and structured playgroups or social skills groups (Wong et al., 2015), each of which
is briefly explained in the sections that follow. Positive outcomes from these pro-
grams include better academic and job performance, independent living skills,
social interaction, and emotion management skills. These strategies have been
used most often in schools, although there also is growing use in inclusive post-
secondary education programs (Hart, Grigal, & Weir, 2010). These programs are
typically designed for young adults with intellectual and developmental disabili-
ties (including ASD) and give enrolled students a chance to participate in college
course work while also learning social growth, independent living, and vocational
skills (Grigal & Hart, 2010; Hart et al., 2010).
104 Core Concepts and Foundational Principles

Comprehensive NDBI
Some evidence supports the use of comprehensive NDBI in typical settings, ac-
tivities, and/or routines for older individuals with ASD. Similar to the use of
these strategies in special education or individual settings, providers establish the
learner’s interest in an activity through arrangement of the setting, activity, or rou-
tine; provide support for the learner to use the targeted behavior; expand on the
behavior when it occurs; and/or arrange natural consequences for the targeted be-
havior or skills. Several NDBI strategies have been shown to reduce challenging
behaviors, including natural reinforcement, incorporating easier tasks, rewarding
attempts, and functional communication training (Machalicek, O’Reilly, Beretvas,
Sigafoos, & Lancioni, 2006). Camargo and colleagues (2014) found that IT and peer-
mediated interventions were very successful in inclusive settings.

Modeling Modeling, self-modeling, and video modeling are all important

strategies that can be used in school, home, and community settings for individu-
als with ASD. Modeling involves demonstrating a behavior to allow the individual
to imitate it, then rewarding the behavior to help him or her learn to use it again
later. Young children learn skills such as object play, pointing, and games from
observing other children in preschool, on the playground, and in other community
settings. Adolescents may learn common expected behaviors to use while watch-
ing a movie, attending a sporting event, or chatting with friends at lunch. Adults
may learn new job tasks and workplace social norms by watching others. Video
modeling of object play has been demonstrated to increase appropriate object play
in young children (e.g., D’Ateno, Mangiapanello, & Taylor, 2003; Hine & Wolery,
2006; Nikopoulous & Keenan, 2004).
In inclusive school settings, typically developing peers naturally model behav-
iors that school-age children with ASD can imitate and learn to exhibit in similar
situations. In addition to academic tasks, such as explaining thinking and showing
work when solving a word problem in Common Core math, peers might model
raising a hand and waiting to be called on before shouting out an answer, waiting in
line in the school cafeteria, and playing games with rules at recess. In adolescents,
the use of static pictures as a self-modeling strategy has also been shown to increase
task engagement while reducing the frequency of teacher prompts (Cihak, Wright,
& Ayres, 2010). Video modeling strategies can be used to teach many independent
daily living skills, such as doing laundry, meal preparation, and self-care. Adoles-
cent students even learned additional daily living skills that were not targeted in
the video modeling intervention (Lasater & Brady, 1995). Young adults with ASD
have been taught how to purchase items they need (e.g., groceries, clothing) using
video modeling strategies (Haring, Kennedy, Adams, & Pitts-Conway, 1987), which
can encourage independence in community settings. A related strategy involves
presenting scripts to adolescents and then slowly fading them to improve problem
identification and seeking help in job settings (Dotto-Fojut, Reeve, Townsend, &
Progar, 2011). These strategies can be used with other NDBI strategies, such as
direct reinforcement and shared control.

Peer-Mediated Interventions In peer-mediated interventions, typically de-

veloping peers learn how to interact with and help individuals with ASD learn
new behavior, communication skills, and social skills by increasing social oppor-
tunities within natural environments. Peers are taught how to engage individuals
 Fostering Inclusion With Peers and in the Community 105

with ASD in social interactions that can be directed by a teacher or initiated by the
student with ASD. A review of peer-mediated strategies (Watkins et al., 2015) for
individuals with ASD ages 4–21 indicated positive results. In preschool, goals are
usually the use of joint play activities. In elementary school, children may learn to
initiate games at recess, and in high school, goals may include initiating conversa-
tion. Although much of the research evidence for these strategies has focused on
younger students, the Circle of Friends intervention is a peer-mediated interven-
tion that was shown to be effective for high school students with ASD (Schlieder,
Maldonado, & Baltes, 2014), improving social interaction, empowerment, and
sense of well-being. Peer mentoring for college students with ASD may increase
academic performance, awareness of social rules, and executive functioning skills
(e.g., Taylor, 2005; VanBergeijk, Klin, & Volkmar, 2008). In addition, colleges have
started holding special first-year courses for students with ASD that give direct
instruction on executive functioning skills, emotion regulation strategies, rules of
social interaction, and study skills. Typically developing peers are often an integral
part of the success of such courses (Wenzel & Rowley, 2010).

Self-Management and Self-Monitoring Self-management is a procedure

used to teach individuals to discriminate their own behavior (e.g., appropriate sit-
ting in class) and record the occurrence or absence of that behavior (Koegel, Koegel,
& Parks, 1992). It is both a tool to teach new skills and an important skill in itself. Self-
monitoring includes tracking one’s own behavior as part of the self-management
process. Self-management and self-monitoring have been used with school-age
children, adolescents, and adults to develop appropriate skills that increase their
ability to participate in community settings. Children as young as kindergarten age
have used self-management to successfully increase on-task performance and re-
duce disruptive behavior (Koegel, Harrower, & Koegel, 1999). In another example,
Newman and colleagues (1995) taught three adolescents with ASD to engage in self-
management and provide their own rewards, which improved their transitions to
new activities. Likewise, adolescents have learned to improve question asking dur-
ing social interaction through self-management strategies (Palmen, Didden, & Arts,
2008). Providing adolescent students with the next day’s schedule and activities (e.g.,
priming) leads to better participation in school tasks (Koegel, Koegel, Frea, & Green-
Hopkins, 2003). Thoughtful limitation of access to preferred activities has helped
adolescents with ASD to increase on-task behaviors and decrease repetitive behav-
iors associated with intense interests (Sigafoos, Green, Payne, O’Reilly, & Lancioni,
2009). In job settings, self-monitoring strategies have been shown to increase task
completion and verbal requests (Ganz & Sigafoos, 2005) in adults with ASD.

Structured Playgroups Structured playgroups use small groups to teach

social skills. Usually these groups are conducted in a small area with very spe-
cific activities and prechosen typically developing peers, as well as clear themes
and roles. Although peers are involved, the playgroups are led by an adult who
uses prompting and scaffolding to help students learn new skills. In an example
of an after-school structured playgroup (Legoff & Sherman, 2006), a school-age
child with ASD worked with building blocks to complete a project with two typi-
cally developing peers and an adult supervisor. Consistent with NDBI strategies,
the adult selected Legos to motivate learning because the child was interested
in them. Each group member received a different responsibility (e.g., engineer,
106 Core Concepts and Foundational Principles

supplier, builder), and the playgroup emphasized teaching verbal and nonver-
bal communication, collaborative problem-solving, sharing, and turn-taking,
including switching roles during the task. Participating in the group and com-
pleting the block project was a natural and direct reinforcer. Children with ASD
participating in the structured playgroups showed increased communication
and socialization scores as compared to children with ASD who did not par-
ticipate in the groups (Legoff & Sherman, 2006; Owens, Granader, Humphrey, &
Baron-Cohen, 2008).

PRACTICAL SUGGESTIONS FOR INCORPORATING

NDBI STRATEGIES INTO COMMUNITY PROGRAMS
This section presents key elements of NDBI recommended for community pro-
grams. This means not only programs designed to be inclusive but also any com-
munity activity in which a person with ASD would like to participate. The goal of
inclusion is to help individuals with ASD gain access to the same activities as their
peers, so these strategies can be used both in specialized inclusive settings and in
usual community programs when a person with ASD wants to attend summer
camp, work at the mall, go to a theme park, or join a softball team. Again, this is
not an exhaustive list of inclusion strategies, but it specifically recommends NDBI
methods that support inclusion.

Creating Individualized Treatment Goals

Any good treatment program must develop individualized goals. When imple-
menting this NDBI strategy into community programs, the goals should relate to
success in the inclusive setting with treatment targets specific to social interac-
tion, adaptive or job skills, and social-communication. Some programs also de-
velop group goals that may include things such as saying positive things to friends,
asking for help, and sharing materials, with specific goals and strategies aligned
with the individual learner’s needs. Often, inclusive settings require the develop-
ment of social goals, such as sharing toys in preschool, joining in a soccer game
in elementary school, and conversing appropriately with colleagues at lunch in
the workplace. In inclusive settings, support staff must be able to determine how
much assistance a person with ASD requires and how to reduce the level of sup-
port as the individual becomes more independent. Assessments related to social
and adaptive skills needed for the environment, such as the Social Skills Improve-
ment System (SSIS; Gresham & Elliott, 2007) or the Adaptive Behavior Assessment
System (ABAS; Harrison & Oakland, 2003), may help in generating age-appropriate
goals. Conducting a task analysis of skills used in the environment can help gen-
erate goals. Observations of interactions between the individual with ASD and
peers may also be helpful. Strategies for developing goals are explored further in
Chapter 10, but for community programs, those goals may need to focus on skills
needed for inclusive settings.

Monitoring Treatment Fidelity

Monitoring treatment fidelity in inclusive settings can sometimes be challenging,
but it is just as important as when working individually. Treatment fidelity indi-
cates the extent to which the intervention was implemented as intended and is
 Fostering Inclusion With Peers and in the Community 107

discussed in greater detail in Chapter 16. Many of the interventions have specific
treatment fidelity criteria that can be used to monitor how well teachers, parapro-
fessionals, job coaches, parents, and other professionals are using NDBI strate-
gies. Even for peer-mediated strategies, treatment fidelity measures can determine
whether peers are receiving the supervision, feedback, and rewards needed to
help them continue to assist students with ASD successfully. Using treatment fi-
delity monitoring can ensure the whole team supporting an individual is using
strategies well and consistently. For example, paraprofessionals in education set-
tings may have a difficult time understanding the importance of fading prompts
and fading their proximity to students in ways that support independence. Treat-
ment fidelity measures can ensure the best service is being delivered throughout
the inclusive setting.

Arranging the Environment

Arranging the environment to encourage the use of appropriate skills in inclusive
settings can be very beneficial for individuals with ASD. In classroom settings,
this often involves placing desired or needed items out of reach to encourage lan-
guage or having a peer ask a student to choose a specific crayon color to encourage
social-communication. In the workplace, arranging the environment to encour-
age independence at work or comfort during social interactions during lunch and
breaks may be useful. For example, placing checklists and other visual supports
within the visual field of an employee with ASD at a checkout register (and other
vocational settings) can help him or her use his or her skills more independently.
In addition, the thoughtful creation of small groups within large-group learning
contexts can reduce social and sensory input while continuing to promote engage-
ment and social interaction.
For example, in a high school physical education class that contains a large
number of students, students with ASD can be grouped with a smaller group of
four to six peers (with appropriate peer training and supervision) who have inter-
est in, and can facilitate, an appropriate reciprocal game of interest to the student
with ASD. A designated space in the gymnasium would be ideal for such a small
group. On a college campus, peer mentors can position themselves within a cam-
pus dining hall so that the student with ASD is encouraged to use appropriate
social-communication initiation skills (e.g., “May I join you?”). They can use NDBI
strategies during this interaction, such as rewarding appropriate commenting with
discussion of preferred topics.

Sharing Control
Strategies for sharing control are seen most often in preschools but can also be
incorporated into activities with older individuals. Sharing control refers to a bal-
anced interaction in which the person with ASD has choices within an interaction
and between activities and shares those choices with another person. This strategy
is elaborated in detail in Chapter 6. Often, shared control is easier to establish in
one-to-one settings; for example, waiting for a child to initiate a teaching activity
works better when the adult has control over the toy the child wants. However,
children can initiate in group settings as well. This is especially relevant to play
and social activities in which initiation is an important way to ensure building
friendships and improving general social skills.
108 Core Concepts and Foundational Principles

One approach is to design games around a student’s special interest, which

ensures the student will be interested in the activity and also allows the student
to be a leader in the context of the game. In one study, researchers helped teach-
ers develop a game for a child with a strong interest in state capitals. They drew a
map of the United States on the blacktop. The teacher called out a state capital, and
students raced to the appropriate state to be safe (Baker, Koegel, & Koegel, 1998).
The student with ASD was the expert. Similar games could be developed with
other interests.
Simple choices in a classroom, such as which color pen to use to write a les-
son or which order to complete a worksheet, are also examples of shared control.
As individuals with ASD get older, joining clubs or organizations in which others
share interests can be helpful. Allowing simple choices of what to have for lunch,
where to place their desk in the office, or what role to play in a meeting may also
provide a sense of control and comfort in challenging situations.

Use of Natural Reinforcement

The goals developed for the setting should lead to activities or interactions that
the individual with ASD enjoys and that can be linked to natural rewards (i.e.,
rewards that are available in the environment). For example, playing well with oth-
ers can lead to longer access to preferred toys and activities. Learning to perform
well at a job leads to a paycheck and greater independence. Conversation is an
excellent goal that can be rewarded directly across ages. For example, using appro-
priate conversational skills can be rewarded with talking about a preferred topic
(Camargo et al., 2014); likewise, turn taking and waiting provide similar natural
rewards, such as getting a turn, positive attention, and sometimes increased access
to preferred items or activities. Some data support the idea that delayed contingen-
cies may increase on-task behavior when children are not supervised (Harrower &
Dunlap, 2001). However, sometimes these linkages are distant, and providers may
need to consider other ways to include direct reinforcement into specific activities
and goals, especially when working with children who may need more immediate
feedback.
In adult social interaction settings for adolescents and adults, the natural
reward of building relationships and friendships is paramount. Similar to other
group therapy models, it is critical to identify group members (both individu-
als with ASD as well as typically developing peer models) who can consistently
attend and participate within the group, thus creating natural reinforcers of shared
enjoyment and experiences. The infusion of cognitive strategies to assist with
attending to and storing information about another individual (e.g., name, favorite
foods, topics of interest) further helps create natural rewards as future conversa-
tions more successfully build on past interactions.

Prompting and Prompt Fading

Prompting is as an excellent strategy that can also be used in inclusive settings.
Often, prompt fading (i.e., reducing prompts to encourage independence) happens
naturally because a provider is not always available to prompt. In peer-mediated
strategies, peers can provide assistance when needed. In inclusive settings, pro-
viders may revert to delivering only verbal prompts, may limit the time between
 Fostering Inclusion With Peers and in the Community 109

prompts for response, or may not use the full range of the prompt hierarchy.
Reviewing treatment fidelity can be essential to ensuring appropriate support in
all settings as well as ensuring that the individual with ASD has the opportunity
to succeed in the inclusive setting.
Prompting, modeling, and reinforcement are recommended for older popu-
lations to assist with completion of specific skills needed in community settings
(Camargo et al., 2014). Prompts can follow the same fading strategies as those
described in Chapter 8. They can be provided by a peer, given through visual cues,
or integrated into group instructions or activities. Prompts can also be provided
using technology, such as a reminder on a phone or a self-management watch.

Taking Balanced Turns

In inclusive settings, there are increased opportunities for balanced turns with age-
appropriate peers as well as with intervention providers or teachers. As such, it is
important to encourage individuals with ASD to have back-and-forth exchanges
with others. This may be taking turns in a game, passing out materials for a class
assignment, or taking turns in a conversation at lunch. In peer-mediated strategies,
peers learn to encourage turn taking and help their friends.

Modeling
Of course, inclusive settings are especially wonderful for having other children
and adults model appropriate behavior and interactions as well as complete social,
academic, and job-related tasks. Individuals with ASD can learn to observe their
peers for clues on how to do things such as play a game, say goodbye before leaving
a party, sit quietly in a lecture, or dance at the prom.

Broadening Attentional Focus

Interventions for social skills should provide opportunities to try new things in
many environments and with different people. This allows students to respond to
varied cues across people and settings and to learn to respond in socially appropri-
ate ways. For example, it may be appropriate when addressing a peer to say, “Hey,
how’s it goin’?” but with a teacher or supervisor, “Hello, how are you today?” may
be a more appropriate greeting. Having a chance to try new skills with teachers,
coaches, friends, acquaintances, and others in a variety of community settings is
one of the benefits of being in inclusive environments. This requires individuals
with ASD to attend to multiple aspects of the environment—who they are talking
to and where they are, for example—and respond accordingly.

Initiating Communication and Interaction

One of the challenges individuals with ASD have is initiating communication and
interaction, and when they do initiate, it may not be appropriate. Inclusive settings
provide many chances for people with ASD to try joining a group, sitting in a movie
appropriately, and interacting during meal times, to name a few. Understanding
when to initiate is also important. Yelling to a friend across the playground at re-
cess may be acceptable, but yelling across a church during service may not be.
110 Core Concepts and Foundational Principles
Table 5.1. Common challenges to inclusion
Challenge
Inclusion is not just placing an individual
in an inclusive environment.
Efficient and accurate data collection
during classroom activities is difficult
while facilitating learning and
managing the behaviors of multiple
children.
Gaining and maintaining the motivation
of typically developing peers to
participate in social opportunities with
children with ASD is challenging.
Peers (or staff) facilitating interactions do Leadership can train peers and staff in specific
not create natural space for interactions
to occur (i.e., doing too much for the
individual with ASD). For example,
the peer takes the student to a break
area when the student is overwhelmed
rather than prompting the student
to use communication strategies to
request a break.
Teachers place too much emphasis on
academic growth in comparison to
social-emotional and communication
growth (e.g., we don’t have time to
work on social skills, we have to work
on academic standards).
Teachers permit students with ASD
to be alone or sit in silence during
unstructured or free play activities
at school rather than facilitating peer
interaction and conversation.
Possible solutions
Leadership needs to make sure that enough
support is in place to help the person with ASD
succeed.
Teachers, parents, and providers can take data on
skills and behaviors to advocate for additional
support when needed.
Providers in the inclusive setting can learn NDBI
strategies and structural supports.
Teachers can collect data on one child at a time or
use rating sheets they can complete at the end
of each activity to gather information on child
progress each week.
Teachers can provide rewards or recognition
to typically developing peers for their
participation.
Teachers can use activities that peers and children
with ASD both enjoy (even grouping children
by interests).
Teachers can switch which typically developing
children work with the student with ASD
throughout the day.
methods of prompt fading and waiting for
initiations.
Leadership can monitor fidelity of
implementation for strategies used by the
peers and paraprofessionals.
An experienced provider can provide ongoing
supervision and assessment to help reduce
prompt dependence.
Experienced peers can offer peer mentoring.
Providers can provide ongoing monitoring to
make sure strategies are appropriate and
working. They can adjust strategies as the
individual requires more or less support.
Program leadership can highlight the importance
of social-emotional growth and the links
between social skills and later success in jobs
as well as quality of life.
Teachers can prioritize specific time for social
skills lessons.
Teachers can facilitate using lunch, breaks,
and afterschool programs to practice social
interaction.
Teachers can provide a balance between teaching
social interactions and allowing students with
ASD to have time to themselves.
Teachers can pair students with ASD together so
they can interact as much or as little as they like
for parts of the day.
Teachers can use strategies such as shared
control and mixing easy and hard tasks to allow
students with ASD to have some control over
the amount of interaction they have each day.
 Fostering Inclusion With Peers and in the Community 111

Table 5.1. (continued)

Challenge Possible solutions

Teachers use reinforcement and rewards Teachers can set up systems of reward and
to only increase academic or behavioral
skills; social behaviors and appropriate
emotional states must also receive
reinforcement.
Social learning groups have group
members who are drastically dissimilar; If they cannot group students who are similar,
thus, goals that are appropriate
for some group members are
inappropriate for others (e.g., the goal
is to work on greetings and eye contact,
but some students have mastered this
skill).
Teachers do not recognize important
skills for adolescents and adults
(e.g., problem solving, goal setting,
emotion regulation, self-awareness,
self-advocacy, self-determination,
social competency, time management,
organization, adult independent living
skills; Wehmeyer, Palmer, Shogren,
Williams-Diehm, & Soukup, 2010) and
overemphasize learning activities
that have limited generalizability and
functionality (e.g., understanding
literature themes from world literature).
recognition for students with ASD for participating
in social activities and using appropriate social
behaviors, such as asking for a break.
Teachers can keep rewards natural so the
individual can use these skills in other settings.
Because these social behaviors are hard for
individuals with ASD, rewarding them is
important.
Teachers can group students who are similar.
they can ask students who have mastered the
skills to be leaders in the group so they can
practice new skills and feel proud of the skills
they already have.
Teachers can break larger groups into small
groups to practice similar skills.
Leadership can emphasize the importance of
generalizable skills needed for transitions and
adult life.
Learning can happen in many settings, including
field trips; these opportunities allow individuals
with ASD to practice skills such as gaining
access to transportation and using technology
for time management and organization.
Parents can integrate life skills, such as cooking or
understanding budgeting, into social activities
(e.g., use $20.00 to purchase and cook a dish
for a potluck).

COMMON CHALLENGES TO INCLUSION

Although inclusion is imperative based on current policy and evidence, including
individuals with ASD in school and community activities developed primarily for
neurotypical populations also presents a variety of challenges. For example, as dis-
cussed previously, inclusion involves more than placing an individual with ASD in
a general education classroom and hoping he or she will gain access to the curricu-
lum. Research indicates that inclusion is more successful if leadership is support-
ive, neurotypical peers understand ASD and how to help their peers with ASD,
providers and parents have data on the supports needed for effective inclusion,
and providers are educated about ASD and inclusive strategies (Pellicano et al.,
2018). Educating others in the use of NDBI strategies can support inclusion. NDBI
strategies are often seen as making sense to practitioners and are easier to use in in-
clusive environments than some more structured strategies. They are designed to
fit into the community. In addition, NDBI strategies have been successfully taught
to children as young as preschool age and can also be motivating to everyone in a
classroom or on a team. Therefore, providing training and education on a few of
the NDBI strategies discussed here can facilitate inclusion that works for both the
learner and the others in the setting. Table 5.1 describes several common challenges
to inclusion as well as potential solutions using NDBI strategies.
112 Core Concepts and Foundational Principles

Case Example: Preschool Program

Alexa’s PLAYC at Rady Children’s Hospital in San Diego is a unique early education
program for typically developing children and children with or at risk for an ASD. Alexa’s
PLAYC uses NDBI to teach developmentally appropriate communication, cognitive
skills, and social skills while fostering independence in young children.
Alexa’s PLAYC offers five classrooms for children age 18 months through kinder-
garten. Classroom educator-to-child ratios range from 1:3 to 1:7, and classroom sizes
range from 12 to 20 children. There are no more than four to five children who have
ASD in each classroom, and each child attends for a half day to allow access for a
greater number of students. Each classroom has an instructional team of early child-
hood teachers and autism education associates (AEA).
Teachers and AEA take on multiple roles within the classroom, such as acting
as lead teacher, handling diaper changes/toileting, leading circle time, and develop-
ing activities. AEA also collect data and make bimonthly home visits with caregivers.
Treatment fidelity checklists are used to monitor implementation of specific tasks and
utilization of NDBI strategies by educators and are used at least biannually to identify
areas of strength and areas requiring clinical oversight.
A multidisciplinary team, including an occupational therapist, speech-language
therapist, psychologist, classroom educator, and parents, develops individualized
goals for the children with ASD. Goals focus on several developmental domains,
such as receptive language, expressive language, pragmatic language, joint attention,
object play, social skills, motor skills, functional routines (e.g., potty, greetings, mak-
ing transitions), and/or behavior reduction. The assessment tool included in the Early
Start Denver Model (ESDM) manual (Rogers & Dawson, 2010) is used to assess
skills and develop goals. Children’s goals are integrated into weekly, theme-based les-
son plans, and the primary focus of each activity is to create opportunities for social-
ization and communication among the children. Specific tasks are scaffolded to meet
the developmental needs of all children.
The team measures each child’s progress biweekly via varied data collec-
tion methods. The psychologist evaluates goal progress and programming every
5–6 weeks, updates present levels, alters treatment plans, and reviews results
with families. During clinical meetings, the full team reviews each child’s goals,
assesses specific behavior plans, and explores need modifications to teaching
strategies.
In order to understand the practical applications of NDBI within a classroom set-
ting, consider Steven, a 2-year-old child at risk for ASD. Steven enrolled in a toddler
classroom with a 1:3 educator-to-child ratio, weekly speech and occupational therapy
consultation, and bi-monthly home visits with his family and his AEA. At the time of
entry into Alexa’s PLAYC at 22 months, Steven’s family expressed concerns with his
early language delays and repetitive behaviors. He was not playing appropriately with
toys but rather examining parts of objects and playing repetitively with numbers, let-
ters, and shapes. Steven would repeatedly turn on and off the lights and would spill
and fill containers.
The multidisciplinary team conducted evaluations and observations and devel-
oped goals. Steven’s goals focused on following directions involving language and
 Fostering Inclusion With Peers and in the Community 113

gestures, increasing pragmatic language functions, using reciprocal play with adults
and peers, increasing complexity of object play, and improving imitation with and
without objects. Steven’s initial standardized testing scores fell in the extremely low
to below average range.
His classroom had a consistent schedule of activities such as circle time, free
play, snack time, outside play, and lunch. Steven had some challenges with transi-
tions between activities so the teacher set up visual schedules of the day and specific
activities (e.g., hand washing). These strategies were effective for him and aided self-
regulation during periods of separation and transition.
Teachers implemented NDBI strategies and principles in Steven’s classroom.
They arranged the classroom to create opportunities for spontaneous communication,
socialization, and play. For example, Steven’s favorite television character figurines
were placed on a shelf he could see but that was out of reach to encourage him to
use verbal and/or nonverbal communication with adults. Some materials, such as
closed playdough containers, toys enclosed in clear bins, and smaller portions of
food offered during snack, required initiation with an instructor in order to request
help. During these opportunities, Steven was encouraged to appropriately gain the
teacher’s attention by calling his or her name or tapping the teacher on the shoulder.
At first, he needed hand-over-hand prompting to get attention, but this was quickly
faded, and he became independent in his use of gesture to gain attention. Steven
had some challenges with attention during circle and free play time, so teachers rear-
ranged the furniture to create defined spaces for playing, to block access to certain
areas of the classroom, and to facilitate proximity between children. Steven’s access
to numbers and letters was systematically utilized to maintain engagement by control-
ling access and facilitating reciprocity via balanced turns with his peers. Within each
activity, teachers followed Steven’s lead to determine his motivation in that activity,
provide a model for play and social-communication (or have a peer provide a model),
and create opportunities to prompt more complex skills. During group activities,
teachers drew Steven’s attention toward another child’s play to broaden his scope of
attention and to encourage imitation of peers.
There were many opportunities to support new learning and to provide natu-
ral reinforcement. For example, teachers used Steven’s enjoyment of numbers,
letters, and shapes to encourage involvement in social games. He passed out let-
ters that corresponded to other students’ names at circle time, handing students
the letter, saying their name, and getting another letter as a means of natural rein-
forcement. During object play, the educator and peers were able to control access
to the puzzle pieces to facilitate communication, and they reinforced Steven’s
communication attempts by providing him the puzzle piece and giving descriptive
verbal praise.
The multidisciplinary team specified prompting levels for Steven’s goals and
continuously evaluated and communicated them to the teaching staff. For example,
during a social game of chase, Steven required an initial verbal and gestural prompt
to join a preexisting game. The educator systematically faded these prompts until
independence was achieved. Next, the team developed the goal to assess Steven’s
request to continue a social routine. Once he was engaged in a game of chase with
several peers, an educator joined the activity. Through the educator’s involvement, he
114 Core Concepts and Foundational Principles

or she was able to model verbal and nonverbal communication to request the continu-
ance of the routine from peers. Wait time and body proximity were most effective
when providing opportunities for Steven to reinitiate the routine.
Steven’s developmental levels at 36 months, when he exited the program, fell
solidly in the average range based on standardized testing. Although he was initially
nonverbal, he was speaking in sentences and used his language for age-appropriate
pragmatic functions. His play included simple imaginative play but continued to be
repetitive and include intense interest in letters. Steven learned how to join social
games involving peers, showing increases in social motivation. At exit, he received a
diagnosis of autism spectrum disorder. He was not eligible for public school services,
so he enrolled in a private preschool classroom with 20 children and two teachers.
This proved challenging for Steven, and his parents asked for reevaluation by the
school given his lack of progress in social and play skills. He received placement in an
inclusive classroom of 20 children with one special education teacher and one general
education teacher. Steven is currently 6 years of age, is enrolled in a general educa-
tion kindergarten classroom, receives no support services, and is reported to have a
“couple of friends” with similar interests.

Case Example: Adult Program

The myLIFE program at the Emory Autism Center is a pilot social and life skills pro-
gram for adults with ASD. Participants in the myLIFE program engage in natural social,
leisure, and life skills activities alongside trained same-age typically developing peers.
Typical activities in the myLIFE program include exercise and fitness activities,
leisure activities (e.g., table tennis, pool, video games), purchasing and eating meals
in a group, preparation of meals, home living skills (e.g., cleaning, hosting parties),
team-building activities, and using public transportation. In addition, direct instruction
of social and independent living skills occurs through invited presentations by com-
munity experts. For example, participants have learned about budgeting and money
management, resume preparation, social interaction, self-determination, gardening,
and other appropriate topics.
Participants with ASD in the myLIFE program are grouped according to age (e.g.,
young adult, 25- to 35-year-olds, age 35 and older) and verbal communication skills
(e.g., limited verbal skills, minimal conversation skills, conversational). Activities are
differentiated according to the interests and developmental level of group members.
Group sizes range from four to eight individuals with ASD, and groups typically meet
once per week for a 6-hour schedule of natural routines. The program aims to mimic
the pattern of a university schedule; thus, groups meet for two 5-week sessions with
a week-long break in between sessions (e.g., fall break; spring break). Most myLIFE
program groups have a one-to-one ratio of participants with ASD to volunteers with
an Emory Autism Center staff member to facilitate the group.
Peers in the program are often volunteers from the Emory University community
(e.g., undergraduate students, graduate students, community members). All volun-
teers are screened via a volunteer application that includes submission of a resume,
availability for participation, age-group preferences, professional references, and a
criminal background check. Approved interested volunteers participate in a multiday
 Fostering Inclusion With Peers and in the Community 115

training module addressing 1) characteristics of adults with ASD, 2) commonly used

strategies, 3) inclusion philosophies and common myLIFE program activities, and 4)
safety procedures.
myLIFE group programs follow a daily routine. On Thursday morning around
9:30 a.m., the 18- to 24-year-old myLIFE group arrives at the Emory Autism Center.
Participants arrive, settle into a multipurpose room, and engage in casual conversation
with other adults with ASD and group volunteers as other group members arrive (e.g.,
arranging the environment, balanced turns, prompting, natural reinforcement). At
10:00 a.m., a member of the community joins the group to teach about home garden-
ing and how to build small wooden planters to grow vegetables (e.g., peppers). The
program pairs verbal instruction with visual supports and hands-on learning oppor-
tunities (e.g., modeling, imitation), and it strongly emphasizes safety procedures for
wood-working (e.g., natural reinforcement).
At 11:00 a.m., the group makes the transition out of the center to an Emory Uni-
versity campus shuttle depot. The group then takes the shuttle to a different part of
Emory’s campus. During the transition to the shuttle stop, participants engage in con-
versation, and center staff and volunteers utilize prompting and redirection strategies
to promote appropriate conversation and social interaction (e.g., modeling, natural
reinforcement). For example, if a participant responds to a comment by changing the
topic to a preferred interest, volunteers are trained to interrupt, redirect, and model
a more appropriate response that remains on-topic, followed by a natural prompt to
encourage the participant to respond appropriately. Though unnatural praise (e.g.,
“Good job being on topic”) is rarely incorporated into social routines, staff and volun-
teers often model typical, natural, and age-appropriate social praise comments (e.g.,
“That’s really interesting”).
The group next arrives at the campus recreational center and engages in recre-
ational exercise or fitness routines (e.g., playing basketball, cardio workout). Strong
relationships have been built with campus staff, which results in initial opportuni-
ties for training on recreational center rules and safety procedures and otherwise
limited involvement from staff unless requested (e.g., modeling, natural reinforce-
ment). At 12:30 p.m., the group again makes the transition to lunch at a campus
food court. Participants in this group have the ability to independently select and
purchase their lunch (e.g., natural reinforcement); other myLIFE groups may require
more support, prompting, modeling, and assistance during this activity. The group
eats lunch together, practicing a wide array of social interaction skills, including
reserving dining space for other group members, engaging in casual conversation,
and adhering to age-appropriate dining etiquette (e.g., natural reinforcement, bal-
anced turns, arranging the environment). Staff and volunteers continue to model,
redirect, and prompt as needed to facilitate appropriate social interactions and din-
ing behaviors.
Following lunch, the group walks to the campus shuttle stop and rides the cam-
pus shuttle to an on-campus apartment complex. The Emory Autism Center rents
a campus apartment in which to practice home-living and other independent living
skills. At the apartment, the group may initially engage in self-directed relaxation
(e.g., lounging on a couch, watching television), and after this brief break (e.g., natural
reinforcement), the group may participate in a home-living skill such as preparing a
116 Core Concepts and Foundational Principles

snack and then cleaning the kitchen. As needed, students learn skills or roles through
a combination of verbal instruction and visual supports, and they always review group
roles prior to engaging in activities. The day concludes with walking as a group from
the apartment back to the Emory Autism Center and continuing to engage in casual
conversation prior to participants saying farewell and leaving to go to their homes
around 3:30 p.m.
Outcomes for the myLIFE program are currently assessed through informal
means (e.g., anecdotal observation, self-report). Participants in the myLIFE program
demonstrate increases in discrete functional skills, such as creating a planter or clean-
ing a kitchen sink. Over time, many participants demonstrate increases in social
competency skills, such as staying on topic in conversation, though this remains
a difficult skill to master for many. Self-report accounts suggest improvements in
self-confidence and self-esteem, such as being willing to engage in social chat in
vocational settings (e.g., grocery store bagger). Most important, myLIFE participants
report increases in social connectedness, and the vast majority of participants enroll in
multiple group sessions and look forward to future interaction with their group mem-
bers. Peer volunteers report increases in awareness of effective strategies in working
with adults with ASD as well as increases in attitudes toward individuals with ASD.

CONCLUSION
This chapter highlights the importance of including individuals with ASD in the
community throughout the life span. This includes access to inclusive school pro-
grams, typical community activities (e.g., church, sports leagues, summer camp,
museums, movies), meaningful employment, and inclusive housing. Successful
inclusive opportunities include support to help the child or adult with ASD ac-
tively participate in the activity or event. Inclusion is a right across the life span
and has been shown to be effective for skill development, generalization of skills,
and improving quality of life. NDBI are particularly well suited for use in inclusive
environments due to their emphasis on the natural environment, natural reinforce-
ment, and functional skills.

REFERENCES
Akshoomoff, N., Stahmer, A. C., Corsello, C., & Mahrer, N. E. (2010). What happens next?
Follow-up from the children’s toddler school program. Journal of Positive Behavior Interven-
tions, 12(4), 245–253.
Americans with Disabilities Act (ADA) of 1990, PL 101-336, 42 U.S.C. §§ 12101 et seq.
Autistic Self-Advocacy Network (ASAN). (n.d.). Position statements. Retrieved from http://
autisticadvocacy.org/policy-advocacy/position-statements/
Baker, M. J., Koegel, R. L., & Koegel, L. K. (1998). Increasing the social behavior of young
children with autism using their obsessive behaviors. Research and Practice for Persons with
Severe Disabilities, 23(4), 300–308.
Biggs, E. E., & Carter, E. W. (2016). Quality of life for transition-age youth with autism or
intellectual disability. Journal of Autism and Developmental Disorders, 46(1), 190–204.
Boulware, G. L., Schwartz, I. S., Sandall, S. R., & McBride, B. J. (2006). Project DATA for Tod-
dlers: An inclusive approach to very young children with autism spectrum disorder. Top-
ics in Early Childhood Special Education, 26(2), 94–105.
Brookman, L., Boettcher, M., Klein, E., Openden, D., Koegel, R. L., & Koegel, L. K. (2003).
Facilitating social interactions in a community summer camp setting for children with
autism. Journal of Positive Behavior Interventions, 5(4), 249–252.
 Fostering Inclusion With Peers and in the Community 117

Bui, X., Quirk, C., Almazon, S., & Valenti, M. (2010). Inclusive education research and practice.
Retrieved from http://www.mcie.org/site/usermedia/application/11/inclusion-works-(2010).pdf
Camargo, S. P. H., Rispoli, M., Ganz, J., Hong, E. R., Davis, H., & Mason, R. (2014). A review
of the quality of behaviorally-based intervention research to improve social interaction
skills of children with ASD in inclusive settings. Journal of Autism and Developmental Dis-
orders, 44(9), 2096–2116.
Centers for Disease Control and Prevention. (2018, August 9). Disability inclusion. Retrieved
from https://www.cdc.gov/ncbddd/disabilityandhealth/disability-inclusion.html
Chamberlain, B., Kasari, C., & Rotheram-Fuller, E. (2007). Involvement or isolation? The
social networks of children with autism in regular classrooms. Journal of Autism and Devel-
opmental Disorders, 37(2), 230–242.
Chiang, H. M., & Wineman, I. (2014). Factors associated with quality of life in individuals
with autism spectrum disorders: A review of literature. Research in Autism Spectrum Dis-
orders, 8(8), 974–986.
Cihak, D. F., Wright, R., & Ayres, K. M. (2010). Use of self-modeling static-picture prompts
via a handheld computer to facilitate self-monitoring in the general education classroom.
Education and Training in Autism and Developmental Disabilities, 45, 136–149.
Crosland, K., & Dunlap, G. (2012). Effective strategies for the inclusion of children with
autism in general education classrooms. Behavior Modification, 36(3), 251–269.
Daly, T. (1991). Social behavior and social understanding of mainstreamed and non-
mainstreamed typical preschoolers. Unpublished doctoral dissertation, University of
Massachusetts, Amherst, MA.
D’Ateno, P., Mangiapanello, K., & Taylor, B. A. (2003). Using video modeling to teach com-
plex play sequences to a preschooler with autism. Journal of Positive Behavior Interventions,
5(1), 5–11.
Diamond, K. E., Hestenes, L. L., Carpenter, E. S., & Innes, F. K. (1997). Relationships between
enrollment in an inclusive class and preschool children’s ideas about people with disabili-
ties. Topics in Early Childhood Special Education, 17(4), 520–536.
DiSalvo, C. A., & Oswald, D. P. (2002). Peer-mediated interventions to increase the social
interaction of children with autism consideration of peer expectancies. Focus on Autism
and Other Developmental Disabilities, 17(4), 198–207.
Dotto-Fojut, K. M., Reeve, K. F., Townsend, D. B., & Progar, P. R. (2011). Teaching adolescents
with autism to describe a problem and request assistance during simulated vocational
tasks. Research in Autism Spectrum Disorders, 5(2), 826–833.
Freeman, S. F. N. (2003). Review of early childhood inclusion: Focus on change. American
Journal on Mental Retardation, 108, 435–436.
Ganz, J. B., & Sigafoos, J. (2005). Self-monitoring: Are young adults with MR and autism
able to utilize cognitive strategies independently? Education and Training in Developmental
Disabilities, 40, 24–33.
Gresham, F., & Elliott, S. N. (2007). Social Skills Improvement System (SSIS) Rating Scales. San
Antonio, TX: Pearson Education.
Grigal, M., & Hart, D. (2010). Think college! Postsecondary education options for students with
intellectual disabilities. Baltimore, MD: Paul H. Brookes Publishing Co.
Haring, T. G., Kennedy, C. H., Adams, M. J., & Pitts-Conway, V. (1987). Teaching generaliza-
tion of purchasing skills across community settings to autistic youth using videotape
modeling. Journal of Applied Behavior Analysis, 20(1), 89–96.
Harrison, P. L., & Oakland, T. (2003). Adaptive Behavior Assessment System II (ABAS-II). San
Antonio, TX: Pearson Education.
Harrower, J. K., & Dunlap, G. (2001). Including children with autism in general education
classrooms a review of effective strategies. Behavior Modification, 25(5), 762–784.
Hart, D., Grigal, M., & Weir, C. (2010). Expanding the paradigm: Postsecondary education
options for individuals with autism spectrum disorder and intellectual disabilities. Focus
on Autism and Other Developmental Disabilities, 25(3), 134–150.
Hestenes, L. L., & Carroll, D. E. (2000). The play interactions of young children with and
without disabilities: Individual and environmental influences. Early Childhood Research
Quarterly, 15(2), 229–246.
Hine, J. F., & Wolery, M. (2006). Using point-of-view video modeling to teach play to pre-
schoolers with autism. Topics in Early Childhood Special Education, 26(2), 83–93.
118 Core Concepts and Foundational Principles

Hong, J., Bishop-Fitzpatrick, L., Smith, L. E., Greenberg, J. S., & Mailick, M. R. (2016). Factors
associated with subjective quality of life of adults with autism spectrum disorder: Self-
report versus maternal reports. Journal of Autism and Developmental Disorders, 46(4),
1368–1378.
Ikeda, E., Hinckson, E., & Krägeloh, C. (2014). Assessment of quality of life in children and
youth with autism spectrum disorder: A critical review. Quality of Life Research, 23(4),
1069–1085.
Individuals with Disabilities Education Improvement Act (IDEA) of 2004, PL 108-446,
20 U.S.C. §§ 1400 et seq.
Koegel, L. K., Harrower, J. K., & Koegel, R. L. (1999). Support for children with developmen-
tal disabilities in full inclusion classrooms through self-management. Journal of Positive
Behavior Interventions, 1(1), 26–34.
Koegel, L. K., Koegel, R. L., Frea, W., & Green-Hopkins, I. (2003). Priming as a method of
coordinating educational services for students with autism. Language, Speech, and Hearing
Services in Schools, 34(3), 228–235.
Koegel, L. K., Koegel, R. L., & Parks, D. R. (1992). How to teach self-management to people with
severe disabilities: A training manual. Santa Barbara: University of California.
Koegel, L. K., Matos-Freden, R., Lang, R., & Koegel, R. L. (2012). Interventions for children
with autism spectrum disorders in inclusive school settings. Cognitive and Behavioral Prac-
tice, 19(3), 401–412.
Koegel, R. L., Werner, G. A., Vismara, L. A., & Koegel, L. K. (2005). The effectiveness of con-
textually supported play date interactions between children with autism and typically
developing peers. Research and Practice for Persons with Severe Disabilities, 30(2), 93–102.
Lasater, M. W., & Brady, M. P. (1995). Effects of video self-modeling and feedback on task
fluency: A home-based intervention. Education and Treatment of Children, 18, 389–407.
Leach, D. (2010). Bringing ABA into your inclusive classroom: A guide to improving outcomes for
students with autism spectrum disorders. Baltimore, MD: Paul H. Brookes Publishing Co.
Legoff, D. B., & Sherman, M. (2006). Long-term outcome of social skills intervention based
on interactive LEGO play. Autism, 10(4), 317–329.
Locke, J., Ishijima, E. H., Kasari, C., & London, N. (2010). Loneliness, friendship quality and
the social networks of adolescents with high-functioning autism in an inclusive school
setting. Journal of Research in Special Educational Needs, 10(2), 74–81.
Machalicek, W., O’Reilly, M. F., Beretvas, N., Sigafoos, J., & Lancioni, G. E. (2007). A review of
interventions to reduce challenging behavior in school settings for students with autism
spectrum disorders. Research in Autism Spectrum Disorders, 1(3), 229–246.
McGee, G. G., Morrier, M. J., & Daly, T. (1999). An incidental teaching approach to early
intervention for toddlers with autism. Research and Practice for Persons with Severe Disabili-
ties, 24(3), 133–146.
National Autism Center. (2015). National Standards Project, Phase 2. Randolph, MA: Author.
Newman, B., Buffington, D. M., O’Grady, M. A., McDonald, M. E., Poulson, C. L., & Hemmes,
S. (1995). Self-management of schedule following in three teenagers with autism. Behav-
ioral Disorders, 20, 190–196.
Nikopoulous, C. K., & Keenan, M. (2004). Effects of video modeling on social initiations by
children with autism. Journal of Applied Behavior Analysis, 37(1), 93–96.
No Child Left Behind Act of 2001, PL 107-110, 115 Stat. 1425, 20 U.S.C. §§ 6301 et seq.
Owens, G., Granader, Y., Humphrey, A., & Baron-Cohen, S. (2008). LEGO therapy and the
social use of language programme: An evaluation of two social skills interventions for
children with high functioning autism and Asperger syndrome. Journal of Autism and
Developmental Disorders, 38(10), 1944–1957.
Palmen, A., Didden, R., & Arts, M. (2008). Improving question asking in high-functioning
adolescents with autism spectrum disorders: Effectiveness of small-group training.
Autism, 12(1), 83–98.
Pellicano, L., Bölte, S., & Stahmer, A. C. (2018). The current illusion of educational inclusion.
Autism: International Journal of Research and Practice, 22(4), 386–387.
Rogers, S. J., & Dawson, G. (2010). Early Start Denver Model for young children with autism:
Promoting language, learning, and engagement. New York, NY: Guilford Press.
Rotheram-Fuller, E., Kasari, C., Chamberlain, B., & Locke, J. (2010). Social involvement of
children with autism spectrum disorders in elementary school classrooms. Journal of
Child Psychology and Psychiatry, 51(11), 1227–1234.
 Fostering Inclusion With Peers and in the Community 119

Schlieder, M., Maldonado, N., & Baltes, B. (2014). An investigation of “Circle of Friends”
peer-mediated intervention for students with autism. Journal of Social Change, 6(1), 3.
Schwartz, I. S., Sandall, S. R., McBride, B. J., & Boulware, G. L. (2004). Project DATA (Develop-
mentally Appropriate Treatment for Autism): An inclusive school-based approach to edu-
cating young children with autism. Topics in Early Childhood Special Education, 24(3), 156–168.
Schwartz, I., Thomas, C. J., McBride, B., & Sandall, S. (2013). A school-based preschool pro-
gram for children with ASD: A quasi-experimental assessment of child change in Project
DATA. School Mental Health, 5(4), 221–232.
Sigafoos, J., Green, V. A., Payne, D., O’Reilly, M. F., & Lancioni, G. E. (2009). A classroom-
based antecedent intervention reduces obsessive-repetitive behavior in an adolescent
with autism. Clinical Case Studies, 8(1), 3–13.
Stahmer, A. C., Akshoomoff, N., & Cunningham, A. B. (2011). Inclusion for toddlers with
autism spectrum disorders: The first ten years of a community program. Autism, 15(5),
625–641. doi:10.1177/1362361310392253
Stahmer, A. C., & Carter, C. (2005). An empirical examination of toddler development in
inclusive childcare. Early Child Development and Care, 175(4), 321–333.
Stahmer, A. C., & Ingersoll, B. (2004). Inclusive programming for toddlers with autism spec-
trum disorders outcomes from the children’s toddler school. Journal of Positive Behavior
Interventions, 6(2), 67–82.
Strain, P. S., & Bovey, E. H. (2011). Randomized, controlled trial of the LEAP model of early
intervention for young children with autism spectrum disorders. Topics in Early Childhood
Special Education, 31(3), 133–154.
Strain, P. S., & Cordisco, L. (1994). LEAP Preschool. Preschool Education Programs for Children
with Autism, 2, 225–244.
Strain, P. S., & Hoyson, M. (2000). The need for longitudinal, intensive social skill interven-
tion LEAP follow-up outcomes for children with autism. Topics in Early Childhood Special
Education, 20(2), 116–122.
Strain, P. S., Kohler, F. W., & Goldstein, H. (1996). Learning experiences . . . an alternative pro-
gram: Peer-mediated interventions for young children with autism. In E. D. Hibbs & P. S.
Jensen (Eds.), Psychosocial treatments for child and adolescent disorders: Empirically based strate-
gies for clinical practice (pp. 573–587). Washington, DC: American Psychological Association.
Taylor, M. J. (2005). Teaching students with autistic spectrum disorders in HE. Education and
Training, 47, 484–495.
United Nations. (n.d.). Convention on the Rights of Persons with Disabilities (CRPD) Enable.
Retrieved from http://www.un.org/development/desa/disabilities/convention-on-the
-rights-of-persons-with-disabilities.html
VanBergeijk, E., Klin, A., & Volkmar, F. (2008). Supporting more able students on the
autism spectrum: College and beyond. Journal of Autism and Developmental Disorders,
38(7), 1359–1370.
Watkins, L., O’Reilly, M., Kuhn, M., Gevarter, C., Lancioni, G. E., Sigafoos, J., & Lang, R.
(2015). A review of peer-mediated social interaction interventions for students with
autism in inclusive settings. Journal of Autism and Developmental Disorders, 45(4), 1070–1083.
Wehmeyer, M. L., Palmer, S. B., Shogren, K., Williams-Diehm, K., & Soukup, J. H. (2010).
Establishing a causal relationship between intervention to promote self-determination
and enhanced student self-determination. The Journal of Special Education, 46(4), 195–210.
Wenzel, C., & Rowley, L. (2010). Teaching social skills and academic strategies to college
students with Asperger’s syndrome. Teaching Exceptional Children, 42(5), 44–50.
Wong, C., Odom, S. L., Hume, K. A., Cox, A. W., Fettig, A., Kucharczyk, S., . . . Schultz, T. R.
(2015). Evidence-based practices for children, youth, and young adults with autism spec-
trum disorder: A comprehensive review. Journal of Autism and Developmental Disorders,
45(7), 1951–1966.
III

NDBI Strategies
6
Implementing Motivational Strategies
Mendy B. Minjarez and Yvonne Bruinsma

S
ocial motivation, defined as preference for and attention to social information
in the environment because it leads to social reward, is a core area of chal-
lenge for individuals with autism spectrum disorder (ASD; Rogers & Dawson,
2010). Children with ASD engage in less attending and responding to others, lead-
ing to the hypothesis that these children have a relative lack of sensitivity to social
reward. Much has been written and researched in this area. This chapter high-
lights three slightly different but complementary perspectives on the role of social
motivation and the origin of the associated challenges in ASD.
First, from a biological perspective, researchers have suggested that the brain
of a child with ASD is wired differently from the brain of a typically developing
child. This means that children with ASD perceive and process social informa-
tion differently, which can be observed in the brain activity of a child with ASD
(Dawson, Webb, Carver, Panagiotides, & McPartland, 2004). Dawson and col-
leagues discussed an underlying biological mechanism that shows a “fundamental
deficiency in social motivation due to the young child’s relative lack of sensitivity
to social reward” (p. 16; Rogers & Dawson, 2010) (Dawson et al., 2002; Dawson et al.,
2004; Dawson, Webb, & McPartland, 2005). This difference leads to a decreased
preference for and attention to social information (e.g., faces, voices, gestures,
speech), which in turn leads to greater impairments in skills (e.g., imitation, shar-
ing emotions, joint attention) over time. In other words, the lack of positive experi-
ences with others may result in withdrawal from others, thus creating a cascading
effect of negative experiences that diminish learning over time.
A second perspective comes from the developmental literature. Research
supports that typical development of social and communication skills occurs in
the context of affect-rich social interactions, in which infant attention is directed
toward socially rewarding information (Kuhl, Tsao, & Liu, 2003). That is, exposure
to language is not enough to promote adequate development; rather, this exposure
must occur in a socially rewarding context through affect-laden interactions with

123
124 NDBI Strategies

BOX 6.1: Motivation is key!

Enhancing social motivation should be a key focus of treatment because it
addresses a core deficit in children with ASD!

caregivers (Ingersoll & Dvortcsak, 2010b). Affect-laden interactions are exchanges

in which the caregiver is highly responsive to any child behavior while smiling,
conveying positive affect, and touching the child. Because children with ASD may
not find social interactions reinforcing and pleasurable, they will not necessarily
seek them out or sustain them—and may even actively avoid them—thereby com-
promising their social and language development.
Third, from a behavioral perspective, research suggests that children with ASD
may experience learned helplessness; that is, they do not perceive a direct relation-
ship between their actions and their environment (Magnuson & Constantino, 2011).
In other words, they lack understanding of the contingency relationship between
responses and reinforcement (Koegel & Egel, 1979; Koegel, O’Dell, & Dunlap, 1988).
This learned helplessness leads to low levels of responses and initiations. As a
result, some Naturalistic Developmental Behavioral Interventions (NDBI) focus
on eliminating learned helplessness by using motivational strategies that expose
the child to the response–reinforcer contingency (Koegel, Openden, Fredeen, &
Koegel, 2006).
These three perspectives complement each other and lead to the same conclu-
sion: enhancing social motivation should be a key focus of treatment because it
addresses a core area of challenge that has cascading negative effects on develop-
ment over time in children with ASD. Across NDBI, increasing a child’s motivation
in interactions is a primary strategy for increasing the child’s ability to gain reward
from social context.

NDBI AND MOTIVATION

Several of the common elements of NDBI have a positive impact on child motiva-
tion. Teaching in the natural environment, including within primary adult–child
relationships (e.g., parent–child); using familiar and enjoyable routines; and using
preferred activities are key principles of NDBI that have a direct impact on moti-
vation (Hancock & Kaiser, 2012; Ingersoll & Dvortcsak, 2010b; Koegel, Bimbela, &
Schreibman, 1996; Rogers & Dawson, 2010). In addition, the NDBI strategies that
provide a child with some control over the learning environment (i.e., balanced
turns and shared control) also tend to increase motivation. Examples of these types
of strategies include choosing motivating and child-preferred activities, sharing
control over materials and reinforcement, following the child’s lead, providing
choices, and using balanced turns. Finally, NDBI all use natural reinforcement
and related motivation-enhancing reinforcement methods (e.g., reinforcing child
attempts at target behaviors, responding to communication bids in all forms). The
use of strategies such as taking balanced turns and following the child’s lead allows
for the use of natural reinforcement as a consequence in naturalistic behavioral
teaching trials. Related strategies, such as reinforcing attempts (also known as a
 Implementing Motivational Strategies 125

BOX 6.2: Motivating, establishing, and abolishing operations

Motivating operations (MO): An environmental variable that changes the
effectiveness of a reinforcer (i.e., it becomes stronger or weaker) and, as a
result, the frequency of behavior also changes (i.e., it becomes more or less
frequent or intense)
Establishing operations (EO): A motivating operation that establishes
(increases) the effectiveness of some stimulus, object, or event as a reinforcer
Abolishing operation (AO): A motivating operation that decreases the
reinforcing effectiveness of a stimulus, object, or event

loose shaping procedure) and the manipulation of access to reinforcers (motivating

operations that change the effectiveness of a reinforcer in either direction), are also
used to enhance motivation. Box 6.2 provides additional details about how these
strategies affect reinforcement, which has a direct effect on motivation. Research
also supports that parents demonstrate more positive affect during interventions
that use natural reinforcement, compared to parent affect during discrete trial
teaching (Schreibman, Kaneko, & Koegel, 1991).
Although the various NDBI models focus on the role of motivation when pro-
viding opportunities for child-initiated teaching episodes, they have differences in
how they conceptualize and target this area. These differences often relate to how
much the model emphasizes a specific area, for example, the use of Applied Behav-
ior Analysis (ABA) teaching methods. For instance, the Early Start Denver Model
(ESDM) targets motivation using a combination of behavioral strategies drawn
from Pivotal Response Treatment (PRT) as well as affect and relationship-based
strategies drawn from the original Denver model. Project ImPACT (Improving Par-
ents as Communication Teachers) uses a similar combination of behavioral strate-
gies (e.g., shared control and natural reinforcement) and developmentally based
strategies (e.g., imitation of the child, animated affect). In PRT, motivation is consid-
ered to be a pivotal area, defined as an area that when targeted results in widespread
gains in untargeted areas (Koegel, O’Dell, & Koegel, 1987). To address the area of
motivation, PRT focuses on specific behavior analytic strategies, such as the use of
natural reinforcement, reinforcing attempts, and interspersal of maintenance (easy)
tasks. In addition, research on PRT suggested that the social component in rein-
forcement delivery plays a key role and that just delivering an object, toy, or activity
as a natural reinforcer is not nearly as effective (Vernon et al., 2019; Vernon, Koegel,
Dauterman, & Stolen, 2012), which supports other NDBI, such as ESDM, in the idea
that teaching in the context of a socially rich interaction facilitates learning.

MEASURING MOTIVATION
To address the limited social motivation of a child with ASD, clinicians must first
identify and assess one or more measures of the child’s level of social motivation.
Motivation is a construct and may seem challenging to measure at first; however,
in the behavioral literature, several operational definitions have been proposed
and successfully used in research. For example, in the PRT literature (Bruinsma
126 NDBI Strategies

& McNerney, 2012), motivation was defined based on 1) the number of child
responses to social and environmental stimuli, 2) decreases in response latency,
and 3) quality of child affect (engagement, enthusiasm, absence of challenging
behaviors) in interactions. It has also been suggested that when child motivation is
high, fewer clinician prompts are required, the need for extrinsic reinforcement de-
creases, interresponse times are low, and response magnitudes are high (Bruinsma
& McNerney, 2012; Ward, 2009). ESDM measures social motivation by noting in-
creases in social orienting, joint attention, and imitation skills (Waddington, van
der Meer, & Sigafoos, 2016). Although these types of behaviors may not need to
be measured in every intervention plan, they can be highly useful when a child
is struggling with motivation and treatment strategies are being used in a more
targeted way to increase motivation. Constructs that may be useful in measuring
variables related to motivation are outlined in Table 6.1.
In keeping with behavior analytic principles, it is useful to write down opera-
tional definitions when measuring motivation. Operational definitions are clear
definitions of behavior that are written to ensure reliability when measuring
behavior. Because these variables can be challenging to define, the recommended
practice is writing definitions that are specific to the child, including child-specific
behaviors that indicate emotional states (e.g., positive affect). Although the mea-
surement strategies discussed in Table 6.1 are somewhat general, they may be use-
ful for capturing these constructs in a clinical setting. Furthermore, clinicians do
not necessarily have to measure motivation; rather, they can attend to these vari-
ables in a general way when gauging motivation. They may also find it helpful to
teach parents to attend to these variables as strategies for reading their children’s
cues related to motivation.

STRATEGIES THAT ENHANCE MOTIVATION

As discussed in Chapter 1, addressing child motivation in ASD treatment has gar-
nered increased attention since the first studies of behavioral interventions demon-
strated efficacy with these children. NDBI are especially well suited to address the
lack of social motivation because they tend to include caregivers and other family
members in interventions that occur during enjoyable play-based and daily rou-
tines. The sections that follow outline a number of NDBI strategies for enhancing
motivation.

Fostering Engagement, Affect, and Shared Enjoyment

NDBI emphasize the importance of positive, warm affect (the extent to which a per-
son conveys positive emotions, such as happiness, joy, interest, and alertness) and
shared enjoyment (desire to interact with others just for the sake of connecting) in
relationships between the caregiver or therapist and the child during intervention.
See Box 6.3 for more ideas about how to convey positive affect. In ESDM, strategies
to build relationships with children lay the foundation for social and communica-
tion development (Rogers & Dawson, 2010). Rogers and Dawson suggested that
“lively, dynamic interactions involving strong positive affect that would lead chil-
dren to seek out social partners as participants in favorite activities” (2010, p. 15) are
advantageous. In other words, ensuring that the child is having fun and experienc-
ing success in a social context are key goals for intervention.
 Implementing Motivational Strategies
Table 6.1. How can I tell if a child is motivated?
Motivational
variable Operational definition
Responsivity How often is the child
answering me?
Reciprocity How often does the child respond
to adult social bids in a
synchronous way?
Response latency How quickly is the child
answering me?
Child affect Affect: How happy is the child?
Do I see smiling, happy facial
expressions, laughing, and high
energy?
Engagement: How engaged is the
child? Do I see that the child is
interested, even enthusiastic in the Engagement: Develop an operational
activity, taking turns, continuing
the activity, and remaining in
proximity?
Behavior: How much challenging
behavior does the child display?
Do I see that the child has no
tantrums or other challenging
behaviors? If the child has
challenging behaviors, operational
definitions should be written so
raters can agree on whether they
occurred or not.
127
Suggested measurement strategy
Take a frequency count of social or
communication demands placed
in 10 minutes, and mark how often
the child responded.
Calculate a percentage.
Observe a 10-minute adult–child
interaction.
Tally each time the adult makes a
social bid toward the child and
how often the child responds in a
synchronous manner.
Calculate a percentage.
Synchronous responses must
immediately follow and be directly
related to adult behavior to be
considered synchronous.
Synchronous responses can
include gestures, affect or facial
expressions, eye contact, actions
with objects or toys, vocalizations,
and other behaviors.
Measure duration between adult
cue or prompt for communication
and the child’s response across
20 prompts or cues.
Calculate an average response
latency time.
Adult prompts or cues do not have
to be consecutive. A representative
sample is fine.
Affect: Develop an operational
definition, and code 1-minute
intervals of a 10-minute adult–child
interaction as primarily 1) negative
affect, 2) neutral affect, or (3)
positive affect.
definition, and code 1-minute
intervals as primarily 1) total
absence of engagement during the
interval, 2) partially engaged and
partially not engaged during the
interval, or 3) engaged continuously
throughout the entire interval.
Behavior: Develop operational
definitions of the child’s challenging
behavior, and code 1-minute
intervals as 1) presence of
challenging behavior during the
interval, 2) some challenging
behavior and some time free of
challenging behavior (even if the
child is not engaged), or 3) no
challenging behavior observed
throughout the entire interval (even
if the child is not engaged).
If affect, engagement, or behavior is
highly variable, coding intervals
can be shorter.
(continued)
128 NDBI Strategies

Table 6.1. (continued)

Motivational
variable Operational definition Suggested measurement strategy

Social orienting Is the child looking at me? Is his or Take a frequency count of social or
her body turned toward me?
Joint attention Is the child alternating eye gaze to
share enjoyment? Is he or she
pointing, showing, or giving?
Imitation Is the child imitating actions or
sounds I am making?
Initiation Is the child initiating communication, Observe a 10-minute adult–child
play, and interaction with me,
or does he or she only respond
when I initiate?
communication demands placed
in 10 minutes, and mark how often
the child showed appropriate body
orientation when the demand was
placed.
Calculate a percentage.
Observe a 10-minute adult–child play
interaction.
Tally how often you observe a joint
attention behavior (e.g., showing,
giving, alternating eye gaze,
pointing, commenting).
Observe a 10-minute adult–child play
interaction.
Tally how often the child imitates an
adult action, sound, or word.
play interaction in which preferred
items are provided to the child
and the adult social partner sits
and observes the child. If the
child approaches the adult, it is
okay to respond and redirect the
child. Otherwise, do not initiate
interactions for 10 minutes.
Tally how often the child approaches
the adult and initiates interaction.
To increase the complexity of the
information being gathered,
categorize the initiations as 1) to
request objects, 2) to request
help, 3) to show objects, 4) to seek
comfort, or 5) to serve a social
purpose (e.g., smiling in the
adult’s face).

Many NDBI place a heavy emphasis on sensory social routines at the begin-
ning of treatment. Sensory social routines are joint activity routines in which each
partner’s attention is focused on the other person, rather than on objects, and in
which mutual pleasure and engagement dominate the play (Rogers & Dawson,
2010). Tickle games, in which the adult pauses and waits for a social response
(e.g., eye contact, smile) from the child before proceeding, are an example of a com-
mon sensory social routine. Sensory social routines, which are particularly empha-
sized in ESDM, are described in more detail in Chapter 12.
Object play routines are similar to sensory social routines in that they are set
up and then repeated. They focus on triadic attention by adding objects, such as
a toy, game, or other materials. ESDM refers to these routines as being focused
on object-partner-self. Some NDBI, such as Joint Attention, Symbolic Play, Engage-
ment, and Regulation (JASPER), place a heavier emphasis on these object-focused
routines, which may lend themselves better to teaching toy play and joint attention
(Kasari, Fannin, & Goods, 2012). Like sensory social routines, object play routines
focus on making an activity fun and predictable for a child. Then, the adult breaks
the routine by pausing or changing the actions to encourage social-communication.
 Implementing Motivational Strategies 129

Ready, Set, Implement!

BOX 6.3: Conveying positive affect
To convey positive affect, consider the following:
• Tone, pitch, and prosody of voice
• Word choice in verbal models
• Body language and gestures
• Body orientation and body proximity to child
• Facial expressions
• Use of animation (e.g., voice, facial expressions, gestures)
• Type of play or activities being modeled
• Frequency of positive comments or praise
• Matching affect to the child’s current state

Although sensory social routines are mainly focused on toddlers and pre-
schoolers, object play routines can be more easily adapted to a wider age range
of children. Any daily living routine or game play can become a routine. Com-
plexity of the routine is determined by the developmental level of the child. For
some children, activities have to be simple and routine-based to encourage more
exchanges; and more complex activities may only last for a few exchanges. For
older and more advanced children, activities can be longer and consist of complex
behavior chains and longer interactions. See Table 6.2 for examples across activities

Table 6.2. Examples of behaviors that can be repeated and varied during object play routines

Activity Setting up During Ending

Memory game Shake the cards in the Model a few standard Measure the stacks of
box while saying, phrases and sounds cards against each
“Shake it up, shake it during the game, other, and do a victory
up,” before opening such as “high five!” dance for a good
the box. and “excellent” for a game.
match and “oh, man!”
or “bummer” for
no match.
Bath time When going to the Wash the doll’s hair or Play a tickling game or
bathroom, sing, body before washing hiding game during
“Slippery fish going your child’s hair or body. towel drying. Narrate
to the bathtub.” Narrate, “Wash, wash, body parts while drying
wash the hair!” and (e.g., “Dry tummy!”
then “Wash, wash, wash “Dry arms!”).
the body!” for both the
doll and the child.
Snack routine Prepare the snack, get During snack, make a When the child is done
the child seated, and game out of pretending eating, make a game
then narrate, “Who to feed each other bites of tickling the tummy
is hungry? You are or actually feeding each and commenting
hungry!” to each other bites. Narrate, about it being full.
person who receives “Yummy, yummy in
a snack. my tummy!” every
few bites.
130 NDBI Strategies

and daily routines. Although repetition of actions and phrases can be useful in
object play routines, it is also important to ensure they do not promote echolalia or
scripted speech and play, which is why communication partners should encourage
variation in the reciprocal interaction once the child is engaged. As such, they
should develop routines based on individual child needs.
ESDM (Rogers & Dawson, 2010), Project ImPACT (Ingersoll & Dvortcsak,
2010b), and other models (e.g., JASPER, Enhanced Milieu Teaching [EMT]) outlined
a number of teaching practices related to affect and enhancing relationships that
are useful in NDBI, including the following:

Effective Use of Affect Therapists and caregivers should use positive affect,
defined as an adult display of genuine and natural positive emotions (e.g., happiness,
joy, silliness, laughter), which is also matched to child’s state, so they do not over-
whelm the child. The use of positive affect should create a positive emotional state in
the child and enhance the reward value of social interaction (i.e., motivate the child
socially). Some models (e.g., JASPER) place more emphasis on matching the child’s
affect and modeling appropriate affect as a way of promoting child regulation
(e.g., model regulating affect, as well as use of positive affect, when appropriate).

Effective Use of Heightened Animation Using heightened animation is one

way to emphasize emotional expressions and affect sharing. Heightened anima-
tion can include exaggerated gestures, facial expressions, and vocal quality. It is
also important to modulate animation when it may be overwhelming for a child
or when a child can benefit from adult modeling of regulation and decreased ani-
mation or affect. With this strategy, as well as use of affect, therapists can help the
child maintain an appropriate arousal level through the use of adult regulation
and matching the child’s emotional state when appropriate.

Consistent Response to the Child’s Communication Cues Therapists and

caregivers should be responsive to child communication cues, which includes stay-
ing attuned to the child’s state, motives, and feelings; reading the child; responding
to communicative cues (verbal and nonverbal); and acting contingently in order to
reinforce the child’s communicative behaviors.

Consistent Response to the Child’s Emotional Cues Therapists and care-

givers should demonstrate empathy by mirroring and validating the emotion and
demonstrating understanding of it. In this way, the adult can provide acknowl-
edgement of child cues without reinforcing undesirable behaviors.

Adult positive affect and creating contexts for shared enjoyment can be used
across many contexts and teaching interactions. However, some NDBI models focus
more on matching the child’s affect or modeling appropriate affect than solely on the
role of positive affect in teaching interactions. For example, both ESDM and JASPER
focus on matching the child’s affect as one strategy for promoting self-regulation, but
in situations where the child is becoming overexcited or overstimulated, the adult
may model calm affect to promote regulation. Furthermore, for some children, high
affect may be too overwhelming, and adult matching of the child’s more subdued affect
may, in fact, be more motivating. As with all treatment strategies, adult use of affect to
promote motivation and engagement should be tailored to the child’s needs.
 Implementing Motivational Strategies 131

Imitating Child Actions

Several NDBI incorporate adult imitation of child behaviors, including EMT,
Project ImPACT, JASPER, and ESDM. EMT and Project ImPACT suggest that mir-
roring the child’s actions enhances social motivation because by doing so the adult
is automatically following the child’s lead (Hancock & Kaiser, 2006; Ingersoll &
Dvortscak, 2010b). Adult imitation of child language, play, or body movements is
used as a motivational strategy in NDBI; in fact, it is often used as part of sen-
sory social routines and joint activity routines. Adult imitation deserves additional
attention, though, because several lines of research suggested that this alone may
account for impressive child improvements. For example, this strategy appears as-
sociated with increased attentiveness (Dawson & Adams, 1984), which certainly
has a positive impact on motivation and engagement. It is also associated with in-
creased social engagement, imitation skills, appropriate behaviors, and spontane-
ous language and play (Ingersoll & Dvortscak, 2010b). Imitation strategies should
only be used when appropriate behaviors can be imitated. Inappropriate or chal-
lenging behaviors should not be imitated.
NDBI models use a variety of strategies to promote imitation. These strategies
are outlined next and are briefly summarized in Table 6.3.

Table 6.3. Strategies for promoting imitation

Type of imitation Description Example

Imitating actions on Imitate appropriate actions the Bang a drum.

objects child does with objects. Stack blocks.
Drive a car.
Feed a baby.
Mirroring child actions Extend imitation of actions Make an animal eat while saying,
while narrating with on objects a step further by “Horse is eating!”
language adding narration. Drive a train while saying, “Train goes
fast!”
Imitating gestures and Use this strategy for kids with Use hand movements in songs.
body movements minimal object or toy play. Perform fingerplays.
Exaggerate subtle gestures to Clap when the child claps.
promote child responding. Perform gross motor activities: jumping,
spinning, reaching, dancing.
Imitating with novel Extend imitation of actions on Doll play: Imitate the child 1) patting
actions objects by introducing novel the baby, 2) rocking the baby, and
actions. 3) putting the baby to a shoulder.
Imitate several child actions; Then, introduce pretending to feed
then, introduce a novel the baby.
action so the child can Car wash toy: Imitate the child
imitate it. 1) driving a car up a ramp, 2) driving
This is similar to reciprocal a car down a ramp, and 3) putting
imitation training (Ingersoll, a car in an elevator. Then, introduce
2010). pretending to wash the car.
Imitating vocalizations Imitate sounds for children Imitate any appropriate sound the
or verbalizations who are preverbal. child makes.
Imitate words or phrases for Imitate the child saying “bu-bu-bu-bu”
children who are verbal. while bubbles are present.
Only imitate appropriate If the child says, “car driving,” repeat it.
vocalization or verbalization. If the child says, “car driving,” say,
Imitate and expand on the “green car driving”.
utterance (one-up rule).
132 NDBI Strategies

Imitating Actions on Objects The adult can imitate any appropriate action
that the child engages in with an object (Kasari et al., 2012; Rogers, Dawson, &
Vismara, 2012). For example, when playing with musical instruments, the adult
might imitate the child shaking a maraca or banging a drum. Imitating play with
toys (Ingersoll & Dvortcsak, 2010b; Kasari, Freeman, & Paparella, 2006) is a similar
but more advanced type of action on object imitation. In this strategy, the adult is
encouraged to have two sets of each toy available. When the child initiates with a
toy, the adult can then follow his or her lead by selecting the same toy and imitat-
ing the child’s actions with it. For example, if the child picks up a baby doll and
hugs it, the adult can pick up another baby doll and imitate this action. These
strategies are also used in reciprocal imitation training (RIT), which is a teaching
protocol used to teach imitation that focuses on using adult imitation to motivate
the child (Ingersoll, 2010). Components of RIT are used in other NDBI, such as
Project ImPACT.

Mirroring Child Actions While Narrating With Language This strategy

extends the first strategy by adding verbal descriptions of the imitated actions
(Hancock & Kaiser, 2006, 2012; Ingersoll, 2010). Narration must be appropriate or
slightly more advanced than the child’s developmental level. For example, if the
child is driving a train car, the parent could imitate that action and add language
by saying, “Drive the train.”

Imitating Gestures and Body Movements This strategy may be especially

applicable to children with minimal appropriate toy play (Ingersoll & Dvortcsak,
2010b; Rogers et al., 2012). Kasari and colleagues (2006) have also noted that it may
be helpful to engage in more relationship-based activities (e.g., sensory social rou-
tines) with children who lack toy play, and imitating gestures and body move-
ments is one such strategy. Sometimes children may not engage in many gestures
or body movements; instead, they may wander aimlessly or not engage. Ingersol
and Dvortcsak (2010b) suggested that it may be useful to imitate and also exag-
gerate the child’s body movements, even if they are subtle. Rogers, Dawson, and
Vismara (2012) described teaching imitation within activities such as fingerplays
and songs in which the adult can teach imitation by stopping the song and prompt-
ing the imitation before continuing the song.

Imitating With Novel Actions Imitating and expanding on actions also

involves imitating actions on objects but adds the additional step of introduc-
ing novel actions (Ingersoll, 2010; Rogers et al., 2012). When using this strategy,
the adult first imitates several child actions and then introduces a novel action
so that the child can imitate it. This is the general procedure used in RIT (Inger-
soll, 2010). This is also similar to the concept of variation in joint activity routines
in ESDM.

Imitating Vocalizations or Verbalizations Imitating vocalizations has

been associated with increased child vocalizations (Ingersoll & Dvortcsak, 2010b;
Kasari et al., 2012; Rogers, 2006a; Rogers et al., 2012). The adult should imitate only
appropriate vocalizations and may want to select which vocalizations to imitate
based on the child’s language goals or skill level. With children who are not yet
 Implementing Motivational Strategies 133

using verbal communication, imitation of sounds is recommended. In children

who are verbal, adults can imitate words, phrases, and sentences as appropriate to
developmental level and goals. When imitating vocalizations, the adult may also
expand on what the child said in order to provide a model of the next steps in com-
munication development. In ESDM, this is known as the one-up rule, meaning the
adult adds one word when imitating the child’s words (Rogers & Dawson, 2010).
For example, if the child says “truck,” the adult might imitate and add a word with
“truck go!”

Using Child-Selected, Highly Preferred Activities

All NDBI focus on the use of child-selected, highly preferred activities. Child-
selected, highly preferred activities are defined as those activities that are chosen
by the child at the time of the teaching interaction (i.e., in the moment). Working
in the context of such activities has been shown to enhance child motivation and
engagement, as well as responsiveness to adults (Kaiser, Yoder, & Keetz, 1992).
The use of this strategy is similar across NDBI models. For example, Kasari and
colleagues (2012) described that in the JASPER model of teaching joint attention
and play skills, intervention is conducted in the context of play activities in which
joint attention and other target behaviors can be modeled once a child initiates
interest in a preferred toy. Use of this framework requires setting up the environ-
ment with developmentally appropriate toys that can facilitate the establishment
of play routines. Hancock and Kaiser (2012) emphasized the developmental prag-
matic communication approach in EMT, which emphasizes teaching communica-
tion and social skills during high-interest activities as one strategy for motivating
children to communicate with adults (Rogers, 2006b). Likewise, ESDM, PRT,
Project ImPACT, and incidental teaching embrace the use of high-interest, child-
selected and initiated, motivating activities as the context for learning (Ingersoll &
Dvortcsak, 2010b; Koegel & Koegel, 2006; McGee, Morrier, & Daly, 1999; Rogers
& Dawson, 2010).
Clinicians should remember that motivating activities are defined by the child
and may change from moment to moment. For example, the child may be interested
in trains for a short period of time and then quickly move on to blocks. In order to
continue teaching within the motivating context, the clinician must move with the
child, or follow the child’s lead—another motivation-enhancing strategy outlined
in this chapter. Child-selected activities may also not always be play based. In fact,
for children with ASD, child-selected activities may even be unusual. For example,
children may be motivated for academic activities (e.g., letters, numbers, reading,
math), topic-based activities (e.g., reading about or watching online videos about
preferred topics that are restricted interests), or repetitive behaviors (e.g., lining up
objects, access to gross motor activities, such as jumping). Research has demon-
strated that repetitive behaviors and restricted interests do not increase or become
exacerbated when used as reinforcement in the teaching context (Charlop, Kurtz, &
Casey, 1990); therefore, doing so is often encouraged when such activities are a
primary source of motivation for a child with ASD.
Some children with ASD initially have a limited number of activities or toys
they are motivated by, and it can be challenging to identify what motivates them.
Box 6.4 contains ideas to identify and expand their interests.
134 NDBI Strategies

Ready, Set, Implement!

BOX 6.4: Tips for identifying interests
The following strategies may be useful for identifying and expanding your
child’s interests:
• Pay attention to body language regardless of communication skills. Is the
child reaching? Turning to or away from the toy or play partner? Initiating?
• Let go of the idea that a toy has a purpose or a game has rules. Connect 4
may be a complex game, but filling up the grid with chips and watching them
fall out is often highly motivating. No rules necessary!
• Rotate toys and activities to prevent boredom and predictability. Keeping toys
in bins and rotating the bins every few days to weeks so that only a portion
of the toys are available at one time can keep things novel for the child.
• Do not forget that restricted interests and repetitive behaviors can be
motivating contexts for teaching.
• Sometimes it seems that the child is not interested in anything at all.
If this appears to be the case, watch what the child does in a free play
situation with access to toys and other items or activities. The child
will do something, and this something can be used as a reinforcer.
Examples include flicking light switches, repetitively tapping on a table,
and waving a pencil in front of his or her eyes.

Careful consideration of how the child’s interests can be expanded may also
be helpful. For example, if an interest is identified, consider what about the object
or activity is motivating. Is it a movement activity? Perhaps similar activities that
include movement would also be of interest. Is it a visual activity? Perhaps other
visually stimulating activities can be explored. Table 6.4 provides some examples
of how to expand interests based on current interests.

Following the Child’s Lead

All NDBI focus on following the child’s lead in some way. Following the child’s
lead is defined in several ways depending on the NDBI model. One form of follow-
ing the child’s lead relates to observing in the moment what toy, object, or activity
the child is interested in and using it as the teaching context. If the child moves
on to a new activity, the adult would then follow his or her lead to the next activ-
ity of interest or between activities. For example, if the child is playing with cars
and decides to move on to coloring, the adult would move to coloring as well and
continue to embed teaching strategies in the new activity. With an older child, the
adult might follow the child’s lead in conversation by moving with the child from
one preferred topic to the next (e.g., talking about the child’s favorite video game
and then following his or her lead to the topic of dinosaurs). In this way, the NDBI
teaching continues to be embedded in child-chosen activities, even as the child
moves from one activity to the next.
 Implementing Motivational Strategies 135

Table 6.4. Expanding your child’s interests

Child likes This may be Child may also like

Bubbles Visually interesting Balloons

Ball or car ramps
Tops or spinners
Sensory toys with liquid inside (e.g., glitter
wand)
Swinging Kinesthetic Spinning in a chair
Tickling games
Pulling the child in a blanket
Pushing buttons on Auditory Musical instruments
a cause-and-effect Freeze dance
toy Rhyming books
Singing songs
Pretend sneeze game
Exploring clay or Sensory Dry rice and beans
putty by pressing Shaving cream
and rolling Finger paint
Kinetic sand

Following the child’s lead can also occur within an activity. For example, while
playing with trains, the child’s attention or interest may shift from building the
train track to wanting to drive the trains on the track. Likewise, when engaging in
a coloring activity, the child’s focus may shift from drawing a picture to wanting to
write letters. This subtler form of following the child’s lead can be a crucial way to
maintain motivation within an activity. It has been suggested that the distinction
between use of child-preferred activities as the teaching context and following the
child’s lead within activities is important because both can be beneficial (Yoder,
Kaiser, Alpers, & Fischer, 1993).
Some NDBI models also emphasize following the child’s lead when placing
demands to practice skills. That is, the adult might wait for the child to initiate a
communication behavior (e.g., reaching) and either reinforce it or take the initiation
as an opportunity to prompt a more complex communication behavior (e.g., verbal
request). These three forms of following the child’s lead (between activities, within
activities, and initiation related) are all designed to have a positive impact on moti-
vation because the adult is closely matching the teaching with the child’s focus,
interest, and motivation to communicate in the moment.
These different forms of following the child’s lead are closely related, and there
is a broad consensus about the importance of this strategy (Kern et al., 1998). NDBI
vary somewhat as to the degree to which they emphasize each variation. Some
models that incorporate the developmental pragmatic communication approach
(e.g., EMT, Hancock & Kaiser, 2012; Project ImPACT, Ingersoll & Dvortcsak, 2006,
2010b) place more weight on promoting child initiations by following the child’s
communication lead and responding to all communication attempts as if they are
purposeful. Incidental teaching also highlights the need to wait for a child’s ini-
tiation (McGee et al., 1999). PRT encourages and plans for initiations but does not
necessarily wait for a child to initiate and may more actively prompt for learning
opportunities.
136 NDBI Strategies

Overall, research supports the use of teaching in the context of child-preferred

activities and following the child’s lead. For example, using child-preferred activities
decreases social avoidance behaviors and increases the length of conversational
interactions (Koegel, Dyer, & Bell, 1987). Siller and Sigman (2002) demonstrated that
“synchronizing” the adult’s behavior with that of the child (i.e., following the child’s
lead and providing little redirection) led to better joint attention and language abili-
ties (Siller & Sigman, 2002).
At times, challenges with following the child’s lead may arise. For example,
some children wander aimlessly and struggle to engage in activities, whereas oth-
ers may leave an area or activity as soon as an adult tries to join. It is also inevitable
that all children will, at times, select activities that are not available or that the
adult does not wish for them to gain access to (e.g., snacks right before dinner).
Please see Table 6.5 for tips on dealing with these issues, which are also discussed
in more detail in the section on shared control. There are also many strategies in
the behavior analytic literature for enhancing motivation and gaining participa-
tion in treatment in more systematic ways. Strategies such as preference assess-
ments, visual schedules, first–then programs, and priming can be combined with
the strategies outlined in Table 6.5, and such interventions should be tailored to
meet individual child needs.

Providing Choices
Research also supports the notion that providing the child with choices during
teaching interactions enhances motivation (e.g., Carter, 2001). A seminal study on
incorporating choice found lower levels of challenging behavior and higher levels
of appropriate social play and pragmatic skills in the choice condition compared to
a nonchoice adult-led condition (Carter, 2001).
Even within child-selected activities, children can be provided with choices.
Effectively providing choices requires the adult to have shared control over materi-
als (see the section on shared control) so that the child cannot obtain all preferred
items in the environment at will. This strategy involves giving the child a clear
indication (verbal or nonverbal) that a choice is available either with regard to what
he or she is playing with, how it will be played with, or what will happen next.
For example, when a child is not actively engaged in selecting an object or activity,
he or she can be offered choices of what to play with that are likely to be motivating
or preferred. During an activity, the child can also be offered choices about how
to play with the toy. This can be done in multiple ways, including 1) choices about
what pieces the child wants next (e.g., more trains or tracks), 2) choices about what
actions to engage in or how to play with the toy (e.g., make the animals eat or run),
and 3) more nuanced or specific choices about how to play with the toy that evoke
more complex language and play (e.g., make the animals run slow or fast). When a
child ceases to engage in goal-directed play or communication behaviors, he or she
can also be given choices about what to do next (e.g., “Do you want more drawing
or should we choose a new activity?”).
Depending on the context, the activity, and the child’s engagement, some or all
of the strategies related to offering choices may be useful for enhancing motivation,
thereby maintaining engagement in the learning context. Offering choices provides
the child with some control or the suggestion of control, which has a positive impact
 Implementing Motivational Strategies
Table 6.5. Addressing challenges with following the child’s lead
Challenge Possible solutions
Child wanders Offer choices to the child.
aimlessly Play with a toy, or start an
and does not activity to entice the child.
engage.
Offer noncontingent
reinforcement (i.e., highly
preferred objects or toys,
sensory social routines with
no demands) to motivate the
child to remain in the area.
Then, introduce demands or
redirect to other activities.
Child leaves Offer high levels of
area or activity noncontingent reinforcement,
when adult especially if the child cannot
tries to join. independently access the
reinforcement (i.e., try to pair
yourself with noncontingent
reinforcement). Slowly begin to
introduce demands, beginning
with maintenance tasks, at a
pace the child can tolerate.
Use behavioral momentum
strategies to engage the child
before placing demands.
When you join the
activity, introduce novel
noncontingent reinforcement
that was not previously
available.
Structure tasks, beginning with
very short intervals or small
amounts of expected behavior,
so that the child is required to
remain with a task for a short
period before appropriately
closing the activity (e.g.,
cleaning up or saying “all
done” and moving on). Increase
expectations for remaining with
the activity over time.
Child moves Follow the child from one
rapidly among activity to the next, and place
activities in an communication demands
effort to avoid for each one so terminating
demands. activities does not result in
task avoidance.
All previous strategies related to
when the child tries to leave
the area apply here as well.
Consider use of first–then
schedules or other behavior
analytic interventions to
decrease avoidance.
137
Examples
Say, “Do you want to play star stacker or
blocks?”
Get out a ball ramp, put the balls down, and
look enticingly at the child. You can also
comment, exclaim, and gesture excitedly.
Give the child a highly preferred item. If
the child takes it, require him or her to
remain in the area to play with it.
Try engaging the child in a highly
motivating sensory social routine. If he
or she engages, begin placing demands
and then redirect to other activities.
If the child is trying to build a marble
ramp, sit down to join, but do not begin
taking turns or take control over any of
the materials. Rather, allow free access.
Because the marble track is hard to
build, begin helping. Offer the marbles,
and help the child put them in. Cheer
with positive affect as they go down the
ramp.
If you wish, after several repetitions, begin
balancing turns, and use the adult turns
to gain shared control over the marbles
and place a maintenance task demand
(behavioral momentum strategy).
When joining a child playing babies, bring
novel items such as a doctor kit or food.
Offer the items noncontingently to
entice the child to stay and expand play.
Do not place demands initially. If you
eventually place demands, they should
be maintenance tasks.
If you sit down to play blocks and the
child tries to leave the area, stop the
child, and prompt, “First build five
blocks, then all done” or “One more
minute.” Use physical prompts to gain
compliance, if needed. After completion,
prompt the child to clean up before
moving on. When the child arrives at a
new activity, embed a communication
trial so moving between activities does
not serve to avoid demands.
If the child leaves the blocks area when
you sit down and moves to the art table,
follow his or her lead and embed a
communication trial to gain access to
art materials. If the child moves again,
this time to the doll house, follow his or
her lead and embed a communication
trial to gain access to the doll house. All
communication trials are maintenance
tasks because the child is demonstrating
low motivation.
(continued)
138 NDBI Strategies

Table 6.5. (continued)

Challenge Possible solutions Examples

Child selects In this case, you must set and If the child wishes to paint but the painting
activities maintain a limit with the child. supplies are not available, maintain the
that are not Regardless of whether the limit (e.g., “Painting is not a choice right
available or item or activity is truly not now”) and offer alternatives (e.g., “You
not a choice at available (e.g., a snack that has can draw, color, or do stickers instead”).
that time. run out) or the adult does not If the child wishes to have a snack before
wish to grant access (e.g., a dinner, maintain the limit (e.g., “Dinner
snack right before dinner), the is in 5 minutes. We are not having
limit must be made clear. The snacks now”) and offer alternatives
child can then be redirected (e.g., “You can have a glass of water
to select activities that while you are waiting” or “You can help
are available. If challenging me finish getting dinner ready!”).
behavior occurs, the limit
should be maintained, the
behavior should be ignored,
and available activities can be
offered once the child is calm.
Setting appropriate limits is
part of sharing control with
the child.

on motivation. Table 6.6 provides examples of different types of choices and how to
use them in teaching interactions.
Although providing choices enhances motivation, several common pitfalls
must be avoided. First, the adult must consider whether the child has the skills to
clearly communicate his or her choice. If the child is unable to reach, point, verbalize,
or use another clear strategy to indicate his or her preference, the adult must rely
on other cues, which can sometimes be more subtle. Many children who do not yet
know how to communicate choices will reach for preferred objects when offered
two choices, but some do not understand that the cue of being offered items indi-
cates they should choose. In such cases, adults may have to rely on more subtle cues,
such as looking at a preferred object. It may also be useful to offer choices in other
ways, such as to leave two or three objects out on a table or in an area while restrict-
ing access to others in order to see if a child gravitates toward one. This strategy is
similar to following the child’s lead, discussed previously. It may also be useful to
explicitly teach children to make choices.
Another common pitfall occurs when adults provide choices at times when
they cannot follow through. Although this seems like an obvious mistake to avoid,
it is a common trap to fall into. When providing choices, adults must ensure that
both choices are available. If one choice is not available, then adults must set limits
to clearly convey the choice is not an option, and they may need to delay target-
ing goals in that moment. Adults must also ensure that both choices are avail-
able immediately. When setting up an opportunity in which a child must choose,
adults should be ready to provide him or her with reinforcement for doing so. If
the reinforcement is delayed because the choice is not ready (e.g., the child requests
food that the adult has to make), learning may be negatively affected.
It is also useful to think about the format for providing choices in light of
the child’s skill set. For example, if choices are being provided verbally, does the
child have the receptive language to understand? In such cases, visual cues can
 Implementing Motivational Strategies 139

Table 6.6. Types of choices to provide and examples at different developmental levels

Type of choice Younger child examples Older child examples

What to play Floor activity: “Do you want to play Activity: “Do you want to build
with, do, or talk trains or ball ramp?” with magnets or blocks?”
about (e.g., in Table activity: “Do you want to do art Conversation: “Do you want
conversation with or puzzles?” to talk about dinosaurs or
older children) Pretend play: “Do you want babies or animals?”
animals?” Community: “Do you want to
Motor or sensory: “Do you want get coffee or ice cream?”
swing or tickles?”
How to play with it
or do it
• What to play with Trains: “Do you want more tracks Activity: “Should we build a
or do next within or trains?” tower or an airplane?”
an activity Art: “Do you want another marker Conversation: “What aspect of
or stickers?” dinosaurs do you want to talk
Dolls: “Do you want bottle or binky?” about next?”
Sensory: “Swing or stop?” Community: “What kind of ice
cream do you want?”
• Choices about Trains: “Should the trains drive or Activity: “Should we build it tall
actions or how park?” or short?”
to play Art: “Should we color it in or draw Conversation: “Should we talk
another one?” about where dinosaurs live
Dolls: “Should the baby eat or sleep?” or what they eat?”
Sensory: “Should we swing or bounce?” Community: “Do you want your
ice cream in a cup or cone?”
• More complex or Trains: “Should the trains drive forward Activity: “Who is going to live
nuanced choices or backward?” in this tower?”
about how to Art: “Should we put the sticker here or Conversation: “Should we talk
play or about the here?” about my trip to the dinosaur
topic Dolls: “Does the baby want milk or museum or yours?”
juice?” Community: “Where would
Sensory: “Do you want to swing slow you like to sit to eat your ice
or fast?” cream?”
What to do next Floor activity: “Are you done with trains Activity: “Are you all done
or do you want to keep playing?” building or should we build
Table activity: “Should we keep doing more?”
coloring or do you want some glue Conversation: “What should we
now?” talk about next?”
Pretend play: “Do you want to make Community: “Do you want to
the dolls eat the food or should we go home or should we go for
move on to the farm animals?” a walk first?”
Motor or sensory: “Do you want to keep
swinging or should we play chase?”

be useful. If a child has been using visual cues to make choices, deciding when to
fade them and teach the child to rely on verbal cues can be useful. As discussed
previously, management of the environment may also be important when offering
choices. For example, removing objects that are not an option and only displaying
items that are a choice can be helpful.

Sharing Control
Shared control is essential to all NDBI models because it is the basis for develop-
ing reciprocity and administering contingent reinforcement. NDBI differ across
models in their emphasis on various aspects of shared control. Shared control
140 NDBI Strategies

increases social motivation by placing emphasis on fostering reciprocity in interac-

tions. Shared control strategies include following the child’s lead; balancing turns
with the child; and then using the adult turn to build engagement, model new
skills, imitate actions, or embed teaching trials where the materials or activity can
be used as reinforcement. Shared control also refers to the balance between follow-
ing the child’s lead and setting limits as needed because the child cannot always
have access to the preferred activity or object. In a more concrete sense, shared con-
trol of materials or activities is required in order for the adult to build a back-and-
forth interaction with the child and to be able to provide contingent reinforcement.
Shared control provides the opportunity for the adult to gain control over preferred
items or next steps in an activity in order to provide those as natural reinforcement,
contingent on correct responses during embedded teaching trials. When applying
the behavior analytic antecedent-behavior-consequence (A-B-C) framework to em-
bedded teaching trials, adult control of materials can be thought of as a step that
must be completed prior to delivering the antecedent or cue for the teaching trial.
Inherent in the definition of shared control is the incorporation of other moti-
vational strategies discussed previously, such as teaching within child-preferred
activities, following the child’s lead, or providing choices. These strategies will
enable the adult to know which items (e.g., toys, objects, food), activities (e.g., tick-
les, swinging the child), or possible outcomes (e.g., providing help, picking the
child up) are motivating for the child in that teaching moment. Because the shared
control also includes balanced turns that result in the adult leading the interaction
and having momentary control over reinforcement, it is also considered a moti-
vational strategy. If the adult does not have control over the reinforcement in this
context, the child will have uncontrolled noncontingent access, which will make it
more difficult for the adult to embed the teaching trial and evoke the desired child
response.
Retaining too much control over an activity or object by either the adult or
the child may decrease the child’s motivation either because the child does not
have enough access to the item or he or she has noncontingent access that may
not keep him or her socially engaged. Rather, shared control should result in a
naturally reciprocal interaction in which the adult and child have balanced turns.
For example, when playing with toys with multiple pieces (e.g., puzzles, blocks,
art activities), adults can be tempted to embed trials that result in reinforcement
one piece at a time; however, doing so may result in too many demands, too little
reinforcement, and an imbalanced and unnatural interaction. In order to adjust
the pacing of instruction in this way, the adult can consider several strategies,
including 1) providing several pieces as reinforcement, rather than one at a time;
2) providing noncontingent reinforcement (“freebies”) between teaching trials;
3) providing noncontingent reinforcement at the beginning of the activity in order
to promote engagement and interest and to decrease the avoidance that sometimes
occurs when an activity begins with a demand; 4) interspersing other strategies
to promote development without explicitly embedding trials, such as verbal nar-
ration, imitation of the child’s actions, and modeling of novel play actions; and, of
course, 5) taking turns with the child in a fun and engaging way that allows for
varying the activity and building social interaction.
Shared control can also be defined in a broader sense, meaning that following
the child’s lead and providing choices is the focus, but limits must also be set as
 Implementing Motivational Strategies 141

needed. That is, the child may select activities, objects, and so forth, but the adult
controls what the choices are at any given time. For example, the child may be
motivated by a snack that is all gone, an activity that the parent wishes to limit for
other reasons (e.g., repetitive behaviors, screen time, snacks before dinner), activi-
ties that are not available (e.g., going to a preferred place, such as a favorite store or
park), and objects that are not available (e.g., a toy that was left at school). Parents
will often ask during parent training what they should do in these instances
because NDBI place so much emphasis on following the child’s lead and teaching
within child-preferred activities. Although NDBI certainly focus on maximizing
the benefits of teaching in these contexts, there must also be limits when the pre-
ferred reinforcement is not available for any reason. In these cases, shared control
includes setting limits as needed while providing the child with alternative avail-
able choices that are likely to be high interest. When the child’s chosen reinforcer is
not available and this type of shared control is being exercised, the child should not
be prompted to engage in any target behaviors until a new reinforcer is identified.
That is, the child should not be prompted to engage in target behaviors that are
related to a reinforcer that is not available.
Many shared control strategies are used across NDBI. Table 6.7 lists of many
of these, sometimes clustered into categories of related strategies, with definitions
and examples of each.
Sometimes shared control strategies have to be chosen carefully. For exam-
ple, as Table 6.7 demonstrates, some strategies lend themselves to teaching certain
behaviors better than others (e.g., the assistance strategy is specifically tailored for
teaching children to request help). Shared control strategies should also be selected
depending on the activity (e.g., breaking it up/inadequate portions for toys with
multiple pieces) and the child. Some children may be upset by strategies such as
playful interruption or obstruction, interrupting routines, sabotage, or protest
techniques, particularly children who are prone to rigid behavior patterns or are
very self-directed or agenda-driven.

Taking Balanced Turns

Balanced turns or turn taking is another motivational strategy used in NDBI. Turn
taking is one strategy used in shared control because the adult can gain control
over reinforcing materials or activities during his or her turn and then administer
these as reinforcement contingent on the child’s next appropriate response. Also,
the adult can use his or her turn as an opportunity to model expanded and more
complex behaviors. Taking turns during activities automatically gives the child
the opportunity to request, imitate, see actions mirrored by the adult, and receive
natural reinforcement when it is his or her turn again. By definition, it teaches reci-
procity but always within the motivating context of child-selected activities.
Across the NDBI models, balanced turns are conceptualized in slightly dif-
ferent ways. For example, in PRT, adults follow the child’s lead, provide choices,
and share control in a balanced way, thereby fostering a balance between targeting
motivation and embedding behavioral teaching trials (Koegel, Koegel, Bruinsma,
Brookman, & Fredeen, 2003; Koegel, Koegel, Harrower, & Carter, 1999; Koegel
et al., 1989). In ESDM, turn taking and dyadic engagement are embedded through-
out the teaching interaction such that “reciprocity and social engagement permeate
142 NDBI Strategies

Table 6.7. Definitions and examples of shared control strategies

Shared control strategy Definition Example

Environmental arrangements: Organizing the environment to optimize learning

Environment: In sight, Storing items where they
out of reach can be seen but not
obtained by the child
Materials: In sight, out Setting up an activity so that Set up clay and supplies (e.g.,
of reach materials can be seen but
not obtained by the child
Arrange the therapy room so that
items are stored up high and/
or in clear bins so the student
cannot obtain them without
communicating with an adult.
rollers, cutters, scissors) on a
table where the adult can reach
them but the child cannot without
communicating with an adult.

Playful obstruction strategies: Reducing anticipation when the child’s wants or needs may be
known; setting up situations in which the child will need to communicate before obtaining
what he or she wants or needs

Controlled access; Maintaining control over Hold up a toy or snack, and wait for
shared control objects; holding the object the child to communicate.
out of reach until the child
engages in the target
behavior
Interrupting routines Pausing in the middle of a Stand at the door, ready to go
known routine so the child outside, but pause until the child
must communicate before communicates.
moving on Pause before handing the child his
or her toothbrush, and wait for
him or her to communicate.
Assistance Setting up activities or Hand the child an unopened chip
situations in which the bag or juice box.
child will require adult Wait while the child struggles to
assistance; also reducing build a toy to evoke asking for
adult anticipation of help.
child needs when natural Place snacks or toys in containers
opportunities arise in that are hard to open.
which the child needs
assistance
Inadequate portions; Providing a few pieces or Provide a few goldfish crackers in a
breaking it up parts of a set at a time bowl, and leave the bag in sight.
in order to elicit multiple Provide a few stickers during an art
communication trials; activity, and let the child know
applies best to toys or there are more.
snacks with multiple Provide a handful of Legos, and hold
pieces or sets of items the rest in the box.
Intentional ignoring Ignoring the child on Turn a toy off, and then turn it
purpose, especially away from the child to evoke an
when the child needs opportunity for tapping an adult’s
help or the adult has shoulder or calling the adult by
a preferred object, to name.
create opportunities for
appropriately gaining
attention
Playful interruption or Playfully interrupting the Pause during a tickle game, and wait
obstruction child’s play so that the for the child to make a response.
child must communicate Pretend that a tree has fallen on the
to have the interruption train tracks and must be removed.
removed Make a doll fall on the dollhouse
stairs so it needs help getting up.
 Implementing Motivational Strategies 143

Table 6.7. (continued)

Shared control strategy Definition Example

Protest Setting up situations that Offer nonpreferred foods or objects.

are known to upset the Interrupt rigid routines and
child in order to provide repetitive behaviors (e.g., lining
opportunities to practice up objects).
appropriate requesting
and protesting
Silly situations; playing Setting up situations that are Turn the power switch to off on a
the naïve adult obviously silly or breaking cause-and-effect toy, and laugh or
known routines in a silly say, “Oh no! What happened?”
way Put pants on your head, and say, “Is
this where they go?”
Walk the wrong way at school, and
say, “Is this where we go?”
Sabotage Providing parts of an activity Provide cereal without a spoon.
while withholding obvious Provide the Wack-a-Mole without the
necessary parts hammer.
Provide paint without a paint brush.

General shared control strategies

Balanced turns or turn Taking turns with the child
taking by requiring him or her to
relinquish objects for brief
turns; in some models,
includes modeling novel
play actions during the
adult turn
Momentum Creating momentum prior
to withholding an object
or action by repeating a
highly reinforcing action
several times in a row
before embedding a trial
Positive addition Adding or enticing the child
with a novel object (Note:
This strategy is helpful
when the adult no longer
has control over materials
because the child already
has all the pieces. It is
a good alternative to
interrupting or requesting
a turn.)
Briefly remove Poppin Pals toy, and
hold it up.
Briefly remove toy car, driving it
once and pausing.
Take turns hammering the
workbench really fast back-and-
forth, and then suddenly pause
when you have the hammer.
Add several blocks in a row to
a tower while making a funny
sound, then pause.
Push the child several times on the
swing, and then hold the child back.
When building a tower, add Little
People to balance on the top
when it is done.
Once the train track is built and
the train is on it, add people or
animals to the train.
When playing babies, introduce toy
food.

the teaching activity” (Rogers & Dawson, 2010, p. 24). Both verbal and nonverbal
turn taking is described as part of the responsive interaction component in EMT
(Hancock & Kaiser, 2012). Nonverbal mirroring of appropriate behavior in a turn
is expressly encouraged as a way to increase the nonverbal connection between
adult and child, much like other models encourage imitation. The Project ImPACT
manual (Ingersoll & Dvortcsak, 2010a, 2010b) outline of parent training sessions
spends 2 of 24 sessions solely on balanced turn taking and teaches turn taking as
an essential strategy that helps create learning opportunities for language and is
used to model and expand play.
144 NDBI Strategies

As discussed in Table 6.7, turn taking is also often used as a shared control strat-
egy. When using turn taking in a more explicit way (e.g., “my turn”/“your turn”),
adults should consider whether this framework is developmentally appropriate for
very young children who may not be ready to learn this skill. In such cases, creat-
ing reciprocity in a more natural way (i.e., balanced turns through natural alterna-
tion of who is in control of materials) may be more appropriate.

Integrating Task Variation and the Interspersal of Maintenance Tasks

Task variation and interspersal of maintenance (i.e., already mastered or easy)
tasks are two related strategies that primarily stem from the behavior analytic lit-
erature. Task variation is defined as varying behaviors being targeted in embedded
teaching trials, varying the teaching materials, and varying the manner in which
they are being used. Research supports that task variation enhances motivation
and engagement (Dunlap, 1984).
Interspersing maintenance tasks is one type of task variation. It is an ante-
cedent strategy used to enhance motivation. This strategy comes out of the gen-
eral behavior analytic literature, where interspersing maintenance tasks is used to
build behavioral momentum (Belfiore, Lee, Scheeler, & Klein, 2002; Bruinsma &
McNerney, 2012; Kennedy, Itkonen, & Lindquist, 1995), thereby enhancing motiva-
tion. This strategy is also used to increase general compliance (e.g., Singer, Singer, &
Horner, 1987). Interspersing maintenance tasks is most clearly defined in the PRT
literature, where this strategy is specifically used to enhance motivation through
interspersal of low-effort, high-probability-of-success trials, otherwise defined as
tasks the child has already mastered. Studies have shown increased participant
response rate and stability and increased observer ratings of child positive affect
when maintenance tasks are interspersed (e.g., Dunlap, 1984; Dunlap & Koegel,
1980; Koegel & Koegel, 1986).
Maintenance tasks are defined based on individual child goals and progress.
Because NDBI all incorporate behavior analytic principles, clearly defined goals
with mastery criteria (e.g., 80% correct responding across 3 consecutive days of
data collection) should be present. Progress on these goals can then be used to
determine when a goal area (i.e., acquisition task) has been met and can be moved
into maintenance. At this point, the goal can begin to be interspersed as a main-
tenance task. This strategy ensures maintenance of skills while also enhancing
motivation.
Use of this strategy requires clinical judgement in the moment about whether a
teaching trial should consist of a maintenance or acquisition task. Adults who work
with the child must evaluate the child’s motivation and engagement in the moment
and decide whether the teaching trial should be a maintenance task (designed to
target motivation) or an acquisition task (designed to target skill acquisition). There
is not necessarily a predetermined ratio of maintenance to acquisition tasks; rather,
the adult must learn to read the child’s cues about level of motivation and decide
on the next steps in the treatment session accordingly. For example, if the adult per-
ceives that the child’s motivation is decreasing, he or she can focus on maintenance
tasks to build it back up. In contrast, when a child is highly motivated, the adult
can more heavily target acquisition tasks. Sometimes, it helps to think about using
a 50/50 ratio of easier and more challenging cues and varying frequency of either
based on the child’s motivation and behavior.
 Implementing Motivational Strategies 145

Using Natural Reinforcement

Consistent with the behavior analytic focus in NDBI, contingent reinforcement is
frequently used to teach skills during behavioral teaching trials that are embed-
ded in natural routines and activities. Contingent reinforcement is defined as rein-
forcement that is delivered only after the target behavior has occurred. That is, the
reinforcement is delivered contingent upon demonstration of the target behavior.
Because NDBI are also defined by their naturalistic approach, however, the type of
contingent reinforcement typically used is natural.
Natural reinforcement is defined as reinforcement that is directly related to
the target behavior and embedded within the teaching interaction (e.g., child asks
for a block and receives the block as reinforcement, child points to a train car and
receives it as reinforcement, child makes eye contact during a tickle routine and is
reinforced with tickles). In contrast, unrelated reinforcement bears no relationship
to the target behavior or context in which the behavior is being taught (e.g., child
labels colors of blocks and receives access to a sensory toy as reinforcement, child
points correctly to receptive labels in a picture and receives food treats as rein-
forcement). Unrelated reinforcement can be effective for teaching skills, but natural
reinforcement has the added benefit of enhancing motivation and generalization.
Natural reinforcement is characterized in a variety of ways across NDBI mod-
els. For example, EMT refers to it as contemporary ABA (Hancock & Kaiser, 2012;
Prizant, Wetherby, & Rydell, 2000) and defines it as the use of contingent reinforce-
ment during natural routines to enhance communication skills. Research in the
area of PRT has demonstrated that the use of natural reinforcement is more effec-
tive for enhancing motivation than unrelated reinforcement (e.g., giving the child
the ball when he or she says “ball” is more effective than giving the child an edible
reinforcer; Koegel, O’Dell, et al., 1987). Furthermore, studies have shown that use
of natural reinforcement leads to more rapid and stable acquisition of target skills
compared to unrelated reinforcers (Koegel & Williams, 1980; Williams, Koegel, &
Egel, 1981) and also promotes generalization of skills in the natural environment
by strengthening naturally occurring direct response–reinforcer relationships
(Schreibman, Stahmer, & Suhrheinrich, 2009). In the JASPER model, emphasis
is placed on setting up the environment with developmentally appropriate toys
that can serve as natural reinforcement for the establishment of play routines
(Kasari et al., 2012). Detailed discussion of reinforcement strategies and their clini-
cal application can be found in Chapter 9.

Using Reinforcing Attempts or Shaping Procedures

Reinforcing attempts or loose shaping procedures are used in many NDBI as a
consequence strategy that enhances motivation and learning. Reinforcing attempts
is defined as reinforcing any reasonable attempt at the target behavior and then
shaping successive approximations of the behavior until the full target behavior
is being evoked. For example, for a child who is learning first words, an initial
reasonable attempt at saying the word “bubbles” might be “buh.” Once the child
has mastered this attempt, the adult can start reinforcing a better approximation,
such as “buh-buh,” until finally the child is able to say the word “bubbles.” In
strict shaping, once the next approximation is the goal, the previous approxima-
tion of the word would no longer be reinforced. This strategy can be frustrating
146 NDBI Strategies

for the child, however, so a loose shaping contingency is often used in which more
than one approximation of a behavior would be reinforced at a time until the child
has clearly mastered the more difficult behavior. For example, for the child who is
learning to say “bubbles,” the adult might reinforce both “buh” and “buh-buh”
until the more difficult attempt can be consistently evoked. In essence, contingent
reinforcement of attempts (or trying) increases the behavior of trying. This, in turn,
leads to more trying.
In NDBI, reinforcing attempts is used across most models. In EMT, one com-
ponent of the responsive interaction framework is to contingently reinforce any
and all attempts at the target behavior. This strategy is also incorporated into Proj-
ect ImPACT, especially with regard to language goals. In PRT, reinforcing attempts
is a consequence strategy designed to enhance motivation. It is defined as the
reinforcement of “reasonable” communication attempts rather than shaping suc-
cessive motor approximations of speech sounds (Bruinsma & McNerney, 2012).
In one study, children in the reinforcing attempts condition, as opposed to motor
shaping, demonstrated substantially larger gains, and children were rated as hap-
pier and exhibiting more appropriate behaviors (Koegel et al., 1988).

CONCLUSION
NDBI utilize a variety of strategies to enhance (social) motivation in individuals
with ASD. These strategies are supported by a large body of evidence and provide a
clear focus for ASD intervention. Although behavior analytic teaching procedures
are useful for targeting specific skills, procedures that enhance motivation play
an important role in ASD treatment, particularly because clinicians cannot rely
on the same level of social motivation that usually motivates typically developing
children to learn. The strategies outlined in this chapter are specifically designed
to enhance motivation in treatment and should be considered carefully when
developing goals and treatment plans. Subsequent chapters will touch on a num-
ber of these strategies in greater detail as they pertain to teaching specific skill sets
and reducing behavior challenges.

REFERENCES
Belfiore, P. J., Lee, D. L., Scheeler, C., & Klein, D. (2002). Implications of behavioral momentum
and academic achievement for students with behavior disorders: Theory, application, and
practice. Psychology in the Schools, 39(2), 171–179.
Bruinsma, Y., & McNerney, E. K. (2012). Pivotal response treatment. In M. E. Fey & A.
G. Kamhi (Series Eds.) & P. A. Prelock & R. J. McCauley (Vol. Eds.), Communication and
language intervention series: Treatment of autism spectrum disorders: Evidence-based intervention
strategies for communication and social interactions (pp. 281–312). Baltimore, MD: Paul H.
Brookes Publishing Co.
Carter, C. M. (2001). Using choice with game play to increase language skills and interactive
behaviors in children with autism. Journal of Positive Behavior Interventions, 3(3), 131–151.
Charlop, M. H., Kurtz, P. F., & Casey, F. G. (1990). Using aberrant behaviors as reinforcers for
autistic children. Journal of Applied Behavior Analysis, 23(2), 163–181.
Dawson, G., & Adams, A. (1984). Imitation and social responsiveness in autistic children.
Journal of Abnormal Child Psychology, 12(2), 209–225.
Dawson, G., Webb, S. J., Carver, L., Panagiotides, H., & McPartland, J. (2004). Young children
with autism show atypical brain responses to fearful versus neutral facial expressions of
emotion. Developmental Science, 7(3), 340–359.
 Implementing Motivational Strategies 147

Dawson, G., Webb, S. J., & McPartland, J. (2005). Understanding the nature of face process-
ing impairment in autism: Insights from behavioral and electrophysiological studies.
Developmental Neuropsychology, 27(3), 403–424.
Dawson, G., Webb, S., Schellenberg, G. D., Dager, S., Friedman, S., Aylward, E., & Richards,
T. (2002). Defining the broader phenotype of autism: Genetic, brain, and behavioral
perspectives. Development and Psychopathology, 14(3), 581–611.
Dunlap, G. (1984). The influence of task variation and maintenance tasks on the learning
and affect of autistic children. Journal of Experimental Child Psychology, 37(1), 41–64.
Dunlap, G., & Koegel, R. L. (1980). Motivating autistic children through stimulus variation.
Journal of Applied Behavior Analysis, 13(4), 619–627.
Hancock, T. B., & Kaiser, A. P. (2006). Enhanced milieu teaching. In R. J. McCauley & M. E.
Fey (Eds.), Treatment of language disorders in children (pp. 203–236). Baltimore, MD: Paul H.
Brookes Publishing Co.
Hancock, T. B., & Kaiser, A. P. (2012). Implementing enhanced milieu teaching with children
who have autism spectrum disorders. In P. A. Prelock & R. J. McCauley (Vol. Eds.), Commu-
nication and language intervention series: Treatment of autism spectrum disorders: Evidence-based
intervention strategies for communication and social interactions (pp. 163–188). Baltimore, MD:
Paul H. Brookes Publishing Co.
Ingersoll, B. (2010). Brief report: Pilot randomized controlled trial of reciprocal imitation
training for teaching elicited and spontaneous imitation to children with autism. Journal
of Autism and Developmental Disorders, 40(9), 1154–1160.
Ingersoll, B., & Dvortcsak, A. (2006). Including parent training in the early childhood special
education curriculum for children with autism spectrum disorders. Journal of Positive
Behavior Interventions, 8(2), 79–87.
Ingersoll, B., & Dvortcsak, A. (2010a). Teaching social communication to children with autism:
A manual for parents. New York, NY: Guilford Press.
Ingersoll, B., & Dvortcsak, A. (2010b). Teaching social communication to children with autism:
A practitioner’s guide to parent training. New York, NY: Guilford Press.
Kaiser, A. P., Yoder, P. J., & Keetz, A. (1992). Evaluation milieu teaching. In S. F. Warren &
J. Reichle (Series & Vol. Eds.), Communication and language intervention series: Vol. 1. Causes
and effects in communication and language intervention (pp. 9–47). Baltimore, MD: Paul H.
Brookes Publishing Co.
Kasari, C., Fannin, D. K., & Goods, K. S. (2012). Joint attention intervention for children with
autism. In M. E. Fey & A. G. Kamhi (Series Eds.) & P. A. Prelock & R. J. McCauley (Vol.
Eds.), Communication and language intervention series: Treatment of autism spectrum disorders:
Evidence-based intervention strategies for communication and social interactions (pp. 139–162).
Baltimore, MD: Paul H. Brookes Publishing Co.
Kasari, C., Freeman, S., & Paparella, T. (2006). Joint attention and symbolic play in young
children with autism: A randomized controlled intervention study. Journal of Child Psy-
chology and Psychiatry, 47(6), 611–620.
Kennedy, C. H., Itkonen, T., & Lindquist, K. (1995). Comparing interspersed requests and
social comments as antecedents for increasing student compliance. Journal of Applied
Behavior Analysis, 28(1), 97–98.
Kern, L., Vorndran, C. M., Hilt, A., Ringdahl, J. E., Adelman, B. E., & Dunlap, G. (1998).
Choice as an intervention to improve behavior: A review of the literature. Journal of
Behavioral Education, 8(2), 151–169.
Koegel, L. K., & Koegel, R. L. (1986). The effects of interspersed maintenance tasks on
academic performance in a severe childhood stroke victim. Journal of Applied Behavior
Analysis, 19(4), 425–430.
Koegel, L. K., Koegel, R. L., Bruinsma, Y., Brookman, L., & Fredeen, R. (2003). Teaching first
words to child with autism and communication delays using pivotal response training: A treatment
manual. Santa Barbara: University of California.
Koegel, L. K., Koegel, R. L., Harrower, J. K., & Carter, C. M. (1999). Pivotal response interven-
tion I: Overview of approach. Journal of the Association for Persons with Severe Handicaps,
24(3), 174–185.
Koegel, R. L., Bimbela, A., & Schreibman, L. (1996). Collateral effects of parent training on
family interactions. Journal of Autism and Developmental Disorders, 26, 347–359.
148 NDBI Strategies

Koegel, R. L., Dyer, K., & Bell, L. K. (1987). The influence of child-preferred activities on
autistic children’s social behavior. Journal of Applied Behavior Analysis, 20(3), 243–252.
Koegel, R. L., & Egel, A. L. (1979). Motivating autistic children. Journal of Abnormal Psychology,
88(4), 418–426.
Koegel, R. L., & Koegel, L. K. (2006). Pivotal response treatments for autism: Communication,
social, and academic development. Baltimore, MD: Paul H. Brookes Publishing Co.
Koegel, R. L., O’Dell, M., & Dunlap, G. (1988). Producing speech use in nonverbal autistic chil-
dren by reinforcing attempts. Journal of Autism and Developmental Disorders, 18(4), 525–538.
Koegel, R. L., O’Dell, M. C., & Koegel, L. K. (1987). A natural language teaching paradigm for
nonverbal autistic children. Journal of Autism and Developmental Disorders, 17(2), 187–200.
Koegel, R. L., Openden, D., Fredeen, R. M., & Koegel, L. K. (2006). The basics of pivotal
response treatment. In R. L. Koegel & L. K. Koegel (Eds.), Pivotal Response Treatments for
autism: Communication, social, and academic development (pp. 3–30). Baltimore, MD: Paul H.
Brookes Publishing Co.
Koegel, R. L., Schreibman, L., Good, A., Cerniglia, L., Murphy, C., & Koegel, L. K. (1989). How
to teach pivotal behaviors to children with autism: A training manual. Santa Barbara: University
of California.
Koegel, R. L., & Williams, J. A. (1980). Direct versus indirect response–reinforcer relation-
ships in teaching autistic children. Journal of Abnormal Child Psychology, 8(4), 537–547.
Kuhl, P. K., Tsao, F., & Liu, H. (2003). Foreign-language experience in infancy: Effects of
short-term exposure and social interaction on phonetic learning. Proceedings of the National
Academy of Sciences, 100(15), 9096–9101.
Magnuson, K. M., & Constantino, J. N. (2011). Characterization of depression in children
with autism spectrum disorders. Journal of Developmental and Behavioral Pediatrics, 32(4),
332–340.
McGee, G. G., Morrier, M. J., & Daly, T. (1999). An incidental teaching approach to early
intervention for toddlers with autism. Journal of the Association for Persons with Severe
Handicaps, 24(3), 133–146.
Prizant, B. M., Wetherby, A. M., & Rydell, P. J. (2000). Communication intervention issues
for young children with autism spectrum disorders. In S. F. Warren & J. Reichle (Series
Eds.) & A. M. Wetherby & B. M. Prizant (Vol. Eds.), Communication and language intervention
series: Vol. 9. Autism spectrum disorders: A transactional developmental perspective (pp. 193–224).
Baltimore, MD: Paul H. Brookes Publishing Co.
Rogers, S. J. (2006a). Studies of imitation in early infancy: Findings and theories. In S. J.
Rogers & J. G. Willams (Eds.), Imitation and the social mind: Autism and typical development
(pp. 3–26). New York, NY: Guilford Press.
Rogers, S. J. (2006b). Evidence-based interventions for language development in young
children with autism. In T. Charman & W. Stone (Eds.), Social and communication develop-
ment in autism spectrum disorders: Early identification, diagnosis, and intervention (pp. 143–179).
New York, NY: Guilford Press.
Rogers, S. J., & Dawson, G. (2010). Early Start Denver Model for young children with autism:
Promoting language, learning, and engagement. New York, NY: Guilford Press.
Rogers, S. J., Dawson, G., & Vismara, L. A. (2012). An early start for your child with autism: Using
everyday activities to help kids connect, communicate, and learn. New York, NY: Guilford Press.
Schreibman, L., Kaneko, W. M., & Koegel, R. L. (1991). Positive affect of parents of autistic
children: A comparison across two teaching techniques. Behavior Therapy, 22, 479–490.
Schreibman, L., Stahmer, A., & Suhrheinrich, J. (2009). Enhancing generalization of treat-
ment effects via pivotal response training and the individualization of treatment proto-
cols. In C. Whalen (Ed.), Real life, real progress for children with autism spectrum disorders:
Strategies for successful generalization to the natural environment (pp. 21–40). Baltimore, MD:
Paul H. Brookes Publishing Co.
Siller, M., & Sigman, M. (2002). The behaviors of parents of children with autism predict the
subsequent development of their children’s communication. Journal of Autism and Devel-
opmental Disorders, 32(2), 77–89.
Singer, G. H., Singer, J., & Horner, R. H. (1987). Using pretask requests to increase the prob-
ability of compliance for students with severe disabilities. Journal of the Association for
Persons with Severe Handicaps, 12(4), 287–291.
 Implementing Motivational Strategies 149

Vernon, T. W., Holden, A. N., Barrett, A. C., Bradshaw, J., Ko, J. A., McGarry, E. S., . . . German,
T. C. (2019). A pilot randomized clinical trial of an enhanced pivotal response treatment
approach for young children with autism: The prism model. Journal of Autism and Devel-
opmental Disorders. Retrieved from https://doiorg.offcampus.lib.washington.edu/10.1007
/s10803-019-03909-1
Vernon, T. W., Koegel, R. L., Dauterman, H., & Stolen, K. (2012). An early social engage-
ment intervention for young children with autism and their parents. Journal of Autism and
Developmental Disorders, 42(12), 2702–2717. doi:10.1007/s10803-012-1535-7
Waddington, H., van der Meer, L., & Sigafoos, J. (2016). Effectiveness of the Early Start
Denver Model: A systematic review. Review Journal of Autism and Developmental Disorders,
3, 93–106.
Ward, S. (2009). What you need to know about motivation and teaching games: An in-depth analysis.
Raleigh, NC: Lulu.
Williams, J. A., Koegel, R. L., & Egel, A. L. (1981). Response–reinforcer relationships and
improved learning in autistic children. Journal of Applied Behavior Analysis, 14(1), 53–60.
Yoder, P. J., Kaiser, A. P., Alpert, C., & Fischer, R. (1993). Following the child’s lead when
teaching nouns to preschoolers with mental retardation. Journal of Speech & Hearing
Research, 36(1), 158–167.
7
Applying Antecedent Strategies
Jennifer B. Symon, Yvonne Bruinsma, and Erin McNerney

L
earning occurs when an individual interacts with the environment, the
environment provides feedback to the individual, and the individual then
changes a behavior in response. These feedback loops result in behavior
changes or learning based on the individual’s experiences. In general, an anteced-
ent is the environmental or preceding event that sets the occasion for and influ-
ences the actions or behaviors that follow. It is the first component in the three-term
contingency (A-B-C) in Applied Behavior Analysis (ABA). Antecedents can evoke
particular behaviors, allow individuals to discriminate when reinforcement may
become available, and change behavior (Cooper, Heron, & Heward, 2007). Behavior
in three-term contingency refers to any behavior by the individual, not just chal-
lenging behavior.
Antecedents immediately precede a behavior and can signal the individual
to perform a learned behavior in such a way that the chance of a known conse-
quence is maximized. Examples of antecedents include instructional cues (e.g.,
“Please brush your teeth”) or contexts that evoke certain behaviors (e.g., being in
the kitchen might evoke requesting a snack as that is a place where the request
often leads to food; arriving at the dentist office might be followed by challeng-
ing behavior to avoid discomfort). Sometimes earlier events can also set the stage
for a behavior. These setting events make it more likely that an antecedent will
evoke a behavior. For example, not sleeping during the night may increase the
likelihood that an antecedent triggers a challenging behavior the next morning
because the person is tired. Setting events can also be biological, such as having a
headache or menstrual cramps (see Box 7.1).
Antecedent-based interventions can optimize the learning environment to
enhance the likelihood that successful learning occurs. To enhance the likelihood
of learning, a practitioner or parent manipulates elements of the teaching environ-
ment, including the physical environment, the materials, the person providing the

151
152 NDBI Strategies

BOX 7.1: Setting events

Setting events are events (e.g., social, physiological) that increase the likelihood
that an antecedent will trigger a behavior.

intervention, and the way in which opportunities are presented. Optimizing the
learning environment by altering the first part of the A-B-C sequence is an ongoing
process, rather than a one-time effort, because contingencies and environmental
variables change during teaching. This chapter provides many examples of these
types of planned changes, specifically related to teaching a host of skills across
school, home, and community settings.
Antecedent-based interventions are useful for reducing challenging and
interfering behaviors. Broad empirical support exists for interventions that alter
the antecedents in an effort to reduce the likelihood of future challenging behav-
iors (e.g., Kern & Clemens, 2007; Wong et al., 2014). Research showed that chang-
ing antecedents skillfully led to decreases in challenging behaviors and increases
in play skills, school readiness, and academics for elementary and middle school
students with autism spectrum disorder (ASD); it also showed improvements
in core deficits of ASD for individuals from early childhood through adulthood
(Wong et al., 2014). When individuals with ASD engage in challenging behaviors
as a means of communicating to gain access to preferred activities or to avoid or
escape tasks, antecedent-based intervention strategies can reduce the effectiveness
of reinforcers that maintain those behaviors by serving to minimize the associa-
tion between the stimuli and the consequences that follow (Cooper et al., 2007).
Reducing setting events that evoke challenging behaviors (e.g., turning down loud
music during homework time) can increase the likelihood of learning. As such, a
benefit of antecedent-based approaches is the preventative focus; planned envi-
ronmental design can eliminate interfering behaviors from occurring altogether
(Kern & Clemens, 2007).
Chapter 13 examines the use of antecedent-based interventions, as well as
other kinds of interventions, to reduce challenging behaviors. This chapter exam-
ines the influence of antecedents on teaching, including the broader contextual
variables and environmental stimuli that set the stage before teaching opportuni-
ties are provided. It discusses how to plan for and optimize the teaching environ-
ment to support successful learning opportunities.
Under the theoretical umbrella of ABA, antecedent-based interventions are
employed in Naturalistic Developmental Behavioral Interventions (NDBI) in many
ways. Overall, NDBI create an appealing learning environment that is enticing to
the learner and sets the stage for high motivation and a desire to socially engage.
Indeed, the old saying “an ounce of prevention is worth a pound of cure” holds
true when the environment and conditions where learning needs to occur are not
just prepared but optimized. The sections that follow provide an overview of NDBI
strategies for preparing the environment for successful embedding of learning
opportunities (the A in the three-term contingency). This chapter provides specific,
practical examples of antecedent strategies used by NDBI.
 Applying Antecedent Strategies 153

PREPARING TO TEACH
Learning is mediated by attention, which is affected by how information is pre-
sented and received. The same stimuli presented in different ways can have a dif-
ferent impact on the learning outcome. Consider a flock of birds soaring across the
sky in the shape of a pyramid. The movement may instantly capture an individual’s
attention as the flock transverses directions during flight and forms a line. Yet, the
same species and number of birds perched in a row on a street lamp or pecking in a
cluster on the ground outside a cafe may go unnoticed or be disregarded. The pre-
sentation of the stimuli affects whether the individual attends to it and ultimately
if the individual learns from it. In learning situations, antecedent-based interven-
tions are introduced following a similar principle; to create teachable moments,
educators optimally construct the environment by presenting materials or stimuli
in ways that capture the attention of a particular learner and maximize the likeli-
hood that successful learning will take place.
NDBI create teachable moments throughout the individual’s daily life; as such,
embedding of learning opportunities is a core feature. Intentionally planning for
teaching (i.e., planning antecedent strategies) across typical and novel activities
and routines is a well-established and recommended practice in early childhood
literature (e.g., Snyder et al., 2015). NDBI adhere to this practice, increasing therapy
hours and learning opportunities by integrating them into all daily life activi-
ties. Furthermore, use of natural routines for teaching is congruent with NDBI in
which parents are highly valued as change agents and interventionists (Dunst,
Trivette, & Masiello, 2010). NDBI ultimately focus on increasing the independence
of the learner; embedded teaching within routines supports advancement to inde-
pendence by providing a large variety of teaching opportunities in the most natu-
ral context. However, it is essential to organize and prepare the environment to
maximize the likelihood that successful teaching can take place. A number of strat-
egies for such organization and preparation are discussed next.

Arranging the Environment

Before setting up opportunities for social interactions and learning new skills, it
is important to first consider the context or environment where learning occurs.
When teaching new skills, carefully planning the environment is particularly es-
sential for NDBI, given that intervention typically takes place across natural en-
vironments, where there may be less inherent control than in highly structured
settings. Purposefully planning the environment to promote learning may in-
clude placing furniture strategically in the room; mitigating potential distractions
(e.g., noise level, lighting, number of individuals present); and carefully organiz-
ing, placing, and managing materials and activities.
Planned furniture and student placements have been shown to be successful
in classrooms to increase communication between students (Kaiser, Ostrosky, &
Alpert, 1993; Odom, McConnell, & Chandler, 1994). As a general example, seating
arrangements and location of materials may facilitate or hinder attention toward
peers. Environmentally arranging a classroom can include seating a student with
ASD next to a classmate with similar interests to promote opportunities for social
interaction and enhance motivation to engage. If a student with ASD’s desk is
placed within a pod surrounded by classmates, opportunities for observation and
154 NDBI Strategies

imitation of correct responses may increase. As an alternative, if all students in a

classroom are given their own materials, they may not need to communicate their
need for items such as pens, paper, or an eraser. Instead, a teacher might set up
the activity to ensure that students need to obtain materials from peers (e.g., one
student has access to the construction paper, another one to the scissors, and a
third to the colored pencils), which would allow easy opportunities for sharing of
materials. It may ultimately lead to increased communication between peers (see
also Chapter 12, the section on cooperative arrangements).
The environment can also be arranged so that a student must navigate around
furniture before getting to the door, increasing the effort needed to elope and thus
decreasing likelihood of elopement. In a clinic setting, children may be seated at a
small table with highly preferred tabletop activities to focus their attention (Chang,
Shire, Shih, Gelfand, & Kasari, 2016). In a community setting, the parent or thera-
pist may purposefully navigate past a colorful water fountain to set the stage for
increased communicative opportunities and social initiations, knowing that the
child will likely show interest and stop to initiate bids for joint attention. At home,
a caregiver may organize toys into clear bins that are in view but out of reach to
interest a child with ASD to initiate an interaction to play.
All NDBI address environmental arrangements, with minor variations in
which types are emphasized. Joint Attention, Symbolic Play, Engagement, and
Regulation (JASPER); the Early Start Denver Model (ESDM); and Project ImPACT
(Improving Parents as Communication Teachers) explicitly advise initially mini-
mizing distractions during intervention (Chang et al., 2016; Ingersoll & Dvortsak,
2010; Rogers, Dawson, & Vismara, 2012). Minimizing distractions can increase the
effectiveness of teaching because the individual can more readily attend to the most
salient cue(s), including the communicative partner. As the child’s skills increase,
distractions can be reintroduced in order to mirror the environment where the
individual will ultimately be practicing the skill and to ensure generalization.
Although the previous examples illustrate arranging the broader environ-
ment, changes to the presentation of learning materials can also substantially
increase the number of learning opportunities. Slight modifications to toy place-
ment during a teaching interaction, for example, may naturally allow for increased
engagement and learning opportunities. If a car rolls down a ramp into the child’s
lap, there is little need for the child to engage in social-communication, and the
child can then continue rolling the car uninterrupted. Simply turning the ramp so
that the car rolls just out of reach (or into the adult’s hands) creates an opportunity
for the child to request the item or to ask for help. It also allows the adult to become
the focus of the interaction rather than the requested objects. Furthermore, if the
child really enjoys the ramp and the car that he or she needs is up on a high shelf,
an opportunity has been created for the child to initiate a request or ask for help.
Likewise, it is helpful to consider the placement of the adult in the interaction.
For example, when pushing a child on the swing, parents may position themselves
behind the child to push more easily but thus lose an important opportunity for
affective sharing and engagement. Reading a book together sometimes prompts
the child to sit on a parent’s lap. However, sitting next to or across from each other
may provide more opportunities for face-to-face contact and may increase social
engagement. Adult placement may be different when the goal of the teaching
interaction is peer engagement. In these situations, an adult may consider placing
 Applying Antecedent Strategies 155

him- or herself behind the child with ASD to reduce orienting to the adult and to
be able to prompt covertly.
Although the organization of the environment is mostly discussed here as
a planning tool, ongoing management of toys and materials during teaching is
equally important. It is helpful to limit the number of toys or sets of materials out
at any one time and to put materials out of sight or have the child pick up as he or
she loses interest in items. Routines around starting with new toy materials and
cleaning up when done are valuable tools to remain organized and prevent a cha-
otic teaching environment. Likewise, when taking out toys or materials, it can be
helpful to know what part(s) are of the highest interest to the child and remain in
control of at least some of them. For example, if the child is naming play actions
with three figurines visible in a plastic bag and one of the figurines is of high inter-
est, then taking out the favorite figurine last may ensure the child remains highly
motivated. Finally, when using large sets of materials (e.g., a train set with tracks,
bridges and trains, an art project with multiple materials), placement of materials is
key, and materials can be put away during the activity as they are no longer needed.

Selecting Materials
NDBI call for carefully preparing materials and selecting toys in a way that pro-
motes specific teaching goals. In JASPER for instance, the adult selects appropriate
materials at precisely the child’s developmental play level to target joint attention
and active engagement. Selected toys and materials should be exciting and inter-
esting enough to attract the child’s interest, but like other NDBI, JASPER typically
recommends limiting the use of toys that do not allow for play expansion because
they have just one function, or because they are too self-contained (e.g., a light-up
musical toy, a toy with electronic buttons). Often JASPER suggests having two iden-
tical sets of toys to ensure the adult can model play behaviors, unless the toy already
has multiple pieces (e.g., a shape sorter, a ring stacker, a pig that has coins inserted
in it). Toys that target the appropriate play level serve to enhance learning oppor-
tunities for coordinated and supported joint attention skills. For example, toys that
are too easy or too difficult may cause the child to become too object focused and
limit the level of engagement and joint attentions skills exhibited, whereas materi-
als at the correct play level would be more engaging, interesting, and motivating.
The child may be more familiar and know what do with the materials, allowing
him or her to focus on acquiring new skills.
Other models, such as ESDM and Pivotal Response Treatment (PRT), recom-
mend the use of chronologically age-appropriate toys and materials that will likely
entice a child to show interest and explore. Age-appropriate toys (as opposed to
developmentally appropriate toys) are valued because they are likely to be of high
interest to same-age peers, which aligns with the ultimate goal of teaching skills
that generalize into social interactions with peers. ESDM also considers toy selec-
tion in terms of thematic teaching and selects materials and activities that sur-
round a theme. For instance, a teacher, clinician, or parent can focus teaching skills
(e.g., vocabulary and play actions, social conversation) around a theme that may
be of interest to the child. For young children, balls can be used to create themes
related to bouncing and throwing. As children become more symbolic, blocks,
cars, figurines, cones, ramps, and markers can become a racing car theme, whereas
156 NDBI Strategies

a house, dolls, beds, blocks, animals, play food items, and markers are well suited
for creating teaching opportunities around the theme of playing family.
In a classroom, teachers can design lessons and create teaching opportuni-
ties around topics or themes of interest to the child, making lesson planning more
focused and more likely to capture the child’s attention throughout each lesson. For
example, a teacher may decide to use transportation as a thematic unit. In that case,
the play centers can include trains, bicycles, cars, buses, trucks, airplanes, and rock-
ets. Spelling words or journal writing assignments can focus on words and topics
associated with transportation. Math centers for a young child can include manipu-
latives such as tires, vehicles, and the number of items that fit into a truck. For older
students, calculations of speed and distance related to transportation can be used in
a mathematical lesson. Outside of the classroom setting, teachers can create cross-
word puzzles related to the theme of transportation or social games with peers, such
as a transportation obstacle course. The variety of possible interactive play oppor-
tunities is limitless when considering grouping toys into a theme whereas a single
individual toy or one type of toys may become challenging to expand on by itself.

Actively Planning Within Daily Routines and Activities

NDBI focus on embedding teaching across daily activities, natural routines, and/or
play (Hancock & Kaiser, 2006; Ingersoll & Dvortcsak, 2010; Kasari, Freeman, &
Paparella, 2006; Koegel, Koegel, Harrower, & Carter, 1999; McGee, Morrier, & Daly,
1999). Bath time, diaper changing, snack or mealtime, walking to the park, and
shopping at the grocery store are all reasonable home and community settings
for teaching. Routines at school can also provide students with ASD countless op-
portunities to frequently practice skills. Across each routine, caregivers, clinicians,
and teachers can intentionally plan for learning opportunities. Some questions to
consider when planning include the following: What maintenance or mastered
goals will be targeted during each activity? Which acquisition or new goals will be
included? What materials will need to be created or provided? What instructional
cues and prompts will be presented? In what order will goals be presented?
For example, a caregiver of a child with ASD might consider several setting
events when planning for a trip to the grocery store as an appropriate setting for
teaching new skills as well as skill generalization. Some general planning con-
siderations would include going to the store at a time when the store is not very
busy and when the caregiver is not rushed. It is also helpful if the child has visited
the store several times before and the same routine is more or less followed each
time. Furthermore, it would be important to make sure the child is well rested
(e.g., not at nap time) and not hungry (e.g., the caregiver could bring some small
snacks that can also be used as reinforcers). Before the outing, the caregiver iden-
tifies what skills he or she plans to target (e.g., practicing social greetings, count-
ing items, reading food labels, requesting), which targets are maintenance (skills
the child already has), and which are acquisition or new skills. The caregiver may
also identify items (e.g., favorite snacks and foods) and activities (e.g., pushing the
cart, sitting in the cart) that the child enjoys, which can be used as reinforcement
and increase participation. It may also be necessary to have a plan for challeng-
ing behaviors as well as some general rules dependent on the developmental level
(e.g., stay with mommy, use inside voices, you may pick one cereal). See Box 7.2 for
more on planning for community outings.
 Applying Antecedent Strategies 157

Ready, Set, Implement!

BOX 7.2: Prepare for a community outing
Be prepared, and plan for challenges before going out. Keep a small bag
or travel box in the car, and fill it with items to keep children busy during
unexpected wait times. Remember, these are antecedent strategies, so offer
them to the child to prevent challenging behavior rather than after challenging
behaviors begin. Below is an example list of items to keep children occupied
while waiting at a restaurant. Be creative!
• Small puzzles
• Rubik’s cube
• Deck of cards
• Small blocks
• Mad Libs or other word games
• Dry erase markers and a small white board
• Stickers
• Beads
• Books or magazines
• Playdough

Likewise, a teacher at school may plan for teaching particular skills during
routines and activities across all academic and co-curricular activities, including
recess, and special assemblies. For instance, a preschool teacher can create com-
munication opportunities during circle time for a student with ASD who enjoys
numbers. Because circle time includes multiple children, it sets the stage for the
teacher to prompt the student to count the number of students present, the number
of students wearing long sleeves, or the number of peers signed up to receive hot
lunch. An elementary school teacher can alter the environment to create commu-
nication opportunities for students to request the type of marker that they want
to use before journal writing, to ask for their preferred classroom job (e.g., ask to
be the line leader or pencil monitor rather than being assigned a role), or to pick a
buddy to go outside with for recess. A high school teacher can also create oppor-
tunities for social-communication and active participation as an antecedent strat-
egy by asking each student up front what topic they plan to write about or which
classmate they would like to check their work with after their journal assignment
is complete. Planning antecedent strategies around naturally occurring opportuni-
ties within these routine activities increases both the number and the variety of
learning opportunities that can be presented in a day.
Table 7.1 provides examples of how to set up goals within activities with
planning. The table presents a few examples of social-communication goals, such
as making appropriate social comments or sharing toys with a peer that a par-
ent or practitioner might determine appropriate for a child with ASD. Then, for
each sample goal in the table, activities are presented as they might be modified or
 158 NDBI Strategies

Table 7.1. Goals and activities for social communication

Goals Blocks Car ramp Chalk outside Playdough

Expanding Build a tower Add descriptors to Practice colors and Noun plus verb
one-word together and the cars going different shapes can be practiced
to two-word make it crash down the ramp (draw X or use with cutting,
phrases down in varied (colors, speed, blue chalk). rolling, and
ways: by a and size are Animals, letters, pushing.
crane, by a the obvious and vehicles Playdough tends
superhero ones, but tend to be most to be difficult
flying, after also consider popular items to to get out of
counting, nonsense ones draw. containers
by swinging like a smelly Use chalk to providing an
the child and car). draw islands opportunity to
allowing his or Use additional in the ocean verbally request
her feet to crash objects to block or lava. Play a help.
the tower. Prior the cars from game jumping Add additional
to crashing, going down the from island to materials to
have the child ramp in order to island on one playdough,
request with one practice 2-word leg or while such as cotton
or two words. phrases like hopping for swabs, glitter,
“move it” or safety. Have the pipe cleaners,
“help me.” child verbalize or tooth picks to
next steps, for make unusual
example, “Jump art.
there.”
Follow Hide a favorite Use only one car, Draw combinations Display the
requests with character and hide the car of favorite different colors
prepositions behind, under, close by. The figurines or of playdough
or on top of the child must find objects by using and ask the
blocks. Make the car following prepositions child to find the
a cage for the the directions, (e.g., Here is the playdough that
character from including the rocket. Where is under the
the blocks. preposition prior should I put the pillow before
to playing with superhero?). playing with it.
the car on the Have the child lie Hide tools under
ramp. down and draw a bowl while
Catch the car as it the outline of his the child is
comes down the or her body on watching, and
ramp, and make the pavement. ask the child
it fly to a new Next practice where it is.
location. Ask the drawing favorite
child where the objects next to
car is (e.g., Is it or on top of the
under or on top outline.
of the pillow?).
Imitate pretend Use the blocks to Race two cars Draw a pretend Make playdough
play actions make a zoo with down the ramp, scene around characters and
cages for little and pretend the a favorite area provide models
plastic animals. slower car is of interest or a of different
Put the animals crying because it favorite book or actions the child
to bed, take lost. Comfort the television show. can imitate.
them for a walk, “sad” car with Imitate the
feed them, etc. the child and actions together.
Some of the get him a snack
blocks can to help him feel
be imaginary better.
animals or
figures or
objects. Make
pretend action
with the object
and prompt for
imitation.
 Applying Antecedent Strategies 159

Table 7.1. (continued)

Goals Blocks Car ramp Chalk outside Playdough

Use social While the tower is When cars crash Use prompt When the child
phrases being built and or get stuck, comments makes a
almost toppling, prompt “Oh, no” for drawings, playdough
say, “Oh no, oh or “oh, man!” such as “Great figure or art
no!” to build Move the ramp job!” or “wow, piece, prompt
anticipation close to the awesome!” to say, “Check it
of the blocks table edge and Draw targets with out” or “Look”
falling. have the car chalk on a fence and have
Prompt the child drive off the or wall, and them combine
to say, “Boom, table. Prompt hit them with the initiation
crash” when the “Oh, oh,” water balloons with showing
tower falls. “oopsies,” or or balls. Use behaviors
“That’s ok!” social phrases to (holding up the
comment on hits item, pointing/
and misses. looking).
When the
therapist makes
a playdough
object, prompt,
“nice” or
“awesome”
in response
to therapist
showing
behaviors.
Imitates Use blocks Make roads for the Use chalk to Use playdough
drawing to make a cars by drawing draw lines and to make circles
circles/lines mountain and lines on the road circles and of all sizes, and
draw a circle on and circles for make snowmen, circle them
paper. The circle parking spots animals, and a on paper with
is a landing or the ice cream sun. Add water a preferred
pad for pretend store. and a big brush writing utensil
helicopters or to “paint” with (e.g., marker,
from where the chalk. multicolored
superhero takes pen, pencil).
off. Prompt child
to draw circles
for additional
landing pads.
Utilize and After the block Using multiple After drawing a Make a few balls
understand tower crashes, cars for the body of a child and many balls
comparatives make two heaps car ramp, ask and body of a of playdough
of blocks and which pile has sibling, ask who and prompt the
ask which pile the most/least is taller. child to take the
is bigger. If amount of cars pile with many
the answer is before giving balls.
correct the child the child access
can build a new to that pile.
tower with that
pile.
160 NDBI Strategies

individualized for the child to promote or create teaching opportunities directed at

the goal using antecedent-based instructions.

Using Individual Preferences to Select Materials

Incorporating the preferences of the individual increases his or her interest in
learning, particularly when some of the tasks are difficult. Research shows teach-
ing with high-interest materials substantially increases learning for children with
ASD (Dunst, Trivette, & Masiello, 2010, 2011). In addition, children show increased
engagement and reduced problem behavior when they actively select their toys,
compared to when a teacher selects them (Reinhartsen, Garfinkle, & Wolery, 2002).
When children with ASD and language delays are offered choices of materials,
they demonstrate improved language and play skills and reductions in disrup-
tive behavior (Carter, 2001). When students with ASD are offered choices between
activities, they display fewer problematic behaviors compared to within-activity
choices (Rispoli et al., 2013).
When a child’s preferences are not clear, clinicians can use tools to iden-
tify motivating activities or items. For example, they can complete preference
assessments formally or informally through observation and identification of the
individual’s interests. There are multiple procedures for conducting systematic
preference assessments, such as free operant preference assessments and paired
choice preference assessment. These procedures are described in detail in the
ABA literature (e.g., Hagopian, Long, & Rush, 2004). Preference is not static; prefer-
ences and interests can change even within a session. In addition, PRT and ESDM
both support incorporating specific or unusual interests into the interventions in
order to capture motivation through these interests, even if they involve activities
or materials that are not developmentally typical.
Perseverative interests can be used to expand peer play and motivation for
social interaction (Baker, 2000; Baker, Koegel, & Koegel, 1998; Koegel et al., 2012;
Koegel, Kim, Koegel, & Schwartzman, 2013). Teaching games modified to incor-
porate restricted interests results in more appropriate social play, maintenance,
and generalization of gains. Clubs at school or in afterschool programs can also be
designed around a child’s perseverative interest (e.g., Minecraft, trains, dinosaurs,
Disney characters). If the interest is very narrow, the club could be built around a
broader theme in order to attract a large enough group of children. For instance,
children interested in specific scientific topics may enjoy a young inventors club.
A child’s interest in numbers or shapes might be incorporated in a cooking club,
whereas a child’s interest in a particular cartoon character might be incorporated
in a club for movie buffs.

Establishing Rapport and Building Relationships

In NDBI, the adult and the relationship between adult and child are central to
the intervention, and indeed the optimization of that relationship contributes
significantly to the child’s success in the learning environment. Because these
relationships are established prior to teaching, this is an antecedent-based strat-
egy. NDBI aim to have the child focused on the communicative partner in affect-
rich reciprocal interactions. Research supports that it is not merely sufficient for
adults to deliver reinforcement but that active adult participation in the delivery of
 Applying Antecedent Strategies 161

Ready, Set, Implement!

BOX 7.3: It is all about you!
Sometimes stuff can get in the way. Remember, toys and objects are
vehicles for engagement, and the child’s engagement with other adults or
children is key! If motivation decreases (e.g., the child is responding less
often, positive affect is decreasing, the child is avoiding interaction by moving
away or turning his or her back to the adult), put the stuff to the side, and go
back to basic engagement strategies like imitation or sensory social routines.
Social motivation is what matters! Once motivation is high again, slowly
bring back toys.

reinforcement can increase social engagement and initiations (Koegel, Vernon, &
Koegel, 2009; see Box 7.3). When caregivers played with the child and incorporated
social reinforcement, such as jumping on a trampoline with the child rather than
providing access to jumping alone, the children initiated social bids more often. In
addition, the children displayed positive affect toward the caregiver while making
requests at substantially higher levels if the adults were engaged in the activities
with the child.
Establishing a positive therapeutic relationship or rapport between the indi-
vidual with ASD and the parent or teacher is essential and an important feature of
NDBI. Research shows that positive rapport will, in general, result in fewer chal-
lenging behaviors than a negative rapport (Koegel, Koegel, & Dunlap, 2006; Magito
McLaughlin & Carr, 2005), which can ultimately lead to better rates of responding,
more engagement with activities, and improved social outcomes.
NDBI practitioners often easily build rapport and positive therapeutic relation-
ships because of the high levels of reinforcement they provide. Not only do they
pair themselves with toys, materials, and activities typically highly motivating to
the child, but they also provide frequent noncontingent reinforcement (NCR), fur-
ther strengthening the relationship between the adult and the child.

Creating a Schedule
Although not specifically part of NDBI, creating a clear schedule across and within
routines provides structure and predictability. A clear schedule also serves as a
powerful antecedent strategy to reduce challenging behavior and increase inde-
pendence. Predictability is useful, particularly for individuals with ASD, who
experience frustration or anxiety from complex social situations, and for those

BOX 7.4: Noncontingent reinforcement

Noncontingent reinforcement is reinforcement that is provided independent
of behavior.
162 NDBI Strategies

who experience challenges with receptive understanding of a daily sequence of

events. Photographic activity schedules increase play behaviors in children with
ASD on the playground (Akers, Higbee, Pollard, Pellegrino, & Gerencser, 2016),
and visual schedules improve students’ on-task behavior in the classroom (Mac-
Donald, Trembath, Ashburner, Costley, & Keen, 2018). In a classroom, conveying
to the students how long they are expected to maintain attention to a nonpreferred
academic task can reduce off-task behaviors. Likewise, the schedule can prepare
an individual with ASD because the student can clearly see when nonpreferred
activities will occur. It can then motivate the student by presenting when preferred
activities will be available.
Schedules can be individualized to fit the needs, preferences, and abilities of
each person. Schedules can be made with objects, photographs, pictures of objects,
printed icons, or written words. Assessment of the individual’s skills and context
are necessary to determine the most appropriate type of schedule. The individual’s
ability to understand that an object, photograph, or icon represents an activity (i.e.,
iconicity) or whether the individual can read are examples in determining what
mode to use on the schedule. In addition, the individual’s ability to understand a
long sequence of activities compared to understanding a simple first–then sequence
will also affect the schedule’s design. The time associated with each activity may
be portrayed on the schedule for those understanding or learning the concept of
time. Inclusion of individual preferences (e.g., preferred color, theme, character)
and choices (e.g., selection of an outdoor activity at recess) into individual sched-
ules can motivate an individual, thus increasing compliance. For instance, an
individual who has a high interest in Star Wars may be motivated by having the
characters or related thematic words on his or her schedule.
Schedules can also be individualized with the help of technology, especially
if the individual is motivated by technology. Auditory reminders or recordings
of upcoming activities can take the place of a visual tool. The use of a reminder
list or calendar on a tech device may also reduce social stigma and allow the indi-
vidual to work toward increased independence. Community skills in children with
ASD have successfully been taught via a digital self-managed schedule (Cheung,
Schulze, Lead, & Rudrud, 2016).
Some individuals with ASD experience difficulties when their routine
changes, and a schedule that allows for flexibility may be helpful. For example,
a situation in which a student receives speech therapy each Wednesday, with
the session time rotating so that he or she does not continuously miss the same
part of class, can lead to confusion on the part of the student. Therefore, pro-
viding a symbol denoting flexibility (e.g., placing a question mark or photograph
of the speech therapist shrugging shoulders next to the icon of speech therapy)
may offer some predictability for the individual to prepare for the sessions even
though the exact time is unknown. In another example, a student may display
challenging behavior during physical education (PE) when it is held indoors due
to inclement weather conditions. In this case, various icons or photographs may
represent options of the PE settings (indoor and outdoor), which can vary on the
daily schedule. In a third example, an individual with ASD may not know how to
independently engage in an unstructured leisure activity. A schedule may then
include options to choose from during these periods (e.g., read a book, use your
cell phone, have a snack).
 Applying Antecedent Strategies 163

Priming
Similar to the way in which schedules assist in articulating a sequence of upcoming
activities and routines, priming is another way to prepare an individual for future
events. Priming is a behavioral intervention involving the presentation of upcom-
ing activities in a low-demand context with high levels of reinforcement, prior to
when the appropriate behavior is expected to be performed (Gengoux, 2015; Wilde,
Koegel, & Koegel, 1992; Zanolli, Daggett, & Adams, 1996). For example, a child with
ASD who is isolated during unstructured play on the playground may have a goal
to increase social interactions with peers. Using priming as an antecedent strategy,
the practitioner or parent could expose the child to several previously learned play-
ground games (e.g., Hide and Seek, Tag) in a more structured one-on-one setting
before recess. Likewise, the practitioner or parent could review a variety of social
initiations to join play on the playground with the child before the child is in the
situation when he or she is expected to initiate.
Reminders about how to play the games and learning types of initiations
before time on the playground with peers provides reinforcement of expected
behaviors before the behaviors need to be displayed. Priming is particularly help-
ful for individuals with ASD who have challenging behaviors and those who have
difficulty with novel situations. It is also a useful tool for increasing skill perfor-
mance (e.g., a reminder to find a friend to play with at recess). Providing a preview
and opportunities to practice difficult social and/or communication skills ahead of
time can increase chances of success while reducing the likelihood of challenging
behavior.
Priming can be accomplished in different ways, including the following:
• Verbal explanations and/or reminders (e.g., “Remember to greet your friends
when you walk into school today.”)
• Visual supports (e.g., pictures or icons showing the appropriate behavioral
expectation)
• Visual schedule showing an upcoming sequence of events
• Actual exposure to and practice of the upcoming event (e.g., visits to meet
the dentist, sit in the chair, and see the tools but not actually have any dental
work done)
The efficacy of priming in preparing individuals for a variety of upcoming
events is supported by research, including priming for class assignments (Koegel,
Koegel, Frea, & Green-Hopkins, 2003), co-curricular activities, social interac-
tions with peers (Bellini & Peters, 2008; Gengoux, 2015), transitions (Schreibman,
Whalen, & Stahmer, 2000), and self-care (Bainbridge & Myles, 1999).
Priming can consist of simple verbal cues, photos, or more advanced technol-
ogy such as video vignettes. Family members, clinicians, and teachers can create
videos and present them prior to participation in a potentially challenging situ-
ation as a reminder of how to display or maintain appropriate behavior. Before
arrival at a new school, the incoming student may view photos or videos of his
or her assigned locker, classroom, desk, or teacher. The student may also walk
through campus to become familiar with the setting and expectations prior to the
first day of classes. Likewise, a teacher could present a short video just prior to
164 NDBI Strategies

recess reminding the student how to initiate participation into a playground game
and maintain good sportsmanship during the game. At home, just before heading
to a birthday party, a parent can show his or her child a brief video of the typical
activities, such as handing the gift to the birthday child, participating in games and
activities, singing Happy Birthday, and thanking the hosts.

Establishing Clear Rules or Expectations

Establishing clear rules and setting behavioral expectations is an antecedent-based
strategy that increases the likelihood of appropriate behavior and decreases challeng-
ing behavior (Kern & Clemens, 2007). Clearly communicating classroom or family
rules and expectations and communicating the consequences of a specified behavior
(before the behavior occurs) are examples of providing clear behavioral expectations.
Generally speaking, rules should be stated clearly and should identify the
expected behavior, rather than what the child is expected not to do (e.g., “ask for
permission to leave your seat” rather than “don’t get out of your seat”; “walking
feet” rather than “no running”). In addition, providers should ensure that any con-
sequences of not following a rule or abiding by an expectation are made clear prior
to the individual having an opportunity to not follow directions. For example, in
a job setting, an individual could be told, “Employees are required to show up on
time each day. If you are more than 5 minutes late, you will receive a written warn-
ing after the second time.” This expectation makes it clear that showing up on time
is important, and failure to meet the expectation results in a disciplinary action.
An added benefit of having clear behavioral expectations is that over time these
expectations can become implicit and will not need additional rehearsal; instead,
they become just “how we do things.” For example, when a child requests dessert
every night and the parent institutes the rule that dessert night is on Wednesday
and Saturday only, then the child comes to accept that as a fact of life. In this way,
simple overall family rules can help prevent unnecessary challenges.

SETTING UP OPPORTUNITIES IN NDBI

The next step after the planning phase, which optimizes the teaching environment
and conditions, is optimizing the delivery of teaching opportunities. NDBI incor-
porate a variety of antecedent strategies, including engaging and enticing, using
routines to set up opportunities, getting the child’s attention, using behavioral mo-
mentum and varying the task, following the child’s lead, and using shared control
to increase the likelihood of success of the intervention. Each of these strategies
is briefly reviewed next. Finally, examples that combine antecedent-based compo-
nents within NDBI are presented at the end of this chapter, and these address spe-
cific routines at home (e.g., bath time, dressing and undressing, bedtime, chores)
and in the community (e.g., grocery shopping, going for a walk). Chapter 6 (on
motivation), Chapter 11 (on communication), and Chapter 12 (on social skills) also
provide a wide range of strategies and examples that may be helpful to the reader.

Engaging and Enticing

As outlined previously, NDBI place high value on social engagement and em-
phasize the social reciprocity between the individual with ASD and his or her
 Applying Antecedent Strategies 165

communicative partner, whether it be a caregiver, a teacher, or a clinician. En-

hanced Milieu Teaching (EMT) and Incidental Teaching include promoting en-
gagement as an important feature of sustaining interaction (see Hancock & Kaiser,
2006; McGee et al., 1999). EMT therapists engage in responsive interaction, which
includes behaviors that increase engagement, such as nonverbal mirroring or imita-
tion, following the child’s lead, and pacing the interaction in order to leave space for
the child’s initiations. ESDM, Project ImPACT, and JASPER include similar compo-
nents and specifically include animation by the adult to build interest (Ingersoll &
Dvortscak, 2010; Kasari et al., 2006; Rogers & Dawson, 2010). The adult uses his or
her voice tone, volume, and affect to interest the child and to get the child excited
about materials or an activity (e.g., “Guess what I have?” “Ohhh, look at this cool
train!”). Other enticing examples include acting sleepy and whispering when the
child is using figures and a house to act out a bedtime routine, acting very excited
when pretending to blow out the candles during a birthday party, or acting grumpy
when the child wakes up a spider puppet you were using. ESDM and JASPER em-
phasize the importance of taking into account the child’s preference and tempera-
ment; affect and animation can be used to help regulate arousal and attention for
the child. For example, when a child becomes too excited, the adult may modulate
his or her affect and tone to be lower and slower to help the child calm down.
Narration is another way to entice the child into play actions. The adult may
narrate his or her actions (e.g., “I am making a snake with my clay”) or the child’s
actions (“Your blue car is going fast”). Narrating in this way, including the addition
of sound effects or songs, helps to establish and optimize the shared interaction
and encourages the child to engage with a partner.
Humor can also be helpful when engaging and enticing a child into play.
Unexpected actions (e.g., exaggeratedly sneezing a small item off your head) or
silly noises (e.g., adding a silly noise when the ball bounces) capture the child’s
interest. However, the adult should be careful that this strategy leads to back-and-
forth interaction and learning opportunities and that the adult is not simply enter-
taining the child.

Using Routines to Set Up Opportunities

NDBI aim to establish social routines and create socially interactive teachable mo-
ments. ESDM, for example, emphasizes creating routines between an adult and
a child as a vehicle for teaching. The adult and child share focus, and once the
routine is established, the child anticipates the adult’s actions. ESDM discriminates
between dyadic play between child and adult (sensory social routines) and triadic
interactions in which the child shares attention toward interesting objects (joint
activity routines). As an example of a dyadic routine, a mother might take a blanket
and playfully begin the game by covering her face, saying, “Where’s mommy?”
then pulling the blanket off her face and tickling the child. The mother may repeat
this a few times to engage the child and see if the child will begin showing pleasure
and engagement (smiling, looking, reaching, vocalizing) and request repetition of
some part of the routine. Then, once the child is smiling, laughing, and/or looking
toward the mother, she may use a time delay (pause) before putting the blanket
over her head again and provide another opportunity for the child to communi-
cate via eye contact, smiling, pointing gesturing, or vocalizing, thus intentionally
creating communicative opportunities. This routine can be further expanded in
166 NDBI Strategies

a variety of ways to include placing the blanket over the child’s head or the child
placing the blanket over the parent’s head. The key component of such routines is
the initial repetition and sameness of it so that the child comes to understand what
to expect. Once sameness is created and the child is engaged, the adult can iden-
tify what is motivating about the activity and create opportunities for the child to
practice new skills (along with easier, already learned skills) within that routine.

Getting the Child’s Attention

Before providing an instructional cue or prompt, the adult must get the child’s
attention. NDBI actively incorporate several strategies to get the child’s attention.
Calling the child’s name and acknowledging the communicative partner verbally
(e.g., saying “yes” or “what”) or nonverbally (e.g., orienting toward the adult) works
with some individuals or in some situations. However, to increase the likelihood
of the child responding consistently when his or her name is called, reinforcers
can be paired, such as holding up a box of preferred items or pausing in a gesture
that often leads to shared enjoyment of an activity. There are other ways to gain at-
tention, such as interrupting the child’s play action, moving into the child’s visual
field, lightly touching a child, and using enticing strategies as discussed previ-
ously (e.g., animation, narration, imitation, humor). In addition, this strategy can
often work best when the environment is arranged in a way that encourages atten-
tion, as described previously.
When teaching in the context of an engaging activity, the caregiver or ther-
apist may need to occasionally interrupt the action to gain the child’s attention
and provide a learning opportunity. When interrupting the child’s actions, the
communicative partner must first determine that the child is still interested in an
activity and has not yet satiated. The communicative partner can gently or unob-
trusively interrupt the child’s action, resulting in the child attending to the partner.
For instance, after dinner in the restaurant, a child who is not yet verbal may notice
a large gumball machine that sends each giant-size gumball down a swirly ramp.
The parent could give the child a coin to put into the machine and immediately
gain the child’s attention by slightly blocking his or her access to twist the metal
lever. Right when the parent places his or her hand on the lever, the child may
make eye contact to begin the communicative interaction. The parent removes the
hand and allows the child to twist the lever.
Communicative partners may need practice to tell when a child is paying atten-
tion because many individuals with ASD prefer not to make eye contact. Often,
when the child is oriented or positioned toward the communicative partner, he or
she is attending. Other signs that a child is engaged may be reaching or looking in
the general vicinity of the play action. Clinicians, teachers, and parents can closely
observe the child’s body positioning and facial gaze to know when the child is pay-
ing attention to the adult and can learn to deliver cues at the appropriate timing.

Using Behavioral Momentum and Varying the Task

Research has documented that creating behavioral momentum by presenting
simple (maintenance) tasks prior to difficult tasks or learning goals results in in-
creased participation and improved behavior (Belfiore, Lee, Scheeler, & Klein, 2002;
Kennedy, Itkonen, & Lindquist, 1995; Kern & Clemens, 2007). Simply said, if a child
 Applying Antecedent Strategies 167

is experiencing success (e.g., when presented with a number of already learned

maintenance tasks that are relatively easy), then he or she is more likely to attempt
a response to a new or acquisition task. The efficacy of interspersing difficult with
already learned tasks is supported by research (e.g., Charlop, Kurtz, & Milstein,
1992; Dunlap, 1984) as a way to increase responding and engagement.
The ratio of easy versus novel or difficulty tasks heavily depends on clinical
judgement. If a child is highly motivated (for definitions and review of motivation,
see Chapter 6), more difficult tasks can be interspersed versus when motivation is
low. For example, a parent may plan teaching opportunities for his or her third-
grade student with ASD to practice on-topic question-asking with peers by inviting
a neighbor over for a couple of hours on the weekend. Sustained interaction with
a peer may be difficult for this child. To maintain the motivation to engage, the
parent can plan for the children to practice question-asking in an activity that is
motivating, easy, and low effort for the child (e.g., playing video games). However,
before the start of video games, they will make ice cream sundaes together, which
is also an easy task and highly preferred but allows for social conversation practice.
While making and eating sundaes, the children discuss topics that are high inter-
est (video games) and share components to ice cream sundae making (toppings, ice
cream flavors). This interaction includes practice of a variety of maintenance skills,
such as asking and answering simple wh- questions. In this case, the only acquisi-
tion goal for the child with ASD while making sundaes may be to practice asking
on-topic questions five times during the activity. The relatively easy conversational
demands in a highly preferred activity, mixed with the more challenging goals
of sustained peer interactions and on-topic questions, may likely set this child up
for success.
Planning and identifying the skills that are mastered as well as those that will
be targeted are part of antecedent-based plans when creating teaching opportuni-
ties. For a more in-depth discussion on maintenance and acquisition, please refer
to Chapter 6, on motivation.

Following the Child’s Lead and Using Shared Control

All NDBI use the strategies of following the child’s lead and using shared control
as ways to enhance child motivation. Chapter 6 discusses the specifics of these
strategies in great detail. However, it is important to reiterate the importance of
these strategies as a vehicle for antecedent manipulation to maximize learning.
Identification of what is motivating for a child and in a balanced way sharing some
control over that action or object in order to provide learning opportunities and
build interaction is the key.
Clearly presented and detailed home and community examples using these
NDBI antecedent-based strategies are presented in Table 7.2. Each example pres-
ents a common or typical daily routine whereby preparing the environment,
preparing the individual, and preparing for teaching opportunities can be embed-
ded through NDBI. This table brings together the antecedent strategies discussed
throughout the chapter to show specific examples to engage children with ASD
and motivate their interest while targeting core symptoms of ASD. The specific
examples offer concrete illustrations of how NDBI are used and may serve as a
springboard for creativity across additional routines.
168
Table 7.2. Optimizing routines
Meal/snack time
Get ready
Set up for success
Wait for an opportunity in which
you know your child is hungry
(but not so hungry he or she is
grumpy!) and you have time
to add a few minutes to the
mealtime.
Make the meal or snack the main
feature of your interaction;
clear off the table, turn off the
television and technology, and
take away any loud toys.
Provide support such as a high
chair or booster seat.
Have choices of food or drink
available, including some
preferred choices.
Consider allowing your child to
eat and then leave the table,
even before the rest of the
family is done (although once
the child leaves, he or she
should be finished eating).
Consider a routine around the
start and the end of snack and
dinner: the child can bring
something to the table or take
something to the kitchen as a
“job.”
For older children, have a
behavioral expectation
about how much the child is
expected to eat and a dessert
rule.
Adjust animation
Take a bite of food your child
likes, lick your lips, rub your
belly, and say, “Yummy!”
Take a bite of nonpreferred
food or pretend to eat a
nonpreferred item and
exaggerate saying, “Yucky!”
Scrunch up your face, and stick Take a bite of apple, lick your
out your tongue.
NDBI Strategies
Focus on your child Create opportunities
Follow your child’s lead Back-and-forth play
Offer your child choices of Try sharing a snack with
foods by holding up two your child. Give him or
items and letting the child her a bite, then take a
show you what he or she bite. Go back and forth
wants (e.g., “Apple or until the snack is gone.
grapes?”). As skills develop, If your child self-feeds, it
graduate to pointing or helps to have a large
verbally indicating choices. item you have control
Allow your child to choose of (e.g., big graham
the placemat, plate, or cup cracker) or to give your
to eat or drink from. child one piece of snack
If possible, sit face to face at a time.
with your child while eating Ask the child to show or
so you can respond to share with Daddy, Teddy
his or her subtle signs of Bear, or Brother.
communication.
Communication
Imitate your child temptations
Imitate your child eating Serve small portions of
crackers or cereal. favorite foods, and keep
Imitate his or her style of the rest in plain sight so
eating, noises the child your child can request
makes while eating, and more.
facial expressions. Fill your child’s cup with a
Place food in your mouth at small amount of liquid
the same rate as your child. from a larger pitcher.
Keep the pitcher on the
Model communication table so the child can
Describe what your child request more from you.
is eating in a repetitive Offer food items your
fashion. Say, “BANANA . . . child does not like so
Yum yum . . . BANANA . . . he or she can practice
Eat the BANANA.” (Point protesting.
to the banana each time Be sure to have the
you say the word or rub food your child does
your tummy when you say like available so your
“yum.”) child does not become
Describe what you are doing frustrated.
while you eat or while you
are setting up the meal.
Say, “I’m pouring Cheerios.
Yum!”
lips, rub your belly, and say,
“Yummy!”
Label various features of
the food you give your
child, such as the smell,
temperature, consistency,
or color.
 Applying Antecedent Strategies
Table 7.2. (continued)
Bath time
Get ready
Set up for success
Have everything ready before
your child gets in the tub. This
may be a few toys; bubbles;
a washcloth for play; and, of
course, a towel. Never leave
your child alone.
Set up a bath time routine
so your child knows what
to expect. Try to keep the
same routine every time. For
example, go to the bathroom,
turn on the water, help your
child take his or her clothes off,
turn off the water, put toys in,
get in the water, wash body,
wash hair, play, then get out.
If there are difficult times during
the bath time (e.g., hair
washing), provide warnings
it is coming and, if necessary,
priming before bath time.
Use a water temperature that
is comfortable for your child,
and do not fill the tub up all
the way.
You might want to bring your
child water-safe toys.
Adjust animation
Wash your child, one body part
at a time. Make a big gesture
to the part you will wash (“I’m
gonna wash your . . . TOES!”
[big point to the toes]).
Pretend to smell each body part
and say that it is dirty. Plug
your nose, scrunch up your
face, and say, “Ooh, stinky!”
Wash, and smell it again
(“Aaahh, all clean!”).
Focus on your child
Follow your child’s lead
Watch for your child’s special
interests. Does your child
like pouring, splashing,
or dunking things in the
water? Imitate and expand
these.
Offer your child a choice of
which body parts you wash
first.
Make the length of bath time
your child’s choice. Stay
extra time after washing if
your child enjoys playing
in the water. End the bath
quickly if your child tries to
get out.
Communication
Imitate your child
Imitate your child’s splashing, Place your child’s favorite
looking at items under
water, or watching water
run over things.
If you are imitating splashing,
show your child big and
small splashes to help him Wash one body part at
or her learn to splash in a
way that does not make a
mess.
Imitate your child’s play with
toys, such as water wheels,
cups or other containers,
a strainer, toys that float, If your child needs
wind-up tub toys, bath
crayons, scrubbers, or
bubbles.
Imitate your child’s sounds
and verbalizations while in
the bath.
Model communication
Help your child learn body
parts by describing them
as you wash. For example,
“I’m washing your . . .
TOES! (while playfully
grabbing toes with
washcloth).” “I’m washing
your . . . FOOT!” “I’m
washing your . . . LEG!”
169
Create opportunities
Back-and-forth play
Push a toy under water,
and watch it pop back
up. Give your child a
turn to do the same.
Blow bubbles across the
top of the water together
with a stretch tube or
straw.
Push bubbles back and
forth or take turns
putting them on the
wall.
Bathe a rubber ducky, and
encourage your child to
help.
temptations
bath time items in clear
plastic containers with
lids. Float the containers
in the bath with the toys
inside.
a time, then stop and
wait for your child to tell
you to continue. Or ask
your child, “Give me the
washcloth,” and wait for
a response.
assistance undressing
before bath, only take
off one item of clothing
at a time, and wait for
your child to show you
he or she wants you to
do more.
(continued)
170
Table 7.2. (continued)
Going to the grocery store
Get ready
Set up for success
Try these strategies when you
have a lot of time for a trip to
the store and not when you
are in a hurry.
Give your child a snack before
going to the store (so your
child is not hungry).
Bring a jacket for your child in
case it is air conditioned in the
store.
Go to the store during less busy
times to keep it from being
overwhelming for your child.
Have a plan of what you need at
the store before you go.
If the grocery store is very
difficult for your child, practice
going to the store when you
do not need to purchase
anything or can get just one
thing and leave. This will help
your child build up tolerance
for going to the store.
Go to the same grocery store
each time, establish a routine
around the order you gather
items, and go to the same
checkout line.
Prime your child with any
limits you need to set during
shopping (e.g., the child can
pick only one cereal, he or she
must stay with mommy).
Be aware of your child’s cues in
the store. Consider bringing a
hat, sunglasses, or earphones
to help make the sensory
experience better.
Adjust animation
Use a quiet, calm voice during
your trip, possibly whispering
to your child.
Try putting your child in a cart
to create an opportunity to be
face to face. If the child wants
to walk, consider bending
down to the child’s level for
communicating important
information.
Even though you are busy at the
store, try to give your child
attention when he or she is
being good at least once every
few minutes.
Source: Project ImPACT for Toddlers, SoCal Bridge Collaborative, 2020, Unpublished Manual.
NDBI Strategies
Focus on your child
Follow your child’s lead
Hold up two similar items,
and allow your child to
choose which one you
will put in your cart and
purchase.
Let your child direct you to
the next area of the store
by pointing.
Imitate your child
If your child makes sounds or
gestures while in the cart,
imitate them.
If your child is looking at an
item you handed him or
her, look at a similar item
next to the child.
Model communication
Provide labels for the items
you put in your cart.
Point to numbers on price
signs, and label them
individually.
Label items you see in the
store or point out favorite
characters (e.g., “I see a
tiger!”).
Narrate what is coming up
next (e.g., “Now we need to
pay at the register!”).
Label the sounds and smells
that you experience at the
store because your child is
likely experiencing them
too (e.g., “Ooh, that’s cold!”
when you open the freezer
door, or “Crinkly” when
you put a bag of chips in
the cart).
Create opportunities
Back-and-forth play
When picking out produce
or something with many
pieces, hand each piece
to your child and have
him or her put it in the
bag.
Communication
temptations
If your child likes to ride in
the cart, stop pushing,
and wait for your child
to ask to go again.
Ask your child if he or she
wants to go “Fast or
slow?” and wait for him
or her to decide.
When you are handing
your child multiple
pieces of something,
pause and wait for him
or her to ask for the next
one to put in the bag.
Play I Spy, and say “I spy
apples!” in the produce
section. Can you find
them?”
 Applying Antecedent Strategies 171

Case Example: Ty
Ty is an 11-year-old sixth grader with a diagnosis of ASD. Ty lives with both parents
and an older sister and attends the local public school. Ty is at or near grade level aca-
demically, with math skills comparable to peers and a reading level at or just below
grade level. Ty enjoys pop music and watching movies. With an excellent memory
and strong interest in cinema, Ty memorizes entire cast names as well as producers,
directors, and release dates. Ty is educated in a general education classroom for the
entirety of the school day and receives support from an inclusion specialist, who pro-
vides modifications and accommodations.
Ty is generally well behaved during class, yet often appears as though not attend-
ing. When called on directly, Ty contributes to or participates in class whole-group dis-
cussions, and the majority of responses are accurate or relevant. However, Ty needs
frequent adult prompting to remain on task. Without verbal or gestural prompts, Ty
engages in off-task behaviors, including repetitive finger flicking in front of his eyes
and slight body rocking when not engaged in the lesson. These behaviors affect Ty’s
grades when he submits incomplete work assignments due to the inability to remain
on task and lack of participation in the learning activity.
Ty refers to other children as friends; yet, he spends each recess alone eating
snacks and roaming around the perimeter of the schoolyard and the track. Some-
times he enters the school building and wanders around the halls. Ty only interacts
with peers when prompted and prefers to have conversations with teachers and
other adults. Ty’s attempts to initiate conversations include comments about song
lyrics and labels or about movie facts such as the date of release or the name of
the director, producer, or studio. The other students in the class like music and
movies, but they talk about the artists, the actors, or the movie plot and discuss
their opinions, likes, and dislikes. Ty contributes rote memory facts to sustain
conversations. However, even if other children like the subject matter, they have a
hard time feeling engaged and interested in the conversation, and they terminate
the interaction quickly. During the previous academic year, at the suggestion of
the individualized education program (IEP) team, Ty participated in drama as an
elective class for one semester. Without scheduled meeting times, plans for col-
laboration with the drama instructor, and clear strategies in place, the experience
was unsuccessful. Ty does not participate in any extracurricular or afterschool
activities.
Using antecedent strategies, teachers and therapists can increase Ty’s active
participation in class and school activities as well as in social interactions with peers
during extracurricular activities. Ensuring Ty is seated in such a way that minimizes
distractions is a first step toward increasing his attention to task and participation
in class. Taking note of stimuli in the environment that may become distracting
(e.g., lighting, noise) and remediating those factors can help him remain engaged
with the lesson. Furthermore, seating Ty next to peers who share some interests
and incorporating students’ interests (i.e., writing about movies, elements of theatre)
along with priming are other antecedent approaches to increase on-task behavior.
To prepare Ty for upcoming events, a weekly and/or daily schedule with goals to
work toward during each part of the schedule may be beneficial. In addition, priming
172 NDBI Strategies

is implemented in a variety of ways. For classroom lessons, the teachers provide Ty

with a list of questions in advance that will be asked and provide Ty with options or
choices ahead of time of the materials he can select from. With these strategies,
Ty should be more likely to attend to the lesson and be prepared for the questions
that will be asked. Ty will likely display increased levels of engagement and on-task
behavior through the choice of materials offered. During unstructured activities and
transitions, an instructional aide may prepare Ty for social initiations by presenting
a list of topics that are mutually interesting between peers. This preplanning will
likely prompt Ty of the skills needed in unstructured social situations. Then, before
dismissal to lunchtime, a teacher or aide may support Ty by creating a visual tool
that states clear rules and expectations to help set the stage for appropriate social
behavior.
Antecedent-based strategies can also be used to increase and improve Ty’s
conversational skills. Based on his description, Ty has a number of interests and an
excellent memory. Shared control strategies and teaching within natural routines
can also be incorporated into an intervention plan. For example, Ty could choose a
preferred conversational topic, and after a few exchanges, the peer could select a
topic. Ty and the peer could then take turns discussing things they are interested
in, with each asking questions of the other or making comments about what they
have heard. Ty might need initial prompting to follow this plan, but priming can help
increase his success. Furthermore, practicing conversations at home or in other set-
tings with familiar adults can help Ty expand the current repertoire for generalization
of the new skills with peers. Selecting appropriate consequences is also a critical
part of such an intervention; consequence strategies are discussed in more detail in
Chapter 9.
Finally, Ty has an interest in drama and theater. To increase success and participa-
tion in drama class, a meeting could be scheduled with the drama teacher prior to the
start of the school year or semester to discuss the schedule and expectations and
to learn about Ty’s preferences and interests. Thus, through active use of a variety of
antecedent strategies, Ty can more effectively use the skills he has already mastered
and practice new skills as well, all while becoming a more active participant in class,
engaging with peers, and enjoying extracurricular activities.

CONCLUSION
This chapter described how antecedent-based strategies are used in NDBI, begin-
ning with advanced planning through application to the teaching environment.
Antecedent strategies are included in NDBI to maximize motivation to initiate, re-
spond, and sustain social interactions, leading to improved skill acquisition. An
early successful learning history can provide a strong foundation for learning in
individuals with ASD. When all variables in the teaching environment are opti-
mized for the learner to experience success and to enjoy the interactions, the stage
is set for a capable and active lifelong learner who has a positive impact on his
or her own education and relationships. After planning and preparing the envi-
ronmental context to enhance the child’s interest and engagement and reduce in-
terfering behaviors, the next steps in NDBI address how specific instructions are
presented and prompts are provided.
 Applying Antecedent Strategies 173

REFERENCES
Akers, J. S., Higbee, T. S., Pollard, J. S., Pellegrino, A. J., & Gerencser, K. R. (2016). An evalu-
ation of photographic activity schedules to increase independent playground skills in
young children with autism. Journal of Applied Behavior Analysis, 49, 954–959.
Bainbridge, N., & Myles, B. S. (1999). The use of priming to introduce toilet training to a
child with autism. Focus on Autism and Other Developmental Disabilities, 14, 106–109.
Baker, M. J. (2000). Incorporating the thematic, ritualistic behaviors of children with autism
into games: Increasing social play interactions with siblings. Journal of Positive Behavior
Interventions, 2(2), 66–84.
Baker, M. J., Koegel, R. L., & Koegel, L. K. (1998). Increasing the social behaviors of young
children with autism using their obsessive behaviors. Journal of the Association for Persons
with Severe Handicaps, 23(4), 300–308.
Belfiore, P. J., Lee, D. L., Scheeler, C., & Klein, D. (2002). Implications of behavioral momen-
tum and academic achievement for students with behavior disorders: Theory, applica-
tion, and practice. Psychology in the Schools, 39(2), 171–179.
Bellini, S., & Peters, J. K. (2008). Social skills training for youth with autism spectrum disor-
ders. Child and Adolescent Psychiatric Clinics of North America, 17, 857–873.
Carter, C. M. (2001). Using choice with game play to increase language skills and interactive
behaviors in children with autism. Journal of Positive Behavior Interventions, 3(3), 131–151.
Chang, Y., Shire, S. Y., Shih, W., Gelfand, C., & Kasari, C. (2016). Preschool deployment of
evidence-based social communication intervention: JASPER in the classroom. Journal of
Autism and Developmental Disorders, 46, 2211–2223.
Charlop, M. H., Kurtz, P. F., & Milstein, J. P. (1992). Too much reinforcement, too little behav-
ior: Assessing task interspersal procedures in conjunction with different reinforcement
schedules with autistic children. Journal of Applied Behavior Analysis, 25(4), 795–808.
Cheung, Y., Schulze, K. A., Lead, J. B., & Rudrud, E. (2016). Teaching community skills to
two young children with autism using a digital self-managed activity schedule. Excep-
tionality, 24, 241–250.
Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). Applied behavior analysis (2nd ed.). Upper
Saddle River, NJ: Pearson.
Dunlap, G. (1984). The influence of task variation and maintenance tasks on the learning
and affect of autistic children. Journal of Experimental Child Psychology, 37(1), 41–64.
Dunst, C. J., Trivette, C. M., & Masiello, T. (2010). Influences of the interests of children with
autism on everyday learning opportunities. Psychological Reports, 107(1), 281–288.
Dunst, C. J., Trivette, C. M., & Masiello, T. (2011). Exploratory investigation of the effects of
interest-based learning on the development of young children with autism. Autism, 15(3),
295–305. doi:10.1177/1362361310370971
Gengoux, G. (2015). Priming for social activities: Effects on interactions between children
with autism and typically developing peers. Journal of Positive Behavior Interventions, 17,
181–192.
Hagopian, L. P., Long, E. S., & Rush, K. S. (2004). Preference assessment procedures for indi-
viduals with developmental disabilities. Behavior Modification, 28, 668–677.
Hancock, T. B., & Kaiser, A. P. (2006). Enhanced milieu teaching. In S. F. Warren & M. E. Fey
(Series Eds.) & R. J. McCauley & M. E. Fey (Vol. Eds.), Communication and language interven-
tion series: Treatment of language disorders in children (pp. 203–236). Baltimore, MD: Paul H.
Brookes Publishing Co.
Ingersoll, B., & Dvortcsak, A. (2010). Teaching social communication to children with autism:
A manual for parents. New York, NY: Guilford Press.
Kaiser, A. P., Ostrosky, M. M., & Alpert, C. L. (1993). Training teachers to use environmental
arrangement and milieu teaching with nonvocal preschool children. Journal of the Associa-
tion for Persons with Severe Handicaps, 18, 188–199.
Kasari, C., Freeman, S., & Paparella, T. (2006). Joint attention and symbolic play in young
children with autism: A randomized controlled intervention study. Journal of Child Psy-
chology and Psychiatry, 47, 611–620.
Kennedy, C. H., Itkonen, T., & Lindquist, K. (1995). Comparing interspersed requests and
social comments as antecedents for increasing student compliance. Journal of Applied
Behavior Analysis, 28(1), 97–98.
174 NDBI Strategies

Kern, L., & Clemens, N. H. (2007). Antecedent strategies to promote appropriate classroom
behavior. Psychology in the Schools, 44(1), 65–75.
Koegel, L. K., Koegel, R. L., & Dunlap, G. (2006). Positive behavioral support: Including people
with difficult behavior in the community. Baltimore, MD: Paul H. Brookes Publishing Co.
Koegel, L. K., Koegel, R. L., Frea, W., & Green-Hopkins, I. (2003). Priming as a method of
coordinating educational services for students with autism. Language, Speech, and Hearing
Services in Schools, 34, 228–235
Koegel, L. K., Koegel, R. L., Harrower, J. K., & Carter, C. M. (1999). Pivotal response interven-
tion I: Overview of approach. Journal of the Association for Persons with Severe Handicaps, 24,
174–185.
Koegel, R. L., Fredeen, R., Kim, S., Danial, J., Rubenstein, D., & Koegel, L. K. (2012). Using
perseverative interests to improve interactions between adolescents with autism and their
typical peers in school settings. Journal of Positive Behavior Interventions, 14(3), 133–141.
Koegel, R. L., Kim, S., Koegel, L. K., & Schwartzman, B. (2013). Improving socialization for
high school students with ASD by using their preferred interests. Journal of Autism and
Developmental Disorders, 43(9), 2121–2134.
Koegel, R. L., Vernon, T., & Koegel, L. K., (2009). Improving social initiations in young chil-
dren with autism using reinforcers with embedded social interactions. Journal of Autism
and Developmental Disorders, 39, 1240–1251.
MacDonald, L., Trembath, D., Ashburner, J., Costley, D., & Keen, D. (2018). The use of visual
schedules and work systems to increase the on-task behaviour of students on the autism
spectrum in mainstream classrooms. Journal of Research in Special Education Needs, 18,
254–266.
Magito McLaughlin, D., & Carr, E. G. (2005). Quality of rapport as a setting event for problem
behavior: Assessment and intervention. Journal of Positive Behavior Interventions, 7, 68–91.
McGee, G., Morrier, M. J., & Daly, T. (1999). Special section: Interventions for young children
with autism. Journal of the Association for Persons with Severe Handicaps, 24, 133–146.
Odom, S. L., McConnell, S. R., & Chandler, L. K. (1994). Acceptability and feasibility of class-
room-based social interaction interventions for young children with disabilities. Excep-
tional Children, 60, 226–236.
Reinhartsen, D. B., Garfinkle, A. N., & Wolery, M. (2002). Engagement with toys in two-year
old children with autism: Teacher selection versus child choice. Research and Practice for
Persons with Severe Disabilities, 27(3), 175–187.
Rispoli, M., Lang, R., Neely, L., Camargo, S., Hutchins, N., Davenport, K., & Goodwyn, F.
(2013). A comparison of within and across activity choice for reducing challenging behav-
ior in children with autism spectrum disorders. Journal of Behavior Education, 22, 66–83.
Rogers, S. J., & Dawson, G. (2010). Early Start Denver Model for young children with autism: Pro-
moting language, learning, and engagement. New York, NY: Guilford Press.
Rogers, S. J., Dawson, G., & Vismara, L. A. (2012). An early start for your child with autism: Using
everyday activities to help kids connect, communicate, and learn. New York, NY: Guilford Press.
Schreibman, L., Whalen, C., & Stahmer, A. C. (2000). The use of video priming to reduce
disruptive transition behavior in children with autism. Journal of Positive Behavior Interven-
tions, 2, 3–11.
Snyder, P. A., Rakap, S., Hemmeter, M. L., McLaughlin, T. W., Sandall, S., & McLean, M. E.
(2015). Naturalistic instructional approaches in early learning: A systematic review. Jour-
nal of Early Intervention, 37(1), 69–97.
Wilde, L. D., Koegel, L. K., & Koegel, R. L. (1992). Increasing success in school through priming:
A training manual. Santa Barbara: University of California.
Wong, C., Odom, S. L., Hume, K., Cox, A. W., Fettig, A., Kucharczyk, S., & Schultz, T. R. (2014).
Evidence-based practices for children, youth, and adults with autism spectrum disorder. Chapel
Hill: The University of North Carolina, Frank Porter Graham Child Development Insti-
tute, Autism Evidence-Based Practice Review Group. Retrieved from http://autismpdc
.fpg.unc.edu/sites/autismpdc.fpg.unc.edu/files/imce/documents/2014-EBP- Report.pdf
Zanolli, K., Daggett, J., & Adams, T. (1996). Teaching preschool age autistic children to make
spontaneous initiations to peers using priming. Journal of Autism and Developmental Dis-
orders, 26, 407–422.
8
Implementing Instructional
Cues and Prompting Strategies
Kyle M. Frost, Brooke Ingersoll, Yvonne Bruinsma, and Mendy B. Minjarez

C
hildren with autism spectrum disorder (ASD) often require additional assis-
tance when learning new skills. Because Naturalistic Developmental Behav-
ioral Interventions (NDBI) models have their roots in behavioral principles
and operant conditioning, they all use instructional cues and prompting strate-
gies to help children acquire new skills outside of their current repertoire. NDBI
are also informed by developmental approaches and an understanding of typical
development; thus, learning opportunities are embedded in natural interactions
and are often more flexible than in more traditional behavioral approaches. The
goal of this chapter is to provide an overview of how various NDBI models deliver
instructional cues within natural, ongoing interactions and use prompts to sup-
port child learning.

DEFINITIONS
Although NDBI models focus on embedding teaching opportunities within natu-
ral contexts such as daily routines and play, these teaching principles originate
from behavioral models and follow principles of operant conditioning. Here, we
present an abbreviated review of behavioral terms that are used in this chapter.

Learning Opportunities
Learning opportunities, also called contingencies or teaching trials, are composed
of antecedents, behaviors, and consequences (A-B-C; Cooper, Heron, & Heward,
2007). A learning opportunity encompasses environmental and instructional
cues that occur before a behavior, the behavior itself, and the consequences that
occur after the behavior, which either increase or decrease the likelihood that the

175
176 NDBI Strategies

behavior will follow the antecedent more frequently. The focus of this chapter is on
a specific type of antecedent: prompts.

Antecedents
Antecedent is a broad term for what happens before, and therefore influences or
cues, a behavior (Cooper et al., 2007). This may involve a specific instruction, envi-
ronmental cues, and/or a prompt to support the child’s correct response. Anteced-
ents are discussed in detail in Chapter 7.

Instructional Cue
An instructional cue or discriminative stimulus (SD) is an antecedent that has
been paired with a specific behavior so that, through learning, it becomes more
likely to evoke that behavior (Cooper et al., 2007). In practice, the term instructional
cue is often used before it consistently evokes the target behavior. In addition, espe-
cially early in teaching, prompting (discussed next) may be required to evoke the
behavior. For example, a mother says, “Time to put shoes on!” Then, she guides her
son to his shoes and helps him put them on. In this case, the mother’s instruction
serves as a cue or SD for her son to put his shoes on, although he needs help com-
pleting this task (the prompt). However, her goal is to teach him to independently
follow the instruction.

Prompt
A prompt refers to an additional cue that can be delivered with or immediately
after the instructional cue (Cooper et al., 2007). The prompt provides the child with
an extra cue or support in order to evoke a correct response, for which the child
can be reinforced. Prompts vary from highly supportive (e.g., physical guidance,
modeling) to less supportive (e.g., subtle gesture, verbal comment), and when used
correctly, are adjusted to the child’s current skill level for the target behavior. In
addition, prompts can be combined with each other as needed (e.g., providing a
verbal choice while pointing to both options). Over time, prompts are gradually
reduced or faded in order to support independent correct responses.

Stimulus Discrimination and Generalization

Discrimination and generalization of stimuli are two inversely related concepts.
Stimulus discrimination refers to the extent to which a stimulus evokes a specific
response to the exclusion of others (Cooper et al., 2007). An example would be when
a child learns to respond to his or her name being called; he or she looks up when
the mother calls his or her name but not the sister’s name. Stimulus generalization
refers to when related or similar stimuli evoke the same response (Cooper et al.,
2007). For example, the child learns to give his or her teacher the ball in response to
“Give me the ball,” “Can I have the ball?” and “My turn with the ball.” A balance of
discrimination and generalization is important for forming concepts and applying
skills flexibly across contexts.
These terms are used throughout the chapter to describe how various NDBI
models embed learning opportunities within child-directed activities and daily
routines and how prompts are used to facilitate child learning.
 Instructional Cues and Prompting Strategies 177

LEARNING OPPORTUNITIES ACROSS NDBI MODELS

Although learning opportunities across NDBI share the same basic A-B-C contin-
gency structure, they are sometimes more loosely defined and applied than in more
structured Applied Behavior Analysis (ABA) interventions. In particular, the distinc-
tion between an instructional cue and prompt is often less clear than in more struc-
tured ABA interventions, with the teaching procedure as a whole often referred to as
prompting or a teaching episode. This is particularly the case when the instructional
cue and prompt are delivered simultaneously. Consider the following example: The
adult says, “My turn!” while holding out her hand, palm up, close to the child. This
includes both a verbal instruction (instructional cue) that is delivered at the same
time as a gestural cue (prompt) to help the child respond by handing the adult a toy.
Several NDBI also allow the child multiple opportunities to respond to a
learning opportunity, with the adult increasing the level of support as needed. For
example, a single NDBI learning opportunity may take the following form: the
adult asks a question (“What do you want?”), pauses briefly to allow a response,
and supports the child with additional prompts until the child successfully com-
pletes the target skill (“Blue car or red car?” . . . “Blue car”). This contrasts with
more traditional ABA approaches, in which the adult delivers a single cue (alone or
in combination with prompts) and provides contingent reinforcement based on the
child’s response to that cue. From the vantage point of a traditional ABA approach,
this example would be viewed as three teaching trials, with a brief intertrial inter-
val, or pause, between them. In other words, how prompts are used in NDBI and
when a trial is considered complete is sometimes defined differently than in more
traditional ABA approaches. This reflects the emphasis on naturalistic and devel-
opmentally informed teaching that is characteristic of NDBI models.
Because learning opportunities are naturally embedded in daily routines and
play, the frequency of teaching may also vary across activities and depend on other
factors such as child motivation.

Embedded Trials
Learning opportunities in NDBI models take place within embedded trials. These
are teaching episodes that occur within daily routines and play, rather than in a
distraction-free therapy setting. Teaching skills within a natural context has several
benefits. It facilitates the generalization of skills; not only can learning opportuni-
ties occur in multiple contexts, but they also can occur within the child’s natural
environment. In addition, this type of embedded learning allows for natural rein-
forcement, rather than reinforcement that is artificially introduced into the learning
environment. For example, when a child asks to go outside to play, the adult can
use this natural opportunity to teach the child to zip his or her coat. The child will
be naturally reinforced by going outside after zipping his or her coat. See Box 8.1
for more ideas on how to embed learning trials and opportunities.
There are different ways to embed learning opportunities that vary in the
extent to which they are initiated by the child or adult. Table 8.1 contains examples
of varied types of embedded learning opportunities in which a communication
response is expected. Learning opportunities are meant to be as natural as possi-
ble, although the adult may manipulate aspects of the environment or briefly inter-
rupt the child’s activity in order to set the stage for an embedded teaching trial.
178 NDBI Strategies

Ready, Set, Implement!

BOX 8.1: Embedding learning opportunities
• Teach within preferred routines, such as playtime, circle time, and snack.
• Use naturally occurring opportunities to teach meaningful skills.
• Wait until you have the child’s attention.
• Use a clear cue that indicates a need to respond.
• Use varied cues to promote generalization.

NDBI models describe the importance of taking turns or balanced turns as a

natural way to embed learning opportunities that increase joint engagement and
evoke communication (e.g., Joint Attention, Symbolic Play, Engagement, and Regu-
lation [JASPER]; Kasari, Gulsrud, Wong, Kwon, & Locke, 2010). Others build in
opportunities for sharing positive affect (e.g., Early Start Denver Model [ESDM];
Rogers & Dawson, 2010; Social ABCs; Brian, Smith, Zwaigenbaum, & Bryson, 2017).
Another strategy is to wait for the child to initiate prior to cuing the child for a
more advanced skill (e.g., Enhanced Milieu Teaching [EMT]; Hemmeter & Kaiser,
1994; Hancock, Ledbetter-Cho, Howell, & Lang, 2016), also known as Incidental
Teaching (Hart & Risley, 1975; McGee, Morrier, & Daly, 1999). For example, if the

Table 8.1. Examples of different ways to embed learning opportunities

Ongoing activity Examples

The adult and child are The adult pauses, holding his or her marble over the slot, and
taking turns putting looks expectantly at the child.
marbles down a The adult playfully blocks the marble as it rolls down and says,
marble run. “Stop!”
The adult closes the jar of marbles tightly and leaves it in sight.
The adult collects all the marbles as they reach the bottom of
the marble run. When the child reaches for them, the adult
asks, “What do you want?”
At snack time, the child asks The adult hands the child a bowl of cereal but leaves the milk
for a bowl of cereal. on the counter.
The adult pours just a few pieces of cereal into the bowl and
hands it to the child.
The adult holds up two types of cereal and waits for the child
to select one.
The adult says, “Mmmm, my turn for a bite!” and eats a
spoonful of cereal, pausing before returning the spoon to
the child.
The adult is helping the child The child reaches for the socks. The adult holds up the socks
put shoes and socks on and shoes and says, “Want socks or shoes?”
before going outside to The adult puts one of the socks on the child, then looks
play in the yard. expectantly at the child and waits.
The adult pretends to put the child’s shoes on his or her own
feet in a silly and exaggerated manner.
The adult hands the child a sock (which the child needs
assistance to put on).
 Instructional Cues and Prompting Strategies 179

child has reached for a cracker, the adult could use this opportunity to teach the
child to point or vocalize to request the cracker.
The adult may also deliberately create clear opportunities for the child to com-
municate. This can be accomplished by using environmental arrangement and
communicative temptations; for example, the adult may place desired items in
sight but of reach, use a clear pause in the activity paired with an expectant look,
withhold parts of toys, or playfully block the child’s play (e.g., Project ImPACT
[Improving Parents as Communication Teachers]; Ingersoll & Dvortcsak, 2009). In
other NDBI models, the presentation of a learning opportunity may be more adult-
led. For example, in Pivotal Response Treatment (PRT), the adult may present a
learning opportunity prior to waiting for the child to initiate (taking out the box
of crackers when the child comes into the kitchen, and asking the child if he or she
wants one); however, these opportunities are still embedded within an ongoing,
motivating activity (Koegel et al., 1989).

Pacing of Instruction
Knowing when to provide a learning opportunity is as important as knowing how
to provide a learning opportunity. Some NDBI models prescribe more frequent
learning opportunities compared to others, with some models recommending
more than one per minute (e.g., Social ABCs; Brian et al., 2017; ESDM; Rogers &
Dawson, 2010 PRT; Koegel et al., 1989), some recommending one every 1–2 minutes
(e.g., Project ImPACT; Ingersoll & Dvortcsak, 2009), and other models recommend-
ing far fewer to leave space for child initiations and adult modeling (e.g., EMT;
Hancock et al., 2016). All NDBI models, however, agree that there should be a pe-
riod of time in between learning opportunities in which the child is allowed to lead
the play activity. In addition, because teaching occurs within ongoing activities,
the frequency with which learning opportunities are embedded in NDBI varies
according to a number of factors. These include the child’s motivation, the nature
of the activity, the difficulty of the task or target behavior, and the value of the re-
inforcer, as well as individual child characteristics.
Across NDBI models, it is considered essential to establish high levels of child
engagement prior to providing a learning opportunity. This means that the child
should be attentive and interested in the ongoing activity. Learning opportunities
can be embedded more frequently during activities in which the child is highly
motivated. In these activities, the child is more likely to maintain attention and
make continued attempts to respond to instructional cues. In addition, the child is
less likely to become frustrated by repeated teaching when he or she is enjoying the
activity. Children may be highly motivated during favorite activities or routines or
when the activity involves a highly valued reinforcer. NDBI strategies such as fol-
lowing the child’s lead serve to increase child motivation by allowing the child to
select a preferred activity. However, teaching can still occur in other less-preferred
activities, such as dressing or chores. In this type of activity, increasing the level of
reinforcement being provided or using other social engagement strategies can be
useful to increase child motivation (e.g., increased animation, singing the clean-up
song, tickling in between putting on items of clothing). However, learning oppor-
tunities should be delivered less frequently in these nonpreferred activities.
In addition, clinicians should consider the difficulty of the target skill relative
to the child’s current repertoire of skills. For example, drawing shapes or writing
180 NDBI Strategies

letters may be appropriate targets

for a child who can hold a pencil
using a three-finger grip. How-
ever, for a child who holds mark-
ers in a fist, this task is much more
difficult and is likely to become
frustrating with frequent repeti-
tions. Likewise, asking a child to
request blocks several times in a
Low High Average
motivation motivation motivation row may be feasible and appro-
priate for a child who has phrase
Reinforcer value Task difficulty
speech but frustrating for a child
Figure 8.1. Ratio of task difficulty to reinforcer value. who is preverbal. To be more spe-
cific, the ratio of task difficulty
to reinforcer value is key; more frequent teaching can occur when task difficulty
is high if reinforcer value is also extremely high. In other words, children are
more likely to persevere through a difficult task if they are highly motivated (see
Figure 8.1). However, if the task is difficult and the reinforcer value is low, this may
not be a productive context in which to embed learning opportunities.
The adult should consider these factors when deciding whether to begin a
learning opportunity and should initiate learning opportunities at a time and rate
that maximize the child’s chance of success. Furthermore, learning opportunities
are just one component of NDBI models and are meant to be interspersed with
other strategies detailed elsewhere in this book (e.g., strategies that promote social
engagement). The long-term goal of intervention is for children to demonstrate
skills independently and spontaneously (i.e., without supports or cues from the
adult). Therefore, in a situation in which the child demonstrates (or approximates)
a skill spontaneously, the adult may choose to reinforce that behavior rather than
prompting the child to use a more advanced skill. For example, a parent who has
been working on dressing skills may reinforce the child for spontaneously picking
up a shirt even if he or she has not put the shirt on independently. This encourages
the child to independently perform aspects of dressing, even though he or she may
still need support to complete the task fully.

Clear Cues
Across NDBI, there is consensus that cues provided with the goal of beginning
a teaching trial must be clear. A child cannot be expected to engage in a targeted
behavior without a clear indication of the expectation. Clear cues should give an
obvious indication of the expected behavior, can be verbal or nonverbal, should
be appropriate for the child’s skill level, and should be directly related to the con-
text and/or teaching materials. If prompting hierarchies (discussed next) are being
used, cues for behaviors should be at the correct level in relation to the child’s per-
formance on the preceding trials. That is, the cue should be matched to the child’s
current level of independence.
Verbal cues are different from other adult verbal behaviors often used in NDBI
to target engagement and enrich the treatment environment (e.g., commenting,
modeling, labeling). For example, when modeling language for a child who is min-
imally verbal, providing a single-word label while gesturing to the toy the child is
 Instructional Cues and Prompting Strategies 181

playing with (commenting or narrating) is significantly different from providing a

label while holding a toy up and looking expectantly at the child (embedded teach-
ing trial). Likewise, narrating the play of a child who is more verbal (e.g., “Your
train is driving so fast!”) is different from playfully interrupting the child and
asking a clear question (e.g., “Should the train drive slow or fast?”). Comment-
ing, labeling, and narrating are adult behaviors that are useful for exposing the
child to appropriate language models during teaching sessions. When used out-
side the context of shared control and contingency, these adult behaviors are not
part of teaching trials. In this case, adults should differentiate verbal models from
cues and prompts through phrasing, gesture, tone, and body language. It is use-
ful to attend to whether adults are asking rhetorical questions during play when
they actually mean to narrate because these may be perceived as prompts or cues
by the child; lack of child response may give an intermittent message that con-
sistent responding is not required. Adults should also make sure that comments
and narration are at the child’s developmental level in order to model appropriate
language and not overwhelm the child with verbal input he or she does not under-
stand. Additional details on narration and adult language models are outlined in
Chapter 11, on communication.

Natural and Varied Instructional Cues

Another important shared NDBI guideline for learning opportunities is that in-
structional cues should be varied, even when working on the same behaviors.
This use of varied cues distinguishes NDBI from more structured behavioral ap-
proaches, which typically prescribe using systematic cues that remain consistent
until the child has mastered a task.
Typically developing children respond to a variety of environmental cues or
verbal instructions. NDBI models attempt to create a learning environment that
includes varied instructional cues, which more closely approximate natural cues
in the environment from the beginning. This enhances stimulus generalization in
that the child is perhaps more likely to respond to a variety of cues without the
need for specific programming.
Instructional cues in NDBI may be more or less direct. For example, the cue
may include the target word (“blow bubbles”) or explicitly require a behavior
(“point to bubbles”), or it may merely hint at or suggest the desired behavior (hold-
ing the bubbles and waiting expectantly). A child with limited verbal skills may
require a more direct and consistent instruction when first learning new words
(e.g., a verbal model), whereas a child who has more skills may be able to respond
to indirect cues (e.g., an open-ended question or time delay). Table 8.2 outlines
examples of varied instructional cues, some of which are direct and others that are
indirect.

Task Variation and Maintenance Tasks

Some NDBI models intersperse learning opportunities for tasks that are new and
for those that have been mastered. This has several functions. First, it promotes
maintenance of skills by giving the child opportunities to practice skills that are no
longer being directly targeted. Second, this strategy can increase the child’s moti-
vation, as outlined in previous chapters. Third, interspersal can reduce frustration
182 NDBI Strategies

Table 8.2. Examples of varied instructional cues

Skill Varied instructions

Receptive language: Direct:

Identifying ball Give me the ball.
Where is the ball?
Point to the ball.
Indirect:
I see the ball!
I wonder where the ball is.
Expressive language: Direct:
Requesting ball Ball.
Ball or car?
You want the ball?
Indirect:
What do you want to play with?
What could I give you?
What do you need?
Holding up the ball and looking expectantly (time delay).
Play action: Direct:
Feeding the baby Feed the baby.
Give baby some food.
Indirect:
Baby is hungry!
Baby wants her bottle.

by allowing the child to succeed more easily when learning a new challenging
skill. Depending on whether a skill is new or has already been mastered, the adult
should approach prompting differently.

PROMPTING STRATEGIES
When supporting learning in young children, the adult should consider what the
child is already capable of versus what he or she may need to learn. For example,
a child may need to learn to independently pull up and button his or her pants. At
first, the child will likely require assistance, or prompting, in order to complete this
multistep task. It is important that the adult teaches the child how to engage in this
skill by initially providing the necessary level of support. Prompting must then be
decreased over time, eventually providing the opportunity for the child to pull up
and button his or her pants independently.
Prompts are used to support learning and increase the child’s successful
responding during embedded learning opportunities. In general, it is desirable
for the child to be successful as frequently as possible and to provide the lowest
level of support needed for a child to respond successfully to promote indepen-
dence over time. At first, however, the child may require substantial support. As
the child acquires skills, prompts are quickly reduced or faded, and the skill is gen-
eralized to other situations. When the child lapses in performing a mastered skill,
the adult may temporarily provide more supportive prompts in order to maintain
that skill. Several factors come into play when selecting an appropriate prompt for
 Instructional Cues and Prompting Strategies 183

a learning opportunity, including the nature of the target skill, the child’s current
skill level, environmental or situational factors, and individual differences in child
characteristics.

Types of Prompts
Prompts can take on several different forms; for example, prompts may be visual
(e.g., gestures, modeling, environmental cues), verbal (e.g., open-ended question,
verbal modeling), and physical. Physical guidance is generally considered the
most highly supportive or intrusive type of prompt (Cooper et al., 2007). However,
physical guidance as well as verbal and visual prompts can vary in the extent to
which they are supportive. For example, physical prompts range from high sup-
port (e.g., hand-over-hand support of a complete task) to low support (e.g., a gentle
tap of the elbow to cue a more complex behavior). Likewise, verbal and visual
prompts may be highly supportive (e.g., showing the child exactly what to do or
say) or less supportive (e.g., subtle or indirect hints such as looking toward the
correct item).
Tables 8.3 and 8.4 provide examples of several types of prompts that can be
used for teaching verbal and nonverbal skills with varying levels of support. The
examples are generally organized from most to least level of support; however,
the various NDBI models may use these prompts in different orders and may or
may not use every type of prompt. NDBI models differ on the extent to which they
emphasize or articulate specific types of prompts. The models also differ in the
extent to which they adhere to rigid prompting hierarchies versus using prompts
that are similar to one another interchangeably to increase stimulus variation. For
example, EMT recommends a specific set of prompts for teaching language skills.
However, PRT does not outline specific prompts to be used, other than to recognize
that prompts vary in supportiveness and should be faded over time.
Different types of target skills may lend themselves to different types of
prompts. Visual prompts may be particularly useful for children who are learning
to imitate gestures, follow directions, use augmentative and alternative communi-
cation (AAC), or use a visual schedule. Verbal prompts are particularly useful for
teaching verbal skills or providing more subtle prompts for skills that the child has
made progress toward learning. In addition, child characteristics may affect the
type of prompt the adult chooses. For example, visual prompts may be preferred
for children who inappropriately repeat the adult’s speech or are dependent on
verbal models to respond to instructions. In contrast, some children may not attend
to subtle verbal cues and may require more explicit verbal cues to attract their
attention. The final section of this chapter provides examples of different types of
prompts that can be used to teach different types of skills.

Prompt Hierarchies
To help facilitate increased independence over time, NDBI typically include a
prompt hierarchy. A prompt hierarchy includes varying levels of prompts meant
to be delivered in the order provided. These can be arranged from most-to-least
supportive or least-to-most supportive. The adult is meant to move flexibly up
and down the prompt hierarchy, increasing support when the child’s response
is incorrect or incomplete and decreasing support as the child learns a skill.
184 NDBI Strategies

Table 8.3. Examples of different types of prompts for verbal skills, ordered from more
supportive to less supportive

Prompt Definition Characteristics Example

Verbal model The adult presents Prompt must be faded “Cookie?”

prompt the full word or quickly. “I want the ball.”
combination of It is not a good choice if the
words that the child child has echolalia.
is expected to repeat It often is accompanied by
verbatim. questioning intonation.
Removed model The adult presents It can be helpful to prevent “Cookie? What do
prompt the child with the child from going on you want?”
the full word or automatic pilot.
a combination of It helps to prevent or
words he or she is discourage echoing.
expected to repeat
verbatim but with
additional words at
the end.
Partial verbal The adult models the It helps to encourage “Buh. . . .”
model first speech sound independent responding.
in the target word or It is useful when kids rely on
phrase. echoing verbal models.
Choice prompt The adult gives the It is useful when kids rely on “Play ball or play
child response echoing verbal models (put cars?”
options to choose the child’s preference first). “Juice or water?”
from. It is more difficult when the
objects are not present.
Fill-in-the-blank The adult pauses It is great for repetitive playful “Ready, set, go!
prompt before the last word actions (e.g., running, Ready, set, go!
of a phrase, after spinning, jumping). Ready, set, . . . .”
having used the full Fill-in-the-blanks are naturally “The doors on the
phrase during the part of early word learning bus go . . . .”
activity. for children, so there are “The itsy, bitsy
many early learning rhymes spider went up
and songs that can be used. the water . . . .”
Open-ended The adult asks the Prompts must be varied. “What do you
prompt child an open-ended Prompts do not contain the want?”
question. answer. “Which one?”
The adult should avoid yes-no “What should I
questions unless working do?”
on teaching yes and no!
Indirect verbal The adult hints at The adult gives a hint or “There are cookies
prompt something without leading comment. on the top
giving an explicit These prompts are less shelf.”
cue. supportive. “I have a toy in
These prompts are useful this box!”
when trying to entice a
child’s interest.
Time delay A visual cue is The cue is an expectant look The adult holds
provided but no or clear pause. up the bubbles
auditory cue. This is an important step and pretends to
toward independence. almost blow but
The child must retrieve does not.
word(s) independently.
 Instructional Cues and Prompting Strategies 185

Table 8.4. Examples of different types of prompts for verbal and nonverbal skills,
ordered from more supportive to less supportive

Prompt Definition Characteristics Example

Full physical The adult physically The adult uses The adult places his or her
prompt guides the child hand-over-hand hand over the child’s hand
in completing the assistance. to guide the child to pick
target behavior. Prompts are highly up the marker and then to
supportive. guide the child’s hand with
Prompts should the marker to the table.
not be forceful or
forcing.
Light or partial The adult uses The adult uses his or The adult lightly touches the
physical physical guidance her finger tips. child’s arm to pick up the
prompt to support some The adult helps marker or gently guides
independent the child start the the child to the table.
response by the behavior or com-
child. plete the behavior
but not both.
Action model The adult The adult helps the The adult points to the
prompt demonstrates an child learn through plastic container, which
action, play act, or imitation. has snacks in it.
gesture to show the
child what to do.
Visual prompt The adult provides The adult provides When teaching yes-no,
a picture, icon, or a nonverbal cue provide a child who
printed text to help to provide extra always responds in an
the child emit the support for the echoic manner (“Do
correct response. child. you want the cookie?
Yes!”) with a visual cue
immediately following the
question “Do you want
the cookie?” to ensure
the child cannot echo the
question and the answer.
Gesture prompt The adult provides The adult provides The adult extends a hand
a gesture that a cue of what is while saying, “Give it
indicates the correct expected. to me.”
answer or supports
comprehension.
Positional The adult moves the The adult provides A blue car and a red car are
prompt correct item closer extra support to on the table. The adult
to the child. increase the chance moves the blue car closer
the child will select to the child and says,
the correct item. “Please give me the blue
one.”
Direct verbal The adult gives a Important step “Give the baby a drink.”
prompt direct instruction to towards “Point to the ball.”
perform an action, independence. “Put your shoes on.”
gesture, or play act. The child must
perform skill on his
or her own.
Open-ended The adult asks a Prompts must be “What should baby do
prompt question to cue a varied. now?”
behavior. Prompts do not “What do we need before
contain the answer. we go outside?”
Indirect verbal The adult gives a The adult gives a “Show me where that goes.”
prompt verbal cue but does hint or leading “Go ahead.”
not explicitly ask a comment. “Baby looks so thirsty!”
question or give an These prompts are
instruction. less supportive.
186 NDBI Strategies

As mentioned previously, NDBI models differ in the extent to which they adhere
to prompting hierarchies, with some models using clearly defined hierarchies
(e.g., incidental teaching, EMT, JASPER; Hancock & Kaiser, 2012; Kasari, Fannin,
& Goods, 2012; McGee et al., 1999) and others using hierarchies more flexibly
(e.g., PRT).

Using Most-to-Least Supportive Prompting Prompts can be delivered via

most-to-least supportive prompting—the most intrusive, or most helpful prompts,
are provided initially and then are gradually reduced in subsequent learning op-
portunities (Cooper et al., 2007). A most-to-least approach can be used in order to
provide errorless learning, in which the child’s successful responding is maximized
when learning new skills. Errorless learning allows for the child to be successful
during all early learning opportunities, which allows for frequent reinforcement.
This approach is often used to teach new skills to reduce frustration during the
learning process.

Using Least-to-Most Supportive Prompting Prompts can also be delivered

via least-to-most supportive prompting—the least supportive prompts are pro-
vided initially, often first providing an opportunity for the child to engage in the
response independently (Cooper et al., 2007). If the child does not respond cor-
rectly at first (within a few seconds of the instructional cue), the adult provides
increasingly supportive prompts in subsequent learning opportunities until the
child responds successfully. In order to prevent prompt dependence, the adult pro-
vides a higher level of support on the following learning opportunity, then quickly
fades it. This approach is often used to increase the child’s independence in per-
forming a skill he or she has accomplished with support.

Choosing a Prompt Hierarchy The supportiveness of the prompt is meant to

match the child’s skill level, with the goal of providing the child enough support
to respond correctly while providing the opportunity for the child to respond as
independently as possible. Some NDBI models outline a specific prompt hierar-
chy to follow for teaching new skills. For example, Project ImPACT and incidental
teaching recommend a least-to-most prompt hierarchy, along with specific types
of prompts. However, other NDBI models do not articulate a hierarchy as clearly,
other than recommending that prompts are faded as quickly as possible.
There is limited research to guide the selection of a prompt hierarchy for
NDBI. Research on prompt hierarchies in discrete trial training has had vari-
able results. One study suggested that most-to-least prompting resulted in more
efficient learning among preschoolers with ASD who were learning one-step
directions (Cengher et al., 2016). Another study that examined individuals’ abil-
ity to learn to build structures with blocks found that a least-to-most prompting
procedure was more efficient because it allowed for individuals to skip steps
in the prompting hierarchy, which was not true in the most-to-least condition
(Seaver & Bourret, 2014). However, in both studies, there were individual dif-
ferences among the children in terms of how quickly they attained indepen-
dent responding using different prompt hierarchies. In addition, it is not clear
whether these results would generalize to prompting that occurs within natu-
ralistic teaching.
 Instructional Cues and Prompting Strategies 187

Ready, Set, Implement!

BOX 8.2: Prompt fading
• Prompts should match the child’s skill level; a brand-new skill may require
highly supportive prompts.
• Provide just enough support for the child to respond and no more.
• As the child learns a skill, quickly reduce the supportiveness of prompts.
• If needed, provide increasingly supportive prompts until the child is
successful.
• Use prompts that fit the situation and child characteristics; be creative!

PROMPT FADING
The goal of NDBI and other teaching models is for the child to initiate sponta-
neously and independently, without the need for prompting or other supports,
such as an expectant pause from the adult. Therefore, the adult must reduce the
supportiveness of prompts over time. This means that the adult must provide
prompting only to the extent that it is necessary. Providing supportive prompts
consistently over time may lead to a pattern in which the child does not en-
gage in the behavior without prompts or assistance; this is sometimes referred
to as prompt dependency. In other words, the child may become reliant on
prompts to complete a skill, rather than gaining the ability to perform the skill
independently. As an alternative, adults may overprompt by quickly provid-
ing prompts that are overly supportive, without giving the child ample time to
practice skills independently. Fading to the use of very subtle prompts, as well
as using time delays to allow the child time to respond independently, sup-
ports the child’s independent use of skills. Many NDBI models also incorporate
strategies such as environmental arrangements to promote child spontaneous
initiation behaviors as a final step in fading adult support (see Chapter 7 for
more information).
Prompts can be faded, or gradually decreased, by moving up and down the
prompt hierarchy as needed (see Box 8.2). In addition, the type of prompt may be
adjusted over time (e.g., from verbal to visual, from physical to verbal) as the child
progresses. Progress is not necessarily linear, and it may take several attempts
before a prompt is successfully faded.

EXAMPLES OF PROMPTS FOR SPECIFIC SKILLS

Some examples of different types of prompts for specific skills are listed next to
illustrate how adults might support the child in learning new skills in a variety of
domains. Different NDBI models focus on more specific teaching targets (e.g., joint
attention skills in JASPER, expressive language in EMT), whereas other models
are broader in scope (e.g., ESDM and Project ImPACT). However, across NDBI, it is
considered important to individualize teaching targets as well as prompts based
188 NDBI Strategies

on the child’s skills and level of need. When delivering prompts, the adult should
be flexible, creative, and responsive to the child’s needs.

Expressive Communication
Expressive communication is a broad term describing communication that is
produced by an individual for a variety of purposes, including showing interest,
connecting with other people, and obtaining wants and needs. Expressive commu-
nication includes spoken language, as well as gesture, AAC, and other nonverbal
behaviors.

Verbal Various types of prompts can be used to teach verbal expressive com-
munication. Verbal prompts are useful for modeling verbal skills and for providing
natural conversational cues to which the child can respond. However, some chil-
dren become reliant on mimicking verbal prompts or rarely initiate without a ver-
bal cue from the adult. For these children, visual and gestural prompts can support
them in responding more independently. In addition, the adult can strategically
use verbal prompts that the child should not repeat (e.g., fill-in-the-blank, a choice
prompt in which the desired item is stated first). More advanced verbal skills, such
as asking questions or using pronouns, can be targeted by creating fun situations
for the child to use that skill (e.g., hiding toys so the child can ask, “Where is it?”;
playing I Spy to work on using pronouns).
• The adult and child are giving the baby doll a bath. After taking the baby doll
out of the tub, the adult, towel in hand, says, “Baby is cold!” (indirect verbal
prompt). After a pause, he or she says, “What should we do?” (open-ended
prompt). When the child still does not respond, the adult says, “‘Dry the baby?’”
(direct verbal prompt).
• After the child asks for a snack, the adult asks, “Do you want chocolate ice cream
or vanilla ice cream?” (knowing the child wants chocolate) (choice prompt).
After scooping the requested ice cream flavor, the adult hands the child the
bowl without a spoon and waits (time delay prompt).

Gestures Physical prompting, as well as modeling the desired behavior, are

particularly useful ways to support the child in learning to gesture, sign, or use
joint attention skills such as showing.
• The child finishes a drawing and wants to start another one. The adult takes
the child’s hand to hold up the picture (full physical prompt) while modeling
“Look, Mommy!” (verbal model prompt) to show the picture to the parent.
• The adult sings “Wheels on the Bus” with the child, pausing at each verse to
gesture along with the song. When the child does not gesture spontaneously,
the adult playfully touches the child’s hands to prompt him or her to continue
the gestures (partial physical prompt).

Augmentative and Alternative Communication Learning opportunities

can be embedded as usual for children who use AAC, with the AAC device or
Picture Exchange Communication System (PECS) book within reach of the adult
and child. In addition to providing verbal prompts, the adult can gesture toward,
touch, or model communicating with the AAC. If needed, the adult can also shape
 Instructional Cues and Prompting Strategies 189

the child’s hand into a point to use a touchscreen or guide the child’s hand toward
the AAC.
• The adult hands the child a bin he or she cannot open. When the child looks up,
the adult pushes the AAC device toward the child (positional prompt). When
the child does not use it, the adult points (gesture prompt) to the icon that says
“open” and says the word “open” (verbal model prompt).
• When giving the child a snack, the adult places three chips in the bowl and
holds on to the bag. When the child reaches toward the bag of chips, the adult
shapes the child’s hand into a point (partial physical prompt) and helps him or
her press “more snack” (full physical prompt).
• The adult gives a choice, “Train, or tracks?” while pointing to each piece on the
child’s PECS book (choice prompt).
• The adult helps the child select the correct icon using hand-over-hand physical
prompting (full physical prompt).

Receptive Language
Receptive language focuses on the understanding or comprehension of language.
Receptive language targets can be embedded in the natural environment in a num-
ber of ways and can be targeted using a range of prompts. Receptive labeling can
be taught with a combination of verbal and gesture prompts and may sometimes
incorporate positional prompts (e.g., placing the correct object closer to the child).
Following directions can be targeted with simple actions (e.g., give me, get the, put
in, give to) and supported by action modeling or gestural or physical prompts. A
combination of verbal and nonverbal prompts is commonly used when first being
taught, and nonverbal prompts are then typically faded as the child gains skills.
• When coloring with the child, the adult says, “Use the red pen” (direct verbal
prompt) and points to the red pen (gesture prompt).
• When shopping with the child, the adult says, “Put the cereal in” (direct verbal
prompt) and models putting the cereal in the cart (action model prompt). The
adult puts the cereal back on the shelf and waits for the child to put the cereal
in the cart (time delay).

Play Skills
Depending on the child’s current play skills as well as receptive language skills,
prompts used in play can be verbal or nonverbal. For children with limited recep-
tive language skills, modeling play actions as well as physical prompts will help
them perform new play skills. For children with more language skills, the adult
can suggest or hint at new play actions to perform.
• In the presence of toy food, the adult picks up the hot dog, pretends to eat it,
and then hands it to the child (action model prompt).
• When the child is pushing a car, the adult hands him or her a toy person and says,
“The boy wants a ride” to help the child put toys together (indirect verbal prompt).
• When the child is playing with playdough, the adult models rolling the play-
dough into a snake to show the child how to make something new with the
playdough (action model prompt).
190 NDBI Strategies

Social Skills
Much like skills in play, use of social skills can be supported using verbal or non-
verbal prompts. This decision is largely dependent on the child’s receptive lan-
guage skills.
• When the child enters the classroom, the adult models saying “hi” to the class-
mate closest to the child (verbal model prompt) and then looks expectantly at
the child (time delay prompt).
• When the child has finished drawing a picture, the adult says, “Show your
sister” (direct verbal prompt) and models holding the picture up for the sister
to see (action model prompt).
• At an art activity, the adult hands the child a marker and says, “Give your
friend the pen” (direct verbal prompt) and points to the child next to him or
her (gesture prompt). The adult then physically guides the child to give his or
her peer the pen by lightly moving the child’s elbow toward the friend (partial
physical prompt).

Daily Living Skills

Daily living skills can be supported using verbal or nonverbal prompts depending
on the child’s receptive language skills and required level of support. A child who
can complete a task independently but needs reminding may benefit from verbal
prompts or visual cues to help him or her initiate. For children who need support
performing a new action, the adult can perform the skill as a model or physically
guide the child in completing the action.
• When getting ready to go outside to play, the adult puts a jacket in front of the
child and waits (positional prompt).
• The adult places a picture schedule of washing hands next to the sink (visual
prompt). As he or she helps the child wash his or her hands, the adult points
to each step.

Case Example: Leah

Leah is a 5-year-old girl with limited verbal skills. Her father, who has been trained in
NDBI strategies, is playing with her. They enter the playroom, where her father has
placed some of her favorite toys on the shelf. He sees her look up at the barn, and he
points at the barn and waits. She reaches toward the barn, so her father shapes her
hand into a point and says, “Get the barn!” before getting the barn off the shelf.
After playing for a few minutes, putting animals in and out, Leah’s father pauses,
holding the cow next to the barn, and says, “The cow goes in the . . . .” Leah does
not respond. After confirming he still has her attention, he says, “The cow goes in the
. . . buh,” and Leah replies, “Barn.” Her father playfully exaggerates the cow walking
into the barn, and says, “Yay! In the barn!” before continuing to play.
A few minutes later, Leah walks over to the door and looks out the window.
She wants to play outside. Her father decides to use this opportunity to help Leah
learn to put her socks and shoes on more independently. He says, “Get your shoes,”
 Instructional Cues and Prompting Strategies 191

and guides Leah toward her socks and shoes. He places her socks closer to her so
that she reaches for them first and narrates the process as she gets ready to go
outside. When she is ready to close the straps on her shoes, he says, “Close,” and
points to the straps. He provides hand-over-hand support to help her close her shoes
tightly. He follows her outside to the next activity.

CONCLUSION
All NDBI use prompts and prompt fading, and most use prompting hierarchies,
although some are more structured and explicit than others. Awareness of the
type of prompt is critical in high-quality teaching, particularly because prompt
fading often requires systematic steps be taken that may require advanced plan-
ning. Although not all NDBI have clear systems for doing so, systematically
tracking the prompt level promotes both consistent teaching procedures and ap-
propriate prompt-fading procedures that are based on analysis of performance at
each prompt level. Although NDBI often fade prompts in a looser fashion than
traditional ABA models do, reliance on the systematic prompt-fading procedures
outlined in the ABA literature may be useful in certain instances. This chapter
provided an overview of how these procedures are applied in NDBI and how they
can be implemented in the natural environment.

REFERENCES
Brian, J. A., Smith, I. M., Zwaigenbaum, L., & Bryson, S. E. (2017). Cross-site randomized
control trial of the Social ABCs caregiver-mediated intervention for toddlers with autism
spectrum disorder. Autism Research, 10(10), 1700–1711.
Cengher, M., Shamoun, K., Moss, P., Roll, D., Feliciano, G., & Fienup, D. M. (2016). A com-
parison of the effects of two prompt-fading strategies on skill acquisition in children with
autism spectrum disorders. Behavior Analysis in Practice, 9(2), 115–125.
Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). Applied behavior analysis (2nd ed.). Upper
Saddle River, NJ: Pearson.
Hancock, T. B., & Kaiser, A. P. (2012). Implementing enhanced milieu teaching with chil-
dren who have autism spectrum disorders. In M. E. Fey & A. G. Kamhi (Series Eds.) &
P. A. Prelock & R. J. McCauley (Vol. Eds.), Communication and language intervention series:
Treatment of autism spectrum disorders: Evidence-based intervention strategies for communica-
tion and social interaction (pp. 163–187). Baltimore, MD: Paul H. Brookes Publishing Co.
Hancock, T. B., Ledbetter-Cho, K., Howell, A., & Lang, R. (2016). Enhanced milieu teaching.
In Early intervention for young children with autism spectrum disorder (pp. 177–218). New York,
NY: Springer International.
Hart, B., & Risley, T. R. (1975). Incidental teaching of language in the preschool. Journal of
Applied Behavior Analysis, 8, 411–420.
Hemmeter, M. L., & Kaiser, A. P. (1994). Enhanced milieu teaching: Effects of parent-
implemented language intervention. Journal of Early Intervention, 18(3), 269–289.
Ingersoll, B. R., & Dvortcsak, A. (2009). Teaching social communication to children with autism: A
practitioner’s guide to parent training and a manual for parents. New York, NY: Guilford Press.
Koegel, R. L., Schreibman, L., Good, A., Cerniglia, L., Murphy, C., & Koegel, L. K. (1989).
How to teach pivotal behaviors to children with autism: A training manual. Santa Barbara:
University of California.
Kasari, C., Fannin, D. K., & Goode, K. (2012). Joint attention intervention for children with
autism. In P. A. Prelock & R. J. McCauley (Eds.), Treatment of autism spectrum disorders
(pp. 139–161). Baltimore, MD: Paul H. Brookes Publishing Co.
Kasari, C., Gulsrud, A. C., Wong, C., Kwon, S., & Locke, J. (2010). Randomized controlled
caregiver mediated joint engagement intervention for toddlers with autism. Journal of
Autism and Developmental Disorders, 40(9), 1045–1056.
192 NDBI Strategies

McGee, G. G., Morrier, M. J., & Daly, T. (1999). An incidental teaching approach to early
intervention for toddlers with autism. Journal of The Association for Persons with Severe
Handicaps, 24(3), 133–146.
Rogers, S. J., & Dawson, G. (2010). Early Start Denver Model for young children with autism: Pro-
moting language, learning, and engagement. New York, NY: Guilford Press.
Seaver, J. L., & Bourret, J. C. (2014). An evaluation of response prompts for teaching behavior
chains. Journal of Applied Behavior Analysis, 47(4), 777–792.
9
Using Consequence Strategies
Allison B. Jobin and Laura Schreibman

A
s discussed in Chapters 7 and 8, understanding how antecedent events
(both setting up the environment and instructional cues) can affect behav-
ior is a very important part of designing and implementing effective and
efficient strategies for teaching. Certainly as important in implementing Natural-
istic Developmental Behavioral Interventions (NDBI) strategies is the appropriate
use of consequences, which is the third component in the antecedent-behavior-
consequence (A-B-C) sequence of learning. Most people likely are more familiar
with strategically using behavioral consequences than they are with using ante-
cedents. Consequence terms such as positive reinforcement and punishment are famil-
iar words in the popular vernacular, and most educators have used the terms and
the strategies on many occasions. However, implementing consequences correctly
requires very specific definitions and procedures that are far more precise than the
colloquial use of these terms. This chapter focuses on the implementation, nature,
and effects of consequence events in NDBI teaching strategies. Although most of
these strategies are also used in the broader field of Applied Behavior Analysis
(ABA) interventions, this chapter discusses their specific application in NDBI.
An antecedent stimulus gains control over a behavior only to the extent that
it promises or predicts a certain consequence (Cooper, Heron, & Heward, 2007).
For example, a special education teacher might notice that one boy in a class with
autism spectrum disorder (ASD) is highly motivated by greetings from adults.
When he says, “Good morning” to his teacher, Ms. Carolyn, she always responds
with a very nice smile and cheery response such as, “Good morning to you, too!”
On the other hand, when he greets Mr. Richard in the same way, Mr. Richard
does not usually return the greeting. Before long, the student greets Ms. Carolyn
every morning but does not greet Mr. Richard. Ms. Carolyn is an antecedent
stimulus that promises a positive social consequence for his greeting, whereas
Mr. Richard is an antecedent stimulus promising no return greeting. This student’s
greeting behavior to these antecedents was controlled by their consequences.

193
194 NDBI Strategies

Another all-too-familiar example is how children learn which parent to ask for
something. If mom usually says “no” to a cookie before dinner and dad usually
gives in to the request, the child will learn which parent is the antecedent promis-
ing a positive outcome for that cookie request!
When altering or teaching a behavior, the focus is on changing the strength
of the behavior. Strength of a behavior is measured in terms of its frequency (how
often it occurs, e.g., how many tantrums in a day), latency (how soon after the ante-
cedent does the behavior occur, e.g., how quickly does the child say “Daddy” when
her father appears), and magnitude (with how much force the behavior occurs,
e.g., decibel level of screaming) (Cooper et al., 2007).
There are two basic directions to changing behavior: increasing it or decreas-
ing it. The section that follows examines how the use of consequences contributes
to such changes.

INCREASING THE STRENGTH OF A BEHAVIOR

As exemplified in Table 9.1, there are two main ways of increasing a behavior. The
first is to follow a behavior with a positive stimulus (i.e., object or event). A positive
stimulus is anything the individual likes or enjoys. Presenting a positive stimulus is
called positive reinforcement, and it is a commonly used procedure. Thus, a child is
presented with a stuffed cat and says “cat.” The correct response is followed by a posi-
tive stimulus such as, “Yes! That’s right!” and access to the toy cat. This sequence of
events serves to increase the strength of the correct response. Sometimes using posi-
tive reinforcement is called rewarding the behavior; this term might be more familiar.
Any behavior followed by a positive stimulus will increase in strength over time.
The second means of increasing the strength of a behavior is to follow a behav-
ior by the removal or successful escape or avoidance of an aversive or unpleasant
stimulus. Many drivers remember to buckle the seatbelts in the car because buck-
ling the belt stops the annoying buzz emitted by the car. Likewise, a child might

Table 9.1. Types of consequences

Behavior more likely Behavior less likely

to occur in the future to occur in the future

Addition
Positive reinforcement Positive punishment
of stimulus

Removal
Negative reinforcement Negative punishment
of stimulus

Refraining from providing reinforcement after a

Extinction
behavior that has previously been followed by reinforcement
 Using Consequence Strategies 195

come home from school and immediately start his or her homework to avoid his
or her mother’s nagging. This way to increase the strength of a behavior is called
negative reinforcement. The aversive stimulus avoided is the negative reinforcer.
A behavior followed by negative reinforcement will increase in strength over time.

DECREASING THE STRENGTH OF A BEHAVIOR

There are three ways to decrease the strength of a response. One way is to fol-
low the occurrence of a response with an aversive stimulus. An aversive stimulus
(punisher) is anything the person does not like. This procedure is called punish-
ment by application or sometimes positive punishment and is another commonly
used strategy. People encounter punishing events all the time. If Susan reaches to
touch a hot stove and burns her finger in doing so, she is less likely to touch the
stove again. This behavior was punished by the unpleasantness of pain.
Another behavior-reducing strategy is to follow a response by removing or
avoiding a positive stimulus. If a child bites his or her sister, the parents remove
the child from the room and place him or her in time-out, where he or she has no
access to favorite toys or television. Because the child has lost positive things after
biting his or her sister, the child is less likely to bite her in the future. This type of
strategy, wherein the person loses something positive, is referred to as punishment
by withdrawal, or negative punishment.
A third strategy for reducing the strength of a behavior is to no longer provide
reinforcement after a behavior that has previously been followed by reinforcement.
This strategy is referred to as extinction and is sometimes described as planned
ignoring. To use a common situation, consider a mother whose child has learned
that he or she can get mom’s attention whenever he or she has a tantrum. Tantrums
have been positively reinforced in the past with mother’s attention (most likely
inadvertently). Mom can use extinction by not providing attention when the child
has a tantrum. If mom can consistently ignore the tantrums, the child learns that
this behavior no longer leads to attention, and the behavior will decrease.
When extinction is initially implemented, there is typically a temporary increase
in the strength of the behavior (called an extinction burst) before the behavior
decreases. It is crucial that an individual using extinction expects this so that he or
she does not decide the strategy is not working and prematurely abandon it. For
example, when the child is used to a tantrum resulting in reinforcement, he or she
may think trying harder (e.g., crying louder, throwing objects) will work when a par-
ent first begins ignoring this behavior. If the parent responds, the child learns that
crying harder, louder, and so forth works. The parent must understand this predict-
able phenomenon and continue to ignore the behavior during this temporary burst.
Another important nuance to extinction is that the person or environment
must be able to tolerate this temporary increase in the behavior. This strategy
would be contraindicated for severe behaviors such as self-injury or aggression to
others. Such considerations are important in the selection of the most effective and
appropriate consequences for behavior change. Parents, teachers, and other care-
givers should carefully consider whether extinction-based interventions are appro-
priate for a specific behavior or setting. Behaviors that are hard to ignore because of
the setting (e.g., tantrums that occur in public) may also not be appropriate to target
with extinction. In these cases, antecedent interventions may be more appropriate,
which are discussed in detail in Chapter 13 on addressing challenging behaviors.
196 NDBI Strategies

Before implementing the Premack Principle

Play on
Do your Help set the
tablet after Eat dinner.
homework. table.
school.

After implementing the Premack Principle

Do your Help set the Play on

Eat dinner.
homework. table. tablet.

Figure 9.1. Before and after implementing the Premack Principle.

APPLYING THE PREMACK PRINCIPLE

A strategy often used by professionals and caregivers alike is the Premack Principle.
This approach involves positioning a higher probability behavior after (or contingent
on) the occurrence of a lower probability behavior in order to increase the likelihood
of the lower probability behavior’s occurrence (Cooper et al., 2007). For example, a
parent might say to his or her child, “First, I need you to do your homework, and then
you can play on your iPad,” (see Figure 9.1) or, “If you read a chapter in your book,
then you can go play on your scooter.” By altering the order of activities the child may
already be doing so that the more preferred activities follow the less preferred ones,
the child is more likely to be successful in all of them! The Premack Principle is some-
times referred to as the first, then; if, then; or high probability, low probability tech-
nique. It has been more fondly referred to as Grandma’s Rule, based on the history of
innumerable grandmothers enticing their loved ones to eat their broccoli before they
can have delicious cookies. The Premack Principle can make a big impact on positive
behavior change by structuring the sequence of expectations and emphasizing what
preferred activities a child can earn for demonstrating a newer, less preferred skill.

PROMOTING CONSEQUENCE EFFECTIVENESS

A contingent consequence is one that occurs because the specified behavior has
been emitted (Cooper et al., 2007). To increase the frequency of a child saying
“thank you,” the adult would apply the positive consequence only when that verbal
response occurred and not when other verbal responses or no response occurred.
 Using Consequence Strategies 197

The consequence must be applied immediately after the behavior or as closely

as possible. This is because the consequence that follows right after the behavior is
emitted has the most effect on behavior. For example, a child is having a tantrum in
the backyard. The mother wants to provide a negative consequence to the tantrum,
but by the time she gets outside, the child has quieted down and is playing nicely
with a toy car. If the mother then takes the child into the house for a time-out,
she will essentially be punishing the nice toy play. This is because the behavior
most closely preceding the time-out was toy play. The general rule is that the more
quickly after a response the consequence is presented, the more potent the effect
it will have.
To a great extent, the number of times a consequence follows a behavior will
affect the consequence strength. Thus, a response followed many times with the
consequence will be stronger than one followed only a few times. The more times
the child’s “thank you” is followed by a positive reinforcer, the more frequently the
child will say “thank you” in the future.
The magnitude of the consequence may also determine its effect. A large bite
of a candy bar might have more effect than a small bite.
Clinicians and parents can also use motivating operations (MOs) to strengthen
or weaken the effect of a consequence, as discussed in Chapter 6. An establishing
operation, or an EO, is an environmental event that increases the value of a stimu-
lus due to deprivation, in this case a consequence (Cooper et al., 2007). To increase
the reinforcing value of a particular toy, the toy should only be available when the
desired behavior occurs. Likewise, the value of a readily available toy might be
less than a special toy available only in certain instances. Indeed, an abolishing
operation (AO) is the reduction in value of a reinforcer due to satiation. In another
example, a hungry child will likely find food a powerful reinforcer, whereas a child
who has just eaten a meal will likely find food a less powerful reinforcer.
Individual differences always play a role in the effectiveness of any conse-
quence. Indeed, people always have to be flexible and not tied to a specific con-
sequence. The value of a certain consequence is even likely to vary depending on
the day for the same child. Preference assessments, following the child’s lead, and
related strategies can be helpful in determining whether consequences will be
reinforcing (see Chapter 7 on antecedent strategies for additional information). See
Box 9.1 for a summary of factors that affect consequence effectiveness and Table 9.2
for an example of how these factors should be taken into consideration in practice.
ABA is a science and a technology. As such, it uses a very specific vocabulary
to describe itself. This has led to some terms that have rather unpleasant and
negative colloquial connotations. Punishment, negative reinforcement, extinc-

BOX 9.1: Factors affecting consequence effectiveness

• Contingency (immediately and depending on the behavior)
• Number of consequences (following the target behavior)
• Magnitude (amount or strength of the consequence)
• Motivating operations (establishing operations and abolishing operations)
• Individual differences (value will vary depending on for whom and when)
198 NDBI Strategies

Table 9.2. Considerations in applying consequences

Questions to ask Response

Example: Leah is learning to brush her teeth to earn pouring out the water at the end.

Is the reinforcer immediate Yes! Leah earns pouring out the water immediately after she
and dependent on the completes the other steps of brushing her teeth. Her father
child’s response? holds the cup so she only gets to pour water once she
is done.
Are the frequency Yes! Leah just started brushing her teeth by herself. She gets
and magnitude of to pour the water out every time she demonstrates the skill.
reinforcement appropriate?
Is the reinforcer actually Yes! She really enjoys watching the water go down the drain.
motivating for the child? Her father changes the cup every couple of days and tries
to have two choices on the counter. Her parents have been
limiting water play to brushing teeth because she used to
play with pouring cups all the time during free time.
Is the reinforcer directly Yes! Pouring out the water from a cup follows naturally from
related to the child’s brushing one’s teeth. First, Leah brushes her teeth. Then, she
behavior? drinks some water and spits it out. The last step is pouring
out the water, which Leah loves to do! Leah is more likely to
keep brushing her teeth because the last step is enjoyable
and has promoted learning the steps of teeth brushing.

tion, and control are just some of these terms. However, when used in the con-
text of behavior analytic intervention strategies, these terms denote very specific
procedures.
Furthermore, these terms refer to the effect the procedure has on a behavior.
This means determining the nature of a consequence by its function, that is, what
it does to the behavior. Thus, a positive reinforcer is a consequence stimulus that,
when presented after a behavior, has the function of increasing the behavior it fol-
lows. In fact, this is the only way to define a positive reinforcer.
For example, Ben, a student with ASD, frequently greets his teacher,
Ms. Maxwell. Ms. Maxwell decides to reinforce the greetings by giving Ben a
hug each time he greets her. Although Ms. Maxwell assumes the greetings will
increase, she is surprised when the greetings decrease. By definition, the hugs were
not a positive reinforcer but a punisher—the greeting behavior decreased when the
hugs followed the greeting. It is possible, and alas not unlikely, that Ben did not
enjoy the hugs because such expressions are aversive to some children with ASD.
Now consider Margie, who is acting out in class by jumping out of her chair
and grabbing other students’ papers. Her teacher decides to punish her by ver-
bally reprimanding her by saying things such as, “Margie, get back in your chair
right now! I have told you to keep your hands to yourself!” He expected Margie
to improve her behavior but found that Margie became more disruptive. The ver-
bal reprimands acted as positive reinforcers—when presented after the disruptive
behavior, the behavior increased. Mr. Washington assumed the reprimands were
aversive because for most individuals they would be. However, Margie is a child
for whom any attention, even negative, serves as a positive stimulus.
As highlighted in these examples, educators, clinicians, parents, and practitio-
ners must keep in mind that they will not always be able to determine a priori the
function a stimulus will have and can only identify it by the effect it has on behav-
ior. At times, a stimulus selected to serve as a reinforcer may not actually function
 Using Consequence Strategies 199

as such in a given situation. This should serve as a cue to the therapist or teacher to
try something new to increase the skill being targeted. It is important to be flexible
in approaching teaching methods and students and clients!
Another point is that the way behavior analysts and interventionists use the
term punishment does not necessarily denote pain. More often pain is not involved
in punishment at all. One very common punisher is saying “no” to a child. A thera-
pist’s frown, a mom’s icy stare, and a father’s hands on hips are all punishers if
they serve to decrease behaviors. A punisher is any stimulus that, when presented
following a behavior, functions to reduce that behavior. As with the child who
stopped greeting his teacher when hugs were offered, an assumed positive stimu-
lus may actually serve as a punisher.
This is the same for time-out. Indeed, many children engage in disruptive
behaviors to avoid a task they do not like. Imagine an adolescent, Gabriel, who
looks down and walks away each time his father tells him to put his dishes in the
sink. Each time, he is told to go to his room (i.e., time-out). This behavior is actually
strengthened or reinforced because it leads to avoidance of the task he was seeking
to avoid from the start. At other times and for other children, time-out might be a
very effective strategy.
When deciding on punishment or extinction as a means to decrease behav-
ior, clinicians should be familiar with the different features and effects of the two
strategies (Cooper et al., 2007). The main difference is that punishment (when used
correctly) leads to a rapid decrease in the behavior and is not associated with an
initial temporary increase. Extinction, as noted previously, typically begins with a
temporary increase in behavior followed by a more gradual reduction in strength.
Extinction also has the advantage of not involving the presentation of an aversive
stimulus. These considerations are essential in determining which type of conse-
quence to provide for a certain situation.
Another point to consider is that punishment has additional limitations. Pun-
ishment teaches a child what not to do but not necessarily what to do. Therefore,
punishment is not a standalone procedure because it should be accompanied with
teaching another response. For example, an educator says “no” to Francie when she
wiggles her hands in front of her eyes (the “no” serves as a punisher because she
stops the finger wiggling), but Francie needs something else to do with her hands.
Thus, the educator might reward Francie with verbal praise for using her fingers
to do a puzzle or clap her hands to music. Finally, using only punishment proce-
dures to reduce a challenging behavior can lead to poor generalization, as behavior
change only occurs when the punisher is present. Generally, NDBI favor the use of
antecedent and reward strategies and limit the use of punishers.

USING CONSEQUENCES TO MAINTAIN BEHAVIOR CHANGE

When implementing NDBI, the goal is to have the effects persist. In fact, if achieved
behavior change is not maintained, then little has been accomplished. Different
schedules of reinforcement are utilized to accomplish this maintenance and to
provide a teaching environment more like the natural environment. This means
that adults provide consequences in different patterns that are designed to make
behavior change more durable (Cooper et al., 2007). Because the real world seldom
provides consequences after every response, teachers do not provide consequences
after every response.
200 NDBI Strategies

Table 9.3. Schedules of reinforcement

Schedule Description

Continuous Reinforcement after every occurrence of behavior

Variable ratio Reinforcement after a variable number of occurrences of behavior
(around an average number)
Fixed ratio Reinforcement after a fixed number of occurrences of behavior
Variable interval Reinforcement after a variable amount of time (around an average
amount of time)
Fixed interval Reinforcement after a fixed amount of time

When first teaching a new behavior, reinforcing every occurrence of the

behavior typically is best because this makes the connection between response and
consequence the clearest. This is called a continuous reinforcer schedule (CRF or
CRS) and is also referred to as an acquisition schedule because it is used during
the acquisition phase of teaching. Once the individual learns the behavior, gradu-
ally reduce the amount and frequency of reinforcers to more closely mimic the
real world. Also, behaviors on a CRF schedule are highly susceptible to extinction
(which, alas, does happen in the real world all the time). Therefore, it is common
practice to gradually move from a CRF to a maintenance schedule, which is one
implemented to make behavior more durable and resistant to extinction.
The main types of maintenance schedules, which are summarized in Table 9.3,
include ratio schedules and interval schedules. In ratio schedules of reinforce-
ment, every response is not followed by a reinforcer, but rather reinforcement
delivery is determined by the number of responses that have occurred since the
last reinforcement for the target behavior. In a fixed ratio (FR) schedule of rein-
forcement, the number of responses required for the reinforcer is consistent. For
example, the child receives 5 minutes of video game time for the completion of
every 15 math questions. In a variable ratio (VR) schedule of reinforcement, the
number of responses varies between reinforcements. Of course, the best example
of a variable ratio schedule is gambling. The number of times a person has to acti-
vate a Las Vegas slot machine to win varies. Gambling behaviors are strong, and
individuals who program the machines are truly experts in building rapid and
durable behaviors in people! Ratio schedules can be used to build very high rates
and durable levels of responding. (However, clinicians must be careful not to make
the ratio too high or extinction might occur.)
In interval schedules of reinforcement, the reinforcer is delivered after a
specified amount of time. The reinforcer is not delivered for free, though. Rather, it
is available after the first response occurs after the interval has passed. For a fixed
interval (FI) schedule of reinforcement, this time interval is consistent. Thus, a
child receives 5 minutes of video game time after working on math for 15 minutes.
It does not matter how many math problems are completed but rather how much
time the child has spent appropriately working. A variable interval (VI) schedule
of reinforcement is one in which the reinforcer is available after a specified time
interval but the intervals vary. The child may earn the 5 minutes of video game
time but after differing amounts of time working on math. He or she gets the video
game time after only 5 minutes on one interval but after 20 minutes on the next
interval, and so forth. Interval schedules typically are associated with moderate
but stable levels of responding.
 Using Consequence Strategies 201

SHAPING AND CHAINING

Sometimes a therapist wishes to strengthen a behavior that does not occur. In these
situations, he or she needs to build up to it. The two main methods of achieving this
are shaping and chaining (Cooper et al., 2007). Shaping occurs when the therapist
provides consequences to responses that gradually lead to the final response. The
therapist does this by reinforcing successive approximations to the target response.
To illustrate, a therapist wants to teach a child to say “dog” when presented with a toy
dog. At first, the child is unable to say the word, so the therapist presents the dog, and
as soon as the child vocalizes, the therapist provides the reinforcer (“Good talking!”
and a toy dog). When the child consistently vocalizes when presented with the dog,
the therapist now waits with the reinforcer until the vocalization approximates a /d/
sound. Because other sounds are not reinforced, they will extinguish. When the child
consistently makes a /d/ sound when presented with the dog, the therapist waits until
his or her vocalizations sound like “da” or “du” before praise. The therapist continues
reinforcing successive approximations of the word “dog” until the child consistently
responds to the toy with “dog.” In shaping, strict definitions are used for which re-
sponses will be reinforced (i.e., the next version of the target behavior) and which will
be put on extinction (i.e., the previous version of the target behavior). Many NDBI use
a looser shaping contingency, such as reinforcing attempts in Pivotal Response Treat-
ment (PRT; Koegel, Schreibman, Good, Cerniglia, Murphy, & Koegel, 1989), in which
successive approximations are reinforced and reinforcement of previous approxima-
tions is slowly faded as the child gains skills, or responding to all communicative
bids in Project ImPACT (Improving Parents as Communication Teachers; Ingersoll &
Dvortcsak, 2009) to increase initiation and build toward specific words and gestures.
Chaining is another method of building up to a more complex target behavior.
Rather than waiting for the individual to make the next advancement in behavior
(as in shaping), in chaining the instructor determines the steps of advancement.
Chaining involves breaking a behavior into component steps and teaching the
steps individually in sequence so that when these steps are performed in sequence
the target behavior is achieved. Self-help skills are frequently taught in this man-
ner. In teaching a child to pull up his or her pants, the instructor might start with
having the child stand with his or her feet in the leg holes of the pants. When the
instructor says, “Pants up,” the child might be prompted to lean over and touch the
pants. The instructor reinforces this response. When the child consistently touches
his or her pants when told “pants up,” the instruction would progress to the next
step in the chain. This involves the child grabbing the waistband of the pants, per-
haps with a prompt at first. Once this step is mastered, the child is required to raise
the pants to his or her knees before reinforcement is delivered. Once this is mas-
tered, the child is required to pull the pants all the way up to his or her waist. This
is an example of forward chaining, where the instruction begins at the beginning
of the complete response.
Most responses can be taught using backward chaining, where the chained
steps are taught from the end step to the beginning. For the pants example, the
instructor would begin with having the pants pulled up and start by reinforcing
touching the waistband. The next step in the chain would be starting with the
pants pulled up to within a few inches of the waist, and the child would have to
pull the pants all the way up. The next step might be starting with the pants at the
knees, and the child would pull them all the way up, and so forth.
202 NDBI Strategies

Thus far, this chapter has discussed the foundational components that under-
lie consequence strategies in NDBI and, in fact, all behaviorally based interven-
tions. However, there are unique ways that consequence strategies are applied in
NDBI. The following section reviews the applications of consequence strategies
specific to NDBI and highlights some ways NDBI may be different from other com-
monly used behavioral intervention strategies.

USING NATURAL CONSEQUENCES

NDBI use natural, rather than unrelated, reinforcement to follow target behaviors
(e.g., Ingersoll & Schreibman, 2006; Koegel, Camarata, Koegel, Ben-Tall, & Smith,
1998). Natural reinforcement is contingently providing an item, activity, or response
that is directly related to the child’s behavior. It often mimics the natural consequence
that might occur if the child were to demonstrate the target skill in the natural, real-
world environment. In some cases, natural consequences are straightforward to set
up. For a child just learning to use words, a mother using NDBI would reinforce her
daughter’s vocalization of “buh” to earn her blowing bubbles. A young boy learning
to expand his language to full sentences would receive reinforcement with stopping
a nonpreferred task—such as completing homework—by saying, “I need a break.”
Use of natural reinforcement can be more complex, as well. Imagine that a
teacher is teaching 7-year-old Mateo to ask another child to play with him. The
teacher tells Mateo to pick between two preferred games, Connect Four and Uno,
and to ask another child to play with him. When Mateo asks his peer, “Do you
want to play Uno with me?” Mateo and his friend get to play the game. In this
example, saying “Do you want to play Uno with me?” is directly reinforced by get-
ting to play the game.
Natural consequences are sometimes referred to as direct reinforcers because
there is a direct relationship between the child’s response and the reinforcer he
or she receives contingent on that response. For example, Solomon is learning to
imitate actions. He loves playing with instruments by banging them on the ground
and on tables. The therapist prompts him to imitate clapping the cymbals together
and then gives Solomon free access to the cymbals. He then chooses to bang them
on the table in front of him, which serves as reinforcement for imitating the thera-
pist’s action. In another example, imitation of a symbolic play act with a preferred
toy would be reinforced by the child’s continued access to the preferred toy and
freedom to play as the child wishes (generally paired with social attention).
This relationship between the response and the reinforcer promotes mainte-
nance and generalization of learned skills (Schreibman & Koegel, 2005). For exam-
ple, when Mateo learned to invite his peer to play using NDBI, his behavior was
reinforced by getting to play a game. When Mateo uses this skill during a playdate
at his house or at the park, he is likely to be reinforced in a similar way—at least
some of the time. When the other children respond to him by playing the game
he suggests, he receives reinforcement for this behavior in the real world, thereby
maintaining the skill over time and across environments. This is in contrast to more
traditional behavioral strategies that might involve the child completing a task to
receive a reward unrelated to the specific behavior being taught. For instance, a
child learned to say, “Will you play with me?” in order to earn a token on a token
chart or a high-five from the teacher for practicing the appropriate social phrase
 Using Consequence Strategies 203

at the table during a lesson. The token is not related to saying “Will you play with
me?” whereas getting to play is directly related to asking the question.
It is optimal when the natural reinforcer matches and is specific to the language
or behavior that was demonstrated. For instance, if a child says, “Ball, please,” it
is best to give him or her a ball. However, if he or she were to say, “Roll the ball,”
the therapist should roll the ball to the child rather than just hand it to him or
her. Social praise also has an important role in consequence strategies. In NDBI,
tangible natural reinforcement should be paired with social praise (e.g., “You did
it!”). When possible and developmentally appropriate, specific social praise is rec-
ommended (e.g., “Great! You asked me an on-topic question!”) to better link the
feedback to the target behavior.
Sometimes, the natural consequence is socially based. For instance, Sylvia is
learning to broaden her conversational segues with peers. When she uses an appro-
priate segue—or one that she has not readily used before—the therapist might smile
at her and respond with an interesting tidbit. Children differ in the degree to which
social praise or social consequences are of interest to them. Regardless of whether
these types of consequences have current value, they should be paired with more
tangible rewards. This not only helps the child to associate social praise with posi-
tive, preferred consequences—which should in turn increase the value of social
praise—but it also increases the value of the therapist as the number one reinforcer!
Indirect or unrelated reinforcers also serve an important function in behavioral
intervention and may, at times, be the most appropriate consequence (Lohrmann-
O’Rourke & Browder, 1998). Indirect or unrelated reinforcement involves provid-
ing a contingent item, activity, or response that is desirable to the individual child
but not related to the child’s behavior. There are certain goals that are not neces-
sarily amenable to natural reinforcement. Some skills, such as toilet training or
refraining from repetitively tapping the desk with a pencil, do not seem to have
a related motivating component. Consider if there is a natural consequence that
could be motivating to the child. Or, is there a natural consequence that encourages
other people to keep doing that behavior?
If a natural reinforcer does not seem to exist, an indirect reinforcer may be
integrated. A child could earn something highly preferred after using the potty or
earn a check on his or her self-management chart for keeping hands folded in his or
her lap during a math lesson. Because NDBI focus on the use of natural reinforce-
ment, clinicians should think creatively when struggling to identify this type of
consequence. For example, if a child needs to write a nonfiction report for school,
choosing a preferred topic (e.g., dinosaurs) and then being reinforced with an object
related to that topic (e.g., a dinosaur toy, sticker, television show) is still more natu-
ral than reinforcing the child with candy. Likewise, practicing math with Legos
instead of counting bears might be naturally reinforcing for a child who likes Legos
and could then add them to a Lego tower after completing each math problem.
One last point to emphasize: When antecedent and consequence strategies
common to NDBI are used together, it is often easier to identify an effective rein-
forcer all together. To illustrate, the antecedent strategy of using highly motivat-
ing materials to teach a child to imitate a pretend play sequence (e.g., a monkey
climbing a vine, jumping into the tree, and picking a banana on a jungle play
structure) could be followed by free play with the monkey and the jungle for
a few moments—serving as positive reinforcement of the imitation sequence.
204 NDBI Strategies

Of course, if an arbitrary or preselected set of pretend play materials were chosen

by a therapist to teach imitation, free access to the materials afterward would not
serve as reinforcement. This is one reason why incorporating preferred materi-
als, when possible, can have a big impact on treatment effectiveness. Likewise,
when setting up a teaching opportunity for behavioral flexibility, a therapist
might take out the child’s favorite Legos. After he or she practices being flexible
by building the therapist’s idea of a castle, the therapist then follows the child’s
idea to build a ship like the Titanic. Although antecedent and consequence strat-
egies from NDBI are discussed in separate chapters, it is important to remem-
ber how they truly work in tandem. Figure 9.2 includes several examples across

• Getting a break for saying “break” or handing a break card

• Giving the student a toy from the shelf after he or she points to it
• Making a silly face after the child makes eye contact with the therapist
• Giving the child the food he or she chooses after offering a choice of
Communication crackers or goldfish
• Going to play outside after the child follows the instruction, “Put on your
shoes and jacket”
• Turning the page in a favorite book after the child points and comments on
what he or she sees

• Flapping the board game cards up and down after taking a turn with the
game
• Pouring all the Lego pieces into another container (dumping things out is
Play the student’s favorite sensory activity) after building a pretend castle
• Sharing a preferred play idea for the pirate ship after following the
therapist’s idea first
• Earning a chance to play freely with cars (e.g., lining them up, parking the
cars) after pretending to fill up the gas tank and go through the carwash

• Getting a turn talking about a favorite topic, volcanoes, after asking a

question about a less preferred topic
• Getting to pick the game after inviting a peer to play together
Social • Continuing a song with gestures with the teacher after filling in the blank on
interaction the lyrics during the pause
• Adding more favorite character figurines to the play activity after
responding to a peer requesting a turn
• Getting to play alone after playing near peers for 5 minutes

• Letting the child flush the toilet after going potty by him- or herself
• Getting to pick out a favorite shirt after the young child puts on pants by
Daily living him- or herself
skills • Listening to a silly bathtime song after going to bathtime the first time asked
• Letting the child who loves to take a bath get in the tub after getting his or
her bath towel first

Figure 9.2. Examples of natural reinforcers.

 Using Consequence Strategies 205

different types of activities, routines, and skills to demonstrate natural reinforce-

ment possibilities in action.

REINFORCING ATTEMPTS
A procedure related to natural reinforcement is the use of loose reinforcement
contingencies, also referred to as loose shaping or reinforcing attempts (Koegel,
O’Dell, & Dunlap, 1988). This component involves providing reinforcement not
only for the requested behavior (e.g., for the child to clean up all the toys on the
floor) but also for a goal-directed attempt in the right direction (e.g., the child clean-
ing up the blocks and cars but not the train set). The goal of this strategy is to keep
the child’s motivation high and to reinforce trying, or initiating, while teaching
novel behaviors.
There is some variation across NDBI approaches in terms of how closely the
child’s performance matches the target in order to receive the reinforcer. Also,
the range of responses that might be reinforced will gradually shift as behav-
iors develop to closer and closer approximations of the final target. For example,
Monica is learning to say “go outside” to request to play in her backyard. At first,
her father might provide reinforcement for “go,” “outside,” and “go ouh.” Once she
starts doing these more consistently, he may only reinforce initiations that are two
syllables. The range of responses may eventually become slimmer until Monica is
ready for an even more complex initiation.
It may feel difficult to reinforce an attempt when the child can (and has) done
better before. However, it is important to remember that reinforcing attempts fol-
lows “good trying” with positive outcomes. This, in turn, reinforces trying or
initiating, which leads to more trying and more initiating—which is essential to
building new skills!

MODELING AND EXPANDING ON CHILD’S RESPONSE

Modeling and expanding on the child’s response includes an adult demonstration
of appropriate behaviors during interactions (e.g., Ingersoll, Lewis, & Kroman,
2007; Ingersoll & Schreibman, 2006). For example, the therapist might provide a
compliment about what the child is building (e.g., “Vincent, I love that tall tower!”)
or narrate what he or she is doing (e.g., “I am building a pool with a diving board.”)
Expanding on the child’s response, also referred to as recasting, involves adding
on to what the child said or did, often along with providing reinforcement. For
instance, Joanna is giving her daughter, Molly, a bath. Molly bounces the rubber
ducks up and down in the water, making a splash. Joanna exclaims, “Duckies!
Splash, splash!” while taking a rubber duck and bouncing it in the water. Modeling
and expanding on the child’s response should follow the child’s focus of interest
and often demonstrates a target skill of interest.
As has been previously highlighted, NDBI optimally involve the use of mul-
tiple components together during learning opportunities. In regard to modeling
and expanding, these strategies can actually be utilized as both antecedent strate-
gies (i.e., before the child’s response) and consequence strategies (i.e., in response
to the child demonstrating a target skill). These strategies are discussed in the con-
text of consequence approaches within NDBI. Their use as antecedent strategies is
discussed further in Chapter 7.
206 NDBI Strategies

Modeling is used to teach target skills from many domains, including lan-
guage, imitation, social, play, cognitive skills, motor skills, and even some self-
care skills. The rationale for modeling and expanding on the child’s response is
that it provides additional opportunities for the child to hear or observe appro-
priate and more complex responses. In NDBI, children often practice the mod-
eled response immediately after or at another time. In some NDBI approaches,
modeling is used as a specific prompt strategy such that the child is expected
to imitate the modeled action or language. In these situations, the model may
serve as both a consequence to an earlier response and an antecedent setting the
stage for the next teaching moment. In other NDBI approaches, modeling pro-
vides an opportunity for the child to learn from observation, but the child is not
expected to demonstrate the skill (although the child often does!). The modeled
behavior is carefully chosen with developmental considerations in mind, such as
modeling behaviors slightly more advanced than the child’s current developmen-
tal abilities.

IMITATING THE CHILD’S RESPONSE

One additional technique common to many NDBI is the practice of imitating the
child’s response. This is often referred to as contingent imitation, mirroring, or
reciprocal imitation. This strategy is used to increase the child’s responsivity and
attention to adults, to increase the child’s future imitation of adult-modeled behav-
iors, and to promote continuation of the interaction. As an example, a grandmother
and granddaughter are playing on the grass at the park. They have a playset of
picnic materials. The granddaughter claps two cups together, and her grandma fol-
lows suit. Soon, the two are swaying back and forth, clapping the cups together. As
the granddaughter puts the cups down, the grandmother picks one up and takes
a big pretend sip of water. The granddaughter then takes the other cup and puts it
to her lips, as well.
Imitating the child’s response is another strategy that sometimes feels unnat-
ural to use at first, especially if the child is using unusual behaviors or sounds.
However, for many children, imitating their sounds and actions can truly increase
their engagement and help them to share their activity. This opens up the door for
other learning opportunities during that episode of engagement. Research indi-
cates that both children with ASD and typically developing children respond with
increased attentiveness to the adult partner when being systematically imitated
(Dawson & Adams, 1984; Dawson & Galpert, 1990). NDBI vary in the degree to
which imitating the child is a central feature of the intervention, and none recom-
mend imitating inappropriate or dangerous behavior. See Table 9.4 for an example
of how consequence strategies, including imitating and modeling, can be effec-
tively implemented.

TROUBLESHOOTING NDBI CONSEQUENCE STRATEGIES

Although the NDBI strategies are likely to be effective much of the time, there may
be roadblocks along the way. This section provides strategies to troubleshoot dif-
ficulties and avoid some of the most common pitfalls. Overall, the soundest advice
regarding implementation of NDBI is to learn and understand the foundational
principles. With a firm grasp on these, practitioners can step back, evaluate each
 Using Consequence Strategies 207

Table 9.4. NDBI-specific considerations in applying consequences

Questions to ask Response

Example: Katie is learning to take turns with another child, Jackson, while playing with trains.
After she takes a turn with the train tracks, she gets another train added to the track. Jackson
gets more figurines added to the play scene for taking turns and responding to turns.

Is the reinforcer actually Yes! Katie loves vehicles, including trains. Because Jackson does
motivating for the not like trains very much, the therapist considers his favorite
children? activities, playing with figurines. The therapist incorporates
trains, train tracks, and figurines into the play materials. Jackson
earns figurines for demonstrating turn taking, and Katie is
reinforced with trains.
Is the reinforcer directly Yes! The children are learning to take turns during play. When
related to the child’s Katie asks for a turn with the train, she gets a train. (Sometimes
behavior? the therapist has to help Jackson give the train to her.) When
Jackson responds to the turn request, Katie is prompted to give
Jackson one of the figurines.
Are attempts reinforced? Yes! Jackson and Katie receive reinforcement not only for taking
turns independently but also for when they need prompting.
Katie earns her reinforcer even if she gives Jackson a train when
he says, “My turn with the little boy (figurine).”
Is there modeling and Yes! Katie usually says, “My tuh,” when asking for a turn with the
expanding on the train. Her therapist then says, “My turn, please.” Sometimes she
child’s response? asks for a turn by pointing to her preferred toy. Her therapist
then expands on this response by overlaying “My turn!” while
Jackson gives her the toy.
Is there imitation of the Yes! The therapist imitates the target responses of requesting and
child’s response? responding to turns. The therapist also imitates the play she
observes from Katie and Jackson, such as connecting the train
tracks, having the figurines talk to each other, and including
unique actions such as when Katie makes the trains fly in the air.

obstacle, and adapt their approach more effectively while maintaining the integrity
of the models.
• “It isn’t working.”
When it seems that an intervention is just not working, there are a few ques-
tions to consider. First, “What is the goal of the interaction?” Although this
seems like a silly question at first glance, NDBI look and feel like play or natural
day-to-day interactions by design. Sometimes this can lead to lack of clarity
about the learning opportunities. It is essential that a clear goal is set when
implementing NDBI. For example, the goal may be building conversation skills
on topics chosen by another person, playing cooperatively on the same theme,
or protesting appropriately. This question may help add that missing structure
needed to set the child up for success.
The second most important question is “What is the reinforcer?” If the an-
swer is not clear, consider restructuring the opportunity to include a clear and
motivating reinforcer. Individuals are much more likely to learn something
new when it is followed by a desired outcome. Along these lines, remember
the foundational tenets surrounding effective use of consequences. Potential
reinforcers must be provided immediately after the target response (or as soon
as possible) and contingently. If it seems the reinforcers are not working, con-
sider whether the reinforcement is being provided on the right reinforcement
208 NDBI Strategies

schedule (Is it consistent enough?) and at the right potency. Is the reward worth
the work? Is it restricted to teaching opportunities, or does the child get to play
with it in and outside of treatment sessions?
• “My child is not motivated for anything!”
Another common snag in implementing NDBI is that reinforcement does not
work. This statement in and of itself is a misnomer. By definition, a reinforcer
is a consequence that increases the future likelihood of the behavior it follows.
So, if the consequence does not change the behavior it follows over time, it was
not actually a reinforcer. This is not an uncommon problem because motivation
can change at the drop of a hat. Moreover, many children with ASD are moti-
vated by less traditional items and activities.
There are a variety of ways to address this potential setback in imple-
mentation of NDBI. The first step is to evaluate the use of reinforcement.
Perhaps the iPad is a highly desirable item for a young girl. However, the
young girl can play on the iPad any time she wants—regardless of whether
she has demonstrated a new skill. Or, perhaps there is a gap of time be-
tween when the girl earns the iPad and when she can use it because it has to
be charged first. Or, maybe the child gets brief iPad breaks after practicing
conversations about her favorite game, Minecraft, but the game she wants
to play takes more than a couple of minutes, thereby making the reinforcer
frustrating.
The most dependable strategy for identifying effective consequences for
increasing positive behaviors is to conduct a reinforcer assessment. This might
include simply observing the child in a free operant situation, in which he or
she is given free access to the materials in front of him or her. The observation
should clarify what the child would do if given free reign of the environment.
This free operant observation is a great approach to take before using NDBI of
any kind.
It is important to be flexible when looking for reinforcers because the
child’s reinforcer might not be a predicted one. If the child in the free play
situation just sits on the floor and spins the wheels of the car, it may be tempt-
ing to think that he or she is not interested in anything in the environment,
but actually the reinforcer is spinning. Because there are many behaviors
relating to spinning (and many toys that spin), it may be effective to incor-
porate spinning in the response and the consequence. The child could be
prompted to say “spin” and then be allowed to spin an object he or she likes
to spin.
Spinning is not necessarily a behavior that clinicians want to encourage
in children with ASD because it is often an inappropriate stereotypic behavior.
However, if this is the only behavior that clinicians can use, they will use it.
By switching to an appropriate spinning toy as the child progresses, the rein-
forcement will move away from spinning to incorporate a wider range of rein-
forcing consequences. In addition to informally observing the child to identify
reinforcers, there are also more structured and formalized reinforcement as-
sessment procedures that are commonly used in the broader ABA field, as well
as tools that are available for purchase or for free online (see Kang, O’Reilly,
Lancioni, & Falcomata, 2013, for review).
 Using Consequence Strategies 209

• “My child demonstrated the target skill, but other children are not responding,
so he or she is not reinforced!”
Sometimes, the way to reinforcement is through the social behavior of another
child. Setting up opportunities to practice social-communication, social inter-
action, or play skills with peers is often ideal to promote generalization and
to use the most natural consequences possible. Yet, difficulties can arise when
relying on peers.
For example, Jackson is learning how to ask for a turn. The toy he asked for
is something he truly wants (so it reinforces “asking for a turn” behavior). His
peer, Mitchell, however, does not give him the toy when Jackson asks for it. One
possibility is that Mitchell did not know Jackson was asking for the toy because
Jackson forgot to say his name and they were on a busy playground. In this
case, the teacher might tell Jackson that Mitchell did not hear him and prompt
him to try again while saying his name. Here, the teacher is highlighting the
natural consequence and then teaching him something new. Another possibil-
ity is that Jackson provided an excellent turn request, but Mitchell did not want
to give up the toy. In this situation, the teacher might either prompt Jackson
to wait and ask again later or consider the motivation for Mitchell. When in-
corporating the use of peers into NDBI implementation, all participants—peer
models included—must have appropriate motivation or reinforcement to dem-
onstrate target skills. In this example, perhaps the teacher reinforces children
who respond positively to turn requests by offering them a different toy or by
reminding them to ask for their turn back in just a few minutes.

• “I don’t want to bribe my child.”

Sometimes people see reinforcement as a form of bribery and are uncomfort-
able using it. However, a bribe is usually something a person uses to get some-
one to do something wrong. NDBI instead provide reinforcement for positive
behaviors that adults wish to encourage. Furthermore, a bribe is typically pre-
sented before the behavior, whereas a reinforcer is presented after the behav-
ior. For instance, giving a child a piece of candy to go hit another child would
be a bribe. Giving the same child a piece of candy for not hitting a child would
be a reinforcer. Even more, adults may at times feel they are forfeiting the au-
thority of their word if they incorporate rewards for an expectation. In actual-
ity, they are strengthening the power of their word by associating it with pre-
ferred items. Also, in everyday life, rewards are truly natural and universal for
positive behaviors. Reinforcement is a common part of daily life for children
and adults alike, not only in circumstances that could be considered a bribe.
When adults get a paycheck for doing their job, they certainly do not consider
it a bribe!

• “I don’t know how to use NDBI to teach more advanced skills.”

As discussed previously in this chapter, use of NDBI is more straightforward
with early learning skills that have clear direct reinforcers and target skills.
For instance, when teaching a child his or her first words to request or protest,
educators should select words around the child’s primary interests and gripes.
The reinforcement would be receiving those preferred items (or stopping those
210 NDBI Strategies

nonpreferred activities). On the other hand, implementation of NDBI with

older children and higher level skills can be daunting. It is more difficult to
identify the natural consequence of an abstract social skill, such as responding
to nonverbal social cues, or a more complex social interaction, such as recipro-
cal conversation at lunchtime. To use NDBI to teach these more advanced skills,
consider the incentive for why other individuals engage in the target skill, and
explore the natural consequence that would follow—at least some of the time.
The finesse is setting up the opportunity to allow for that direct reinforcement
to occur.
For example, Michael is an 8-year-old who enjoys having conversations
with others—as long as he gets to talk about his favorite topics: dinosaurs and
earthquakes. One of his goals is to expand conversations to less preferred top-
ics, especially those another peer has chosen. Right now, he changes the topic
to his favorites or just does not respond if another person starts a conversa-
tion on another topic. To utilize NDBI consequence strategies, his therapist tells
him that he can take turns choosing the topic of conversation. Once he makes
three or four exchanges on a topic chosen by his peer, he can then segue into
his preferred topic of conversation (i.e., the direct reinforcer). The therapist re-
members to reinforce attempts by moving on to the other topic of conversation,
sometimes after just one exchange on a neutral or nonpreferred topic and other
times after he has made at least three exchanges.

CONCLUSION
Application of these consequence strategies is critical to the effective implementa-
tion of NDBI. Consequence strategies are founded in traditional ABA approaches
but also have unique adaptations in NDBI. These strategies are likely to not only
support the teaching of new skills but also maintain previous learning. Conse-
quence strategies have their greatest impact when effectively incorporated with
others that have been reviewed in prior chapters.
As a reminder, all NDBI learning opportunities occur within the context of
the three-term contingency, or the A-B-C sequence of learning. Thus, when setting
out to use NDBI, first consider the antecedent strategies to set the stage for learning
and to create effective teaching opportunities. Also identify the child behaviors to
reinforce and the behaviors to not reinforce. Finally, as discussed in this chapter,
decide how to respond to the child to promote long-lasting learning. Even though
NDBI often look and feel like play and natural, real-life interactions, informed
observers will find multiple iterations of the A-B-C sequence. Now that you are
familiar with the core antecedent and consequence strategies central to NDBI, the
following chapters explore teaching specific new skills.

REFERENCES
Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). Applied behavior analysis (2nd ed.). Upper
Saddle River, NJ: Pearson.
Dawson, G., & Adams, A. (1984). Imitation and social responsiveness in autistic children.
Journal of Abnormal Child Psychology, 12, 209–225.
Dawson, G., & Galpert, L. (1990). Mothers’ use of imitative play for facilitating social respon-
siveness and toy play in young autistic children. Development and Psychopathology, 2,
151–162.
 Using Consequence Strategies 211

Ingersoll, B. R., & Dvortcsak, A. (2009). Teaching social communication to children with autism: A
practitioner’s guide to parent training and a manual for parents. New York, NY: Guilford Press.
Ingersoll, B., Lewis, E., & Korman, E. (2007). Teaching the imitation and spontaneous use of
descriptive gestures in young children with autism using a naturaistic behavioral inter-
vention. Journal of Autism and Developmental Disorders, 37, 1146–1456.
Ingersoll, B., & Schreibman, L. (2006). Teaching reciprocal imitation skills to young children
with autism using a naturalistic behavioral approach: Effects on language, pretend play,
and joint attention. Journal of Autism and Developmental Disorders, 36, 487–505.
Kang, S., O’Reilly, M. F., Lancioni, G., Falcomata, T. S., Sigafoos, J., & Xu, Z. (2013). Comparison
of the predictive validity and consistency among preference assessment procedures: A
review of the literature. Research in Developmental Disabilities, 34, 1125–1133.
Koegel, R. L., Camarata, S., Koegel, L. K., Ben-Tall, A., & Smith, A. E. (1998). Increasing speech
intelligibility in children with autism. Journal of Autism and Developmental Disorders, 28,
241–251.
Koegel, R. L., O’Dell, M., & Dunlap, G. (1988). Producing speech use in nonverbal autistic
children by reinforcing attempts. Journal of Autism and Developmental Disorders, 18, 525–538.
Koegel, R. L., Schreibman, L., Good, A., Cerniglia, L., Murphy, C., & Koegel, L. K. (1989). How
to teach pivotal behaviors to children with autism: A training manual. Santa Barbara: University
of California.
Lohrmann-O’Rourke, S., & Browder, D. (1998). Empirically based methods to assess the
preferences of individuals with severe disabilities. American Journal on Mental Retardation,
103, 146–161.
Schreibman, L., & Koegel, R. L. (2005). Training for parents of children with autism: Pivotal
responses, generalization, and individualization of interventions. In E. D. Hibbs &
P. S. Jensen (Eds.), Psychosocial treatments for child and adolescent disorders: Empirically based
strategies for clinical practice (pp. 605–631). Washington, DC: American Psychological
Association.
10
Guiding Meaningful Goal Development
Grace W. Gengoux, Erin E. Soares, and Yvonne Bruinsma

T
he previous chapters highlighted that the Naturalistic Developmental
Behavioral Interventions (NDBI) approach focuses on the selection of mean-
ingful goals. Many of the previous chapters emphasize how to select func-
tional goals in specific skill domains such as communication, social skills, adaptive
behavior, and academics and how to teach these skills in developmental sequence
using NDBI strategies. This chapter extends these discussions to provide practical
guidance on how clearly operationalizing goals can make tracking progress and
mastery easy, as well as how NDBI providers select and prioritize meaningful
objectives across developmental domains.
Parents and providers may find it difficult to write goals that adequately cap-
ture the meaningful changes that they want to promote in a child or adolescent’s
development. In fact, one of the major challenges in NDBI goal development is that
the most important goals can be difficult to measure. For instance, when the true
goal is improving social reciprocity, that objective may seem difficult to break down
into achievable subcomponents (e.g., imitating an action) that can be practiced in
treatment sessions and daily activities.
NDBI approaches are unified in emphasizing the importance of selecting
meaningful, measurable, and attainable goals for individuals with autism spectrum
disorder (ASD). They highlight creating and teaching goals that follow a develop-
mental sequence and advance a child’s capacity for independence. The constructiv-
istic approach inherent in NDBI means that goals should be taught in settings that
naturally capture children’s attention, engage them to connect their new skills to
previously mastered skills, and systematically increase the level of difficulty of tar-
geted skills. Writing goals that are just one step beyond a child’s current knowledge
helps to promote success, as well as generalization of targeted skills. In addition, it
is suggested that goals include the full range of developmental domains (cognition,
social, communication, daily living skills, motor, and play) and integrate knowledge
across domains. This approach increases the generalizability of learned skills; when

213
214 NDBI Strategies

skills are taught in a discrete or isolated manner, children struggle to absorb them
and practice them in alternative settings. Instead, the NDBI approach suggests using
varied materials and people to teach skills to children within their daily interactions
and routines to provide a solid foundation for effective and efficient learning.
Theories of child development suggest that skills develop in a certain order;
thus, it makes sense to follow this order when teaching. In fact, one important con-
tribution of the developmental theory underlying NDBI approaches is the empha-
sis on ensuring that therapy goals are just above a child’s current skill level and,
as such, fit within the developmental skill sequence. Selecting skills in a predeter-
mined rigid order from a curriculum may be convenient but may also result in low
skill maintenance. In addition, an uninformed goal-selection process may produce
goals the child has already mastered or those that are too advanced. Furthermore,
a child should learn to use a skill under different conditions with many communi-
cative partners (generalization), and the skill should have enough depth and flu-
ency to be truly useful to the child. The important constructs of developmental
sequence and generalization are at the heart of the NDBI approach to goal selection
and are central in the discussion throughout this chapter.

FORMULATING GOALS
When developing NDBI goals, providers must create target skills and write goals that
are not only functional, developmentally appropriate, and individualized to each
child but are also relevant to the child’s culture and valued by the family. Before dis-
cussing these issues in detail, this section provides practical guidance on writing and
working toward measurable objectives across the different developmental domains.
NDBI goals should be written with an instructional program outlining exactly
how they will be practiced to ensure that all providers are teaching the skills in a
coordinated manner. The Project DATA (Developmentally Appropriate Treatment
for Autism) model, for instance, recommends writing instructional programs that
clearly delineate the target skill, the steps of that skill, examples of how to teach the
skill, mastery criterion (how to know that the skill has been effectively learned),
and ways in which both generalization and maintenance will be promoted.
As advocated by various NDBI, well-written goals across domains share many
characteristics. Goals should be specific, be measurable, have mastery criteria, and
be written based on the typical sequence of development. Target skills and goals
should also be relevant to the child’s culture and important to the child’s family.
When family members consider the goal to be meaningful, they are more likely to
present naturalistic opportunities for the child to practice and maintain the skills,
which subsequently facilitates generalization.

Measurable Goals
All NDBI are congruent in their emphasis on goals that are measurable. Measur-
able goals need a clear statement of whichever behavior is expected. This should
be written with adequate descriptive information, and the behavior should be ob-
servable and specific. If the overarching goal is to foster and practice joint attention,
observable behaviors might be pointing at something, gazing in the same direction
as a peer, or orienting one’s head to an object or item that another person has identi-
fied. These goals are measured by observation so that an adult could determine the
 Guiding Meaningful Goal Development 215

success of a child with this goal by reading the objectives and observing his or her
play. The following example is a goal written in NDBI format:
“Amad will visually follow when a peer points to an object at a distance, look
at the object, and then make eye contact with the peer. He will demonstrate the
behavior at least two times across three consecutive play sessions, with at least
three different peers.”
Goals should also list the antecedent to the target behavior. This helps to pro-
vide context for the skill as well as to outline a goal that has a clear identifier to
maintain consistency across teachings. For example, if a child has a goal of using
the toilet independently, an antecedent could be the identification of the need to
use the toilet. Or, if a child’s targeted skill is to say a reciprocal “hi” when seeing or
meeting a new person, the other person saying “hi” would act as the antecedent.
For instance, in the example with Amad, the addition of the following specifi-
cation would make the antecedent for the goal more clear:
“In response to a peer saying, ‘Hey, look at that!’ while standing no more than
5 feet away from Amad and pointing to an object across the room (antecedent), Amad
will visually follow when a peer points to an object at a distance, look at the object,
and then make eye contact with the peer. He will demonstrate the behavior at least
two times across three consecutive play sessions, with at least three different peers.”

Mastery Criteria
As evidenced in the previous example, reasonable and measurable mastery criteria
are also crucial to include when writing goals consistent with the NDBI approach.
Mastery criteria specifically define how providers can judge if the child learned a
specific behavior, as well as the child’s level of mastery with the target behavior.
Including mastery criteria ensures that teaching is focused and retains clarity. With-
out clear mastery criteria, providers would have difficulty determining when a child
has successfully learned a skill and thus when to proceed to more advanced skills.
Mastery criteria also help determine how quickly a child might learn skills by pro-
viding time-limited goals within the child’s developmental and individual abilities.
In the previous example, evaluators would consider that Amad has mastered
the specific joint attention task after completing the behavior two times within
three consecutive sessions, with three different peers. It is important to note that
special care should be taken when mastery criteria utilize percentages (e.g., Amad
will look at the object 75% of the time). Percentages can be poor characterizations
of success; can be very hard to measure, as in the previous goal example; and can
be meaningless with few trials. In addition, percentages can be especially unhelp-
ful in writing goals that target behaviors that are spontaneous or independent of a
peer or teacher because providers would have difficulty defining the opportunity.

Maintenance and Generalization

NDBI goals specify the criteria for maintenance and generalization of each tar-
geted behavior. Focusing on maintenance ensures that skills are maintained over
time and thus saved in a child’s tool box of skills for regular and repeated use. For
generalization, skills must also be performed successfully across various natural-
istic settings and with various people. When target behaviors are used in novel
situations or with novel people, this is usually an indication that a skill has been
216 NDBI Strategies

generalized. Goals should be written with specifications about the settings, mate-
rials, and individuals with whom the skills should be demonstrated. Criteria can
also be included about how long the skill should be maintained. After sufficient
practice, a learned skill should be robust enough to be demonstrated consistently
across all relevant contexts.
Table 10.1 includes several examples of measurable goals for a 3-year-old child
with ASD. Sample objectives are provided across several important domains,
including joint attention, imitation, play, and self-care. Each objective clearly speci-
fies the relevant setting or antecedent, as well as mastery and generalization cri-
teria. Objectives are then broken down into five or six steps to illustrate how a
provider may sequentially teach components of the objective to a child. The objec-
tives are written clearly and concisely and are formatted to include the setting, the
specific behavior of focus, an antecedent if applicable, and the mastery and gener-
alization criteria.

Parent Training Goals

Parent training goals can be identified based on assessment of parent skills at the
start of treatment and also based on discussion of parent priorities for their own
learning. Just like goals for child skill acquisition, parent training goals should
be meaningful, individualized, and clearly operationalized. Many NDBI programs
have criteria for treatment fidelity. These can be applied to assessment of therapist
treatment fidelity but also assessment of parent treatment fidelity. However, parent
training goals can also span a wide range of additional skills, depending on the
parent’s learning priorities.
Parent training goals fall into several categories. As described previously, these
goals may relate to parent acquisition of specific skills. A parent may decide that
he or she wants to learn to implement a particular NDBI approach with treatment
fidelity. For instance, the Pivotal Response Treatment (PRT), JASPER (Joint Atten-
tion, Symbolic Play, Engagement, and Regulation), and Project ImPACT (Improv-
ing Parents as Communication Teachers) programs often include parent training as
a core part of intervention and systematically teach parents to implement the same
procedures therapists are using. A parent might also select a specific treatment
strategy to learn and practice (e.g., natural reinforcement, reinforcing attempts).
Another approach to goal development would involve selecting a specific child
skill and then teaching a parent how to use NDBI techniques to target that skill.
For instance, a parent might decide that he or she wants to learn how to incorporate
NDBI strategies for facilitating peer play or into homework sessions.
Goals may also relate to style of interaction. For instance, in Early Start Denver
Model (ESDM) treatment, the emphasis is on teaching parents to use a responsive
interaction style that complements the therapy delivered by ESDM providers. Par-
ent goals might also be for frequency of practice. A provider might recommend
30 minutes of practice per day, and the parent goal could be to consistently achieve
this objective. Another option would be to set a goal for incorporating practice into
a particular daily routine. In this case, a parent might have the goal to prompt for
at least five communication behaviors and three play skills during each bathtime.
Regardless of the exact focus, clear parent training goals that are mutual priorities
can form the basis for collaborative and productive treatment progress. Box 10.1
provides a simple way to organize one’s thoughts while writing a goal.
 Guiding Meaningful Goal Development 217

Table 10.1. Examples of measurable goals that specify the antecedent, as well as mastery and
generalization criteria

Joint attention When engaged in toy play within a routine (setting), child will spontaneously
objective share a smile with a nearby adult (3–6 feet away) by clearly shifting gaze
from object to adult eyes and back to object, while smiling, to share pleasure
(behavior), three or more times in 10 minutes of social play on 3 different
days of treatment (mastery criterion) with mother and therapist across
three different object activities (generalization).
Step 1 (baseline) Child shares a smile with eye contact for 2–3 seconds with partner during
coordinated play.
Step 2 Child shares a smile with nearby adult during object activity by shifting
gaze partially (either from object to adult or from adult to object).
Step 3 Child shares a smile with nearby adult during object activity by shifting gaze
from object to adult and back at least one time in 10 minutes of play.
Step 4 Child shares a smile with nearby adult during object activity by shifting
gaze from object to adult and back at least three times in 10 minutes of
play on a single day with mother or therapist during one or more object
activities.
Step 5 Child shares smiles with nearby adult (3–6 feet away) during object
activity by shifting gaze from object to adult and back three or more
times in 10 minutes of play on 3 different days with mother and
therapist across three different activities.
Imitation objective When songs are sung during intervention sessions (setting) and the adult
models a novel motion (antecedent), the child will independently imitate
by copying the same motion (or approximation) within 5 seconds of the
first model (behavior) across five or more different actions and three or
more songs during three consecutive intervention sessions (mastery
criterion) with mother or therapist in home and in clinic (generalization).
Step 1 (baseline) Child independently imitates three familiar motions within 5 seconds of
the first model.
Step 2 Child independently imitates 10 different familiar motions across five songs
within 5 seconds of the first model without adult prompting.
Step 3 Child independently imitates one novel motion within 5 seconds of the
first or second model.
Step 4 Child independently imitates three novel motions across two songs within
5 seconds of the first model.
Step 5 Child independently imitates five novel motions across three songs during
one intervention session with mother or therapist at home or in clinic.
Step 6 Child independently imitates five novel motions across three songs during
three consecutive intervention sessions with mother or therapist in
home and in clinic.
Play objective During independent play time (designated time during clinic sessions
or outside of intervention sessions when adults are otherwise occupied;
setting), child independently gets materials for either an open-ended
or closed-ended activity, brings to table or other play space, completes
play task, and puts away (behavior) at least two times in a single day
for a duration of at least 15 minutes for three consecutive sessions
(mastery criterion) with three different activities at home and in clinic
(generalization).
Step 1 (baseline) Child can occupy self appropriately with trains for up to 10 minutes with
occasional adult guidance.
Step 2 When prompted verbally to get play materials, child retrieves items, takes
to play space, and plays independently for at least 10 minutes; child may
need assistance (modeling and repeated gestural prompts) to clean up.
Step 3 Child independently gets play materials, brings to play space, and
completes task of at least 10-minute duration; child may need verbal
prompting to clean up.

(continued)
218 NDBI Strategies

Table 10.1. (continued)

Step 4 Child plays independently by getting materials, bringing to play space,

completing play task, and putting away at least one time for a duration
of at least 10 minutes.
Step 5 Child plays independently by getting materials, bringing to play space,
completing play task, and putting away at least two times in 1 day for
a duration of 15 minutes for three consecutive sessions with three
different activities at home and at clinic.
Self-care objective During morning or evening self-care routine in bathroom (setting) when
adult instructs child to brush teeth (antecedent), child independently
brushes toothbrush over teeth (upper and lower teeth, front and back;
behavior) two times per day for 3 consecutive days (mastery criterion)
with both mother and grandmother at home and at grandmother’s
house (generalization).
Step 1 (baseline) Baseline: Child puts toothbrush in mouth independently.
Step 2 Child brushes toothbrush over back teeth (upper and lower) with gestural
prompt.
Step 3 Child brushes toothbrush over front teeth (upper and lower) with gestural
prompt.
Step 4 Child brushes toothbrush over all teeth one time per day for 2 days
independently.
Step 5 Child independently brushes toothbrush over all teeth two times per day
for 3 days with mother and grandmother at home and at grandmother’s
house.

ASSESSMENT
Before developing goals for an individual child, providers must conduct careful as-
sessment to establish an understanding of the child’s baseline level of ability in each
area of interest. Practice parameters for assessment of children with ASD empha-
size that information about cognitive development, adaptive skills, communication
abilities, and family context are critical for inclusion in any comprehensive assess-
ment (Volkmar et al., 2014). Assessment can be formal and include standardized
tests but should also include observation in the natural environment and parent
and caregiver input. Assessment looks different for every child, based on many fac-
tors, including age, developmental level, and abilities. NDBI approaches commonly

Ready, Set, Implement!

BOX 10.1: Identify a goal
Think of a new behavior you want to teach, and write it down in the center of a
piece of paper. Make sure you provide enough observable details that it will be
clear to any observer whether the behavior occurred. Next, at the top of your
page, add information about the context in which the behavior is supposed to
occur and any cue or prompt that should happen first. At the bottom of the
page, write down how many times the behavior should be observed to be
considered mastered and across which generalization contexts. You should
now have a clear written goal including antecedent, behavior, mastery, and
generalization criteria.
 Guiding Meaningful Goal Development 219

utilize a combination of standardized assessments, curriculum checklists, and be-

havioral observation to develop goals for children with ASD. Each method offers a
distinct type of information relevant to goal selection.

Standardized Assessments
Standardized assessments have been developed to be delivered in a consistent
manner across children. When administered by trained providers, the results of
these assessments should be directly comparable and should therefore be easily
interpreted across settings by practitioners trained in the assessment. Some stan-
dardized assessments involve direct interaction with a trained evaluator, and other
assessments involve parent or caregiver responses to a standard set of questions.
Norms available for many standardized assessments also provide helpful bench-
marks for comparing a child’s current performance level with that of typically de-
veloping peers in the same age range.
Norm-referenced standardized tests are commonly used to measure child
developmental level. These include tests such as the Mullen Scales of Early Learn-
ing (MSEL; Mullen, 1995), Bayley Scales of Infant and Toddler Development (BSID;
Bayley, 2006), Differential Ability Scales (DAS; Elliott, 2007), and Wechsler Pre-
school and Primary Scale of Intelligence (WPPSI; Wechsler, 2012). Intelligence
tests (e.g., Wechsler Intelligence Scale for Children [WISC; Wechsler et al., 2003],
Stanford Binet Intelligence Scales [SBIS; Roid, 2012], Kaufman Assessment Bat-
tery for Children [KABC; Kaufman & Kaufman, 2004], Woodcock-Johnson Tests of
Cognitive Abilities [Schrank, Mather, & McGrew, 2014]) can provide similar infor-
mation about broad aspects of cognitive functioning and relative strengths and
weaknesses in aspects of learning and information processing for school-age chil-
dren and teens. There are also a wide range of standardized language and com-
munication tests (e.g., Preschool Language Scale, 5th Edition [PLS-5; Zimmerman,
Steiner, & Pond, 2011], Communication and Symbolic Behavior Scales [CSBS;
Wetherby & Prizant, 2003]) often used with children with ASD.
Standardized, norm-referenced tests provide the most global-level infor-
mation about a child’s developmental level. They do not identify specific target
behaviors to be addressed in intervention but rather broad areas of functioning
in which the child may be performing below the expected level. Because of their
broad focus, these measures are typically administered at infrequent intervals, as
they are not very sensitive to change. A child’s progress is likely to be observable
by behavior observation or a skills checklist long before it would be detectable on
a developmental or intelligence test. However, for NDBI implementation, knowing
a child’s developmental level or cognitive profile can be invaluable for helping the
provider design developmentally appropriate goals.
For instance, a low score on the Visual Reception subscale of the MSEL or
on the Cognitive subscale of the BSID at the start of treatment could indicate that
the child has limited understanding of visual symbols. For this child, it may be
appropriate to prioritize goals involving play with toys and real objects rather than
pictures and books. In contrast, another child might show relative strengths on
the DAS Nonverbal Reasoning Ability or WISC Visual Spatial scale, which could
indicate that inclusion of visual supports in the initial treatment goals would help
the child progress more quickly. As another example, if a child who is nonver-
bal shows relative strengths in Receptive Language abilities on the MSEL or BSID,
220 NDBI Strategies

this information could guide providers to use activities such as following verbal
instructions (i.e., receptive language skills) as a maintenance task while teaching
more difficult expressive communication behaviors. Thus, knowing about broad
areas of strength and weakness can help providers determine an appropriately
individualized developmental sequence for teaching.
A number of parent/caregiver report measures have also been standardized
and allow for comparison of a child’s reported skills to a large normative sample.
For instance, measures of adaptive behavior (Vineland Adaptive Behavior Scales
[Sparrow, Cicchetti, & Saulnier, 2016]; Adaptive Behavior Assessment System
[Harrison & Oakland, 2003]), communication (MacArthur-Bates Communicative
Development Inventories [Fenson, Marchman, Thal, Dale, Reznick, & Bates, 2007];
Communication and Symbolic Behavior Scales Developmental Profile Infant Tod-
dler Checklist [Prizant & Wetherby, 2002]), and social skills (Social Responsiveness
Scale [Constantino & Gruber, 2012], Social Skills Improvement System [Gresham
& Eliott, 2008]) are commonly used in assessment of children with ASD. Although
not developed specifically for the purpose of identifying treatment goals, informa-
tion from these types of assessments is also highly relevant to goal selection. Some
items on these measures are specific enough that they can be considered possible
treatment targets (e.g., naming common objects, greeting familiar people, washing
own face). Other items suggest broader areas of deficit where a series of sequential
goals might be developed (e.g., reading at the second-grade level, imitating play
acts, taking care of a cut or scrape). Because these measures are typically completed
by parents, they often give important insight into a child’s typical performance in
the natural environment, which is a critical consideration in planning treatment
priorities. For instance, if a child performed well on a standardized test of expres-
sive language but the parent report indicates that adaptive communication skills
in natural contexts are still significantly impaired, then additional treatment of
communication skills would be needed, in spite of strong tested language ability.

Curriculum Checklists
Skill checklists are another useful method for identification of potential treatment
goals in NDBI. These tools often list skills both by domain and in developmental
sequence, making them easy to use for identifying next steps for a child’s treat-
ment. These tools typically are designed with the treatment modality in mind and
already have embedded assumptions about which types of skills will be important
to target (e.g., high density of social-communication skills with emphasis on be-
haviors such as joint attention and imitation). There are many available checklists,
both those developed specific to an individual NDBI approach and those devel-
oped for more general use in Applied Behavior Analysis (ABA) programming. Rec-
ommended methods of administration vary across tools but often include parent
report of skills as well as observation of the child.
As an example, ESDM typically uses play-based methods for in vivo assess-
ment of a child’s skills across a range of developmental areas and complements the
clinician observation with parent report of a child’s typical performance at home,
particularly for skills that are difficult to observe in a clinic setting. Using a curricu-
lum checklist, interventionists conduct one or more play sessions to observe various
types of play (parent–child play, solo child play, assessor-directed play) and may
interview family members to collect a full picture of the child’s typical performance
 Guiding Meaningful Goal Development 221

across key developmental milestones (Rogers & Dawson, 2010). Once complete, this
information forms an assessment profile organized by developmental domains
(e.g., expressive and receptive language, social skills, motor skills). The profile can
yield information about skills that are firmly established and always performed, as
well as skills that are partially established and demonstrated intermittently. Upon
completion of the initial assessment, the child’s team and parents can collaborate to
form a plan of objectives to be taught to the child in naturalistic, play-based teach-
ing sessions. For instance, two to three goals per developmental domain may be
identified as priorities for a 12-week intervention period (Rogers & Dawson, 2010).
Checklists are also used by several other NDBI approaches for identification
of key target behaviors for treatment (structured play assessment used in JASPER
and social-communication skills checklist used in Project ImPACT). Though these
tools are most relevant to young children and are not yet widely disseminated or
standardized, they have the advantage of being highly specific to NDBI treatment.
See the following case example for samples of clearly operationalized and develop-
mentally based learning objectives.

Case Example: José

José is a 22-month-old boy recently diagnosed with ASD. He has limited verbal abili-
ties, lacks eye contact, and engages with toys by lining them up and then moving
along to another activity. Table 10.2 includes examples of goals, by developmental
domain, that might be created for José.

Table 10.2. José’s goals by developmental domain

Receptive communication José will follow four out of five one-step directions (e.g., “sit
down”) in a 50-minute therapy session for three consecutive
sessions with at least two different adults.
Expressive communication While playing an activity with a parent, José will request that the
activity continue by naming the game or saying “play again”
during four out of five opportunities for three consecutive
sessions with at least two different activities.
Joint attention José will follow the gaze of someone pointing at a novel
object at a distance during four of five opportunities across
3 consecutive days with at least three different types of
items (e.g., an item of food, a toy, a person).
Social engagement During a social routine with a parent, José will remain engaged
as evidenced by appropriate eye gaze, facial expression,
gesture, body orientation, or vocal communication for a period
of at least 45 seconds during four out of five opportunities over
three consecutive sessions with mother and father.
Peer interaction José will ask a friend to share a snack with him by saying
“more snack” during four out of five opportunities over three
consecutive sessions with at least three different peers.
Fine motor skills José will open a container independently on four out of
five opportunities across 3 consecutive days with at least
three different types of containers (including containers
with screw-on lids) at home and in clinic.
Gross motor skills During song routines when an adult models a gross motor action,
José will spontaneously (within 3 seconds) imitate at least
four actions in three different songs across three consecutive
sessions with his mother and therapist at home and in clinic.
222 NDBI Strategies

Other types of curricular assessments can be helpful for identification of specific

treatment goals, even if they do not include norms to allow comparison with typi-
cally developing children. These are tools that measure discrete behaviors that
can be directly targeted as treatment goals, in contrast to the developmental tests
discussed previously that evaluate global areas of functioning. For instance, tools
such as the Assessment of Basic Language and Learning Skills (ABLLS; Partington,
2010) and Verbal Behavior Milestones Assessment and Placement Program (VB-
MAPP; Sundberg, 2014) may be useful for NDBI providers because they have been
developed specifically for use in identifying ABA treatment goals. By comparing a
child’s performance across one of these comprehensive assessments, providers can
identify areas of particular deficit to prioritize. In contrast, if an important develop-
ment area has already been identified (e.g., joint attention), tools such as the Early
Social Communication Scales (ESCS; Mundy, Hogan, & Doelring, 1996) can be used
to obtain detailed information about performance on discrete aspects of this skills
(e.g., initiation of joint attention vs. response to joint attention). These measures are
useful because the results directly identify behaviors that can be taught in treat-
ment sessions.
An even wider range of checklists has been developed for ABA treatment and
for early childhood education generally, and many of these tools will also be useful
to NDBI providers. For instance, the published skills checklist from Project DATA
(Schwartz, Ashmun, McBride, Scott, & Sandall, 2017) is highly compatible with the
NDBI approach and can be used for identifying behavioral teaching targets for
preschool-age children with ASD. NDBI programs, particularly those embed-
ded in or formatted like preschools, also often take advantage of published goal-
development materials designed for use in early childhood education settings
(e.g., Carolina Curriculum for Preschoolers with Special Needs [Johnson-Martin,
Attermeier, & Hacker, 2004]; Assessment Evaluation and Programming System for
Infants and Children [AEPS®; Bricker, 2002]). This can be especially helpful when
providers seek to align treatment goals with standards being applied to typically
developing children in the same age range (e.g., for group instruction of children
with varying abilities), or when the overall goal is to prepare the child with ASD to
function as independently as possible in an inclusive preschool setting. In the same
spirit, curricular materials from the classroom of a school-age child with ASD can
be used to form the basis for selection of treatment targets relevant to that child’s
classroom participation.

Behavioral Observation
Children with ASD often present with an uneven profile of skills, or with so-called
splinter skills. As a result, merely using a curriculum based on general chronologi-
cal age, or on overall developmental age for that matter, may be insufficient. It may
be more helpful to carefully observe the child in each skill domain and determine
which skills the child can perform independently; which skills the child needs
support with but can do partially; and which skills the child is absolutely not able
to do at all, even with help.
Observation also often provides valuable data regarding skill performance.
Sometimes a child has acquired a skill but is not reliably or independently using
the skill. Such challenges with skill performance can occur for a number of reasons,
including poor skill fluency, challenges with generalization, or environmental
 Guiding Meaningful Goal Development 223

Table 10.3. Examples of external variables that may impact skills performance

Variable that affects

skill performance Limiting variables Enhancing variables

Caregiver or teacher Adult overprompts and does not
allow the child to answer.
Teacher does not have a clear
prompt.
Siblings or peers A sibling or peer with challenging
behaviors may prevent the
child with ASD from exhibiting
appropriate sharing behavior.
Environmental Toys are freely accessible without
factors the need for the child to request.
A single copy of each toy limits
the possibility of play imitation.
Teacher is priming the student.
Caregiver arranges the environment
to optimize the chance the student
will engage in the target behavior.
A sibling or peer can persevere
in prompting greeting behavior
while the child is distracted.
Toys are organized out of reach to
promote requesting.
Duplicate items are available to
promote imitation.

barriers. In this case, observations may reveal mediating variables enhancing or

limiting a child’s skill performance, such as parent or caregiver skill level, sibling
or peer help or interference, or environmental factors influencing performance.
Knowledge of these variables may result in goals that are more specific and indi-
vidualized, while also taking into account mediators of the child’s behaviors. For
example, if there is an environmental issue that makes performance of a skill dif-
ficult, barriers can be removed or caregivers can be taught alternate behaviors.
When teaching handwashing, ensuring the child can push the soap dispenser is
an easy fix, as is making sure that the child can reach the faucet handle or that
there is a towel available. A more difficult barrier to address can be a caregiver
insistent on motoring the child through handwashing sequences to ensure cleanli-
ness. Table 10.3 includes additional examples of external variables that may affect
a child’s skill performance.
Several NDBI programs have developed specific protocols for observational
assessment that rely on either live observation or review of video-recorded interac-
tions or transcripts to obtain detailed behavioral data used to assess baseline func-
tioning and track treatment progress. For instance, enhanced milieu teaching (EMT)
emphasizes the importance of careful assessment of language levels and analyzes
language samples from play and routine interactions between the child and the
parent or interventionist (Hancock & Kaiser, 2002). Language samples are subse-
quently examined to determine the length of the child’s utterances (mean length of
utterance), the total number of words, the number of different words, the number
of utterances with a certain length, and the number of spontaneous and prompted
target words. EMT also uses SALT, or the Systematic Analysis of Language Tran-
scripts (Miller & Chapman, 1985), after transcription to generate detailed analyses.
Observation can also provide valuable information about strategies parents
are already using to enhance a child’s development and provide insight into which
parent training goals may be most important to target in initial sessions. Some
NDBI programs include assessment of parent skills as part of the treatment plan-
ning process. This can be implemented via informal observation and discussion.
Other times, assessment focuses on measuring parent treatment fidelity of the spe-
cific treatment strategies. For example, parent training in PRT and ESDM routinely
involves observational assessment of parent implementation of the targeted moti-
vational strategies. This information can then be used to plan subsequent parent
224 NDBI Strategies

training sessions to teach specific intervention strategies that were not observed in
the assessment. In a case where a parent is already using clear prompts and contin-
gent reinforcement to teach new skills, the parent training feedback may focus pri-
marily on incorporating the child’s interests and interspersing maintenance tasks
or utilizing those prompting and reinforcement skills in the context of affect-laden
interactions. In contrast, if a parent is observed at baseline to ask frequent ques-
tions without contingent reinforcement, a provider may focus first on establishing
a shared understanding of the benefits of natural reinforcement and coaching the
parent in strategies for establishing shared control of items of interest during play.
Regardless of whether standardized assessments, checklists, behavioral
observation, or (ideally) a combination of methods is being used, clinical judgment
is critical when selecting and prioritizing goals. The following section outlines
family and cultural factors, as well as child-related developmental considerations,
which can help providers effectively use assessment results in selecting goals that
will be the most meaningful for children and their families.

CONSIDERATIONS FOR GOAL SELECTION

If a child’s skills are significantly delayed across multiple areas of development, one
of the most difficult decisions for a parent or provider to make is which goals to
prioritize. Even the most intensive programs often need to trim down the number
of goals to ensure that each objective receives sufficient practice to improve. Parents
who work with their children during daily routines will also find that the days pass
quickly. Without a clear plan for which goals to practice each day, progress on impor-
tant goals can be slow. Yet, selection can seem overwhelming when there are many
possible skills to target. Thus, having clear priorities helps everyone on the treatment
team work toward the same objective and provide the most effective treatment.

Cultural Considerations
One critical aspect of meaningful goal selection includes considering family val-
ues and culture, as well as ecological goodness of fit (i.e., the extent to which the
selected goals are relevant in the child’s natural environment and consistent with
the family’s daily routines). There is a large body of literature highlighting the
importance of family-centered practices (Sukkar, Dunst, & Kirby, 2016) and the
importance of involving parents as stakeholders and equal and essential partners
in the intervention (Keilty, 2010). The process of incorporating a family’s culture
and values into treatment plans starts during assessment. If providers are using
standardized assessments to establish baseline abilities, it can be especially impor-
tant to actively seek out parent input to determine how representative the child’s
performance on standardized tests is of actual skill performance in natural envi-
ronments. Even if a skill appears mastered during testing, it could be a critical goal
to incorporate if the child does not regularly perform that skill at home or in im-
portant community settings. For instance, a child may show the ability to respond
to his or her name or follow a simple instruction during testing; however, if those
behaviors are not typically performed at home, they should likely be incorporated
into the treatment plan.
Parents and other caregivers should be asked to contribute their opinions and
wishes early in the process of treatment planning. If a parent feels that a particular
 Guiding Meaningful Goal Development 225

goal is important to the family, it should be strongly considered for the initial treat-
ment plan. For example, in some families it might be important that the child learn
to properly greet family members, take off shoes before entering the house, or eat
with utensils. In other contexts, demonstration of solitary play skills, academic
abilities, and independent toileting might be more important to family members.
This consideration is particularly important when establishing goals for par-
ent training. Parents must be involved in decision making about which skills they
will learn. Although further research is needed into how ASD treatment should
be modified to benefit ethnically and culturally diverse families, cultural beliefs
clearly affect how important specific goals (e.g., compliance, initiations, reduction
of self-stimulatory behavior) are for family members. In fact, many evidence-based
treatment programs may differentially incorporate values from the dominant
European-American culture, such as the importance of individualism, competition,
speed, and explicit communication, and may require modifications for appropri-
ate use with diverse families (McDermott, 2001). The more carefully family values
are incorporated at the start of treatment, the bigger long-term positive impact that
treatment is likely to have on the family because parents are more likely to practice
goals that they view as a priority.

Importance of Caregiver Buy-In

Often parents and caregivers have clear preferences regarding important skills to
target, and providers should take careful account of these. For instance, some fami-
lies consider self-help goals to be top priorities because of the immediate impact
they have on reducing parental stress and improving family quality of life. Other
families prioritize safety skills, reductions of specific challenging behaviors, or
value-specific communication objectives, such as saying “mama” or “papa.”
If a parent feels strongly about a goal that providers consider to be well
beyond a child’s current level of ability, providers can collaborate with parents
to select interim goals that move the child toward the long-term objective. For
instance, parents often wish their children would answer questions about things
that happened during the day at school. For a child who does not yet know how
to answer any open-ended questions, a provider could encourage focusing first
on the descriptive language necessary for answering questions about immediate
events while they are occurring. A child who is already able to answer ques-
tions about current events could work on answering questions about past events
that are known to the parents (which allows parents to prompt correct responses
if needed—something they cannot do if they do not know what happened at
school).
The fact that family members value a particular goal is an important reason
to make it a priority because doing so will establish the family as active stake-
holders and increase buy-in. When developing a short list of top goals, provid-
ers should make a habit of asking parents for their input early in the process
so that any strong preferences can be built directly into the treatment plan. It is
particularly important to have parent buy-in related to the parents’ own learning
objectives; therefore, parents should be intimately involved in selecting goals for
parent training as well. Providers should work collaboratively with parents to
develop parent training goals that are aligned with skills that the parents have
shown strong interest in learning. Such parent training goals will not only assist
226 NDBI Strategies

Ready, Set, Implement!

BOX 10.2: Consider family values and preferences
To explore goodness of fit for a new goal, you will want to consider family
values, cultural practices, and daily routines. Make a list of at least three specific
questions you could ask family members in order to determine whether a
proposed goal is likely to be a good fit for the family. Here are some examples:
1. Does this goal match with your top priorities?
2. Will changing this behavior make a meaningful difference in your life?
3. Will you have a lot of opportunities to practice this goal?
4. Is this goal relevant and important for your family’s daily life?
5. Does this goal align with your family’s values?
6. Does this goal help you get to your long-term objectives for your child
and family?

parents in being able to support and teach their child but also show respect for
their values and parenting priorities. Box 10.2 summarizes goodness of fit for
goal development and provides some sample questions to investigate stakeholder
buy-in.

Selecting Functional Skills

The term functional refers to the importance of ensuring that anything taught is
relevant to the student’s life and can be used right away. Chapter 3 reviews the
importance of selecting functional skills in NDBI; this section offers a practical ap-
plication for goal selection. One way to determine whether a skill is functional is
to assess whether it will make a substantial difference in the person’s life. Will the
new skill be valuable to the individual (i.e., improve quality of life or provide the
individual with more independence)? For example, if a child is struggling to learn
how to speak, the provider may want to teach words that will help him or her to be
more independent. Teaching to say or sign “thank you” is less relevant at that stage
and less functional when compared to teaching requests for actual items. The case
examples that follow highlight these important considerations.

Case Example: Jenna

Jenna is a 2-year-old girl with ASD who is not yet verbal and engages in high levels of
challenging behaviors. She enjoys bubbles and playing tickle games with her parents.
Her current goal is to learn functional words: When Jenna wants an item or activity,
she will independently use 10 words to request items or actions within a 10-minute
sample with at least three communicative partners and across at least two settings.
Is this goal functional? Maybe; Jenna’s provider should choose words for items
or actions that Jenna loves and encounters regularly; some of those key words
include bubbles, tickle, and cracker. Because Jenna exhibits challenging behaviors, it
 Guiding Meaningful Goal Development 227

may also be important to pick words that can serve the same function of the problem
behavior (e.g., teaching “no” for escape or “mama” for attention).
Will these skills have a meaningful effect? Yes; learning first words will make
a big difference for Jenna’s independence. It can be tempting to pick first words
that are important to adults (e.g., hi, thank you) or that apply to lots of activities
(e.g., more, go), but children with ASD often learn best when requesting things they
really want and when the natural consequence for each new word is different (as it
would be for tickle, cracker, and bubbles). In addition, Jenna’s provider should avoid
teaching one word that can be used for everything but rather should teach the labels
for actual items, actions, or activities.

Case Example: Kaleb

Kaleb is a 10-year-old boy diagnosed with ASD. He enjoys playing board games. He
is currently working on cognitive and academic skills. Kaleb’s therapist has decided to
target the skill of reading: When asked about a book he read that day, Kaleb will inde-
pendently answer three content questions about the reading, accross at least three
reading assignments.
Is this goal functional? Likely; for reading skills to be functional, Kaleb must
understand what he is reading (e.g., reading comprehension). To begin, Kaleb could
read about topics that interest him in environments that are motivating (e.g., reading
instructions to operate a toy or game that he is interested in playing). Another idea is
to try writing a message about how the child can find a hidden preferred item. When
information that is useful or interesting to the child is embedded into text, reading
comprehension will be naturally reinforced.
Will teaching reading skills have a meaningful effect? Yes; reading is a critical
learning skill for children at this age. If it is within his cognitive capacity, improving
Kaleb’s reading skills as well as his motivation to read (by practicing his skills in moti-
vating and reinforcing contexts) will enable him to find greater academic success.

Case Example: Ashir

Ashir is a 13-year-old boy diagnosed with ASD. He has conversation-level language
skills, enjoys playing video games, and largely struggles with social skills, particularly
at school. His current goal is to improve his personal boundaries: Ashir will demon-
strate appropriate social boundaries with peers at recess, defined as remaining at
least 2 feet away unless whispering, for at least 80% of 10-minute samples (scored
in 1-minute intervals) on three consecutive occasions with at least three different
peers.
Is this goal functional? Yes; this goal is functional, especially if skills are prac-
ticed in the context where problems are occurring (e.g., school recess) and across
interactive partners.
Will improving his personal boundaries have a meaningful effect? Yes; especially
for teens, knowing how close to stand and when touching is appropriate is critical
for social success. Some teens may be motivated by positive peer response; others
may need additional natural reinforcement for practicing this skill.
228 NDBI Strategies

DEVELOPMENTAL CONSIDERATIONS
As noted previously, students learn skills best when they are presented and taught
in a predictable developmental sequence so that targeted skills are incrementally
above the child’s current abilities and the selection of subsequent skills follows
a clear trajectory from the current level of functioning toward more advanced
age-appropriate skills. When considering developmental principles in writing
goals, providers should focus on core deficits in various developmental domains,
teach the next skill in the developmental sequence for that domain, consider the
cascading effect while teaching skills and writing goals, focus on the depth of the
skills taught, and ensure that goals are age appropriate. Each of these issues is out-
lined in detail next.
When setting goals, providers should take current developmental level into
account and then set the child up for success by programming just slightly above
the current level without setting the goals too high. This approach is related to
Vygotsky’s theory that children learn best the skills that are within a “zone of prox-
imal development” (Rutland & Campbell, 1996). This zone includes skills that the
child can do with guidance but not yet independently or spontaneously. When pro-
gramming in this way, therapists focus on the skill in the child’s zone of proximal
development, practice the skill with modeling and guidance, and then gradually
move on to more advanced skills one step at a time upon mastery of previous skills.
For example, if a child can already combine words into short phrases, the next
developmentally appropriate goal within this domain could be to model, prompt
for, and practice expanded utterances. In addition, if a child was able to under-
stand, process, and complete one-step instructions, interventionists could work on
modeling and prompting for two-step instructions. Once two-step instructions are
mastered, they could move on to novel combinations of instructions, three-step
instructions, and so forth. This progression of goals follows a clear, linear develop-
mental trajectory and focuses on teaching the next skill that is just one small step
above the child’s current ability level.

Key Challenges
Theories of ASD can provide some guidance about the most important skills to
target. For instance, a number of specific social skills have been identified as criti-
cal targets for early intervention, including joint attention, initiations, imitation,
and play skills (Kasari, Freeman, & Paparella, 2006), because these skills form a
foundation for understanding other individuals and participating in social activi-
ties with others (Baron-Cohen, Lombardo, & Tager-Flusberg, 2013; Roeyers, Van
Oost, & Bothuyne, 1998). Based on this rationale, some NDBIs target specific core
deficits thought to be responsible for broad aspects of autism-specific impairment.
For instance, the JASPER program deliberately prioritizes joint attention and sym-
bolic play due to theoretical rationale that these skills are critical for enhancing
engagement and remediation of the core symptoms of ASD (Kasari, Gulsrud,
Wong, Kwon, & Locke, 2010; Kasari, Paparella, Freeman, & Jahromi, 2008). Other
approaches have prioritized imitation skills, given the critical role that imitation
plays in learning from others, taking turns, and sustaining both verbal and non-
verbal engagement (Ingersoll & Schreibman, 2006; Schreibman et al., 2015). In
contrast to behavioral imitation training focused on copying of discrete and often
 Guiding Meaningful Goal Development 229

nonfunctional behaviors, the NDBI reciprocal imitation training approach teaches

imitation as a means of enhancing social engagement and capacity for naturalistic
learning (Ingersoll, 2010; Landa, Holman, O’Neill, & Stuart, 2011).
A similar rationale underlies the concept of targeting pivotal areas, which
is central to the PRT approach. Research on PRT has aimed to identify pivotal
areas, which, when targeted, produce widespread effects across broad areas of
development. For instance, the PRT approach places priority on incorporating
a child’s interests, including easy tasks, and reinforcing attempts because when
treatment is provided in this way it enhances the child’s overall motivation for
social-communication, leading to reductions in learned helplessness and gener-
alized improvements in symptoms of ASD (Koegel & Koegel, 2006). Likewise,
providers may prioritize teaching of initiations, response to multiple cues, or self-
management because these skills have also been shown to result in widespread
improvements in untargeted areas. The case examples that follow examine goal
setting through a developmental perspective.

Case Example: Alex

Alex is a 2-year-old boy diagnosed with ASD. He is not yet verbal, prefers solitary
play, and displays flat affect. His current goal is to increase his joint attention initiations:
During play with a peer or adult, when Alex sees something interesting he will initiate
joint attention at least five times in a 15-minute activity, independently across two
settings and with both a peer and an adult in two consecutive probes. Joint attention
initiations are defined as looking, giving, or pointing accompanied by alternating eye
contact, for the purpose of sharing enjoyment or attentional focus. Probes must
include an example of each type of initiation to consider the goal fully mastered.
Is this goal a good fit for Alex from a developmental perspective? Probably;
within the range of joint attention behaviors (e.g., looking, giving, pointing), eye gaze
alternation to share enjoyment or attentional focus would be the earliest skill to teach
Alex. Joint attention begins to develop around the first birthday and is a precursor to
and prerequisite for learning how to talk.
Will increasing his joint attention have a meaningful effect? Yes; joint attention
is likely to increase positive affect for Alex and his parents, as well as communication
skills, by means of improving triadic attention. Additionally, joint attention skills are a
foundation for later learning from peers and in the classroom.

Case Example: Cole

Cole is a 3-year-old with ASD. He currently communicates by using about 20 single
words and enjoys cause-and-effect toys. He has high levels of stereotypy and
typically screams when near peers. One of his current treatment goals is sharing toys
with peers: During structured play at school, Cole will independently hand a toy to a
peer upon request four out of five times in a 30-minute probe across two consecutive
sessions and with two different peers.
Is this goal a good fit for Cole from a developmental perspective? Maybe not;
parallel play remains the preferred type of play with objects until around age 2.
Sharing with peers begins between age 2 and 3 but remains difficult for many
230 NDBI Strategies

typically developing 3-year-olds, especially with highly preferred toys. Increasing prox-
imity with peers and parallel play may be foundational skills for this skill set, followed
by making simple requests from peers and responding to peer initiations.
Will teaching sharing skills have a meaningful effect? Yes; tolerance of peer
proximity and ultimately sharing will provide opportunities for inclusion and peer
modeling.

Case Example: Josephine

Josephine is a 10-year-old with ASD who speaks in full sentences and enjoys game
play. She is often inflexible and perseverative in topic selection. One of her current
treatment goals is reciprocal commenting in play and conversation (nonobject or
action-related comments): Josephine will independently comment on an action by
her peer during game play at least three times in a 15-minute sample across two con-
secutive sessions with at least three different peers.
Is this goal a good fit for Josephine from a developmental perspective? Maybe;
most 10-year-olds engage in complex and sustained play with others, but most
10-year-olds do not sit around and chat. Conversations still center around activities,
games, and rule-governed social play.
Will increasing her reciprocal commenting skills have a meaningful effect? Yes,
because reciprocal commenting will be reinforcing to a communication partner and
allow for practice with flexibility and topic expansion during conversations.

Case Example: Marco

Marco is a 15-year-old with ASD who is nonverbal and uses the Picture Exchange
Communication System (PECS) Phase 4 for requesting. He has limited play skills and
limited peer interaction. One of his current goals is increasing greetings and good-byes:
Marco will independly gesture hello and goodbye (e.g., waving) to at least three dif-
ferent peers at the beginning and end of music club at school across two consecutive
sessions.
Is this goal a good fit for Marco from a developmental perspective? Yes; this is an
early-emerging component of social interaction that is simple and highly ritualized.
Will increasing his greetings have a meaningful effect? Yes, because greetings
are likely reinforcing to a communication partner.

Cascading Effects
Developmental cascades can be defined as “the cumulative consequences for devel-
opment of the many interactions and transactions occurring in developing systems
that result in spreading effects across levels, among domains at the same level, and
across different systems or generations” (Masten & Chicchetti, 2010, p. 491). Models
of developmental cascades suggest that certain skills may be foundational for the
development of other important skills and that not acquiring these foundational
skills can result in so-called negative cascading effects. As an example, respond-
ing to joint attention bids is a skill often considered to be a critical foundation for
subsequent learning. That is, once a child learns to consistently respond when his
 Guiding Meaningful Goal Development 231

or her attention is directed to another object, he or she will more easily follow other
instructions and have the opportunity to learn about many new materials. An-
other example is the pivotal area of initiations (Koegel, Koegel, Harrower, & Carter,
1999). When children learn to initiate by asking questions (e.g., “What’s that?”),
this opens up opportunities for learning new vocabulary. If a skill is expected to
provide such a foundation for the development of other meaningful skills, it makes
sense to make this an early target in treatment. It is important for clinicians to have
an understanding of how skills layer one on top of the other, so prerequisite or
foundational skills are not overlooked and treatment goals are not set for skills that
the child lacks readiness for.
Other goals, when accomplished, may increase access to valuable learning envi-
ronments. For instance, once basic reading ability is established, the child can take
advantage of a whole new array of learning environments not previously accessible
to him or her. When parents and providers are selecting goals, skills expected to have
significant cascading effects are excellent priorities, whether because of their foun-
dational nature or because of the access to subsequent learning that they facilitate.

Depth of Skills
Another important developmental consideration is the depth of skills being taught
and practiced. Depth means making sure that a variety of related skills are also
learned and that the child can perform the new skill flexibly and in a variety of
ways. Although skills should be taught in a particular developmental sequence,
they should also increase in depth to eventually provide a strong skill base for the
child. For example, a pretend play goal may include a variety of actions to ensure
enough depth: feeding the baby, giving the baby a drink, putting the baby in bed,
changing the baby’s clothes, burping the baby, and singing to the baby. This varia-
tion in play behaviors ensures that children can use the skills they have in a flex-
ible way, without too much reliance on specific contextual cues or models. It is also
important to consider fluency of these skills to ensure performance deficits do not
emerge due to lack of fluency.

Age Appropriateness of Goals

A final consideration for goal selection pertains to the need to contemplate whether
selected goals fit with the chronological age of the individual with ASD, as op-
posed to the developmental age of the person. This is especially relevant for adoles-
cents and adults with ASD with limited verbal skills and/or intellectual disability
because they may developmentally function at a much younger level compared
to their chronological age. Selecting goals that are closer to age may provide ad-
ditional independence as well as increased access to age-appropriate materials, ac-
tivities, and resources.

CONCLUSION
Inherent in the NDBI approach is the assumption that not all potential goals are
equal. There are some skills that are clearly more important to teach and should be
a focus of any treatment program for a child with ASD. Although it may be easier to
target goals that are simple to define, measure, and practice repeatedly, the most im-
portant objective is actually to select goals that will produce meaningful changes in
232 NDBI Strategies

child and family functioning. This chapter tackled the challenge of selecting mean-
ingful goals, acknowledging that the core ASD deficit of social reciprocity is dif-
ficult to measure but critical to address for real progress to occur. It acknowledges
how overwhelming it can be to select among hundreds or thousands of potential
goals and provide guidance to parents and providers in prioritizing. To guide the
provider, this chapter recommended specific goal areas that should be included in
any program for a child with ASD. It also discussed the theoretical rationale for
prioritizing pivotal skills, such as joint attention and initiations, and the importance
of considering family values and designing goals in a way that they can be embed-
ded into daily routines. Finally, it outlined the importance of selecting goals that are
both functional for the child and developmentally appropriate and defining them
in a way that is measurable and relevant across environments.
Chapter 11 discusses NDBI strategies for targeting communication skills, fol-
lowed by social skills in Chapter 12 and adaptive skills in Chapter 13. Enhancing
functional communication, social interaction, and adaptive skills is critical for
enhancing independence and self-determination for many individuals with ASD.
By incorporating the strategies for goal selection discussed in this chapter, parents
and providers can design focused treatment programs for communication and
other skill areas that will facilitate meaningful progress.

REFERENCES
Baron-Cohen, S. E., Lombardo, M., & Tager-Flusberg, H. E. (Eds.). (2013). Understanding other
minds: Perspectives from developmental social neuroscience (3rd ed.). Oxford, United Kingdom:
Oxford University Press.
Bayley, N. (2006). Bayley Scales of Infant and Toddler Development, Third Edition. San Antoniio,
TX: Harcourt Assessment.
Bricker, D. (Series Ed.). (2002). Assessment, Evaluation, and Programming System (AEPS®) for
Infants and Children (2nd ed.). Baltimore, MD: Paul H. Brookes Publishing Co.
Constantino, J. N., & Gruber, C. P. (2012). Social Responsiveness Scale-Second Edition (SRS-2).
Torrance, CA: Western Psychological Services.
Elliott, C. D. (2007). The Differential Ability Scales (2nd ed.). San Antonio, TX: Harcourt
Assessment.
Fenson, L., Marchman, V. A., Thal, D. J., Dale, P. S., Reznick, J. S., & Bates, E. (2007).
MacArthur-Bates Communicative Development Inventories: User’s guide and technical man-
ual (2nd ed.). Baltimore, MD: Paul H. Brookes Publishing Co.
Gresham, F. M., & Eliott, S. N. (2008). Social Skills Improvement System Rating Scales.
Minneapolis, MN: NCS Pearson.
Hancock, T. B., & Kaiser, A. P. (2002). The effects of trainer-implemented enhanced milieu
teaching on the social communication of children with autism. Topics in Early Childhood
Special Education, 22(1), 39–54.
Harrison, P. L., & Oakland, T. (2003). Adaptive Behavior Assessment System-Second Edition.
San Antonio, TX: The Pscyhological Corporation
Ingersoll, B. (2010). Brief report: Pilot randomized controlled trial of reciprocal imitation
training for teaching elicited and spontaneous imitation to children with autism. Journal
of Autism and Developmental Disorders, 40, 1154–1160.
Ingersoll, B., & Schreibman, L. (2006). Teaching reciprocal imitation skills to young children
with autism using a naturalistic behavioral approach: Effects on language, pretend play,
and joint attention. Journal of Autism and Developmental Disorders, 36, 487–505.
Johnson-Martin, N. M., Attermeier, S. M., & Hacker, B. J. (2004). The Carolina Curriculum for
Preschoolers with Special Needs (2nd ed.). Baltimore, MD: Paul H. Brookes Publishing Co.
Kasari, C., Freeman, S., & Paparella, T. (2006). Joint attention and symbolic play in young
children with autism: A randomized controlled intervention study. Journal of Child
Psychology and Psychiatry, 47, 611–620.
 Guiding Meaningful Goal Development 233

Kasari, C., Gulsrud, A., Wong, C., Kwon, S., & Locke, J. (2010). Randomized controlled
caregiver mediated joint engagement intervention for toddlers with autism. Journal of
Autism and Developmental Disorders, 40, 1045–1056.
Kasari, C., Paparella, T., Freeman, S. N., & Jahromi, L. (2008). Language outcome in autism:
Randomized comparison of joint attention and play interventions. Journal of Consulting
and Clinical Psychology, 76, 125–137.
Kaufman, A. S., & Kaufman, N. L. (2004). Kaufman Assessment Battery for Children (2nd ed.).
Circle Pines, MN: AGS.
Keilty, B. (Ed.). (2010). The early intervention guidebook for families and professionals: Partnering
for success. New York, NY: Teachers College Press.
Koegel, L. K., Koegel, R. L., Harrower, J. K., & Carter, C. M. (1999). Pivotal response interven-
tion I: Overview of approach. Journal of The Association for Persons with Severe Handicaps,
24(3), 174–185.
Koegel, R. L., & Koegel, L. K. (2006). Pivotal Response Treatments for autism. Baltimore, MD:
Paul H. Brookes Publishing Co.
Landa, R. J., Holman, K. C., O’Neill, A. H., & Stuart, E. A. (2011). Intervention targeting
development of socially synchronous engagement in toddlers with autism spectrum dis-
order: A randomized controlled trial. Journal of Child Psychology and Psychiatry, 52, 13–21.
Masten, A. S., & Chicchetti, D. (2010). Developmental cascades. Development and Psychopa-
thology, 22, 491–495.
McDermott, D. (2001). Parenting and ethnicity. In M. J. Fine & S. W. Lee (Eds.), Handbook of
diversity in parent education: The changing faces of parenting and parent education (pp. 73–96).
San Diego, CA: Academic Press.
Miller, J., & Chapman, R. (1985). Systematic Analysis of Language Transcripts. Madison, WI:
Language Analysis Laboratory.
Mullen, E. M. (1995). Mullen Scales of Early Learning. Circle Pines, MN: AGS.
Mundy, P., Hogan, A., & Doelring, P. (1996). A preliminary manual for the abridged Early Social
Communication Scales. Coral Gables, FL: University of Miami.
Partington, J. W. (2010). The Assessment of Basic Language and Learning Skills-Revised. Pleasant
Hill, CA: Behavior Analysts, Inc.
Prizant, B. M., & Wetherby, A. M. (2002). Communication and Symbolic Behavior Scales Devel-
opmental Profile (CSBS DP™), First Normed Edition. Baltimore, MD: Paul H. Brookes
Publishing Co.
Roeyers, H., Van Oost, P., & Bothuyne, S. (1998). Immediate imitation and joint attention in
young children with autism. Development and Psychopathology, 10(3), 441–450.
Rogers, S. J., & Dawson, G. (2010). Early Start Denver Model for young children with autism:
Promoting language, learning, and engagement. New York, NY: Guilford Press.
Roid, G. (2012). Stanford-Binet Intelligence Scales, Fifth Edition. Torrance, CA: WPS.
Rutland, A. F., & Campbell, R. N. (1996). Relevance of Vygotsky’s theory of the “zone of
proximal development” to the assessment of children with intellectual disabilities. Journal
of Intellectual Disability Research, 40(2), 151–158.
Schrank, F. A., Mather, N., & McGrew, K. S. (2014). Woodcock-Johnson IV Tests of Achievement.
Rolling Meadows, IL: Riverside.
Schreibman, L., Dawson, G., Stahmer, A. C., Landa, R., Rogers, S. J., McGee, G. G., . . .
McNerney, E. (2015). Naturalistic developmental behavioral interventions: Empirically
validated treatments for autism spectrum disorder. Journal of Autism and Developmental
Disorders, 45(8), 2411–2428.
Schwartz, I. S., Ashmun, J., McBride, B., Scott, C., & Sandall, S. R. (2017). The DATA Model
Skills Checklist. Baltimore, MD: Paul H. Brookes Publishing Co.
Sparrow, S. S., Cicchetti, D. V., & Saulnier, C. A. (2016). Vineland Adaptive Behavior Scales, Third
Edition. New York, NY: Pearson.
Sukkar, H., Dunst, C. J., & Kirkby, J. (Eds.). (2016). Early childhood intervention: Working with
families of young children with special needs. London, United Kindom: Taylor & Francis.
Sundberg, M. L. (2014). The verbal behavior milestones assessment and placement program: The
VB-MAPP (2nd ed.). Concord, CA: AVB Press.
Volkmar, F., Siegel, M., Woodbury-Smith, M., King, B., McCracken, J., State, M., & the
American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Qual-
ity Issues (2014). Practice parameter for the assessment and treatment of children and
234 NDBI Strategies

adolescents with autism spectrum disorder. Journal of the American Academy of Child and
Adolescent Psychiatry, 53(2), 237–257.
Wechsler, D. (2012). Wechsler Preschool and Primary Scale for Intelligence (4th ed.). Bloomington,
MN: Pearson, Psychological Corporation.
Wechsler, D., Kaplan, E., Fein, D., Kramer, J., Morris, R., Delis, D., & Maelender, A. (2003).
Wechsler Intelligence Scale for Children, Fourth Edition (WISC-IV). San Antonio, TX: Pearson.
Wetherby, A. M., & Prizant, B. M. (2003). Communication and Symbolic Behavior Scales™
(CSBS™), Normed Edition. Baltimore, MD: Paul H. Brookes Publishing Co.
Zimmerman, I. R., Steiner, V. G., & Pond, R. E. (2011). Preschool Language Scale-5 (PLS-5).
San Antonio, TX: Psychological Corporation.
IV

Applications of NDBI Strategies

11
Targeting Communication Skills
Mendy B. Minjarez, Rachel K. Earl, Yvonne Bruinsma, and Amy L. Donaldson

C
ommunication is a fundamental component of early development and
is widely acknowledged as an area of need in autism spectrum disorder
(ASD). ASD is characterized in part by deficits in social-communication,
which includes both verbal and nonverbal communication (American Psychiat-
ric Association, 2013). This chapter begins with an overview of communication
development and communication challenges often observed in children with ASD.
It then moves to examination of Naturalistic Developmental Behavioral Interven-
tions (NDBI) strategies used to target communication goals and finally provides a
discussion of the application of NDBI strategies to specific target behaviors across
developmental levels.

COMMUNICATION PROFILE OF CHILDREN WITH ASD

Communication challenges are often the first concerns to be identified in the devel-
opment of a child with ASD. Most, but not all, children with ASD exhibit a delay in
production of first words (Tager-Flusberg, Paul, & Lord, 2005), although a smaller
proportion (25%–30%) experience a loss or regression in acquired language skills
in the second year of life (Goin-Kochel, Esler, Kanne, & Hus, 2014; Lord, Shulman,
& DiLavore, 2004; Werner & Dawson, 2005). When parents were asked retrospec-
tively about their child’s early development, communication deficits were reported
to be present as early as 12 months of age (Mitchell et al., 2006; Osterling & Dawson,
1994). Prospective studies of infants with an older sibling with ASD, and thus at
an elevated risk for developing ASD themselves, have identified communication
impairments within the first year of life and delays in the onset of babbling
and consonant acquisition by 6 months of age (Iverson & Wozniak, 2007; Paul,
Campbell, Gilbert, & Tsiouri, 2013).
Infants who go on to be diagnosed with ASD also show delays in nonverbal
communication, such as imitation, joint attention, and gesture use, within their first
year of life (Ozonoff et al., 2010; Zwaigenbaum et al., 2005). These early impairments
237
238 Applications of NDBI Strategies

in nonverbal communication correlate with spoken language, cognitive, and motor

skills early in a child’s development (Iverson & Wozniak, 2007; Luyster, Kadlec,
Carter, & Tager-Flusberg, 2008; Thurm, Lord, Lee, & Newschaffer, 2007). Spoken
language acquisition within the first years of life, along with cognitive abilities,
have been linked to overall outcome of individuals with ASD across the life span,
highlighting the importance of early intervention that targets communication
(Billstedt, Carina Gillberg, & Gillberg, 2007; Howlin, Goode, Hutton, & Rutter, 2004;
Venter, Lord, & Schopler, 1992).
Although communication deficits are considered universal within ASD, the
type and severity of challenge is highly variable (Kjelgaard & Tager-Flusberg,
2001; Tager-Flusberg et al., 2005). Some children with ASD demonstrate vocabu-
lary, semantic, and grammatical skills congruent with typical development, and
they struggle instead with the social-communication, such as breadth and depth
of communicative intent (Prizant & Wetherby, 1987); coordination of nonverbal
and verbal communication (Stone, Ousley, Yoder, Hogan, & Hepburn, 1997); social
and communicative reciprocity; reading social and contextual cues; and adjust-
ing communication use to context (Tager-Flusberg & Joseph, 2003; Tager-Flusberg
et al., 2005). On the other hand, a significant number of children with ASD dem-
onstrate severe language deficits or complex communication profiles in which the
child does not develop spoken language (Kjellman, Hedvall, Fernell, Gillberg, &
Norrelgen, 2012; Tager-Flusberg et al., 2005). This variable presentation of commu-
nication difficulties underscores the importance of dynamic, personalized treat-
ment objectives and interventions for children with ASD and their families.

COMMUNICATION DEVELOPMENT
IN TYPICALLY DEVELOPING CHILDREN
In order to understand early differences in the communication skill development of
children with ASD and to develop appropriate treatment targets to support skills
acquisition, clinicians need to understand how communication develops typically
(Tager-Flusberg et al., 2005). Although some variations exist in the rate at which
typically developing children gain communication skills, a common developmen-
tal trajectory has been well established (e.g., Bates, 1976; Brown, 1973; Owens, 2015;
Tager-Flusberg et al., 2005). Communication is typically categorized in three areas:
use, content, and form.
In the first category, use (defined as pragmatics or the rules for communicat-
ing through language), children learn to communicate through nonverbal means,
which develop into coordination of nonverbal and verbal communication. Within
the first months of life, a typically developing infant begins to recognize his or
her mother’s voice and to synchronize eye gaze and facial expressions with his or
her caregiver. Throughout the first year of life, an infant will develop a variety of
communicative behaviors that serve the purposes of requesting, indicating prefer-
ences, and directing attention. What begins as simple gestures, such as reaching
and pushing away, evolves into more complex gestures, such as pointing to request
and giving an object to request assistance, by the end of a typically developing
child’s first year of life. As early as 7 months of age, young children will use eye
gaze (initiating joint attention) to direct another’s attention to an object or event
of interest. They will coordinate with vocalization and gesture between 9 and
13 months of age; these behaviors differ from requests because their intent is to
 Targeting Communication Skills 239

draw and share attention to an object or event of interest for the purpose of show-
ing, giving, commenting, or requesting information but not to gain access (Crais,
Douglas, & Campbell, 2004). By 12–18 months of age, a child will often coordinate
such gestures with vocalizations, eye contact, and/or verbalizations.
At preschool and school age, children continue to expand their use of com-
municative intent, as well as their use of social-communication within discourse,
social interaction, development of relationships, and conflict negotiation. By pre-
school, the following social competencies should be demonstrated with peers:
describing play to peers, clarifying peers’ comments, expanding on peers’ com-
ments, responding to initiations, asking peers questions, maintaining conversation
topics, giving information to peers, asking for help from peers, initiating conver-
sations, and giving peers compliments (Brown & Conroy, 2001). Once they reach
school age, children increase the sophistication of their social-communication
skills, using discourse to gain access to sustain cooperative group participation,
resolve conflicts, persuade others, participate effectively with others, gain access
to social activities, offer contradicting opinions, and develop rich relationships
(Brinton & Fujiki, 2005).
With regard to the second category, content (which includes semantics or
the meaning of words [vocabulary]), typically developing infants between 6 and
12 months of age begin intentional vocalizations, or babbling, while also making
rapid receptive communication gains, including the understanding of infant social
games and words that correspond with a particular action. First words typically
emerge between 10 to 16 months of age, beginning with familiar objects and indi-
viduals and appearance or disappearance and recurrence (“more,” “all gone,” “hi”;
Chapman, 2000). As children develop, their vocabulary progresses from primarily
agents, actions, and modifying words to include prefixes and suffixes, root words, fig-
urative language, and understandings of word relationships by later school-age years.
Related to the third category, form (which includes phonology [rules about
speech sounds], morphology [small units of meaning within words], and syn-
tax [word order]), this vocabulary expansion typically progresses to combin-
ing two words together between 18 and 30 months of age. Children typically
start combining words after their single-word vocabularies reach a certain level
(50–200 words; Bates, Dale, & Thal, 1995). The typical profile and progression of
syntactic and morphological development can be described using Brown’s Stages
of Language Development (Brown, 1973). Following acquisition of two-word com-
binations, children increase their sentence complexity from approximately 24 to
30 months using prepositions (in, on), plurals, and -ing verbs. From 30 to 36 months,
children start using three-word utterances with irregular past tense and posses-
sives, and then by 42 months, they combine nearly four-word sentences with use
of past tense, three-person verbs, and articles (a, the). Finally, by 5 years of age, chil-
dren typically speak in complex, 4+ word utterances with use of contractions (e.g.,
“Kitty’s eating”; “He’s little”) and irregular forms.
Paramount to early communication, particularly in the area of use, is develop-
ment of different types of communicative intent or the functions of communication
(Bruner, 1981). Individuals use communication for multiple reasons or functions—
to gain access to something, to negotiate, to compliment someone, to share atten-
tion, to request information, and so forth. These have also been referred to as
speech acts (Dore, 1975). Three early emerging communicative functions or intents
fundamental to early development include 1) behavior regulation—behaviors that
240 Applications of NDBI Strategies

Table 11.1. Intent or functions of communication

What is the child telling you?

Function Definition Example

Behavior regulation Behaviors that regulate the behavior Requests for objects, actions, or
of another person assistance; protests
Social interaction Behaviors that draw and/or maintain Gaining attention, social games
attention to oneself (e.g., Peekaboo), and greetings
Joint attention Behaviors that draw another person’s Showing, commenting, and
attention to an object or event of requesting information
interest
Sources: Bruner (1981); Crais, Douglas, & Campbell (2004).

regulate the behavior of another person; 2) social interaction—behaviors that draw

and/or maintain attention to oneself; and, 3) joint attention—behaviors that draw
another person’s attention to an object or event of interest (see Table 11.1 for further
discussion of each).
Successful interventions targeting communication development in children
with ASD are careful to align treatment targets with typical communication mile-
stones and the typical progression of language acquisition (Schreibman et al., 2015;
Tager-Flusberg et al., 2009). Attention to these emerging communicative intents is
often the starting place for NDBI, especially those interventions that focus more on
communication targets, such as Pivotal Response Treatment (PRT) and incidental
teaching.

USE OF NDBI FOR TARGETING COMMUNICATION

As early as the 1960s, Applied Behavior Analysis (ABA) was used as a means to
improve communication skills in young children with ASD (Lovaas, Berberich,
Perloff, & Schaeffer, 1966; Risley & Wolf, 1967). Lovaas and colleagues (1966) found
that use of reward contingencies was successful in teaching increasingly accurate
imitation of spoken language to two nonverbal children with symptoms of ASD.
As the field has recognized the importance of contextualized, naturalistic social
interaction in social-communication and language development, particularly re-
lated to intentionality and reciprocity, and as early intervention objectives have
shifted to a greater emphasis on generalization of skills outside of the treatment
setting, ABA has evolved from exclusive discrete trial training (DTT) to behavioral
interventions implemented in naturalistic settings with developmentally informed
learning targets (NDBI; Schreibman et al., 2015). Since the late 1990s, the evidence
to support the use of NDBI for targeting early communication skills for individu-
als with ASD and a range of baseline cognitive, communicative, and behavioral
abilities has grown substantially. In accordance with a developmental perspective,
NDBI integrate goals for language acquisition within a social context and in align-
ment with a child’s other treatment targets.
Numerous studies have shown that ABA principles in a naturalistic setting
promote significant communication gains in children with ASD (Koegel, O’Dell,
& Dunlap, 1988; Rogers et al., 2006; Rogers & Vismara, 2008). For instance, in 2010,
Dawson and colleagues conducted a randomized control led trial (RCT) of the
Early Start Denver Model (ESDM) for 48 toddlers with ASD between the ages of 18
 Targeting Communication Skills 241

and 30 months of age. Toddlers who were randomly assigned to the ESDM inter-
vention showed significant improvements in receptive and expressive language
and an overall reduction in ASD symptoms over 2 years compared to toddlers
receiving treatment as usual from community providers. Mohammadzaheri, Koe-
gel, Rezaee, and Rafiee (2014) conducted an RCT comparing PRT to a more tra-
ditional ABA approach for children ages 6–11 years of age and found that chil-
dren receiving PRT showed significant increases in length of spoken utterances
and social-communication skills. In 2013, Ingersoll and Wainer showed significant
gains in frequency of spontaneous language for children 3–6 years of age whose
parents received training in Project ImPACT (Improving Parents as Communica-
tion Teachers). An RCT of the Joint Attention, Symbolic Play, Engagement, and Reg-
ulation (JASPER) intervention conducted with children 3–5 years of age who were
minimally verbal found that, when compared to a matched group receiving tradi-
tional ABA-based services, children enrolled in JASPER showed increased gesture
use, including use of coordinated gaze, points, gives, and shows to request (Goods,
Ishijima, Chang, & Kasari, 2013). These and other NDBI programs, all of which
have robust evidence to support their efficacy in improving communication skills
in children with ASD, target shared domains of communication and use similar
strategies for teaching communication skills, reviewed in detail next.

Specific NDBI Strategies for Targeting Communication Goals

Although NDBI may vary in the extent to which they prioritize certain communi-
cation goals and may emphasize certain strategies more than others, they all target
communication skills in some way. The following sections provide a more detailed
overview of strategies most commonly used in NDBI to target the developmental
domain of communication, including how to embed basic communication trials,
specific strategies (e.g., use of narration, recasting, and imitation), and strategies to
target motivation (e.g., shared control strategies).

Embedding Communication Learning Trials When targeting nonverbal and

verbal communication skills, most NDBI focus on strategies for embedding oppor-
tunities for communication during naturally occurring adult–child interactions.
Such opportunities incorporate principles of ABA in that they typically rely on the
three-term contingency or the antecedent-behavior-consequence (A-B-C) frame-
work for setting up learning trials. They incorporate developmental principles by
being embedded during child-selected or preferred activities and natural routines,
by employing natural consequences whenever possible, and by focusing on target
behaviors that are functional and developmentally appropriate. When adults (e.g.,
parents, clinicians) become aware of how to set up communication trials in the nat-
ural environment, they realize that there are hundreds of opportunities per day to
practice various forms of communication. Communication trials can be embedded
in multiple ways but will always rely on following the child’s interest and build-
ing interaction by sharing control and then continuing by following and leading
in a reciprocal manner. In addition, adults should have the child’s attention prior
to beginning a trial, should embed the trial in a motivating activity, and should
have momentary control over some aspect of that activity (another aspect of shared
control) in order to give access to reinforcement following the communication be-
havior. Once the child’s interest is understood and attention and brief control of
242 Applications of NDBI Strategies

materials are obtained, the trial should begin with an antecedent (A), which is a
verbal or nonverbal indication that the child needs to communicate. Once the child
makes a response (B), the adult must make an assessment of the correctness or ap-
propriateness of that response and provide contingent reinforcement or error cor-
rection (C). It is important to set up naturalistic opportunities in the environment
that will serve as the antecedent (e.g., a desired toy on high shelf, a missing puzzle
piece, a snack enclosed in an inaccessible jar) in order to encourage initiation of
communication bids to environmental stimuli rather than primarily responses to
adult communication bids. These types of environmental arrangements are explic-
itly emphasized in several NDBI, such as incidental teaching (IT).
This type of teaching trial can be applied to many nonverbal and verbal com-
munication goals across settings, activities, and routines. Word use can be evoked
through a time delay (waiting for the child to come up with the word spontane-
ously), a carrier phrase (e.g., “ready, set . . .”), or a situational cue (holding up an
item and waiting for the child to label it with a word) (see also Chapter 8, on cues
and prompting). When the child uses the correct word or a reasonable attempt,
the adult then reinforces the response with praise and access to or continuation
of a desired activity. When the child does not respond correctly, NDBI encourage
an errorless instructional format in which the adult prompts the correct response,
thereby giving the child the opportunity to be successful. With verbal children,
this prompt might consist of a verbal model. With nonverbal individuals, a physical
prompt might be provided to ensure success, for example, if the child is working on
goals such as pointing, use an augmentative and alternative communication (AAC)
device or Picture Exchange Communication System (PECS). The same format can
be applied to other nonverbal communication behaviors, such as gestures, eye con-
tact, and joint attention.

Narrating and Modeling Most NDBI models encourage adults to model

words in the context of the child’s interests and within daily routines (Hancock
& Kaiser, 2002; Ingersoll & Wainer, 2013; Rogers & Dawson, 2010). Research shows
that consistent exposure to developmentally appropriate language models is as-
sociated with enhanced language skills in typically developing children (Hart &
Risley, 1995), as well as children with developmental delays. For example, when
changing a diaper, a parent may label each action and object: “up” to lift the child
onto the changing table, “tickle” when tickling the child’s tummy, “wipe” when
wiping, followed by “all clean.” Repetition within daily routines ensures the child
hears the words many times, even when the parent is not sure the child under-
stands or is paying attention. Most NDBI suggest using simple words or very short
phrases when narrating and expanding as the child’s language develops, although
some models have more emphasis on narration (JASPER) compared to others (PRT).
However, even when using short phrases, use of grammatically correct language
is recommended to promote language development (use “eat the cookie” instead of
“eat cookie”) (Sandbank & Yoder, 2016; Venker et al., 2015).
Over time, vocabulary and increased verbal complexity can be introduced
through play narration and through teaching trials embedded in a child’s daily
routines. For example, narration while playing with trains can increase from
single-word labels (e.g., “train,” “Go!”) to phrases (e.g., “Go train!”) and sentence
speech (e.g., “The train is going fast!”). Ingersoll and Wainer (2013) encouraged
adults to avoid questions when narrating during this first words stage and to use
 Targeting Communication Skills 243

comments instead to promote language acquisition. For example, instead of asking

a child at play, “What’s that?” or “What are you doing?”, an adult could comment
on what the child is playing with (e.g., “red car,” “big ball”). This format also avoids
confusion for the child, as questions imply that a response is required, whereas
comments do not. Narration of play by adults is beneficial not only for children’s
acquisition of expressive language skills but also their acquisition of receptive lan-
guage. For children who do not acquire spoken language skills, such exposure is
still instrumental in development of language skills for communication via AAC
methods.

Recasting and Using the One-Up Rule When using embedded communica-
tion trials, additional modeling strategies can be added following a trial to enhance
learning over time. Recasting is defined as repeating the word the child attempted
but correcting the production and/or elaborating on it. For example, if the child
says “buh-buh” for bubbles, the adult might say, “Bubbles!” while blowing bubbles
for the child. If the child says, “Red go car,” the adult might say, “Red car go.”
Recasting can also include expansions of the child’s language to model language
that is slightly above the child’s language level. Rogers and Dawson (2010) sug-
gested the one-up rule, in which adults speak to children in phrases or sentences
that contain the same number of words the child’s spontaneous sentences contain
plus one additional word. For example, if the child says “block,” the parent models
“green block.” At first, the additional word can be added in the recast, providing
models before requiring the additional word:
Adult: “Block?”
Child: “Block.”
Adult: “Green block!” (while giving the green block to the child)
This way, learning is scaffolded to ensure that the child is exposed to increas-
ingly longer phrases or grammatical structures without being required to use them.
The child eventually can be required to use the longer phrases to obtain a desired
item or continue a preferred activity (McGee, Morrier, & Daly, 1999). Again, the
adult should use grammatically correct sentences when employing this technique.

Implementing Shared Control Strategies Because setting up opportunities

for communication relies on both the child’s motivation to participate and the use
of natural reinforcement in most NDBI, shared control must be a part of imple-
menting any learning trials. The adult follows the child’s interest and then can
take a turn in order to gain control over an object or outcome that can be used as
contingent reinforcement. Shared control occurs when the adult balances follow-
ing the child’s lead with turn taking (balanced turns). Direct and natural reinforce-
ment can then be facilitated when the adult creates or capitalizes on situations in
which he or she has control over an object or outcome (e.g., getting help, getting
picked up) that a child wants or finds rewarding. That is, the adult’s turns are used
as opportunities to embed teaching trials because the object or activity can then be
used as natural reinforcement. In addition to following the child’s lead, the adult
may also share control by modeling new actions or activities, taking turns where
teaching trials are not embedded and noncontingent reinforcement is given, imi-
tating the child, and setting limits as needed. For example, if the child is interested
244 Applications of NDBI Strategies

in or motivated by something he or she cannot have access to, the adult may offer
choices that are currently available.
There are many shared control strategies outlined across NDBI, including
Project ImPACT, PRT, ESDM, and IT. Together, these strategies can result in a wide
variety of types of trials embedded in a wide variety of activities and routines.
Shared control strategies, their definitions, and examples are outlined in Table 11.2.
Although these strategies are focused on the portion of the interaction in which the
adult has control over the materials in order to evoke a communication behavior,
the full shared control of an interaction includes the reciprocity and balanced turns
that occur between the adult and child. Shared control strategies are discussed in
Chapter 6 as well.

Using Motivational Strategies The many motivational strategies used in

NDBI are often incorporated when targeting communication goals with children
with ASD. These are discussed briefly here in terms of teaching communication
because they are elaborated in more detail in Chapter 6, on motivational strategies.
Noncontingent Reinforcement Noncontingent reinforcement (i.e., giving
the child access to reinforcement without placing demands) can be used in two
primary ways to build motivation when targeting communication skills. It should
not be used when an instruction or cue has already been provided. If no instruc-
tion has been delivered, noncontingent reinforcement can be provided to enhance
motivation. The first way noncontingent reinforcement is often used is when the
child is given access to a small amount of reinforcement as a way of enticing or try-
ing to gain the child’s interest in an activity. For example, the adult might tickle the
child briefly or swing the child around and then pause for communication or give
a few pieces of a toy to get the child started before having the child request more
pieces. Several additional examples can be found in Box 11.1. In these examples, the
child is initially given noncontingent access to a part of the toy or activity. As this
strategy often piques motivation, the next steps are then held back in order to set
up a communication trial and then provide contingent reinforcement.
The second way noncontingent reinforcement is used is to create behavioral
momentum when targeting communication. This procedure entails giving the
child the requested action or item while modeling the target word or behavior,
preferably in rapid succession, prior to stopping and prompting for the response.
After multiple models and multiple doses of reinforcement, the child is more likely
to respond to the cue or prompt independently.
Reinforcing Attempts or Shaping Reinforcing attempts or shaping is often
used to target communication goals. As discussed in Chapter 6 (on motivation) and
Chapter 9 (on reinforcement), this process entails providing reinforcement in re-
sponse to a good attempt for the child’s communication level, even if it was not en-
tirely accurate, in order to build motivation, increase success, and encourage future
attempts. If a child is using single words, the focus is likely to be on word attempts,
for example, a child who says “ca-cuh” for “cracker” or “nana” for “banana.” If the
child is using multiword phrases, the focus may be on reinforcing phrases even if
articulation is lower quality than it is with single words. Good attempts at phrase and
sentence speech may also be longer or more complex utterances that contain gram-
matical errors. Research shows that when attempts at communication are reinforced,
 Table 11.2. Shared control strategies for targeting communication goals

Shared control
strategy Definition Nonverbal example Early language example Later language example

Environmental arrangement—Arranging the environment to foster communication

Environment: In Storing items where they can
sight, out of be seen but not obtained
reach (e.g., storing preferred toys
up high or in clear bins that
cannot be opened without
help)
Activity: In Setting up an activity so that
sight, out of materials can be seen but
reach not accessed (e.g., setting
up art supplies on the table
but out of the child’s reach)
Store snacks on a high shelf.
Provide them to the child
contingent on pointing to
request.
Place crayons out of reach
on the table while coloring.
Exchange a Picture Exchange
Communication System
(PECS) card to request a
crayon.
Store the phone or tablet on
the counter. Provide access
contingent on a single-word
request (e.g., “phone”).
Place tools out of reach while
playing with playdough. Require
a single-word request (e.g.,
“roller”) to receive a new tool.
Store the remote control on
the mantle. Provide access
contingent on using a phrase
to request (e.g., “Please turn
on Daniel Tiger”).
Place stickers out of reach during
art.
Require a phrase (e.g., “three
green stickers”) to request
stickers.

Reducing adult anticipation of child wants or needs—Wait for the child to communicate before providing what he or she wants

Control access Following a child’s interests After a child begins playing with Hold up a piece that goes with the When engaging in reciprocal
or shared and taking turns; embedding a ring stacker, place another puzzle the child is doing. Provide play with a child using a
control learning opportunities ring on. Then, hold up a new the piece when the child labels barnyard and animals, model
that lead to natural, direct ring and wait. Provide the toy it (e.g., “cow”). Then, take a turn a new activity by driving a
reinforcement when the child exchanges a after the child places his or her tractor. Then, offer two sets
PECS card. piece in the puzzle. (e.g., tractors and horses)
for the child to choose from.
Provide a set when the child
uses a phrase to request (e.g.,
“Let’s play tractors”).
Interrupting Pausing in the middle of a Stand at the door, ready to Pause with the child’s shoe in hand Pause with the child still buckled
routines known routine so the child go outside. Open the door and foot in the air. Put the shoe into the car seat at the park.
must communicate before when the child uses the on when the child says “shoe.” Unbuckle when the child says,
moving on “outside” button on his or her “Let’s go do the swings.”
augmentative and alternative
communication (AAC) device.

245 (continued)
246 Table 11.2. (continued)
Shared control
strategy Definition
Reducing adult anticipation of child wants or needs—Wait for the child to communicate before providing what he or she wants
Assistance Setting up activities or
situations in which the
child will require adult
assistance; reducing adult
anticipation of child needs
when natural opportunities
arise in which the child
needs assistance
Inadequate Providing a few pieces or
portions/ parts of a set at a time in
breaking it up order to generate multiple
communication trials
(applies best to toys or
snacks with multiple pieces
or sets of items)
Intentional Ignoring the child on purpose,
ignoring especially when the child
needs help or the adult
has a preferred object,
to create opportunities
for appropriately gaining
attention
Nonverbal example
Hand the child an unopened chip Place the child’s snack in screw-top
bag. Open it when the child
hands it back for help.
Provide a few goldfish crackers
in a bowl. Provide more when
the child reaches for the bag
on the table.
Turn away from the child when
his or her cup is empty. Turn
back to accept the empty
cup for help when the child
appropriately taps your
shoulder.
Early language example
containers. Wait until the child
says “help” before opening it.
Provide the child with Mr. Potato
Head, but keep the pieces.
Provide each piece as the child
labels it (e.g., “nose,” “eyes”).
Turn away while holding the
needed puzzle piece. Turn back to
provide the piece when the child
says “mom.”
Later language example
Open a marble ramp toy. Provide
a few pieces, and wait while
the child struggles to build it.
Provide help when the child
says, “Let’s build the ramp.”
Provide the child with several
magnetic tiles while keeping
the rest. Provide more pieces
as the child says what he or
she is going to build next (e.g.,
“I am going to build the roof
now”).
Turn away while holding the
paintbrush for the paints the
child already has. Turn back,
when the child calls your
name.
 Other shared control strategies
Playful Playfully interrupting the
interruption child’s play so that he or she
or obstruction must communicate to have
the interruption removed
Sabotage Providing parts of an activity
while withholding obvious
necessary parts
Protest Setting up situations that
are known to upset the
child in order to provide
opportunities to practice
appropriate requesting and
protesting
Silly situations/ Setting up situations that are
playing the obviously silly (e.g., putting
naïve adult pants on head) or breaking
known routines in a silly
way (e.g., going the wrong
way when walking into
school)
247
Pause during a tickle game.
Continue when the child
makes eye contact and/or
vocalization.
Provide cereal without a spoon.
Give the spoon when the child
points to it.
Offer a nonpreferred food.
Remove it when the child
appropriately pushes it away.
Turn the power switch to off on a Give Daddy a child’s fork at dinner
cause-and-effect toy and laugh
or say, “Oh no!” Turn it back on Daddy” in an exaggerated tone.
when the child taps it.
Make a toy tree fall on the tracks
to block the train. Move it after
the child fills in the adult phrase
“ready-set” with “go.”
Provide tracks without any trains.
Give the trains when the child
says “train.”
Stop the balls part way down the
ball track. Let them go when the
child says “move.”
and say “Here’s your fork,
Give the fork to the child when
he or she says, “Mine!”
Place a hand over the carwash
entrance on a toy garage.
Move it after the child uses
a phrase to state what is
next (e.g., “It’s time to wash
the car”).
Provide the pieces to the game
but not the board. Give the
board when the child says,
“We need the board to play
the game.”
Go out of turn during a board
game. Give access to the
spinner when the child
appropriately says, “It’s not
your turn.”
Pretend to put pants on your
head during the dressing
routine, and act silly. Help put
pants on correctly when the
child says, “Pants go on legs!”
248 Applications of NDBI Strategies

Ready, Set, Implement!

BOX 11.1: Noncontingent reinforcement
Try these uses of noncontingent reinforcement to enhance a child’s interest
when starting a new activity!
• Give a few blocks, train tracks, Magna-Tiles, and so forth to get the child
started with building, but keep the rest in the box.
• Give the child one marker to begin coloring, but maintain control over the rest.
• Help the child spread the glue on his or her paper, but keep the glitter on
your side of the table.
• Give the child a small amount of snack (e.g., crackers), and keep the bag
on the table out of reach.
• Throw the ball to the child, and when he or she throws it back, pause.
• After setting up the marble ramp, put the marbles in, but remove them
from the bottom before the child can do so.

motivation remains strong and the attempts improve over time. It can be helpful to
use recasting when reinforcing attempts. That is, while reinforcing the child’s approx-
imation of the target behavior, model the full correct target behavior.
Task Variation, Varied Turns, and Interspersal of Maintenance and Acquisition
Tasks Task variation strategies are also often used when targeting communica-
tion goals. These strategies are elaborated in Chapter 6, on motivation. Task variation
is simply making sure that demands are varied so as not to induce boredom. Inter-
spersal of maintenance and acquisition tasks is defined as switching between easy
(maintenance) and hard (acquisition) tasks as a way of maintaining motivation. Main-
tenance tasks are motivating and can enhance behavioral momentum because the
child experiences success and reinforcement easily. Acquisition tasks ensure that the
child is practicing new skills. Because all types and levels of communication are use-
ful, no matter what a person’s language level may be, interspersal is also important
for maintaining a range of language skills while also moving goals forward.

Imitating the Child Imitating the child’s actions, sounds, or expressions is an-
other widely used strategy for introducing and evoking verbal and nonverbal com-
munication. For children who are nonverbal and not yet imitating speech sounds,
imitation of actions on objects and song routines are helpful tools to introducing
this skill (see also Chapter 6, on motivation, and Box 11.2). Sensory social routines,
described in more depth in Chapter 12, on social skills, are especially useful for
promoting imitation. Adults can imitate their child’s actions, termed nonverbal
mirroring in Enhanced Milieu Teaching (EMT), then introduce a new element and
wait to see if the child imitates the new action (Kaiser & Delaney, 1998; Kaiser &
Trent, 2007). The use of contingencies, access to the reinforcing object or interaction
following the completion of these desired actions, are often built in to imitation
teaching and can also be applied to teaching verbal skills.
 Targeting Communication Skills 249

Ready, Set, Implement!

BOX 11.2: Imitate the child
Try the following types of imitation when engaging the child to teach social-
communication skills:
• Imitation of motor actions
• Imitation of sounds and words
• Imitation of facial expressions
• Imitation of gestures
• Imitation of actions on objects
• Imitation of actions within song routines

TEACHING COMMUNICATION ACROSS

DEVELOPMENTAL LEVELS USING NDBI STRATEGIES
The NDBI strategies outlined in this chapter can be used to teach at all develop-
mental levels. The following section discusses the application of these strategies
across multiple developmental levels and target behaviors.

Intent and Preverbal Communication

The first time a parent hears a word from his or her child is never the first time the child
actually communicates. Before that first word, the child has communicated with the
parent for months—requesting, sharing, and drawing attention to him- or herself in
complex nonverbal or prelinguistic ways. The earliest forms of communication begin
with the reciprocal back-and-forth nonverbal interactions as well as vocalizations and
other social and communicative interactions between parent and baby throughout the
first year of life. These seemingly simple, yet actually complex turn-taking sequences
set the stage for the emergence of increasingly longer and more varied exchanges. Eye
contact, shared enjoyment, joint attention, and gestures (discussed later) are all forms
of preverbal communication that occur early in development. These early forms of
communication create essential pathways to verbal communication and cannot be
overlooked when teaching first words to children with ASD. Children with ASD who
are preverbal may or may not engage in these skills, and building these skills up is the
starting point for any child who is not yet using verbal speech.
Selecting Preverbal Communication Targets and Strategies for Intervention
As indicated previously, given the foundational nature of intentionality in commu-
nication, intervention for any child typically focuses on these functions as a start-
ing point. Communicative intent is expressed in many ways—through eye contact,
gestures, vocalization, and verbalization. Behaviors that regulate others are typi-
cally the first to develop; these include requests for objects, actions, or assistance
and protests. Social interaction behaviors include gaining attention, social games
(e.g., Peekaboo), and greetings. Finally, joint attention behaviors include showing,
commenting, and requesting information (Bruner, 1981; Crais et al., 2004).
250 Applications of NDBI Strategies

Although many children with ASD demonstrate behaviors that regulate oth-
ers, such as requesting actions and objects, some may not (Wetherby & Prutting,
1984). Because these behaviors are often the first demonstrated by young children
and can be paired with tangible reinforcers, such as food and highly preferred
objects, they are readily taught. Children can learn such behaviors progressively in
a naturally occurring developmental sequence—first using eye contact to request
objects and actions, then reaching to request, followed by pointing, and progress-
ing to vocalization and verbalization (Crais et al., 2004).
Sophistication in the behaviors can be added through combinations of behav-
iors, such as reach plus eye contact, or point plus vocalization plus eye contact. For
example, if a child demonstrates interest in a toy or activity, such as bubbles, the
adult might blow the bubbles. For children encountering an activity or toy for the
first time, a useful guideline may be to engage the child in three opportunities to
experience the activity or toy so he or she may understand and fully appreciate it.
As such, the adult might blow the bubbles three times in an unhurried manner,
assuming the child is engaged and appears to enjoy the bubbles. After the third
time, the adult could pause and wait for the child expectantly, holding the bubbles
in the child’s sightline. If the child looks at the adult and/or reaches for the bubbles
(depending on the expected developmental level of the request), the adult should
immediately reinforce the request, for example, by saying, “Bubbles! You want
bubbles” and blowing again. Development of behavior regulation intentionality is
a significant step in development of more sophisticated intentional communicative
acts, such a joint attention. Behavior regulation requires a child to focus his or her
attention on an object and communicate the intent to a partner about that object.
Ingersoll and Dvortcsak (2006) emphasized that parents use the previously
mentioned strategies in Project ImPACT, along with highly animated interactions
to increase communication engagement opportunities, such as exaggerated body
movements and facial expressions. ESDM recommends that parents and teach-
ers intentionally position themselves in front of children to assist with eye con-
tact (Rogers & Dawson, 2010) for both behavior regulation and social purposes.
ESDM and PRT both recommend teaching children to use eye contact to request;
one way to do this is to wait for eye contact prior to granting access to a desired
item (Koegel, Koegel, & Brookman, 2003; Rogers & Dawson, 2010). For example, an
adult can hold up a bottle or desired snack and wait for the child to look at him or
her before giving the item to the child. ESDM also introduces nonverbal communi-
cation as “talking bodies” and suggests that parents wait for a cue from the child
rather than anticipating the child’s needs by automatically meeting them. Environ-
mental arrangements and a large variety of communication temptation strategies
are essential tools in this phase to create learning opportunities throughout daily
routines and play (see Chapter 12, on social skills interventions, for a detailed dis-
cussion, including discussion of sensory social routines).
Social interaction requires the child to focus his or her attention on the com-
munication partner—another key developmental step in intentionality. Thus, it is
not surprising that children with ASD may rely on development of both behavior
regulation and social interaction skills to demonstrate joint attention behaviors.
When teaching social interaction skills, adults might use a similar progression
as behavior regulation skills. That is, if teaching a child to initiate and/or main-
tain interaction during a social game, the child might first use eye contact, then a
 Targeting Communication Skills 251

facial expression (e.g., smile), then a reach or gesture, then a vocalization, then a
verbalization. For example, the adult might initiate a Peekaboo game with a scarf
by first placing it over the adult’s head and saying, “Where’s X?”, then slowly pull-
ing it off. This might be repeated two more times, assuming the child is engaged
and interested in the game. On the third trial, the adult pauses with the scarf still
on his or her head expectantly, giving the child an opportunity to initiate a gesture
(pulling off the scarf) or a vocalization or verbalization (“Where’s X?”). If the child
does so, the adult and child continue taking turns with high affect. If the child does
not produce a communication bid, the adult slowly pulls off the scarf with a big
smile. If the child still appears interested in the social game, on the next trial the
adults might try placing the scarf loosely on the child’s head for variation.
Finally, joint attention is of particular interest with regard to children with
ASD. It develops near the end of the first year of life for typically developing chil-
dren. Sometimes joint attention is called triadic attention because attention is lit-
erally shifted between the communication partner and a third object—hence the
importance of the foundation skills of focusing communicative intent related to
an object (behavior regulation) and focusing communicative intent on a person
(social interaction). Most developmental researchers think this is a necessary step
in order for the child to begin to understand that a word references a specific object
or action. Indeed, the strong predictive relationships between early joint atten-
tion behaviors and later expressive and receptive language appear to support that
notion (Morales et al., 2000; Mundy & Gomes, 1998). Joint attention is key to social-
communication and interaction. Many of the early interactions have high affective
value and appear highly reinforcing for both child and adult, further establishing
strong social bonds and reciprocity. Children with ASD often lack both early joint
attention behaviors and the high affective state that typically developing children
demonstrate.
There are two aspects to joint attention: initiating joint attention and respond-
ing to joint attention. Initiating joint attention is when a child directs another per-
son’s attention to something of interest (e.g., the child says to a peer, “Look! An
airplane” while pointing in the sky). Responding to joint attention is when a child
reacts to another person’s initiation of joint attention (e.g., while sitting in a class-
room, the teacher looks out the window, and the child looks out as well). Children
should be initiating and responding to joint attention by 12 months of age; the com-
plexity and subtlety of the communication bids increases with age. Although chil-
dren with ASD demonstrate use of behavior regulation communicative intents
and/or are often responsive to teaching of such behaviors, joint attention behaviors
can be challenging for children with ASD and may need to be explicitly taught,
which is why they are emphasized in many NDBI treatment models (e.g., JASPER,
ESDM). Please see Table 11.3 for additional examples of different types of joint
attention behaviors.
Teaching joint attention is separated across initiation and response. As to be
expected, teaching initiation can be challenging. Adults must set up opportunities
for the child to express interest in an object or event and capitalize on the child’s
motivation to share such interest. This means following the child’s gaze or point
and commenting on it. Adults must demonstrate to the child that they are inter-
ested in what the child is looking at, observing, interested in, and engaged in. By
creating natural opportunities such as these, adults encourage the child to share
252 Applications of NDBI Strategies

Table 11.3. Joint attention behaviors

Behavior When does it develop? Example

Initiating joint attention

Eye gaze alternation 6–12 months Looking from airplane in the sky to
communicative partner
Pointing 9–12 months Pointing at a trash truck driving by
Giving 9–11 months Sharing food with family members
Showing 9–14 months Holding up a toy of interest and looking at
an adult until he or she reacts

Responding to joint attention

Following a point 6–9 months Looking at the truck as the parent points
to it
Following an eye gaze 9–12 months Shifting eye gaze to what the parent is
looking at
Source: Bruinsma, Koegel, & Koegel (2004).

interesting stimuli in the environment and activities. Adults can also create more
contrived situations with specific cuing hierarchies for the child to point to, show,
and tell about objects and activities until more spontaneous productions occur. For
example, adults can encourage the child to point out particular objects of interest or
specific categories of objects (e.g., animals, cars) when reading books. As the child
is learning to point to things to draw attention, adults can support the child by giv-
ing him or her a target that is pre-positioned into the book or physical environment
to support the child in this task. Small, round, removable stickers (often found in
office supply stores) can be helpful in creating visual cues and decreasing reliance
on adult prompts when working in this way.
With regard to responding to joint attention bids, progression in both linguis-
tic and contextual cues is required—that is, when drawing a child’s attention to an
object or event of interest, adults should start with high affect and a clear linguistic
and visual cue (e.g., “Look, X” with point and head turn). In addition, they should
make sure that the object they will be looking at holds high reinforcement value!
The child needs to receive reinforcement for looking if adults hope to encourage
the child to repeat the behavior. Adults should slowly reduce the saliency of the
cuing and the magnitude of the reinforcer as the child becomes responsive to joint
attention bids across communication partners.
JASPER emphasizes joint attention behaviors and constantly models a variety
of examples while also promoting an affectively rich interaction with some label-
ing. In addition, some research in PRT has shown that eye gaze alternation to share
enjoyment (a social purpose) increases during child–parent interactions as a col-
lateral effect of PRT (Bruinsma, 2004). This suggests the focus of PRT strategies to
enhance the child’s success in the interaction may support the development of early
forms of joint attention behaviors and may in fact help to explain why children
learn to use verbal communication in PRT programs. Selection of highly preferred
materials, especially those that are related or part of a child’s perseverative interest,
may be especially important. Vismara and Lyons (2007) showed that incorporating
these interests into interactions may increase a child’s joint attention behaviors,
making the case for a careful selection of materials for teaching interactions.
 Targeting Communication Skills 253

Augmentative and Alternative

Communication for Individuals Who Are Nonverbal
Some individuals with ASD will benefit from AAC systems that support commu-
nication across multiple modalities. AAC can take many forms (or a combination
of forms), including use of sign language, low-technology picture symbol systems,
such as PECS (Frost & Bondy, 2002), or high-technology speech-generating devices,
such as applications on iPads or devices developed specifically for the purpose of
generating speech (e.g., Dynavox). The main goal of any communication system is
always to encourage the individual to communicate his or her message, regardless
of the modality. For example, a child might be using a speech-generating device for
communication, but adults should never ignore the child’s request using a pointing
gesture (just as they would never ignore the same gesture from a child who is verbal).
Research supports that children with ASD demonstrate effective communica-
tion across multiple modalities (Mirenda, 2003). In addition, use of some types of
AAC may provide support as children acquire verbal language; for example, PECS
has been found to be an effective bridge to verbal communication for some chil-
dren with ASD (Carr & Felce, 2007; Ganz & Simpson, 2004). Although parents and
clinicians sometimes worry that the use of AAC will hinder the development of
verbal language, research does not support this concern. Thus, it is essential to sup-
port the child’s acquisition of communicative intentionality regardless of modality
in order to pave the way to successful communication.
Progress monitoring, defined as careful data collection regarding the child’s
progress in intervention, is key to determining if providers should seek alterna-
tive communication methods for a child. For example, within ESDM, if a child is
not making sufficient verbal language progress (acquisition of 5–10 spoken words)
within 3 months of intensive intervention focusing on verbal language, the team
begins to support the child’s acquisition of communicative intent via alternative
methods while continuing to support acquisition of verbal language. If the child
demonstrates strong motor imitation skills, use of sign language is introduced as an
alternative communication method to possibly bridge verbal language acquisition.
Should the child demonstrate motor imitation challenges, PECS can be introduced
(Dawson et al., 2010). Frost and Bondy (2002) indicated there are no prerequisite
skills required to introduce PECS, although clinicians should be mindful as the
child progresses through the phases because skills such as matching pictures to
objects in the environment may facilitate successful use of PECS as the complexity
increases. When using PECS, careful adherence to the manual is recommended
for effective acquisition of communicative intent. If verbal language does not
develop as the child progresses through these low-tech methods (or others), the
child should receive consultation from a speech-language pathologist (SLP) who
specializes in AAC to determine the next steps in determining the AAC device
and programming to fit the child and family’s needs. Indeed, consultation with an
AAC team, including an SLP and occupational therapist skilled in serving children
with complex communication needs, should be pursued prior to implementation of
any long-term AAC protocol.

Strategies for Teaching Augmentative and Alternative Communication Goals

Teaching children to use AAC via NDBI strategies is very similar to teaching any
early communication skill. When teaching PECS, NDBI clinicians should follow the
254 Applications of NDBI Strategies

PECS protocol (Frost & Bondy, 2002) because it outlines very clear steps for teach-
ing PECS as well as ABA-based strategies for doing so. In order to ensure access to
communication across contexts, the child’s communication book should include
PECS icons for all possible communication contexts, objects, and events of interest
that may be encountered throughout the day. One area of frequent communication
breakdown is when a child wishes to use his or her communication book to com-
ment on or request a particular object or event and the PECS icon is not present in
the book or the child does not have access to the book at that time, which severely
limits the child’s communication opportunities. Continual updating of the book
reinforces communication, maintains child motivation, and promotes reciprocal
social interaction. It may be useful to consider that a verbal child has their words
with them at all times, as should a child using AAC!
The use of other communication devices can be taught in the same way. These
devices are often introduced and initially taught during speech and language ser-
vices or NDBI therapy sessions. As such, treatment should be closely coordinated
with an SLP with specific AAC expertise when necessary. Again, the same strat-
egies for teaching early communication skills can be applied to teaching device
use. Very quickly after introduction of the device, communication partners across
contexts should be trained in use of the device in order to maximize opportunities
for use across communication contexts and to ensure access to communication for
the child. Again, it is important that the device be available at all times because
this is the child’s means of communication. Adults would not limit a child’s verbal
language opportunities to specific times of day or physical environments; children
who use AAC devices (both low and high tech) require the same universal access.
A PECS system or device is only useful to the child if it is available or feasible to use
in the natural environment!
When teaching AAC, adults should remember to continue recasting, nar-
rating, and modeling language. Indeed, adults and peers should be taught and
encouraged in use of the AAC device themselves during interactions with the
child with ASD; this is called aided language modeling (Drager et al., 2006). When
children are nonverbal, their lack of verbal responsiveness sometimes conditions
adults to become less verbal during adult–child interactions. However, continuing
to expose these children to a language-rich environment, through both verbal and
AAC modeling, remains critical to their development; adults must scaffold their
receptive and expressive development in this way.

First Words
As indicated previously, initial treatment goals are often focused on intentional-
ity. As the child’s expression of intentionality progresses developmentally (e.g.,
eye contact, gesture, vocalization, verbalization), the focus can begin to shift to
assisting the child in shaping his or her vocalizations closer to accurate produc-
tions. Production of first words may occur concurrently with other behaviors
to demonstrate intentionality. An example would be the child who first looks
at the caregiver to indicate wanting to be picked up, then starts to raise his or
her hands to request, then vocalizes, then combines the approximation for “up”
with raised arms. Once a contingent vocalization is consistent, then the parent
or teacher can begin to introduce new word approximations. Vocalizations and
 Targeting Communication Skills 255

verbalizations can be encouraged by the use of imitative songs, narration and

word modeling during play, recasting, and contingent social games in sensory
social routines (see also Chapter 12, on social skills). Early vocalizations can
form the foundations of first words for preferred objects and can encourage con-
tingent word use as a means to request (e.g., “bu” for “ball”). However, adults
should be cautious in early stages of communicative intent about requiring a vo-
calization or verbalization (approximation) for every opportunity; they should
remember to intersperse acquisition and maintenance. As children are first ac-
quiring early communication skills, development can fluctuate, and a child’s
motivation can be diminished if he or she is constantly pushed to maximize
his or her performance. Interspersing reinforcement of nonverbal communica-
tion behaviors (e.g., gestures, eye contact) can be useful for ensuring motivation
remains adequate.

Selecting First Word Targets Selecting first word targets carefully is impor-
tant to ensure many opportunities for success (Koegel, 2000). Parents, therapists,
and teachers often teach nouns first when building vocabulary, with an initial
focus on words used to request, because children with ASD learn best when highly
motivated, and their motivation is often highest when requesting preferred objects.
However, teaching action words is also key. Children need a way to describe what
they want to do and the way they participate in their daily lives. The ability to
prompt for the word many times throughout the day is essential, as is the need to
select words based on the child’s preferences.
Developmental literature shows certain sounds develop earlier and will
most likely be easier for the child to produce (e.g., “buh,” “mah”). Because all
children are different—and children with ASD can have unusual and complex
patterns of speech development—it can be useful to consult with the child’s
SLP when selecting first word targets. Some first word targets may be challeng-
ing for a variety of reasons, as described in Table 11.4. In this table, examples
of first words or word categories are listed, along with a description of why
they are or are not good first word targets. In many cases, verbs and words like
“more” may be good first word targets but some may have some pitfalls (e.g.,
prone to overgeneralization). These pros and cons are also briefly discussed in
the table.

Strategies for Teaching First Words First words are typically taught
using some of the shared control strategies outlined previously to target ver-
bal requesting and vocalizing or verbalizing during sensory social routines.
These strategies all incorporate child-preferred objects or activities, shared con-
trol, and natural reinforcement to motivate children to verbally communicate.
Strategies that lend themselves particularly well to teaching first words include
sensory social routines, environmental arrangements (in sight, out of reach),
playful interruption or obstruction, controlling access, and inadequate portions
or breaking it up. Table 11.5 outlines a range of ideas for materials that can be
used at this stage and some advantages and disadvantages of each for teaching
first words. For example, some toys lend themselves better to multiple trials
than others, are ideal for taking turns, or facilitate shared control more natu-
rally than others.
256

Table 11.4. Tips for selecting first word targets

Example first words Good first word target Child-specific considerations Possible challenges

Carrier phrases: These are usually helpful for first Child must understand to fill in, rather Child can become prompt dependent and have
Ready, set, go; words because they create inherent than repeat. difficulty moving on to acquiring more words.
one, two, three momentum and can easily be associated
with fun actions.
Labels for preferred Many children with autism spectrum Be sure the child understands verbs. Be careful to ensure that the action is specific
actions: Up, push, disorder (ASD) love physical stimulation, Some children do better starting out and clear. You may wish to avoid consonant
hop, pop and these are usually top picks. with nouns. blends as first word targets.
More This usually is not a good first word Once a child has 25–50 labels, this can This word is easily overgeneralized. The child may
target, although it is frequently taught be an easy word to add as long as use “more” for everything he or she wants.
early as a sign. the child continues to use specific Remember that you want to teach object–label
labels. correspondence at this stage of development.
Yes This usually is not a good first word This word can be added into the This word is easily overgeneralized, as
target. child’s repertoire later and may need described previously.
to be specifically taught. It can also be conceptually challenging or some
children to learn.
No, all done, or They can be good first word targets They can be useful as a replacement These words are often hard to teach because
other words that because protest emerges with behavior if the child engages in they may be needed when the child is
indicate an activity communicative intent. problem behaviors. frustrated. Specific teaching strategies may
ending or stopping be required, which will be more successful
once a child can easily say other words.
Animal sounds: These can be good first word targets. They These are often a fun way to label These may not be as functional or universal as
Moo, meow, often appear early in development for animals, but they are not reinforcing teaching animal names.
ruff-ruff typically developing kids. to all kids. They should only be taught
to children who are reinforced by play
or activities that relate to animals.
Labels for preferred These are helpful for most kids. Once you It can be useful to choose labels for For children who are struggling to learn words,
items, such as pick a few labels, try to ensure that there items that are both highly preferred it may be challenging to choose a word that
bottle, block, choo- are many opportunities throughout the and include sounds you have heard they can practice often enough.
choo, and baby day for requesting the item. the child say.
Academic objectives: These can be good first word targets These are only good first word targets They are often loved by parents and can be
Colors, numbers, because they are clear labels, like any if they are motivating for the child. highly preferred, but they are not always
shapes other noun. functional. Try to incorporate them once the
child has 50 or more consistent functional
words or only rely on them for children who
are difficult to motivate with other objects.
 Table 11.5. Material selection for teaching first words

Type of material Examples and suggestions Advantages Disadvantages

Simple toys that Pretend telephone They are often highly motivating and interesting If you only have one of these toys, it can be
consist of one Pretend car keys to manipulate, especially for younger children or difficult to foster reciprocity and balanced
piece, often Steering wheel those who are less verbal. turns, which can result in one type of
with buttons to iPads Try to have two of the same object so that you can opportunity to gain initial access, unless you
manipulate Poppin’ Pals imitate what the child is doing in order to promote incorporate turn taking.
Leapster interaction and communication. Kids can get overly focused on the electronic
Toy instruments (e.g., piano) It is easy to follow the child’s lead in interactions nature of these toys, which can interfere
because the toys are simple. with interaction and reciprocity.
Simple cause-and- Ball ramps These are coveted toys that lend themselves to both Because the actions on these toys are
effect toys with Car ramps action words (in, on, or go) and nouns (cookie, repetitive and the vocabulary can be limited,
multiple pieces Marble ramps chip, or ball). be sure to mix it up with your words and
Ball popper They can be good for breaking it up. play acts. For example, add other targets,
Connect Four You can elaborate on the play and communication. such as receptive skills, following directions,
Cookie Monster that eats sharing, or turn taking.
cookies
Toy piggy bank with giant
coins
Toy gumball machine with
balls
Puppets Puppets with mouths you Puppets can be involved as an addition to many Some children find puppets scary, at least
can stick your hand into to activities and can bring humor to play. initially.
manipulate as if they are Routines that involve sound effects (e.g., pretend For first word learners, make sure the verbal
talking sneezing) are particularly effective. targets are clear (e.g., have the child label
Colorful big monsters, Children also often find it funny when puppets eat or the food the puppet will eat).
animals, or dinosaurs spit out toy food.
They allow for modeling and creation of imaginative
play schemas.
Playdough Sets with a clear action (e.g., It is great for teaching actions such as roll, push, and Playdough can quickly turn into a solitary
figurine with hair that cut. activity, so balanced turns and shared
grows, contraption that There can be many items and colors associated with control are important.
produces spaghetti) the activity for the child to request. Some children try to eat it.
Playdough tools (e.g., Some adults object to the mess. Try containing
roller, pizza cutter, plastic the activity by presenting it on a plastic tray!
scissors)
Different colors of playdough

(continued)
257
258
Table 11.5. (continued)
Type of material Examples and suggestions
Puzzles Sound puzzles
Wooden inset puzzles
Shape sorters
Books Touch and feel books
Sound books
Pop-up books
Simple storybooks
Preschool games Gone Fishin’ (or any fishing
that have a simple game)
(often electronic) Elefun (elephant that catches
action (Note: These butterflies)
do not have to be Lucky Ducks (pond with
played according ducks)
to the rules. Many Balloon Lagoon
children just find Penguin Race Game
the materials (penguins that climb and
to be fun and slide down a track)
motivating.)
Advantages
Puzzles can provide a range of vocabulary if
the pieces are different objects (e.g., animals,
vehicles).
Sounds are often highly motivating.
Varied sounds can provide a range of opportunities.
It is easy to incorporate actions with puzzle pieces if
the pieces contain animals, vehicles, and so forth.
They provide lots of opportunities for different
communicative functions, such as requests for
information (“Where’s the missing puzzle piece?”)
and commenting.
Books offer many opportunities for labels, actions,
and joint attention.
They can be highly preferred, and it is easy to
incorporate the child’s favorites.
There are good opportunities for varied vocabulary
once the pictures have some complexity to them.
Be sure to follow the child’s gaze and label what the
child is looking at—this promotes initiating joint
attention.
Simple actions (“swim” and “on”) and nouns
(“duck” and “net”) are easy to label.
Communication trials are easily embedded if you
retain control over some of the pieces and use
breaking it up (e.g., the fish, ducks, butterflies,
penguins).
There are lots of opportunities for reciprocity, joint
attention, and shared enjoyment (e.g., watching
the elephant spray the butterflies in Elefun).
Disadvantages
Be sure to use balanced turns. It is tempting to
have the child communicate for each puzzle
piece, but this may be frustrating and does
not create a natural interaction. Intersperse
having the child communicate to receive
a piece with giving noncontingent access
and commenting or initiating joint attention
and shared affect with regard to his or her
pieces.
Because the vocabulary can get repetitive, it
may be helpful to intersperse different tasks
(e.g., receptive targets) into the activity.
Bigger books or books with added features
such as sound or pop-ups can increase
opportunities for reciprocity, shared
enjoyment, and balanced turns.
A useful strategy for embedding trials is to
have the child label something on the page
and then turn the page as reinforcement.
Avoid taking too many of the turns yourself
and asking lots of questions to keep the
interaction reciprocal.
At first, try to use the game for its motivating
and engaging materials. The object is not
necessarily for someone to win but to have
fun with the materials as a toy. This is why
games for older kids will sometimes still
work. If Connect Four is about putting chips
in and seeing them fall out, then you do
not need to understand the objective of
the game.
Be sure not to get stuck on trying to play
the game by the rules if this is not
developmentally appropriate or motivating
for the child.
 Music or musical Small harp If you have multiple instruments, you can easily Musical instruments can be difficult for shared
instruments Drum target requesting and turn taking. control but great for turn taking, imitation,
Small guitar or ukulele These lend themselves nicely to interspersing and small-group music-making activities.
Xylophone imitation trials as well. Try having duplicates of instruments so the
Maracas Freeze dance is easy to request for first word adult can imitate the child’s actions to
Tambourine learners. It is fun, too! encourage engagement and reciprocity.
Triangle Kids’ songs are easily found on many web sites, such
Kids’ songs as YouTube. Many kids love the versions of pop songs
Freeze dance that are adapted for kids (e.g., Kidz Bop).
Blocks or building Big blocks Multiple pieces are good for breaking it up. Have the Small Legos can be a choking hazard.
toys Lego or Duplo blocks child request a few pieces at a time. Sometimes the actual building of structures
Wooden building sets First word learners often like to knock down towers. The is too difficult, and reinforcement is too
Lincoln Logs bigger the better! This is also a fun opportunity for delayed for first words learners. Be aware of
Magna-Tiles joint attention and shared enjoyment! this pitfall, and provide assistance with the
Building (e.g., building a house, barn, or castle) lends building to enhance motivation.
itself easily to play expansion (adding other play
items).
Pretend play toys Doctor kit Multiple pieces are good for breaking it up. Have the Although thematic play with these items is
Babies with bottles, binkies, child request one or a few pieces at a time. usually above the developmental level
or blankets You can incorporate these items with other play sets, of first word learners, these items might
Dolls and dollhouse such as puppets, and building toys. provide opportunities to model simple
Barn with animals functional play acts (e.g., feed baby).
Pretend food and dishes Due to lack of play skills, these items are not
Plastic dinosaurs motivating for all first word learners.
Balloons Balloon pump They lend themselves nicely to routines that can Balloons can be a choking hazard. A child
Rocket balloons repeat (e.g., blowing up balloons and letting them should not be allowed to blow up a balloon
Different color balloons go). Model the routine, then pause and have because it can pop, which may force
the child request (verbally or nonverbally), as in particles into the child’s mouth and possibly
sensory-social routines. down his or her airway.
You can create many routines (e.g., balloon soccer, in Some children are afraid of balloons,
which the adult picks up the child so he or she can especially if the game is to blow them up
kick it). and then let them fly around the room.
When you rub balloons, they become static and stick;
this can be funny.
Balloons create fun opportunities for balanced turns,
reciprocity, shared enjoyment, and joint attention.

(continued)
259
260
Table 11.5. (continued)
Type of material Examples and suggestions
Water play Water balloons
Hose and buckets
Small watering can
Bath toys
Water sensory bin with cups, Water play can be combined with many other
water wheel, and other
items for scooping and
pouring—fun to include
soap bubbles
Bubbles Hand blown with many
different shapes, tools, and
so forth
Bubble machines
Train sets and other Train sets with many pieces
vehicles Trash trucks that can really
dump
Dump trucks
Small vehicles (e.g.,
Matchbox)
Car ramps
Toy garage (some have an
elevator) and cars
Bridges and especially
tunnels that make sound
Advantages
Many of these activities can have multiple pieces that
are easy to have shared control with and work well
for verbal requesting. You can practice turn taking,
too!
activities (e.g., make plastic animals or dolls swim).
Water balloons are amazing, and filling them is an
activity on its own. Throw water balloons at targets
drawn with chalk.
Dumping and splashing water is a popular early play
activity.
During cooler days, make a water sensory bin with
a plastic tub or container and some scooping and
dumping toys. The bathtub or the sink can also be
great places to play with water.
Easy activity that can be used for prompting a variety
of words such as “blow,” “pop,” and “dip.”
Bubbles create good opportunities for joint attention
and shared enjoyment.
Multiple pieces are good for breaking it up. Have the
child request a few pieces at a time.
The child can practice varied vocabulary because
there are many pieces and different actions and
locations are possible.
Adult imitation of the child’s actions is easy because
multiple pieces are typically available.
Embedded trials are easy with these types of
activities (e.g., add a figurine on the track for
playful interruption, dump over and over for
momentum, and set up for initiations when
important pieces are missing).
Disadvantages
Never leave a child alone with water.
Water can become repetitive and
perseverative for some children. In this case,
you might have to limit access. For children
who become rigid about wanting access to
water play, it is best not to allow play in the
sink because this may make other routines
(e.g., hand washing and brushing teeth)
more difficult. Instead, use a water sensory
bin.
They can become boring quickly for some
children.
They can become perseverative for some
children, in which case you may have to
limit access.
It can be difficult when you only have one
vehicle.
Be sure to determine why this type of play
is most interesting and reinforcing for
the child. For example, does the child like
driving the train? Seeing the train emerge
from the tunnel? Listening to the sound of
the train going through the tunnel?
 Arts and crafts Coloring These activities lend themselves well to multiple Some first word learners do not have an
Pasting strategies for embedding trials because there are interest in these types of activities yet;
Stamps many pieces for the child to request. however, most children can do all these
Stickers Try using a variety of fun craft supplies, such as activities at their own level.
Collaging colorful pom-poms for gluing; cotton balls for Some adults do not like the mess. Try doing
Painting making puffy clouds; Popsicle sticks for coloring or these activities on plastic trays, and limit
Beading gluing things to; pipe cleaners for easier beading; how many supplies you allow the child
beading with uncooked pasta; glitter or large sequins to obtain at once. This is another way of
for gluing; cut or torn tissue paper, old magazines, applying shared control.
or colored paper for collaging; and vegetables (e.g.,
potatoes and carrots cut in shapes) for stamping.
Sensory activities Shaving cream They provide many opportunities for embedded They can be messy. Some of these activities
Fake snow trials, where the child has to request items. can also be done on plastic trays (e.g.,
Sensory bins (e.g., dry Activities such as parachute and swinging lend shaving cream) or in bins (e.g., sensory
beans, rice, kinetic sand) themselves nicely to sensory-social routines. bins).
with accessories (e.g., cups They are often highly reinforcing. Some children can perseverate on these
for scooping, small toys You can incorporate a range of items (e.g., paint activities, so you may have to limit access.
for burying) brushes to make patterns in shaving cream; small Be sure you know which sensory activities are
Finger painting toys in sensory bins, such as sea creatures in motivating for a child and which may be
Parachute kinetic sand). aversive. These activities need to be tailored
Blanket for swinging, pulling There are lots of opportunities for shared enjoyment, carefully to the child’s preferences.
the child across the floor, balanced turns, and reciprocity.
or hiding under
Cooking activities Cookie decorating Take shared control over ingredients and utensils (e.g., They may not be appropriate for young
Ice cream sundaes measuring cups), and prompt single word requests. children or children with severe
Ants on a log (nut butter on Balance turns with who gets to add ingredients. impairments, but activities can often be
celery with raisins) Practice following simple verbal instructions (e.g., adapted.
Smiley face sandwiches, “put in”). As long as you can have multiple pieces,
pancakes, and so forth These are especially great activities for older children steps, or repetitive actions, these activities
Jell-o still working on first words. work well.
Playing with random Rope or string These activities are completely dependent on It can be challenging to come up with more
objects Cups the creativity of the adult but are often highly than a few different types of opportunities to
Lids motivating for the child. communicate.
Sticks
Plastic storage containers
Tubes

261
262 Applications of NDBI Strategies

The most common prompting strategies for teaching first words are time
delay and model prompt. Prompting strategies are outlined in detail in Chapter 8.
Depending on the child, one prompting strategy may come before the other. For
example, if a child has quickly learned several object labels, a time delay can be
used almost from the beginning, with a model prompt as backup if the child does
not respond. Within the context of play interactions and joint activities, comment-
ing on objects or events and pausing provides the child with a verbal model and
then allows him or her to engage. This is often effective, not only for engagement
and social interaction, but also for assisting the child in verbal production and/
or initiation of a new, related interaction behavior. Particularly for children with
limited vocabularies, this provides opportunities to increase exposure to words
within context. This can then be faded to time delay once the child has gained
some vocabulary knowledge. Carrier phrases may also be useful at this stage as a
strategy for prompting the child to fill in the missing word (e.g., adult says, “ready,
set” and child responds with “go”).
Even in the first words stage, many NDBI place an emphasis on ensuring that
opportunities for initiations are created. Use of sensory social routines, in which
the adult repeats a motivating action (e.g., tickles) several times and then pauses so
that the child can indicate a desire to continue, can be very helpful at this stage of
development, especially because these routines tend to be motivating for children at
the first words developmental level. Environmental arrangements, in which objects
are out of reach or in closed containers, are also helpful for promoting initiations
at this stage. Reducing adult anticipation of the child’s needs and waiting for the
child to initiate is another useful strategy. For example, the adult might wait expec-
tantly for the child to say “shoe” before helping put shoes on. Controlling access or
shared control with a time delay cue may also be helpful for teaching verbal initia-
tion behaviors. Building behavioral momentum by providing noncontingent rein-
forcement is also especially effective at this stage. This entails giving the child the
requested action or item while labeling the target word without prompting the child
to say it. When this is done in rapid succession prior to prompting for the word, the
child may be more likely to respond. Please see Table 11.6 for additional examples.

Phrase Speech
The transition from single words to word combinations is a slow, deliberate process
that cannot be rushed. Expecting a child to speak in short phrases too quickly can
result in decreased motivation, echoic responding (the child simply repeats what
the parent said), prompt dependency, and thus a lack of initiations. As such, if a

Table 11.6. Noncontingent reinforcement

Target word Action with target word Description of momentum

Ball Rapidly tickle the child withEach time you tickle the child, say “ball.” After two
a ball. to four times, hold back the ball and model,
“Ball?”
Chip Fill up the Connect Four Each time the chip goes into the game frame, say
game with chips. “chip.” After a few times, hold up the chip and
ask, “Chip?”
Go Pick up the child, and swing Each time the child is swung, say “go.” After two to
him or her once around. four swings, pick up the child, wait, and ask, “Go?”
 Targeting Communication Skills 263

child is taught to use phrase speech before he or she is developmentally ready to do

so, the language will be rote and will not be meaningful to the child; it is analogous
to how young children first learning the alphabet think of the letters LMNOP as
one unit until they learn that each letter is distinct and separate. Once a child has
obtained a range of single words (at least 50) and can use them spontaneously, in-
dependently, and functionally, an adult’s efforts can shift to continuing to expand
the child’s vocabulary and targeting length of utterances.
It is important to make sure the child is using a variety of words consistently
(nouns, verbs), functionally, and spontaneously before moving on to word combina-
tions or phrases. Many clinicians use about 50–80 single words as a benchmark before
moving on to focusing on phrase speech; in typical language development, chil-
dren start to combine words together when their vocabularies reach 40 to 200 words
(Bates et al., 1995). It is also important to continue to intersperse teaching trials for
single words to ensure that vocabulary is expanded and motivation remains high.
Interspersing teaching trials for words the child already knows (maintenance tasks)
is important for enhancing motivation at this stage. It can be helpful to make lists
of these new words and possible two-word combinations for each highly preferred
activity so that the same combinations across and within activities are targeted.
Please see Table 11.7 for an overview of considerations on when to begin inter-
spersing word combinations. Although this table does list criteria, acquisition of
the listed skills is not necessarily a requirement prior to targeting phrase speech.
Rather, the information provided may be useful to consider when evaluating the
child’s progress and skill level with single words and can be used to guide how and
when to move into phrase speech.

Selecting Phrase Speech Targets Selecting phrase speech targets carefully is

important to maintain child motivation as a new, more challenging skill is introduced.
Phrase targets that can be easily practiced in the natural environment are a good place
to start in order to ensure many opportunities for success. The ability to prompt for
the phrase many times throughout the day is essential, as is the need to select phrases
based on the child’s preferences. Some common patterns exist with regard to how
children develop production of short phrases. Table 11.8 indicates common patterns
as children begin putting two words together (Bowen, 1998; Brown, 1973). In addi-
tion to the combinations of words listed previously, between 27 and 30 months of age
children typically demonstrate use of present progressive (-ing), in, on, and plural (-s).

Strategies for Teaching Phrase Speech Phrase speech is taught using the
same embedded teaching trials that were used to target single words. At first, fre-
quent models (i.e., model prompts) will be required to prompt the child to expand
beyond single-word responses. For example, if the child responds with “car” when
the parent holds up the car, the parent might have to model the phrase “red car” to
prompt the child for the phrase. The parent should not deliver the reinforcement
until the child has used the phrase. To practice a newly taught phrase, the adult can
wait expectantly (i.e., time delay) for the child to elaborate on his or her initial com-
munication before reinforcing the child’s request. When modeling, the adult should
teach a variety of two-word combinations and vary those phrases within and across
activities from the beginning. This will help prevent prompt dependency, rote
phrase learning, and overgeneralization. For example, some children will learn
a phrase within a specific activity and will not vary their phrases when prompted
264 Applications of NDBI Strategies

Table 11.7. Ready, set . . . phrases!

Criteria Examples

Are the single Saying the word with object not present:
words • Asking for “bubbles” while bubbles are not in sight
spontaneous • Saying “juice” while standing in front of the refrigerator
and Saying the word without prompting:
independent? • Using the correct word to request an object when the object is offered
• Commenting or labeling by using the correct word when not requesting the
objects
Using multiple words in the same situation:
• Asking for “open” while bringing the bubble container to the parent
• Then, saying “bubbles” to the parent when all the bubbles have popped
Are the single Are the words directed to the communicative partner and related to
words something in the environment (e.g., an object the child is requesting or
functional? commenting on)?
If the words can be identified as delayed echolalia or scripting, they should
be correctly used in context, be directed at the communicative partner, and
directly related to something in the environment, as above.
A portion (half or more) of the words should be clearly spontaneous and not
stereotyped.
Are the words Using the word across activities:
generalized? • “Bubbles” when playing bubbles outside and to refer to bubbles in the
bathtub
• “Open” to open a door, a snack bag, and multiple types of containers
Using the word with different communicative partners:
• With therapist
• With mom
• With dad
• With sibling
• With peers
Are the words Using a variety of words within an activity demonstrates that the words are
varied within spontaneous, independent, functional, and generalized. For example:
an activity? • “Blow,” “blowing,” “more,” or “go” during bubbles
• “Big” or “little” when playing with blocks of different sizes
• “Fast” or “slow” when driving cars or trains
• Labeling the pictures (e.g., vehicles, animals) rather than saying “puzzle” for
each puzzle piece
• “Up” or “down” when engaged in the sensory-social routine of being picked
up or spun around
Do the words Saying the word to obtain access as well as to comment:
serve • Saying “open” while the parent holds the container up
multiple • Saying “open” to comment when the child successfully opens the container
functions? independently
Saying the word to request as well as to draw attention to an action or object:
• Saying “bubbles” to request more bubbles
• Saying “bubbles!” to the parent in response to bubbles being blown
Can the words By adding grammatical markings:
be simply • “Bubble” to “bubbles”
expanded? • “Pop” to “popping”
By adding a simple second word to make a phrase:
• “Open bubbles”
• “Big bubbles”
• “Blow bubbles”
Are there any Although useful to learn in the long run, be careful when adding words that
words to can be overgeneralized at first because these may hinder development of
avoid? phrase speech:
• “Want”
• “More”
• “Go”
 Targeting Communication Skills 265

Table 11.8. Common patterns of two-word utterances

Pattern Example Meaning

Reference operations

Nomination That boy That is a boy.

Recurrence More cookie There is more cookie.
Negation—denial No hit I did not hit.
Negation—rejection No water I don’t want water.
Negation—nonexistence Cat go The cat has gone.

Semantic relations

Action + agent Mommy kiss Mommy is kissing.

Action + object Push choo-choo Pushing the train.
Agent + object Daddy car Daddy (drives) the car.
Action + locative In home I am at home.
Entity + locative Sissy swing My sister is on the swing.
Possessor + possession (object) Mommy cookie Mommy’s cookie.
Entity + attribute Milk cold The milk is cold.
Demonstrative + entity This bug THIS bug (not THAT bug).

(e.g., the child only uses “water on” when playing with water balloons but will not
request “fill it up,” “water,” or “balloon”). Others will learn to use a phrase within
one context but will not use the phrase in the next (e.g., the child will use “open the
door” to leave the house but not to open the door on the toy car garage).
Modeling, recasts, and use of the one-up rule (discussed previously) can be
helpful ways to introduce new phrases or word combinations into an activity,
familiarizing the child with the new phrase without placing demands to say it just
yet. Please see Table 11.9 for the four steps for introducing a variety of phrases into
an activity. This example might be applicable to a child who is building single-word
vocabulary or just expanding beyond single words; however, the same sequence
can be used to target a range of communication skills.
As demonstrated in the example, the adult should occasionally repeat the
phrase that the child independently chose because he or she is teaching that all of
these phrases are acceptable within this activity. The adult should also remember
to vary the productions to avoid fostering stereotyped speech by associating spe-
cific phrases with certain activities. By alternating the productions, the adult shows
the child that all of the phrases are acceptable.

Questions
Throughout communicative development, asking questions for social and needs-
based purposes is an important skill. Likewise, responding to questions is key to de-
veloping social reciprocity. The following section addresses strategies for selecting tar-
gets in this skill area, as well as strategies for teaching question asking and answering.
Selecting Targets Early in development, requests for information, a joint atten-
tion behavior, might be expressed by a point and a shrug or a point and a vocalization
with a rising intonation (i.e., a “proto-request for information”; Crais et al., 2004). For
example, a toddler might hear an airplane, look out a window, point, and look back
at his or her caregiver with a quizzical expression, to which the caregiver responds,
266 Applications of NDBI Strategies

Table 11.9. Using modeling to introduce new phrases

Mastered skill (maintenance task): “Push me”

Goals (acquisition tasks): “Go faster” and “Let’s swing”

Teaching step Antecedent Behavior Consequence

Step 1: Introduce Therapist says, “What Child says, “Push me!” Therapist swings the child.
trial should I do?” while He or she models the new
holding the child phrase, “Go faster!”
still in the swing. Therapist repeats this
process several times.
Step 2: Introduce Therapist says, “What Child says, “Push me!” Therapist continues to
the new phrase should I do?” while withhold swinging from
(acquisition) holding the child the child.
still in the swing. He or she prompts again
(see next trial).
Therapist models Child says, “Faster” Therapist swings the child.
the new phrase, or reasonable He or she recasts, “Go
“Go faster?” while approximation. faster!”
holding the child Therapist repeats several
still in the swing. times.
Step 3: Practice Therapist asks, “What Child says, “Go Therapist swings the child.
the new phrase should I do?” while faster!” He or she repeats, “Go
until mastery holding the child faster!”
still in the swing. Therapist continues to
repeat.
Step 4: Vary Therapist asks, “What Child says, “Go Therapist swings the child.
phrases should I do?” while faster!” He or she repeats, “Go
within tasks holding the child faster!”
by adding still in the swing.
additional Therapist holds Child says, “Go Therapist swings the child.
phrases the swing while faster!” He or she models with
waiting. the new phrase, “Let’s
swing!”
Therapist holds Child says, “Go Therapist continues to
the swing while faster!” withhold swinging from
waiting. the child.
He or she prompts again
(see next trial).
Therapist models the Child says, “Swing” Therapist swings the child.
new phrase, “Let’s or reasonable He or she could
swing!” while approximation. use differential
holding the child reinforcement of the
still in the swing. new word by swinging
the child even higher.
Therapist recasts, “Let’s
swing!”
He or she repeats the
phrase several times.
Therapist asks, “What Child says, “Let’s Therapist swings the child.
should I do?” while swing!” He or she could
holding the child use differential
still in the swing. reinforcement again.
Therapist repeats, “Let’s
swing!”
 Targeting Communication Skills 267

“It’s an airplane.” Encouragement of such requests for information is key throughout

communicative development, and adults should not wait until the child has reached
a certain level of language development to encourage such behaviors. Indeed, con-
sistent with most language input, research indicates that children understand ques-
tions prior to expressing them; as such, asking children questions and modeling
answers from an early age is fundamental to language development. Requesting in-
formation supports a child’s understanding that other people have information that
they can obtain. The child also learns that he or she has information to share with
others (Donaldson & Olswang, 2007). With regard to the linguistic form of common
types of requests for information (e.g., wh-questions), questions with clear, concrete
answers that provide information (e.g., “What’s that?” “Where is it?”) often emerge
before questions with more abstract answers (e.g., “Why?”). Children typically first
understand and produce questions in the following sequence: what; yes/no; where;
who; when; and why, how, which, and, whose (Bloom, Merkin, & Wootten, 1982).
However, research indicates that this order may be influenced by frequency of use of
these words and frequency of exposure (Rowland, Pine, Lieven, & Theakston, 2003).

Strategies for Teaching Question-Asking and Responding Prior to target-

ing production of questions, adults should target responding to questions. Doing
so will ensure that children understand question forms and will support later pro-
duction of questions—the developmental sequence is the same for both compre-
hension and expression, as indicated previously. When targeting responding to
questions, adults should embed opportunities within highly preferred activities
and natural contexts whenever possible. For example, within a preferred music
activity, the adult might bring out two instruments and ask, “Who gets the tam-
bourine, and who gets the cymbal?” After the child makes a selection, the question
can be reinforced, “Who chose the tambourine? You did!”
Book activities can provide additional opportunities for targeting respond-
ing to and understanding requests for information, particularly as children are
learning to distinguish between question types. For example, pictures in books
that depict characters doing actions allow children to respond to specific questions
(e.g., a picture showing a boy sitting and eating ice cream and a girl sitting and
petting a cat allows for responses to who, what, and which questions). As the child
demonstrates increased responses to comprehension of questions based on his or
her responses, the child may start to spontaneously produce questions as well.
With regard to targeting production of questions, Koegel and colleagues (2014)
supported use of child-preferred objects and NDBI motivational strategies to teach
this skill. It can take some creativity on the part of adults to set up situations where
questions can be prompted and then naturally reinforced. When first teaching
questions, it can be helpful to have two adults, one to prompt the child from behind
(prompter) and one to reinforce the child’s question by providing the answer and
access to natural reinforcement (communicative partner). If only one adult is
used, the child can become confused by the prompt because a model prompt (e.g.,
“What’s that?”) can be perceived as the adult asking the child the question, rather
than modeling it. It can also be helpful to brainstorm how to set up situations in
which the targeted question can be asked within preferred activities. Making a list
of preferred activities, which questions to target, and how they will be targeted can
be a useful exercise. Table 11.10 provides several examples for several types of ques-
tions commonly targeted in intervention for children with ASD.
 Table 11.10. Ideas for teaching question-asking
Question General teaching strategy
What’s that? Start by teaching the child to ask, “What’s
that?” in relation to items that are
hidden in a bag or box.
Once the child understands the cues to ask
the question, generalize to items the child
actually does not know the name of.
What? After you have targeted labeling, move
on to other types of “what” forms,
such as “What is X doing?”, then “What
(function)?” (e.g., What do I wear on my
feet?) then “What if X?”
Where? Start by teaching the child to ask, “Where
is it?” or “Where is the ___?” in relation
to items that are hidden in readily
available locations (e.g., under your leg,
inside your hand).
Once the child understands the cues to ask
the question, generalize to items that are
hidden further away (e.g., in a cabinet).
Make a game of it!
268
Example 1
Place several preferred toys in a bag.
Shake the bag expectantly while looking at the
child.
Have the back-up prompter model the prompt,
“What’s that?” while pointing to the bag.
Reinforce the child with an item from the bag
when he or she asks, “What’s that?”
Provide the answer to the question when
handing the item to the child.
Use pop-up books with clear pop-up actions to
prompt for a variety of “what” questions.
Make the popping action several times, and
engage the child in the action.
Model the phrase “What is the bunny doing? He
is hiding.”
If the child is indicating interest, prompt to ask
the question “What can you ask me?” (or use a
back-up prompter). Reinforce with the pop-up
action.
Gain shared control over a preferred item in play, Hide several pieces to a toy prior to starting
and hide it in the immediate vicinity.
Look inquisitively at the child, shrug shoulders, and
hold hands out as if to say, “Where did it go?”
Another way to provide a clear cue is to have
a single item in a container that the child can
see. Then remove it, hide it, and show the
empty container to the child while looking
inquisitively.
Example 2
Gather random items that the child does not
know the name of.
Introduce them into play with other
preferred items.
Ask novel questions, such as “Do you know
what this is?” or “Hmmm. This is a new
toy. Do you know the name of it?”
Reinforce the child with the item when he or
she asks, “What’s that?” and provide the
answer to the question.
It may be helpful to demonstrate novel,
exciting actions with these items because
they may not be familiar to the child.
Play a guessing game with random objects
in which each person pretends to perform
a common action with the wrong object
(e.g., pretend to brush teeth with the
dishwashing brush; brush hair with a fork).
Model and then prompt “What is X doing?”
It is helpful to have at least three players in
the game or a back-up prompter.
an activity in locations that are nearby but
not within arm’s reach.
Ask novel questions or make statements,
such as “I have more trains, but they are
hiding!” or “If you want more trains, we
need to find them!”
Reinforce the child with the item when he
or she asks, “Where are the trains?” and
provide the answer to the question.
269
Hide and Seek can also be a fun way to
teach this skill. Have a preferred adult
hide and another adult to whom the
child can direct the question (e.g.,
“Where is mommy?”).
Who? Start by teaching the child to ask, “Who
is it?” or “Who has it?” in relation to
preferred materials.
Then, generalize to other naturally
occurring situations (e.g., “Who is
coming?” “Who is it?” in relation to
someone the child does not know).
When? Start by teaching the child to ask “When?”
or “When can I have it?” in relation to
preferred materials.
Then, generalize to other naturally
occurring situations (e.g., “When can I
have my snack?”).
Have the back-up prompter model, “Where is it?”
or “Where is the ___?”
Reinforce the child with the item when he or she
asks the question.
Provide the answer to the question when
handing the item to the child (e.g., “It’s under
my leg!”).
Using two to three people, make a game of
passing objects among the adults so that the
child does not know who has them.
Cue the child with comments such as, “Someone
has the toy!” or “I wonder who has the toy!”
Have a back-up prompter prompt the child to ask
an adult, “Who is it?” or “Who has it?”
When the child asks, the person who has the toy
can respond with “I have it!” and provide the
toy as reinforcement.
Set up play with several preferred items or an
item with multiple pieces.
Gain shared control over the pieces, and cue the
child with comments such as, “You can have
these soon!” or “I’ll be done with these in a
few minutes.”
Have the back-up prompter prompt the child to
ask, “When?”
Respond with an appropriate answer (e.g., “Right
now!”), and provide the item to the child as
reinforcement.
When first teaching this skill, always reinforce
the child immediately. Once the child can ask
“when” more independently, you can start
delaying reinforcement (e.g., by saying “in
1 minute”) because this is an appropriate
outcome of this question. Some children may
need to formally be taught how to wait before
introducing this step.
Make a game of it! Use exaggerated speech
when giving the answers and make it
silly! For example, “The trains are in the
closet! How did they get there? Silly!”
Generalize the skill to other situations, such
as the following:
• If someone comes to the door, prompt the
child to say, “Who is it?” before opening
the door.
• When plans are made for someone to
come over, make comments, such as,
“Someone is coming over later!” to
prompt the child to ask, “Who?”
Generalize the skill to other situations
by delaying access to preferred items
throughout the day on purpose and
prompting the child to ask “when”.
For example, if the child wants a snack but
will be told to wait, prompt him or her
to ask, “When can I have it?” and either
reinforce immediately with “Right now!”
(if just learning) or shortly thereafter, for
example, “In 1 minute” (if working on
expanding time frame).
(continued)
 Table 11.10. (continued)
Question General teaching strategy
Why? Start by teaching “because”: “We eat
because we feel X.” Have the child fill in
the blank. Do several of these examples.
After the child has the idea, switch the
examples to question form, “Why do we
eat? Because we are hungry.”
Use only concrete examples that the child
may have experienced very recently
until the concept is very clear. Then,
move to more abstract examples, again
starting with “because” and shifting to
question form (e.g., “We sit by friends at
lunch because X”).
How? Start by teaching the child to ask “how” in
relation to preferred toys or materials.
Set up situations where the child may not
know how to do something and can ask
more concrete “how” questions, such
as “How do we do it?” or “How does it
work?”
“How” questions may need to be taught
after the more concrete “what,” “where,”
and “who” questions are mastered.
These questions require greater
receptive language and cognitive ability
to learn.
270
Example 1 Example 2
Use fill in the blank to prompt “because” in a Identify a highly motivating game such as
tickling game: “I tickle you because I love you.” water balloons.
Progressively leave off more words until the child Model “why” questions and “because”
reliably says “because.” answers: “Why did the balloon pop?
Introduce the question “Why do I tickle you?” Because you threw it!”
“Because I love you!” Reinforce with silly tickle Hold the next water balloon contingent on
games. the child answering the question, and
then prompt to ask you (“What can you
ask me?”) Reinforce with new water
balloons.
When using a toy that the child may need help When doing a project with the child (e.g.,
with (e.g., Lego building, snap circuits), get out craft kits, cooking) that has a clear
the toy, and cue the child with comments such outcome, begin the project, and cue the
as “Hmmm, this looks tricky. I wonder how we child with comments such as, “We are
do it.” going to bake cookies. Do you know how
Have the back-up prompter model varied to do it?” or “We are going to make paper
questions, such as “How do we build it?” or snowflakes. What should we do?”
“How does it work?” Have the back-up prompter model varied
questions, such as “How do we make
them?” or “How do you do it?”
 Targeting Communication Skills 271

Stockall and Dennis (2014) found that the use of visuals within a PRT frame-
work helped to teach basic “what” and “where” questions. Visual cues can be espe-
cially helpful when a backup prompter is not available or as a strategy for fading
the backup prompter. For example, when teaching “What’s that?” after the adult
cues the child by presenting the bag of toys, a visual cue can be used to prompt
“What’s that?” Likewise, when teaching “where” questions, the adult can present
the toy in a container, then remove it, as discussed previously, and present a visual
cue to prompt the child to ask, “Where is it?” Visual cues can then be faded using
prompt fading strategies. Furthermore, Donaldson and Olswang (2007) found that
simply providing opportunities to engage in highly preferred activities with typi-
cally developing peers increased the likelihood of using requests for information
(questions) by young children with ASD. As such, targeting this social-communi-
cation skill within naturally occurring social interactions with high likelihood of
engagement, perhaps with siblings or neighborhood peers, may be warranted to
increase generalization.

Reciprocal Conversation
As indicated previously, reciprocal interaction starts well before a child becomes
“conversational” (whether via verbal language or use of an AAC device). A child’s
social and communicative reciprocity is developed through the initiation and
responsivity of his or her early communicative intents with caregivers and early
communication partners. It is essential that parents, teachers, and communication
partners focus on early communicative reciprocity through interactions that are
responsive and engaged, whether the child is communicating via gestures, vocal-
izations (vocal play), verbalizations, or language use. Conversational reciprocity is
built on this early interaction and turn taking.
For example, when the child initiates a social game such as Peekaboo with a
blanket, the caregiver responds by lifting up the blanket. When the child responds
by placing the blanket back on her head, the caregiver elaborates on the game
by saying, “Where’s Sophia?” The child starts giggling and waits for the adult
to pull off the blanket. The adult slowly starts to pull off the blanket, elongating
the phrase, “Peeeeee-kaaaaa.” The adult waits. The child giggles. The child pulls
off the blanket and approximates “booo.” The adult elaborates on the game, put-
ting the blanket on his or her own head. The game continues with gestures, facial
expression, affect, vocalizations, and approximations. It is a complex engagement
that lays the foundation for later conversational reciprocity.
Although all NDBI include instruction in the foundational components of
language, fewer detail instruction of more advanced language use, such as back-
and-forth conversation. Strategies for teaching reciprocal conversation within an
NDBI framework have been most studied in the context of PRT (Boettcher, 2004;
Koegel et al., 2014; Stockall & Dennis, 2014). Stockall and Dennis (2014) showed
that visual cues can be an effective tool for targeting conversation, particularly
when using items that are a topic of interest and motivation for the child. The
use of self-management motivational strategies has been found to be effective
in teaching early conversation skills to children with ASD with more developed
language (Boettcher, 2004). Skills such as responding to conversational bids with
comments or questions, remaining on topic, and sustaining responding for several
272 Applications of NDBI Strategies

conversational exchanges or for a specified period of time have been effectively

taught using self-management, in which the child monitors these skills during
conversation and self-evaluates afterward whether reinforcement was earned. In
self-management, the parent or teacher teaches the child to discern whether he
or she has engaged in the targeted behavior (e.g., remaining on topic) and then
teaches the child to self-monitor responses on an ongoing basis in order to earn
reinforcement. The use of a behavior recording chart, which allows the child to
earn points for on-topic and sustained conversation toward a desired reward, is an
effective tool for teaching self-monitoring conversation practice, as well as teach-
ing the child to reinforce his or her own behavior over time. Chapter 13 presents
elaboration on teaching self-management skills.
Another method that may support conversational reciprocity for some chil-
dren is video modeling (VM), which has been shown effective for targeting social-
communication skills (Ferraioli & Harris, 2011; Schreiber, 2011; Wang, Chui, &
Parrila, 2011). Within VM, the child watches a video of a peer and/or adult demon-
strating a discrete skill or target behavior and then practices the skill, often with
facilitation from an adult within the context of a motivating activity. This method
can be effective in supporting social interaction and relationship building between
children with ASD and peers or siblings. As children gain skills or when it is fea-
sible to prompt the target skills, children can sometimes star in their own modeling
videos. It is important, however, to ensure that correct production of the skill can
be evoked so incorrect responding is not modeled.
Peer mediation has also been found effective in supporting the social-
communication skills and reciprocity of children with ASD (National Autism
Center, 2015). Peer or sibling mediation involves the direct teaching of peers or
siblings to increase their initiations and responsiveness to the child with ASD in
order to facilitate communicative success. Peers have been successfully taught to
initiate interactions; maintain interactions; and promote a variety of play, motor,
and communicative interactions with children with ASD (Zhang & Wheeler, 2011).
Within peer mediation, Pierce and Schreibman (1995, 1997) taught strategies based
on PRT, such as gaining attention, elaborating and extending communication, nar-
rating play, and offering choices. The overall emphasis was to increase the child
with ASD’s social and communication skills by motivating him or her to socially
engage. Adults can teach peers and siblings to change their own social and com-
municative behaviors to enhance their social interactions with children with ASD,
resulting in increased social opportunities and authentic relationship development
(Donaldson, Nolfo, & Montejano, 2018).

CONCLUSION
There are many communication skills to target when working with individuals
with ASD. This chapter focused on expressive communication; teaching receptive
communication requires developing a separate set of goals. We hope the strategies
elaborated here will provide clinicians with examples and ideas for how to target
communication goals, but this information is not a substitute for solid clinical as-
sessment based on clinician expertise and the use of appropriate assessment and
monitoring tools, including standardized assessments, checklists, and data collec-
tion over time.
 Targeting Communication Skills 273

REFERENCES
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(DSM-5). Washington, DC: Author.
Bates, E. (1976). Language and context: The acquisition of pragmatics. San Diego, CA: Academic
Press.
Bates, E., Dales, P., & Thal, D. (1995). Individual differences and their implications for theo-
ries of language development. In P. Fletcher & B. MacWhinney (Eds.), Handbook of child
language. Oxford, United Kingdom: Basi Blackwell.
Billstedt, E., Carina Gillberg, I., & Gillberg, C. (2007). Autism in adults: Symptom patterns
and early childhood predictors. Use of the DISCO in a community sample followed from
childhood. Journal of Child Psychology and Psychiatry, 48(11), 1102–1110.
Bloom, L., Merkin, S., & Wootten, J. (1982). Wh-questions: Linguistic factors that contribute
to the sequence of acquisition. Child Development, 53, 1084–1092.
Boettcher, M. (2004). Teaching social conversation skills to children with autism through
self-management: An analysis of treatment gains and meaningful outcomes. Dissertation
Abstracts International, 65, 3135.
Bowen, C. (1998). Brown’s stages of syntactic and morphological development. Retrieved on
March 18, 2018, from http://www.speech-language-therapy.com/index.php?option=com
_content&view=article&id=33
Brinton, B., & Fujiki, M. (2005). Improving peer interaction and learning in cooperative
learning groups. In T. A. Ukrainetz (Ed.), Contextualized language intervention: Scaffolding
K–12 literacy achievement (pp. 289–318). Eau Claire, WI: Thinking Publications.
Brown, R. (1973). A first language: The early stages. Cambridge, MA: Harvard University.
Brown, W., & Conroy, M. (2001). Promoting peer-related social-communicative competence
in preschool children with developmental delays. In H. Goldstein, L. A. Kaczmarek, &
K. M. English (Vol. Eds.), Communication and language intervention series: Vol. 10. Promoting
social communication in children and youth with developmental disabilities: Children with devel-
opmental disabilities from birth to adolescence (pp. 173–210). Baltimore, MD: Paul H. Brookes
Publishing Co.
Bruinsma, Y. E. M. (2005). Increases in the joint attention behavior of eye gaze alternation to
share enjoyment as a collateral effect of Pivotal Response Treatment for three children with
autism. Dissertation Abstracts International: Section B: The Sciences and Engineering, 65(9-B), 4811.
Bruinsma, Y., Koegel, R., & Koegel, L. (2004). Joint attention and children with autism:
A review of the literature. Developmental Disabilities Research Reviews, 10(3), 169–175.
Bruner, J. (1981). The social context of language acquisition. Language and Communication,
1(2/3), 155–178.
Carr, D., & Felce, J. (2007). Brief report: Increase in production of spoken words in some
children with autism after PECS teaching in Phase III. Journal of Autism and Developmental
Disorders, 37(4), 780–787.
Chapman, R. (2000). Children’s language learning: An interactionist perspective. Journal of
Child Psychology and Psychiatry, 41, 33–54.
Crais, E., Douglas, D., & Campbell, C. (2004). The intersection of the development of ges-
tures and intentionality. Journal of Speech, Language, and Hearing Research, 47, 678–694.
Dawson, G., Rogers, S., Munson, J., Smith, M., Winter, J., Greenson, J., . . . Varley, J. (2010).
Randomized, controlled trial of an intervention for toddlers with autism: The Early Start
Denver Model. Pediatrics, 125(1), e17–e23.
Donaldson, A. L., Nolfo, M., & Montejano, M. (2018). Relationships, friendships, and successful
social communication: Addressing disability. Seminars in Speech and Language, 39, 166–177.
Donaldson, A., & Olswang, L. (2007). Investigating requests for information in children
with autism spectrum disorders: Static versus dynamic assessment. Advances in Speech
Language Pathology, 9(4), 297–311.
Dore, J. (1975). Holophrases, speech acts and language universals. Journal of Child Language,
2(1), 21–40.
Drager, K., Postal, V., Carrolus, L., Castellano, M., Gagliano, C., & Glynn, J. (2006). The effect
of aided language modeling on symbol comprehension and production in 2 preschoolers
with autism. American Journal of Speech-Language Pathology, 15, 112–125.
274 Applications of NDBI Strategies

Ferraioli, S. J., & Harris, S. L. (2011). Treatments to increase social awareness and social
skills. In B. Reinchow, P. Doehring, D. V. Cicchetti, & F. R. Volmar (Eds.), Evidence-based
practices and treatments for children with autism (pp. 171–196). New York, NY: Springer.
Frost, L., & Bondy, A. (2002). The Picture Exchange Communication System training manual
(2nd ed.). Cherry Hill, NJ: Pyramid Educational Consultants.
Ganz, J., & Simpson, R. (2004). Effects on communicative requesting and speech develop-
ment of the Picture Exchange Communication System in children with characteristics of
autism. Journal of Autism and Developmental Disorders, 34(4), 395–409.
Goin-Kochel, R., Esler, A., Kanne, S., & Hus, V. (2014). Developmental regression among
children with autism spectrum disorder: Onset, duration, and effects on functional
outcomes. Research in Autism Spectrum Disorders, 8(7), 890–898.
Goods, K., Ishijima, E., Chang, Y., & Kasari, C. (2013). Preschool based JASPER intervention
in minimally verbal children with autism: Pilot RCT. Journal of Autism and Developmental
Disorders, 43(5), 1050–1056.
Hancock, T., & Kaiser, A. (2002). The effects of trainer-implemented enhanced milieu
teaching on the social communication of children with autism. Topics in Early Childhood
Special Education, 22(1), 39–54.
Hart, B., & Risley, T. (1995). Meaningful differences in the everyday experience of young American
children. Baltimore, MD: Paul H. Brookes Publishing Co.
Howlin, P., Goode, S., Hutton, J., & Rutter, M. (2004). Adult outcome for children with autism.
Journal of Child Psychology and Psychiatry, 45(2), 212–229.
Ingersoll, B., & Dvortcsak, A. (2006). Including parent training in the early childhood special
education curriculum for children with autism spectrum disorders. Journal of Positive
Behavior Interventions, 8(2), 79–87.
Ingersoll, B., & Wainer, A. (2013). Initial efficacy of Project ImPACT: A parent-mediated
social communication intervention for young children with ASD. Journal of Autism and
Developmental Disorders, 43(12), 2943–2952.
Iverson, J., & Wozniak, R. (2007). Variation in vocal-motor development in infant siblings of
children with autism. Journal of Autism and Developmental Disorders, 37(1), 158–170.
Kaiser, A., & Delaney, E. (1998). Responsive conversation: Creating opportunities for
naturalistic language teaching. Young Exceptional Children Monograph Series, 3, 13–23.
Kaiser, A., & Trent, J. (2007). Communication intervention for young children with disabilities.
In: Handbook of Developmental Disabilities, (pp. 224–243.). New York, NY: Guilford.
Kjelgaard, M., & Tager-Flusberg, H. (2001). An investigation of language impairment in
autism: Implications for genetic subgroups. Language and Cognitive Processes, 16(2-3),
287–308.
Kjellmer, L., Hedvall, A., Fernell, E., Gillberg, C., & Norrelgen, F. (2012). Language and com-
munication skills in preschool children with autism spectrum disorders: Contributions
of cognition, severity of autism symptoms, and adaptive functioning to the variability.
Research in Developmental Disabilities, 33(1), 172–180.
Koegel, L. (2000). Interventions to facilitate communication in autism. Journal of Autism and
Developmental Disorders, 30(5), 383–391.
Koegel, R., Bradshaw, J., Ashbaugh, K., & Koegel, L. (2014). Improving question-asking
initiations in young children with autism using pivotal response treatment. Journal of
Autism and Developmental Disorders, 44(4), 816–827.
Koegel, R., Koegel, L., & Brookman, L. (2003). Empirically supported pivotal response inter-
ventions for children with autism. In A. E. Kazdin (Ed.), Evidence-based psychotherapies for
children and adolescents (pp. 341–357). New York, NY: Guilford Press.
Koegel, R., O’Dell, M., & Dunlap, G. (1988). Producing speech use in nonverbal autistic chil-
dren by reinforcing attempts. Journal of Autism and Developmental Disorders, 18(4), 525–538.
Lord, C., Shulman, C., & DiLavore, P. (2004). Regression and word loss in autistic spectrum
disorders. Journal of Child Psychology and Psychiatry, 45(5), 936–955.
Lovaas, O., Berberich, J., Perloff, B., & Schaeffer, B. (1966). Acquisition of imitative speech by
schizophrenic children. Science, 151(3711), 705–707.
Luyster, R., Kadlec, M., Carter, A., & Tager-Flusberg, H. (2008). Language assessment and
development in toddlers with autism spectrum disorders. Journal of Autism and Develop-
mental Disorders, 38(8), 1426–1438.
 Targeting Communication Skills 275

McGee, G., Morrier, M., & Daly, T. (1999). An incidental teaching approach to early interven-
tion for toddlers with autism. Journal of the Association for Persons with Severe Handicaps,
24(3), 133–146.
Mirenda, P. (2003). Toward functional augmentative and alternative communication for stu-
dents with autism: Manual signs, graphic symbols, and voice output communication aids.
Language, Speech, and Hearing Services in Schools, 34, 203–2016.
Mitchell, S., Brian, J., Zwaigenbaum, L., Roberts, W., Szatmari, P., Smith, I., & Bryson, S.
(2006). Early language and communication development of infants later diagnosed
with autism spectrum disorder. Journal of Developmental & Behavioral Pediatrics, 27(2),
69–78.
Mohammadzaheri, F., Koegel, L. K., Rezaee, M., & Rafiee, S. M. (2014). A randomized
clinical trial comparison between pivotal response treatment (PRT) and structured
applied behavior analysis (ABA) intervention for children with autism. Journal of Autism
and Developmental Disorders, 44(11), 2769–2777.
Morales, M., Mundy, P., Delgado, C., Yale, M., Messinger, D., Neal, R., & Schwartz, H.
(2000). Responding to joint attention across the 6- through 24-month age period and early
language acquisition. Journal of Applied Developmental Psychology, 21, 283–298.
Mundy, P., & Gomes, A. (1998). Individual differences in joint attention skill development in
the second year. Infant Behavior and Development, 21(3), 469–482.
National Autism Center. (2015). Findings and conclusions: National Standards Project, Phase 2.
Randolph, MA: Author.
Osterling, J., & Dawson, G. (1994). Early recognition of children with autism: A study of
first birthday home videotapes. Journal of Autism and Developmental Disorders, 24(3),
247–257.
Owens, R. E. (2015). Language development: An introduction (9th ed.). London, United
Kingdom: Pearson.
Ozonoff, S., Iosif, A., Baguio, F., Cook, I., Hill, M., Hutman, T., . . . Steinfeld, M. (2010). A pro-
spective study of the emergence of early behavioral signs of autism. Journal of the American
Academy of Child & Adolescent Psychiatry, 49(3), 256–266.
Paul, R., Campbell, D., Gilbert, K., & Tsiouri, I. (2013). Comparing spoken language treat-
ments for minimally verbal preschoolers with autism spectrum disorders. Journal of
Autism and Developmental Disorders, 43(2), 418–431.
Pierce, K., & Schreibman, L. (1995). Increasing complex social behaviors in children with
autism: Effects of peer-implemented pivotal response training. Journal of Applied Behavior
Analysis, 28, 285–295.
Pierce, K., & Schreibman, L. (1997). Using peer trainers to promote social behavior in
autism: Are they effective at enhancing multiple social modalities. Focus on Autism and
Other Developmental Disabilities, 12, 207–218.
Prizant, B., & Wetherby, A. (1987). Communicative intent: A framework for understanding
social-communicative behavior in autism. Journal of the American Academy of Child &
Adolescent Psychiatry, 26(4), 472–479.
Risley, T., & Wolf, M. (1967). Establishing functional speech in echolalic children. Behaviour
Research and Therapy, 5(2), 73–88.
Rogers, S., & Dawson, G. (2010). Early Start Denver Model for young children with autism:
Promoting language, learning, and engagement. New York, NY: Guilford Press.
Rogers, S., Hayden, D., Hepburn, S., Charlifue-Smith, R., Hall, T., & Hayes, A. (2006).
Teaching young nonverbal children with autism useful speech: A pilot study of the
Denver model and PROMPT interventions. Journal of Autism and Developmental Disorders,
36(8), 1007–1024.
Rogers, S., & Vismara, L. (2008). Evidence-based comprehensive treatments for early autism.
Journal of Clinical Child & Adolescent Psychology, 37(1), 8–38.
Rowland, C. F., Pine, J. M., Lieven, E. V. M., & Theakston, A. L. (2003). Determinants of
acquisition order in wh-questions: Re-evaluating the role of caregiver speech. Journal of
Child Language, 30(3), 609–635.
Sandbank, M., & Yoder, P. (2016). The association between parental mean length of utterance
and language outcomes in children with disabilities: A correlational meta-analysis.
American Journal of Speech-Language Pathology, 25, 240–251.
276 Applications of NDBI Strategies

Schreiber, C. (2011). Social skills interventions for children with high-functioning autism
spectrum disorders. Journal of Positive Behavior Interventions, 13(1), 49–62.
Schreibman, L., Dawson, G., Stahmer, A., Landa, R., Rogers, S., McGee, G., . . . McNerney, E.
(2015). Naturalistic developmental behavioral interventions: Empirically validated treat-
ments for autism spectrum disorder. Journal of Autism and Developmental Disorders, 45(8),
2411–2428.
Stockall, N., & Dennis, L. R. (2014). Using elicit and technology to engage preschoolers with
autism in conversations. Intervention in School and Clinic, 49(4), 195–202.
Stone, W., Ousley, O., Yoder, P., Hogan, K., & Hepburn, S. (1997). Nonverbal communication
in two-and three-year-old children with autism. Journal of Autism and Developmental
Disorders, 27(6), 677–696.
Tager-Flusberg, H., & Joseph, R. M. (2003). Identifying neurocognitive phenotypes in autism.
Philosophical Transactions of the Royal Society of London B: Biological Sciences, 358(1430),
303–314.
Tager-Flusberg, H., Paul, R., & Lord, C. (2005). Language and communication in autism.
Handbook of Autism and Pervasive Developmental Disorders, 1, 335–364.
Tager-Flusberg, H., Rogers, S., Cooper, J., Landa, R., Lord, C., Paul, R., . . . Yoder, P. (2009).
Defining spoken language benchmarks and selecting measures of expressive language
development for young children with autism spectrum disorders. Journal of Speech,
Language, and Hearing Research, 52(3), 643–652.
Thurm, A., Lord, C., Lee, L., & Newschaffer, C. (2007). Predictors of language acquisition in
preschool children with autism spectrum disorders. Journal of Autism and Developmental
Disorders, 37(9), 1721–1734.
Venker, C., Bolt, D., Meyer, A., Sindberg, A., Weismer, S., & Tager-Flusberg, H. (2015). Parent
telegraphic speech use and spoken language in preschoolers with ASD. Journal of Speech,
Language and Hearing Research, 58, 1733–1746.
Venter, A., Lord, C., & Schopler, E. (1992). A follow-up study of high-functioning autistic
children. Journal of Child Psychology and Psychiatry, 33(3), 489–597.
Vismara, L., & Lyons, G. (2007). Using perseverative interests to elicit joint attention behaviors
in young children with autism: Theoretical and clinical implications for understanding
motivation. Journal of Positive Behavior Interventions, 9(4), 214–228.
Wang, S., Chui, Y., & Parrila, R. (2011). Examining the effectiveness of peer-mediated and
video-modeling social skills interventions for children with ASD: A meta-analysis in
single-case research using HLM. Research in Autism Spectrum Disorders, 5(1), 562–569.
Werner, E., & Dawson, G. (2005). Validation of the phenomenon of autistic regression using
home videotapes. Archives of General Psychiatry, 62(8), 889–895.
Wetherby, A., & Prutting, C. (1984). Profiles of communicative and cognitive-social abilities
in autistic children. Journal of Speech and Hearing Research, 27(3), 364–377.
Zhang, J., & Wheeler, J. J. (2011). A meta-analysis of peer-mediated interventions for
young children with autism spectrum disorders. Education and Training in Autism and
Developmental Disabilities, 46(1), 62–77.
Zwaigenbaum, L., Bryson, S., Rogers, T., Roberts, W., Brian, J., & Szatmari, P. (2005). Behavioral
manifestations of autism in the first year of life. International Journal of Developmental
Neuroscience, 23(2), 143–152.
12
Improving Social Skills and Play
Yvonne Bruinsma and Grace W. Gengoux

D
evelopment of meaningful social skills for children with autism spectrum
disorder (ASD) is important for optimizing outcomes and quality of life
(Bellini & Peters, 2008). Although deficits in social reciprocity are a defin-
ing feature of the condition and can be restricting and challenging to treat, there is
robust evidence that these necessary skills can be improved with intervention (e.g.,
Rogers, 2000). Naturalistic Developmental Behavioral Intervention (NDBI) strate-
gies can be utilized in teaching beginning, intermediate, and advanced social skills;
however, as discussed throughout this chapter, it is not enough simply to be able to
perform specific social skills. True social competence and meaningful social rela-
tionship development involves much more than the discrete behaviors (e.g., saying
“hi,” taking turns, sharing toys). High-quality social skills intervention must fos-
ter reciprocity and affective sharing and enhance social motivation to allow social
interaction to become truly enjoyable. Generalization of skills, individual interests
and motivators, complex combinations of social behaviors adapted flexibly across
providers, caregivers, and settings, and natural reinforcement of social interactions
are ultimately important components to think about when designing a social pro-
gram. The final goal, after all, is to help individuals with ASD build capacity for a
lifetime of meaningful relationships with others in a way that is enjoyable to them.
This chapter begins with a focus on foundational social skills, such as social
initiations and imitation. Then, the development of play skills is briefly reviewed.
Because children interact and learn through play, tips and ideas for utilizing and
teaching play activities across developmental levels are provided. Social, play,
and communication skills develop concurrently, and advancement in one domain
is often necessary for another skill to improve. As a result, the reader is some-
times referred to the chapters on communication skills (Chapter 11), inclusion
(Chapter 5), or motivational strategies (Chapter 6). Finally, this chapter provides
practical strategies and tips to organize and structure interactions between peers.

277
278 Applications of NDBI Strategies

This chapter focuses on treatment strategies that can be delivered in the natu-
ral environment and with typically developing peers. It does not include a review
of the many existing evidence-based social skills treatment models designed to be
implemented with groups of children with ASD outside the context of the child’s
daily routines. Although social groups can be effective, they fall outside the scope
of NDBI. Excellent reviews of the current evidence for social skills group treatment
can be found elsewhere (Gates, Kang, & Lerner, 2017; Williams White, Keonig,
& Scahill, 2007).

SOCIAL INITIATIONS
Social initiations include both the ability to initiate interaction and the desire to
do so for a social purpose: to comment, to call attention to oneself, to show, and
to share an experience. Social initiations are one of the most important priorities
when addressing the development of social skills in ASD because they serve as
building blocks for social interaction. The specific behaviors used to initiate a spe-
cific social interaction depend on the child’s developmental level, the communica-
tive partner, and the context. For example, an early social initiation in a child who
is prelinguistic may simply be looking up to the communicative partner to share
enjoyment while being pushed on the swing. During that early preverbal phase
of development, typically developing children engage in many nonverbal social
initiations, including giving objects, alternating eye gaze, sharing enjoyment and
affect, showing objects and actions, and pointing (please refer to Chapter 11 for a
more in-depth discussion of joint attention initiations). Once the child becomes ver-
bal, social initiations expand to include requesting information, usually beginning
with “What’s that?” questions and then increasingly more complex wh- and other
questions or comments about interesting things in the environment.
As the child’s verbal and social skills develop, initiation behaviors become
increasingly more complex and context specific. For example, initiating access to a
group of kids playing a ball game during recess will likely be different from initiat-
ing a game of catch during a one-on-one playdate. Even more complex behaviors
may include asking someone for a ride or asking someone to the school dance.
Social initiations allow children to join others in play and social interactions and
sustain those interactions across a variety of environments and help to build key
skills and relationships. In addition, and perhaps even more important, social ini-
tiations allow the child the opportunity to begin interactions with others and cre-
ate his or her own learning opportunities and relationships. The ability to engage
in social initiations appears to be associated with long-term positive outcomes
for children with ASD (Koegel, Koegel, Shoshan, & McNerney, 1999) and predict
future social competence with peers (Meek, Robinson, & Jahromi, 2012). Less fre-
quent initiations have also been associated with lower levels of social engagement
with peers (Sigman & Ruskin, 1999).
Research suggests that social initiations generally, and joint attention behav-
iors specifically, do not naturally emerge from intensive, highly structured, Applied
Behavior Analysis (ABA)-based intervention focused on prompting and reinforc-
ing skills and may therefore need to be explicitly taught (Jones, Carr, & Feeley, 2006;
Kasari, Freeman, & Paparella, 2006; Martins & Harris, 2006; Whalen & Schreibman,
2003). In addition, even when taught, these skills are especially difficult to gen-
eralize and maintain across environments, although generalization may be more
 Improving Social Skills and Play 279

common when joint attention skills are taught during play interactions by natu-
ral caregivers and providers such as educators, coaches, parents, and peers (White
et al., 2011). Evidence exists that natural caregivers and providers can learn to
implement strategies that enhance engagement with strong treatment fidelity, and
that this produces meaningful and substantial change in child outcome variables
(Gulsrud, Hellemann, Shire, & Kasari, 2016; Harrop, Gulsrud, Shih, Hovsepyan, &
Kasari, 2017; Kasari, Gulsrud, Wong, Kwon, & Locke, 2010). The naturalistic interac-
tions of NDBI make them especially effective for teaching social initiations. Four
strategies especially stand out for teaching social initiations: sensory social rou-
tines, object play routines, environmental arrangements, and time delay strategies.

Sensory Social Routines

Sensory social routines consist of back-and-forth ritualized social exchanges be-
tween the adult and child that are highly reinforcing for both (Rogers & Dawson,
2010). Beginning in infancy, caregivers sing silly baby songs in high-pitched voices
while babies babble back at exactly the right time and even in the right cadence
when the parent pauses (Longhi & Karmiloff-Smith, 2004). Many nursery rhymes
across cultures allow for repetitive interactions and entice both caregiver and child
to be silly, use imitative gestures, and have fun. Emotional attunement (Rogers,
Dawson, & Vismara, 2012) and dyadic synchrony (Harrist & Waugh, 2002) are key
to a successful sensory social routine. In addition, affective sharing, which is often
reduced in children with ASD (Kasari, Sigman, Mundy, & Yirmiya, 1990), is an
important part of sensory social routines.
Harrist and Waugh (2002) described three components to a successful syn-
chronous interaction. First, there must be a shared focus of attention in which
caregiver and child both visually follow each other. Then, during this period of
extended engagement, caregiver and child coordinate their interactions in time.
This is mostly driven by the caregiver and refers to a matching of the caregiver
to the child’s activity level in body movements, orientation, vocal rhythm, vocal
pitch, and sounds. This coordination can include imitation and expanding the
child’s utterances or actions. The last component of the synchronous interaction
is the addition of contingency, which simply means that actions by the caregiver
will likely lead to actions by the child, which then leads back to actions by the
caregiver and so on (Harrist & Waugh, 2002). Successful sensory social routines
have a strong affective component: The play partner is smiling, modulates his or
her energy to be slightly higher than the child, uses large exaggerated gestures and
facial expressions, uses movement, sings, and closely watches the child to maxi-
mize engagement and initiations.
An example of using a sensory social routine to encourage social initiation
in a child with ASD might appear as follows: For a child who likes the “Itsy Bitsy
Spider” song, the parent may start singing while pretending to be a tiny spider
crawling up the child’s arm. The child and parent take several turns and establish
a period of prolonged engagement until a pace has developed within the routine
with reciprocal affective sharing in which child and parent both smile, alternate eye
gaze, and alternatively approach and retreat. The parent may then pause to wait
for the child to make eye contact or show an excited facial expression (the social
initiation) before continuing the song. In this way, the parent provides a behavioral
contingency with natural reinforcement for appropriate eye contact/expression,
280 Applications of NDBI Strategies

which may enhance the child’s motivation to look at the adult’s face and share
positive affect as the interaction continues. This type of behavioral contingency
(in which the parent does not respond until the child shows the target behavior) in
the context of an affectively charged interaction can be a powerful way of enhanc-
ing social-communication above and beyond the natural interaction contingencies
described by Harrist and Waugh (2002).
During these prolonged interactions, the parent will closely watch the child to
see if the child remains motivated and engaged. When the child’s affective sharing
behaviors reduce (less frequent looking, smiling, reaching, vocalizing), the parent
may end the activity, or as an alternative, the parent may try to expand the routine,
introducing novelty, such as a new song or a novel gesture added to the routine.
Sometimes the child may become too excited, as evidenced by high-energy behav-
iors that do not match the activity or the caregiver (screaming, high-pitch noises).
Rather than vary the task, the caregiver can model calm affect, shift the routine to
a calming theme, or slowly end the activity and help the child reregulate.
Table 12.1 contains tips for generating ideas to establish a shared focus of atten-
tion and coordinated synchronous periods of engagement. With a little bit of prac-
tice, sensory social routines can be implemented with relative ease and can provide
an important sense of connection between adult and child. Although the routines
described so far do not use objects, object play can easily be interspersed into sen-
sory social routines, making them into what are typically referred to as object play
routines.

Object Play Routines

Object play routines are like sensory social routines with the addition of a toy or an
object (Rogers & Dawson, 2010). Like sensory social routines, these routines are typi-
cally repetitive in nature—the adult and child repeat some sequence of events with
slight variations. Object play routines go beyond simple turn-taking activities be-
cause while an object is introduced in the interaction, the adult remains the essential
ingredient. The importance of the role of the adult was further confirmed in a study
by Koegel, Vernon, and Koegel (2009), suggesting that social engagement and initia-
tions were higher when the adult participated in the delivery of reinforcers (e.g., the
adult jumped on the trampoline with the child) rather than simply delivered the re-
inforcer (e.g., the adult provided access to the trampoline to allow the child to jump).
Data suggested that in the condition where the adult actively participated in rein-
forcement, the child exhibited increased social engagement and initiations, which
this study defined as affect and eye contact directed to the adult, physical orientation
toward the adult, and more positive affect in general (see also Vernon et al., 2019).
One example of a routine with objects is building a tower with blocks together.
Most children will find building high towers and the subsequent crashing highly
reinforcing. Building and crashing are repetitive actions that can easily be expanded
over time. For example, sound effects can be added to blocks crashing; anticipation
of block placement and the subsequent potential for crashing can be exaggerated
with excited and suspenseful facial expressions and careful placement of additional
blocks; and overstated gestures can enhance affective sharing and increase the
salience of the cues. In many object play routines, adding novelty is an important
strategy that helps to expand the routines, can promote affective sharing through
novelty and surprise, and can serve to increase initiations. Introducing novelty to
 Improving Social Skills and Play 281

Table 12.1. Tips to create a shared focus of attention for coordinated joint engagement

Sensory social
routine component Tips

Facial expressions Exaggerate: Overdo facial expressions and gestures. Take big breaths,
widen eyes, raise eyebrows, and amplify a silly “mad” face.
Smile and laugh while making eye contact.
Silly faces: Exaggerate unexpected and funny expressions with props
(glasses, wigs, and fake mustaches).
Imitation Copy a movement the child is already making, but exaggerate it.
Copy and enlarge sounds (slurping, sneezing, coughing).
Imitation can be subtle: copy the way the child is sitting or standing.
Gestures Use popular gestures:
• “Where is it?” (hand in the air halfway up with palms up)
• “I don’t know” (shrug shoulders)
• “Oh, no!” (widen eyes, hand clasped on mouth)
• “Surprise!” (widen eyes, raise hands up)
• “Hooray” (raise hands up in the air)
• “I’m disappointed” (slump shoulders, look down)
• “Shhh” (finger on mouth, eyes squinting)
• “No-no” (wag index finger)
Sing popular songs (see examples on YouTube): “Itsy Bitsy Spider,”
“Slippery Fish,” “Wheels on the Bus,” “Speckled Frogs,” “If You’re
Happy and You Know it,” “Hokey-Pokey,” “I’m a Little Tea Pot,”
“Twinkle Twinkle Little Star,” or “Pat-a-cake.”
Physical action Pretend to be a spider coming to tickle. Play a chasing game (“I’m going
to get you!”). Bounce on pillows or exercise balls. Spin in office
chairs. Pull the child on a blanket or in a box. Sway in hammocks.
Swing and toss the child into blankets or pillows.
Sing nursery rhymes: “This Little Piggy”; “Row, Row, Row Your Boat”;
“Five Monkeys Jumping on the Bed”; or “Motorboat, Motorboat.”
Using your voice Singing: Traditional songs can be adapted to be silly. Any routine can
also be a repetitive song or rhyme.
Sound effects: Pretend cough or sneeze. Pretend to eat something and
not like it (“Eew, yak!” This is also fun with puppets). Talk really low
or high. Make animal sounds. Make loud snoring when pretending to
sleep. Make raspberry noises.
Use dramatic play voices:
• Troll: “Who’s that tromping over my bridge?”
• Evil queen: “Would you like to eat my poison apple?”
• Olaf: “I like warm hugs.”
Pretend to have a really high or really low voice.
Energy Use slightly higher energy.
Use slightly lower energy.
Keep watching: The child’s energy may change during an activity.
Modulate right around the child’s level, and be sure to be calmer
when the child is becoming too excited to help regulate
Interrupting routines: Make a regular activity into a routine by adding
repetitive phrasing and gestures (e.g., as you are walking up the
stairs say, “We go UP, we go UP, we go UP” while tickling the child on
UP. Then, pause right before the next UP.
Surprises: Draw an elephant on a thumb. Play Peekaboo with a tickling
hand under the table. Hide behind the door, and peek out suddenly.
Using daily routines Play Peekaboo during dressing or folding laundry.
Play Head Shoulders Knees and Toes during bath time or dressing.
Use sound effects during mealtime (“Ahhh!” after sipping a drink,
“Yumm!” after a bite of food).
282 Applications of NDBI Strategies

building a tower might include adding new building materials, such as different
kinds of blocks or little figurines to balance on the blocks. The block tower can be
knocked down by a ball, a car, a little battery-powered train, or a monster puppet
eating the bottom block. Tickling could be added after the blocks crash.
Another strategy for promoting initiations during object play, which is out-
lined in the Project ImPACT (Improving Parents as Communication Teachers)
approach, is called The Wrong Way. In this strategy, the adult performs a routine
or action in an incorrect or silly way with lots of animation to entice the child to tell
the parent it is not right. Examples of this could be to wear something obviously
backward, provide a fork with a bowl of soup instead of a spoon, or attempt to put
toothpaste on the hairbrush instead of the toothbrush. Table 12.2 provides addi-
tional examples of object play routines.

Environmental Arrangements
Incidental Teaching (IT; McGee, Morrier, & Daly, 1999) places a substantial empha-
sis on the importance of all initiations. In this NDBI, the adult waits to provide any
instructional cues or prompts until the child has made an initiation toward the
object or activity. IT organizes the environment to increase the likelihood of initia-
tions by placing toys in sight but out of reach, or in reach but in containers that the
child cannot open. Frequent rotation of toy sets and regular sensory preference as-
sessments (Mason, McGee, Farmer-Dougan, & Risley, 1989) ensure highly desired
toys are available for each child. Environmental barriers to access, such as a gate
dividing up sections of a classroom, may also provide opportunities for initiations
while separate but overlapping zones in a classroom may function as visual cues
to prompt teachers and students to initiate activities and optimize engagement.
Enhanced Milieu Teaching (EMT; Hancock & Kaiser, 2006) also places high
value on initiations, especially verbal social initiations, and assesses for the number

Table 12.2. Examples of object play routines

Toy Ideas for adult actions

Shaving cream Squeeze out a little at a time.

Push the shaving cream inside a latex glove.
Add food coloring to the shaving cream.
When the child is in the tub or a little wading pool, smear shaving
cream on arms or legs for sensory effect.
Balloons Blow up the balloon, and let it fly away.
Inhale a little bit of the helium of a balloon, and use that funny voice to
speak.
Draw a face on the balloon, and make it talk.
Rub the balloon to increase static electricity, and attach it to the child’s hair.
Lift the child up to push the balloon with his or her head or swing the
child with his or her legs to kick the balloon.
Water balloons Attaching the balloon to the faucet, opening the faucet, and uncoupling
and tying the balloon typically all need adult support.
Draw targets with chalk on the sidewalk or a fence.
Exaggerate the anticipatory reaction of getting hit by a water balloon.
Spinning tops and Even simple tops usually need adult spinning to get them started.
Bey Blades Bey Blades have launchers that are difficult to operate.
While tops or Bey Blades are spinning, provide barriers with your foot
and exaggerate both the anticipation of contact and the reaction
when it does touch.
 Improving Social Skills and Play 283

of initiations at the beginning of intervention. If initiations are low, EMT recom-

mends greatly reducing or removing all prompting and using a combination of
environmental arrangements with responsive interaction (verbal and nonverbal
turn taking, adult imitating the child, and following the child’s lead) until initia-
tions increase. Project ImPACT utilizes communication temptations specifically to
increase initiations (Ingersoll & Dvortcsak, 2010). For example, providing inade-
quate portions refers to the strategy of giving the child a little bit of something (e.g.,
a food) that is highly reinforcing. The adult then stays close to the child and waits
to see if the child will indicate a desire for more of the item.

Time Delay Strategies

Time delays are a valuable tool to promote initiations, and all NDBI use time delays
to design opportunities for social initiations. The simplest way to think about time
delays is to think about designing opportunities for a child to respond to environ-
mental cues alone and refrain from providing other types of prompts. Often this
involves first establishing a routine in which the child learns to respond to verbal
prompts and then removing the verbal prompt and pausing for the child to fill
in the learned response out of habit. IT uses this in its prompting hierarchy very
specifically when teaching adults to “wait, ask, say, do” (McGee, Morrier, & Daly,
1999). For example, during a music activity, the caregiver and child may be taking
turns with a drum, but the child has begun to look over at the maracas, which are
in a closed transparent container. The caregiver may acknowledge the child’s in-
terest in the maracas but wait to provide any type of prompt to see what the child
will do. If the child continues to look at the maracas and maybe try to open the
container but does not provide any request (verbal or gestural), the caregiver may
then ask, “What do you need?” If the child continues to try to open the box, the
caregiver may ask, “Open?” If the child still does not respond, then the caregiver
may physically guide the child to give the container to the adult to ask for help.
The Early Start Denver Model (ESDM; Rogers & Dawson, 2010) notes the
importance of carefully selecting the toy for the interaction and recommends
using those toys that require adult cooperation to create the desired effect. This
will ensure the adult is an active participant and part of the natural reinforcer,
and it also provides the adult with built-in shared control. Time delay can then
be used during these familiar routines to allow the child to practice verbal initia-
tion. For example, bubbles are often reinforcing for children and usually require
an adult to open the bubble jar, take out the wand, blow the bubbles, and dip back
into the jar. If the routine has been established and the child is in the habit of ver-
bally requesting bubbles, the time delay can be inserted just before the child would
request more bubbles. As the child is excitedly popping the bubbles, the adult will
stop blowing and wait for the child to return. A time delay prompt would then be
provided, where the adult may hold up the wand or exaggerate sucking in air to
begin blowing but stop right before blowing while looking at the child expectantly.
Once the child reliably responds to theses cues to request bubbles to be blown, the
adult may then fade the time delay prompt and close the bubble jar and place it
nearby. When all the bubbles are popped, the child is likely to return to the adult to
find the adult smiling and oriented to the child but not getting ready to blow more
bubbles. Thus, the child’s behavior will become increasingly more independent of
the adult.
284 Applications of NDBI Strategies

IMITATION SKILLS
In typical development, imitation skills appear early in the first year of life
(Meltzoff & Moore, 2000) and expand quickly in those first 2 years to include vocal
imitation (sounds and words), object imitation, and gesture imitation (Masur &
Rodemaker, 1999). Imitation is thought to be a foundational skill with a cascading
effect to other areas, meaning imitation skills may enhance or limit the acquisi-
tion of a number of other (social and communication) skills, including intentional
communication (Sandbank et al., 2017), expressive language (Charman et al., 2003;
Stone, Ousley, & Littleford, 1997; Stone & Yoder, 2001; Toth, Munson, Meltzoff, &
Dawson, 2006), play (Stone et al., 1997), and potentially joint attention (Carpen-
ter, Pennington, & Rogers, 2002). Imitation skills, in particular motor imitation,
together with joint attention and social approach behaviors also appear to help
predict treatment outcomes (as measured by IQ score and adaptive behaviors)
in early intervention programs (Sallows & Graupner, 2005; Smith, Klorman, &
Mruzek, 2015).
For children with ASD, the skill of imitating others tends to be delayed or
limited, but the ability to notice that others are imitating them appears relatively
intact (Berger & Ingersoll, 2013, 2015; Contaldo, Colombi, Narzisi, & Muratori,
2016). Evidence suggests that when adults, especially mothers, imitate the child
with ASD (copy movement, repeat verbal utterances, copy facial expressions),
the number of social gazes, joint attention behaviors, play skills, and proximity
(child tends to move closer to the person imitating them) increase substantially
(Dawson & Adams, 1984; Dawson & Galpert, 1990; Ezell et al., 2012; Field et al.,
2013; Ishizuka & Yamamoto, 2016; Slaughter & Ong, 2014). These findings provide
support for use of adult imitation of the child in NDBI as a strategy to promote
social engagement.

Strategies for Teaching Imitation

NDBI use a number of strategies to teach imitation, including reciprocal imitation
training (RIT), turn taking, modeling, and prompting.

Reciprocal Imitation Training RIT is a naturalistic intervention that focuses

first on teaching object imitation, then expansion of play skills, and finally gesture
imitation skills. RIT has several studies showing its effectiveness in increasing ob-
ject and gesture imitation skills and expanding play skills (Ingersoll & Lalonde,
2010; Ingersoll, Lewis, & Kroman, 2007; Ingersoll & Schreibman, 2006). Some of
these studies indicate collateral effects in language, pretend play, and joint attention
(Ingersoll & Lalonde, 2010; Ingersoll & Schreibman, 2006). RIT has been success-
fully implemented by siblings (Walton & Ingersoll, 2012) and by parents (Ingersoll
& Gergans, 2007) and can be successfully taught via an innovative self-directed
distance learning format (Wainer, Pickard, & Ingersoll, 2017; Wainer & Ingersoll,
2013, 2015). RIT was designed to be implemented with children but has shown
some promising efficacy with adolescents with ASD and significant intellectual
disability (Ingersoll, Berger, Carlsen, & Hamlin, 2017; Ingersoll, Walton, Carlsen, &
Hamlin, 2013). A brief overview of RIT is provided here, but the manual is an ex-
cellent resource with helpful details for parents and clinicians wishing to use RIT
(see Box 12.1).
 Improving Social Skills and Play 285

BOX 12.1: Reciprocal imitation training

Reciprocal imitation training (RIT) is described in a detailed parent manual
by Dr. Brooke Ingersoll. This resource is available online at https://ieccwa.org
/uploads/IECC2014/HANDOUTS/KEY_2720064/RITManual.pdf

For object imitation, RIT recommends using two of the same set of toys of
interest to allow both the adult and the child to have access to the same toy without
requiring turn taking. The manual provides some pointers about where the par-
ent should position him- or herself in relation to the child and what types of toys
work well. Before teaching in RIT begins, the adult starts by imitating the child’s
play actions, gestures, body movements, and vocalizations or sounds while nar-
rating and describing actions the adult observes. Once a back and forth is estab-
lished like in a social game, every 1–2 minutes the parent provides a model of an
action with an object and waits up to three times for 10 seconds each to see if the
child will copy the action. If the child does not copy, the parent provides a verbal
prompt: “You do it.” If the child still does not respond, the parent uses partial or
full physical prompts to help the child imitate the action. Once the child imitates
the action, the parent praises the child and allows him or her to play with the toy
for 1–2 minutes while the parent returns to imitating the child until the next teach-
ing trial. Expanding the child’s play skills and teaching gesture imitation follow
the same pattern. A final section in the manual provides ideas about how to inter-
sperse imitation teaching trials throughout daily routines.

Turn Taking, Modeling, and Prompting ESDM refers to RIT as part of how
it teaches imitation (Rogers & Dawson, 2010), and its manual shows considerable
consensus with RIT on how to teach imitation skills. However, as a more com-
prehensive program, ESDM provides imitation teaching trials throughout its full
curriculum (e.g., within sensory social routines, in joint activity routines) and often
uses turn taking with one toy to set up a teaching trial. ESDM breaks object imita-
tion down into increasingly complex levels from one step imitation to imitation
with “a series of counterconventional acts” (Rogers & Dawson, 2010, p. 140) such
as using a plate for a hat and cardboard boxes for shoes. ESDM also prompts for
oral-facial imitation (within games that involve identification of body parts or by
exaggerating facial expressions such as exaggerating puffing of cheeks for blowing
a balloon up) and gesture imitation.
EMT uses a combination of turn-taking strategies, modeling, and prompting
to teach imitation on objects, called nonverbal mirroring. The adult begins by imi-
tating all actions by the child. He or she then introduces a new action and waits to
see if the child imitates the new action (Kaiser & Trent, 2007).

Strategies for Vocal Imitation

ESDM addresses teaching vocal imitation as an important precursor to expressive
communication skills, especially for those children who do not produce many noises
and sounds on their own yet. Teaching vocal imitation is mentioned separately here
because it is slightly more intricate. Vocal imitation teaching trials involve modeling,
286 Applications of NDBI Strategies

prompting, and immediate reinforcement for correct responses and attempts, just
like motor, gesture, or oral-facial imitation. Both Pivotal Response Treatment (PRT)
and ESDM suggest carefully observing the sounds that the child is making, even if
these are unintentional sounds as part of a stereotypic behavior or a play routine.
This ensures that targets for vocal imitation are selected to incorporate the sounds
the child already makes (Koegel, Sze, Mossman, Koegel, & Brookman-Frazee, 2006;
Rogers & Dawson, 2010). Rogers and Dawson (2010) noted that children who tend to
be relatively quiet in general may be more likely to emit sounds when engaged in a
high-energy exciting routine that is predictable in nature. Once the child vocalizes,
the adult imitates the sound immediately and reinforces the child with a high-value
natural reinforcer (e.g., more intense tickles). Of course, the adult would not rein-
force any sound associated with challenging behaviors (e.g., crying, shrieking, or
whining sounds).
ESDM emphasizes the importance of building up the use of the sound by tempt-
ing the child to engage in “vocal rounds” (Rogers & Dawson, 2010, p. 144), in which
the adult and the child engage in back-and-forth imitation of each other with the same
sound. Once a sound is identified and the child is regularly initiating the sound, the
adult can assign meaning to it and incorporate it into a joint activity or sensory social
routine. For example, if the child makes a humming sound (i.e., “mmmm”), the par-
ent may use a cow puppet to tickle the child and model “mmmooo.” In addition, the
adult can pair the sound with an object by providing the child access to the action
or toy as soon as the child is making the targeted sound, even if the sound is ini-
tially unintentional. Once the child reliably imitates the target sound, the adult can
expand the repertoire by differentially reinforcing other sounds and combinations
of vowels and consonants in the same way as described previously.

PLAY
Children with ASD often have difficulty integrating social dimensions into their
developing object play (Wolfberg & Schuler, 2006), and they tend to engage in less
frequent functional and symbolic play overall (Rogers, 2005). These characteris-
tics are symptomatic of broader social and cognitive impairments of ASD, such as
problems with reciprocity, flexibility, and symbol use. However, limited play skills
also place children with ASD at a developmental disadvantage because play pro-
vides a context for a diverse set of naturally occurring learning opportunities (Jung
& Sainato, 2013) that are often social in nature. These factors make play a critical
target for intervention (National Research Council, 2001).

Play Development
In infancy, play begins as an exploration of objects as the child engages in touching,
smelling, banging, and mouthing. Play also includes affective social exchanges be-
tween parent and child (Rogers, 2005), often in the form of reciprocal social games
and sensory social routines such as Peekaboo and tickle games, as described pre-
viously. Children typically begin to demonstrate functional play with objects and
then add symbolic elements to their play later in the second year of life (Wong &
Kasari, 2012). During the preschool years, play becomes increasingly more socially
complex as pretend play schemes are expanded into imaginary and sociodramatic
play. See Table 12.3 for a condensed time line of play development. Although it is

Table 12.3. Play development in typically developing children and approximate age of
emergence
Type of play and approximate
age of emergence
Exploratory or sensory motor
play (3–6 months)
Presymbolic play I or
combinatorial play
(8–12 months)
Presymbolic play II
(13–17 months)
Functional play
(18–24 months)
Animated play
(18–24 months)
Autosymbolic play
(17–24 months)
Symbolic play Level 1
(19–22 months)
Symbolic play Level 2
(after 24 months)
Constructive play
(after 24 months)
Symbolic play Level 3
(after 30 months)
Symbolic play Level 4
(after 36 months)
Game play (after 36 months)
Symbolic play Level 5
(36–42 months)
Improving Social Skills and Play 287
Examples
Banging a block, pushing a block off the table, mouthing,
smelling or visually examining an object
Child combines actions on a toy (e.g., banging, throwing,
turning).
Child dumps objects from containers.
Child puts objects into toys that belong (e.g., figurine in car).
Child uses objects how they were intended (e.g., builds tower
with blocks, rolls playdough).
Child combines toys consistently for short one-step actions
(put the baby in the bed).
Child extends functional play actions by adding sounds and
making them “live” (e.g., baby doll talks, airplane crashes
with crash sounds).
Pretend actions are directed at self (e.g., pretending to fall
asleep).
Play actions are still short, and objects are used in predictable
ways.
Child pretends to do imitative activities familiar to others
(e.g., cooking, reading, cleaning, shaving).
Play includes short, isolated schema combinations (child
combines two actions or toys in pretend, e.g., rocking
the doll and putting it to bed; pouring from a pitcher into
a cup).
Child performs pretend actions on more than one object
or person (e.g., feeds self, doll, mother, and/or another
child).
Expansions of imitative play from Level 1 with more details:
Pretend cooking now includes putting a lid on the pan,
putting the pan in the oven, and collecting items associated
with cooking or eating such as dishes, pans, silverware,
glasses, and a highchair.
Child may reverse roles: “I play you, and you play me.”
Child makes something novel from pieces (e.g., building a
palace from blocks or sand).
Pretend play routines begin to include personal experiences
that make an impression (e.g., going to the doctor, having a
birthday).
Child talks to and with inanimate objects.
Compensatory play: Child reenacts experienced events as in
Level 3 but may modify the ending.
Play sequences are longer and develop during play.
Child will play simple games with some rules, although he or
she does not like losing and views rules as flexible.
Child uses representation regularly (e.g., a stick is a snake or
a hairbrush).
Imaginative play includes “set ups” that incorporate blocks,
sand, pillows, or other constructive materials. Fences,
houses, and parking garages are popular to organize
objects and favorite items.
Child uses multiple reversible roles (e.g., child is the
manicurist, hair dresser, and cashier, but the parent is
always the customer).
Child uses a doll or puppet as a participant in play.
(continued)
288 Applications of NDBI Strategies

Table 12.3. (continued)

Type of play and approximate

age of emergence Examples

Symbolic play Level 6
(42–60 months)
Symbolic play Level 7
(after 60 months)
Game play with rules
(after 60 months)
Sources: Belsky & Most (1981); Casby (2003); Westby (2000).
Child elaborates play sequences through planning and
building of scenes and may hypothesize different
outcomes.
Child uses dolls and puppets as play agents, and each can
have multiple roles.
Child has expanded play into imaginative integrated
sequences with many steps and multiple participants.
Child may have several storylines going at one time.
Child collaborates with others in play.
Child can play complex games with multiple rules.
Child accepts rules and limits.
Child can independently make up games with rules.

easy to forget about the importance of play in adolescence and adulthood, shared
recreational leisure and athletic activities (e.g., hobbies, organized sports) remain
critical opportunities for socialization and connection with others throughout the
life span.
Play development in both typically developing children and children with
ASD is not necessarily linear or straightforward. Although Table 12.3 shows
types of play as distinct categories, these do not necessarily emerge one at a
time, and multiple types of play are often observed simultaneously, especially
as children gain increasing skills. The table is provided to give the reader a
broad overview of types of play and should be used flexibly as a resource when
thinking about what play skills to teach. Research shows it is important to select
play goals that match a child’s developmental level, rather than age, and to
select goals at or just above the child’s current play level (Lifter, Ellis, Cannon,
& Anderson, 2005; Lifter, Sulzer-Azaroff, Anderson, & Cowdery, 1993). Further-
more, because plays skills build on each other developmentally, it is important
to not jump ahead too rapidly but to allow for substantial expansion within
each phase.

Teaching Play in NDBI

Because appropriate social play depends on the context, it is not effectively taught
as a discrete set of skills. Instead, teaching needs to involve meaningful and enjoy-
able engagement with materials, which is often best accomplished in natural social
settings (Liber, Frea, & Symon, 2008; Strain & Schwartz, 2001). In fact, acquisition
of play skills is complex and circular: Children need to have play skills in order
to participate in social interactions with peers, but they also need exposure to
social opportunities in order to learn to play appropriately (Jordan, 2003). Research
suggests that play skills can be taught (though quality may be different; Thorp,
Stahmer, & Schreibman, 1995) and that improvements in play may also lead to better
social interaction, better language skills, and decreased self-stimulatory behavior
(Baker, 2000; Stahmer, 1995; Thorp et al., 1995). Teaching children with ASD to en-
gage in thematic play also allows for interactive play with peers (Rogers, 2005), and
 Improving Social Skills and Play 289

play is generally considered a critical context for friendship development in child-

hood (Jordan, 2003).
Research has suggested that symbolic play skills can be taught using a variety
of behavioral approaches and prompting methods (Stahmer, Ingersoll, & Carter,
2003). However, rather than relying primarily on adult prompts and praise to teach
play skills (as in Colozzi, Ward, & Crotty, 2008), naturalistic techniques have had
success promoting spontaneous play by incorporating the child’s interests and
arranging environments to be conducive to play (Kohler, Anthony, Steighner, &
Hoyson, 2001). Kasari and colleagues (2006) conducted a randomized controlled
trial using naturalistic strategies combining behavioral and developmental meth-
ods; they found that children who were taught functional and symbolic play
behaviors showed more diverse types of symbolic play and higher play levels
during interaction with their mothers than children in the joint attention or control
conditions. Several other studies have suggested that NDBI strategies (following
the child’s lead, using a least-to-most intrusive prompt hierarchy, and providing
natural reinforcement) are effective at enhancing play skills. Still, it appears neces-
sary to directly teach symbolic play behaviors because many children with ASD do
not spontaneously start using these important skills without targeted intervention
(Lifter et al., 2005; Wong, 2013, Wong & Kasari, 2012).
Several studies examined the effectiveness of PRT for expanding play skills.
In addition to improvement in language and joint attention, collateral changes in
toy play were reported (Pierce & Schreibman, 1995, 1997b). Results also indicated
increases in symbolic play (Stahmer, 1995) and sociodramatic play (Thorp et al.,
1995) as well as play complexity and social interactions. Lydon, Healy, and Leader
(2011) compared PRT with video modeling and showed improvement and better
generalization in the PRT condition.
ESDM has developed a detailed curriculum that breaks down play skills into
progressive developmental steps (Rogers & Dawson, 2010) up to and including
construction and representational or symbolic play. This helpful list of increas-
ingly more complex tasks provides an excellent overview of the development of
play. The Joint Attention, Symbolic Play, Engagement, and Regulation (JASPER)
model uses play with objects as the main conduit for intervention and empha-
sizes that it is important that play is varied within a play level prior to moving on
to a more difficult play level. Box 12.2 provides some practical tips for play with
toddlers.

Symbolic Play Symbolic play is play where the child uses actions or objects
to represent other actions or objects. It begins to develop around the middle of
the second year of life and tends to progress from pretend actions by the child, to
imaginary objects, and then simple one-step actions with functional objects (feed-
ing the doll with a spoon). Imitation plays a central role because imitative pretend
play actions and dress up begin to take center stage (e.g., wearing Mommy’s shoes,
copying the way Daddy talks on the phone by clenching the pretend phone be-
tween the ear and the shoulder while walking). Over several years, symbolic play
then continues to expand across a large variety of themes, from simple one-step
sequences to multistep, multiple-role schemas with other children.
This type of play closely mirrors language development in both typically
developing children and children with ASD or other disabilities (Kasari, Paparella,
290 Applications of NDBI Strategies

Ready, Set, Implement!

BOX 12.2: Tips for toddler play
• Engage and entice the child first: Follow the child’s lead by imitating his
or her play actions and providing noncontingent reinforcement.
• Use general household items that are readily available, such as food cans
for stacking, plastic food containers for hiding items, and spoons and
metal pans or bowls for drumming.
• Avoid electronic toys with buttons and sounds. They tend to be a
distraction from the social aspects of play.
• Think about the toy prior to presenting it to the child: What could be
fun about this object? The sound of the blocks falling? The view of the
parachute figurine falling down from the landing? The feeling of the
playdough being squished?
• When presenting the toy and the action, watch the child closely to see
if he or she is engaged and enticed to play. Follow the child’s lead to
maximize engagement.
• Oftentimes your affect while presenting the new action and toy makes a
big difference: Be enthusiastic and excited!
• Have backups available if the child is not interested. Having several toys
available and a plan for each can keep motivation and interest high.
• Consider having multiples of the same toy for easy modeling of actions.
• Use daily routines to intersperse modeling of simple play actions or
silly play. For example, an adult wearing a diaper as a hat is funny and
engaging to most children.

Freeman, & Jahromi, 2008; Thiemann-Bourque, Brady, & Fleming, 2012; Toth et al.,
2006). Symbolic play tends to be especially difficult for children with ASD, likely
because it requires many social skills to execute (Jarrold, Boucher, & Smith, 1996)
and because symbolic understanding is delayed or impaired. Furthermore, as play
sequences get longer and more complex, children with ASD may have difficulty
planning these longer sequences and managing the different roles.
Adults should ensure that symbolic play in this phase is varied and flexible.
Thus, the play partner must model flexible and varied actions, scripts, and schemes
in play and should avoid repeating the same actions over and over. It is also impor-
tant to provide varied play materials to encourage flexible play. NDBI are especially
well suited for teaching this type of play because of the emphasis on embedding
teaching in natural routines and using varied teaching examples, but it is up to the
play partner to model variety. Motivation for symbolic play can often be enhanced
easily with the use of sound effects, funny voices, unexpected actions, silly faces,
and creative use of many different play materials. A play partner’s energy, humor,
ingenuity, and resourcefulness can make NDBI feel almost irresistible to the child.
See Box 12.3 for more tips on teaching symbolic play.
 Improving Social Skills and Play 291

Ready, Set, Implement!

BOX 12.3: Tips for teaching symbolic play
• A favorite play routine for pretend actions is to pretend to go to sleep and
snore loudly. Be sure to act very surprised when the child wakes you up
with a pretend alarm clock or rooster call. Taking turns in this activity is an
easy way to build engagement.
• Model functional play actions that the child can recognize from his or her
own daily routines, such as actions in bathing (wash Superman in the
bath with the washcloth), bedtime (put the elephant in bed), shopping
(“pay” for a special treat with pretend money), or cooking (stir the pot
with big wooden spoon to make soup, then feed a figurine).
• The easiest mistake to make in this phase is too much too fast.
Remember to build a lot of variety and spontaneity in the child’s
repertoire of play actions before moving on to more complex play.
• Some children with ASD do not see the fun in dress-up activities, but
dress up can be minimal with a silly hat, a pair of plastic glasses, or a
power shield made from cardboard box. The important thing is to have
fun with the dress-up activity.
• Make sure to include maintenance tasks so that not all of the play actions
are novel and difficult for the child.
• If the child always wants to play the same sequences or with the same
materials, try providing a first, then approach. That is, reinforce varied and
spontaneous play or responding to another person’s topic of play with
access to the child’s preferred play materials or sequence.
• Accepting others’ ideas in play is hard for many young children but tends
to be especially hard for children with ASD. Make sure that the child has
a large repertoire of possible play actions and sequences to pick from
before targeting flexibility.
• Choices can be among sets of symbolic play toys (e.g., doctor set and
puppet, pretend utensils and dolls, figurines with cars and a toy garage).
Then, within the choices provided, follow the child’s lead to see what is
of interest.
• Remember not to start prompting immediately. Build engagement,
find the motivator, and then intersperse a novel action or sequence.
Narrating appropriate play actions can provide important feedback and
build vocabulary, as long as the child is attending to most of the narration
and the adult is not just background noise. Be sure to match the child’s
language level.
292 Applications of NDBI Strategies

Game Play Between ages 3 and 4, typically developing children begin to en-
gage in a variety of board games. Some early games lend themselves more to teach-
ing compared to others. Games that have an exciting action associated with a turn
or games in which the child is anticipating a surprising or exciting ending tend to
be more motivating. For example, in the Doggy Doo game, the object is to make the
dog poop. In Pie Face, the object is to avoid getting hit in the face with whipped
cream. In Pop the Pig, the pig is fed until it burps, and in Pretty Pretty Princess,
the players collect jewelry along the way. Sometimes games can be adapted to be
more exciting or incorporate a child’s restricted interest. Memory can be more mo-
tivating if it contains pictures of the child’s favorite toys, objects, or characters, and
perhaps special prizes can be earned for matches. Candy Land, a short board game
where game pieces are moved on the game board, can be much more fun if small
candies are earned along the way. A child whose perseverative interest is maps
may like Candy Land if it is presented as a way to explore the map. A child who
likes car brands may be enticed to play Don’t Break the Ice if car logos are attached
to the ice cubes and tapped by the hammer. See Box 12.4 for more strategies to
make game play successful.
Game play also includes a variety of social games. Social games are not that
different from sensory social routines, except they become increasingly more com-
plex and more rule governed. Social games are helpful because their rules are
easily changed to accommodate children with ASD who may be struggling with
a certain component of a game, and they incorporate many of the reinforcing fea-
tures of sensory social games. Table 12.4 shows examples of favorite social games
and how they can be varied and adjusted.

Ready, Set, Implement!

BOX 12.4: Game play tips for board games
• Initially make games super short; end the game when the child is still
very motivated to play!
• Prompt a variety of tasks (not just asking for a turn). Commenting
on the other person’s turn, giving items, and responding to the play
partner should also be prompted throughout the activity and can be
good ways to introduce task variation and interspersal of maintenance
tasks with turn-taking goals. In addition, if the game requires dice or
other items to be handed back and forth between players, prompt a
variety of requests for dice: “Give me the dice,” “Can I have the dice?”
and “Dice please” are all good options and can be alternated. Variety
builds the child’s repertoire and prevents inflexible language and play
behaviors.
• If multiple children are playing the game, be sure to prompt and praise
all participants, not just the child with ASD (see also the section on
cooperative arrangements and successful playdates).
 Improving Social Skills and Play 293

Table 12.4. Tips for social games

Game: What Time Is It, Mr. Fox?

Description
In this game, Mr. Fox (the adult) stands a short distance from the child, turned away so
that he or she cannot see the child. The child calls to Mr. Fox and asks, “What time is it,
Mr. Fox?” The adult states it is 3 o’clock, and this allows the child to take three steps toward
Mr. Fox. This process is repeated until either the child touches Mr. Fox and wins the game
or Mr. Fox answers, “It’s lunch time!” and chases the child to pretend to eat him or her.
Tips
This game initially needs a prompter to help the child understand the game, and the ability to
count up to five is helpful.
Mr. Fox should initially be played by the adult.
Add painters, tape to the floor to mark where the child is supposed to step.
The reinforcer is usually the sudden chase at the end.

Game: Hide and Seek

Description
The adult counts to a predetermined number while the child hides. The adult searches for the
child until he or she is found. In some versions, both run back to “home,” and whoever gets
there first wins.
Tips
When priming for the game, set clear up-front limits about where the child is allowed to hide
(e.g., only hide in the living room, stay in the garden) to prevent not knowing where the
child is. In open spaces, it can be helpful to draw the boundary with chalk or ensure there is
a physical barrier for safety.
If multiple children participate, have children search in pairs with one child asking, “Am I
getting warmer or colder?” and the other child answering “warmer.”
Priming can include reminders about what to do when finding the individual who was hiding
(e.g., “You can say, ‘I found you’ or ‘There you are!’”). If the child appears underwhelmed
by finding the hiding individual, it may not be sufficiently reinforcing. This can be
addressed by adding a chase at the end back to the base, or the hidden child can be primed
to jump out and give high-fives or other actions the child may find exciting.

Game: Red Light, Green Light

Description
One person calls “red light . . . green light” while the other person moves toward the caller
on “green light” and stops on “red light.” Sometimes the person calling red light, green
light is turned away from the individuals moving. In this version, the winner is the person
who reaches the caller first.
Tips
Place snack items or another desired activity at the end so children will be motivated to reach
the caller.
In summer, have children carry small buckets of water or water balloons while moving toward
the person calling red light, green light. When the caller calls an agreed on “magic” word
(e.g., “rainbow light”), the children are allowed to run toward the caller to attempt to throw
the water or water balloons at the caller.

Game: Freeze Dance

Description
While the music plays, all participants dance. When the music stops, everyone freezes in
place. If you are still moving when the music stops, you are out.
Tips
Prompt children to ask a question or make a comment to a peer before they can be unfrozen.
This is a great family game to involve younger siblings and other family members.
(continued)
294 Applications of NDBI Strategies

Table 12.4. (continued)

Game: Duck, Duck, Goose (requires three or more participants)

Description
Everyone but the counter sits in a circle. The counter walks behind the children in the circle
while lightly tapping each person saying “duck” or “goose.” When the word “goose” is
used, the person tapped with goose must jump up and attempt to tag the counter before
he or she completes the circle and sits down in that person’s spot in the circle.
Tips
Partner children who are “it” to give them an opportunity to discuss and decide when to say
“duck” and when to say “goose.”
Change it up with favorite phrases: “duck” becomes “pepperoni pizza,” and “goose” becomes
“breadsticks.”

Useful NDBI Strategies for Teaching Play

All NDBI value the importance of play and its role in development, and many gen-
eral NDBI strategies can be used to teach play. These include a variety of prompt-
ing strategies, turn taking and balanced turns, child choice and shared control,
and balancing new or acquisition tasks with maintenance or already learned tasks.

Prompting Strategies When teaching functional play acts (e.g., using the
hammer to beat down a peg, hitting a drum, rolling a car), the adult should begin
by providing some choices of preferred toys. Once the child selects a toy or indi-
cates an interest by reaching or approaching it, wait and see if spontaneous func-
tional play occurs (e.g., the child begins to roll the car). If the child initiates an
appropriate action, the adult immediately imitates the action and describes the ac-
tion with praise (e.g., “Drive the car; great job!”). If the child continues to explore
the toy but does not use it functionally, the adult can provide a model in his or her
turn with the car and prompt for imitation by handing the car back to the child
saying, “You do it.” If the child does not imitate the action, a most-to-least prompt-
ing hierarchy is used to help the child complete the action.
Momentum is another antecedent strategy that sets the stage for an upcoming
play act and helps to entice the child into a play action. For example, when model-
ing rolling a car down a ramp, the play partner may roll the car in place to “rev it
up” with sound effects and excited facial expressions before actually rolling the
car down the ramp. This may create anticipation and excitement and make it more
likely that the child will engage with the adult and the toy and imitate the action.
Modeling and nonverbal prompting can be used to teach simple or advanced
play skills, such as symbolic substitution in play, or the ability to pretend some-
thing is different from what it actually is, using ambiguous objects. Ambiguous
objects are similar in shape or color compared to the actual object but not distinc-
tive on their own. Rogers and colleagues (2012) used the example of a Popsicle
stick to represent a spoon. Then, during an established joint activity routine (feed-
ing the baby with a spoon), a variation is presented that models a mastered play
action (feeding with the spoon) with the actual item and then immediately fol-
lowing the same action with the new ambiguous item (feeding with the Popsicle
stick). The child is prompted to imitate both actions, and if two sets are available,
parent and child may alternate using the actual item (spoon) and the ambiguous
item (Popsicle stick).
 Improving Social Skills and Play 295

Games tend to provide excellent opportunities to prompt more advanced

communication skills such as commenting. The inherent structure of the game
already provides visual and gestural cues (e.g., dice or a hammer that is passed
over) to take a turn, allowing for natural prompt fading quickly. Pairing comments
with common gestures used to congratulate or commend others on their turn (e.g.,
high-fives, fist bumps) can be helpful in prompting procedures because the ver-
bal prompt can be faded more easily to a time delay or gestural prompt. Given
that game play consists of a series of repetitive actions, it is important to make
sure interactions remain varied because children with ASD tend to remember pat-
terns. For example, when playing the matching game Memory, a play partner could
model a variety of responses when turning two nonmatching cards, rather than
saying “no match” in the same tone each time. Fading prompts quickly is essential
when teaching game play to ensure the game is not rote.
When playing games with multiple partners, the prompter should consider
carefully where to prompt from. For example, if the child is playing with a peer,
the prompter may want to be behind the child rather than as a third partner at the
table. This prevents the peer from referencing the adult rather than the child with
ASD and prevents the child with ASD from referencing the adult rather than the
peer. In addition, it is much easier to fade out—the ultimate goal for any prompter.
Priming can also be used to teach the rules of social games in advance and has
been shown to enhance peer social interactions (Gengoux, 2015). Priming can also
be used to clarify behavioral expectations (e.g., “Keep your hands to yourself, and
wait your turn”) and prepare for winning or losing the game (e.g., “Remember, it is
about having a great time with your friends, not winning or losing”).

Turn Taking and Balanced Turns Turn taking supports back-and-forth inter-
actions (Harrist & Waugh, 2002) and may enhance requesting, commenting, and
toy play skills (Rieth et al., 2014) during any stage of play development. When chil-
dren are learning functional and symbolic play, having two sets of the same toys
can allow the play partner to model the desired play actions. On the other hand, it
is also sometimes helpful to have only version of the toy (e.g., one ball for the ball
ramp) to play with. This naturally provides opportunity for turn taking. The adult
can also add novel components to his or her turn—a sound effect, an element of
speed, or an unexpected change that mixes up the interactions and increases the
likelihood of high interest in continuing the activity. This strategy is often called
addition and can be used to make the play partner’s turn more reinforcing.
Turn taking can also be helpful when the child is engaging in repetitive play
patterns. Using a child’s strong interest in repeating the same action over and over
may function as a way to motivate the child to practice novel but related skills. For
example, the adult can copy the child’s behavior, then model slight variations on
the repetitive action and encourage the child to try imitating the variation before
returning to playing the way he or she usually does. The adult thus establishes
a turn-taking routine, taking advantage of his or her turn to model a creative or
silly use of the same materials, thereby encouraging the child to expand his or her
play routine.
Turn taking is a natural part of most game play and includes watching the
play partner, waiting for a turn, commenting, requesting, and affective shar-
ing. At first, the goal may be to take the turn when the opportunity is presented,
296 Applications of NDBI Strategies

but ultimately affective sharing regarding the play partner’s turn is at least as
important because it increases the likelihood that the child is a preferred play
partner. Sometimes it can be easier to teach the finesse of turn taking in advanced
social games rather than board games because these provide less structure and
fewer rules.
When beginning to practice this new skill, limit prompting of turn taking
in the third person (avoid overusing “It’s Miss Mia’s turn”). Instead, prompt the
child to say “my turn” to request his or her turn and “your turn” when giving
a turn to the partner. The adult should not provide a teaching trial every time a
turn is taken, and some turns should just be that—a turn in a play exchange. Turn
taking in games can be prompted in diverse ways because play partners should
not consistently require the child to ask for a turn or announce a turn (“Whose
turn is it?” “My turn” or “Your turn”). Rather turn taking should naturally flow
within the activity in the same way it would in a joint activity routine. If a play
partner needs to constantly prompt the child to take a turn or give a turn, the
adult may consider tweaking the game or going back to social games to ensure
that the child is picking up on the nonverbal cues of turn taking and is interested
in the game.
Child Choice and Shared Control Strategies It can be challenging to estab-
lish shared control of materials in a way that keeps the play fun. For instance, if a
child is interested in dumping balls out of a bucket (an interest common in young
children), simple blocking is not necessarily recommended because many young
children reject this type of incursion into their play. A more helpful strategy may
be to arrange the environment in such a way that adult help is required to play
with items. For example, the bucket is accessible, but the balls are in a box that can-
not be opened alone (using transparent plastic boxes with snap-on lids is helpful).
Although adult play partners may be tempted to simply open the box, waiting for
a behavior that indicates a desire to access the balls provides a natural communica-
tion temptation. Addition is another shared control strategy that tends to be suc-
cessful; for example, while the child is playing with a bucket and balls, adding a
puppet that is eating the balls provides a playful way to obtain control over some
of the balls.
Providers are encouraged to take note of unusual play interests because
these can often be highly motivating. Consider the example of an adult and
a child playing in the child’s bedroom with a box of figurines. The child may
appear interested in the beginning of the interaction but then slowly start to turn
away from the adult. Finally, with a figurine in hand, the child runs over to the
bed and forcefully sits down on the bed with the figurine before returning to the
box to exchange the figurine and repeat the sequence (sit down with figurine,
jump up, run to the bed, forcefully sit down, get back up, and bring the figurine
back to the box for the exchange). After two rounds, if the adult notices this is a
routine and imitates the child, the routine can be turned into a game. After a few
repetitions, the adult may then offer a variation (an acquisition task) and model
the figurine jumping on the bed while saying, “Wheeee!” The child imitates the
model, and the adult and the child repeat the sequence. This unusual routine
could likely not have been predicted by the adult, but because the adult paid
attention and closely monitored the child’s interest, the adult was able to capital-
ize on the interest.
 Improving Social Skills and Play 297

Balancing Maintenance and Acquisition Tasks and the One-Up Rule In

every teaching episode, the adult should alternate between new tasks (acquisition)
and mastered or maintenance tasks, as well as noncontingent reinforcement and
imitation. This alternation ensures motivation remains high and the interaction is
balanced (see also Chapter 6). Acquisition tasks should consist of tasks that are just
above the difficulty level of the mastered task (i.e., within the child’s zone of proxi-
mal development). For example, if the child is engaging in a variety of functional
play actions, animated play with a figurine, doll, or puppet could be targeted next.
If the child has mastered putting a figurine in the school bus, the next target may
be to have the figurine say hello to the figurine bus driver. Not all figurines should
be animated when filling the bus because just putting them into the bus would be
the maintenance task.

TEACHING PLAY WITH FRIENDS

Chapter 5 provides an in-depth review of literature on inclusion and peer-mediated
interventions. This section adds practical strategies that promote engagement with
peers. It conducts a short review of the literature, followed by practical tips and
ideas to promote cooperation and engagement between peers in small-group ac-
tivities and in playdates.
Teaching play can most easily be accomplished in natural contexts (homes,
schools, community settings) because play is something that all children do wher-
ever they go. To help children with ASD learn to play with peers, they must have
regular access to peers who are potential playmates. Children with ASD ideally
should be regularly included alongside their natural peer group of siblings and
neighborhood children. Teaching that occurs in these inclusive contexts will be
particularly powerful for promoting peer relationship development. It is criti-
cal that play interventions focus not just on teaching discrete play skills but also
on integrating children into their peer culture in meaningful ways (Wolfberg &
Schuler, 2006).

Establishing the Play Partner as a Reinforcer

Establishing the social partner as a reinforcer is key in NDBI because there is evi-
dence that learning is enhanced when it takes place within emotionally meaning-
ful social interactions (Schreibman et al., 2015; Topál, Gergely, Miklósi, Erdőhegyi,
& Csibra, 2008). Making peers reinforcing requires careful planning and ongoing
monitoring and may include many steps for some children with ASD. Simply mea-
suring peer proximity in unstructured situations may be one very rough way to
quickly gauge how reinforcing peers are (McGee et al., 1999), but generally speak-
ing, careful and in-depth assessment of peer interactions is almost always nec-
essary from a young age. As children become older, their natural environment
expands to include peer interaction as an even more critical social context.
Although a goal for most children may be to play with same-age and often
same-gender peers, it may initially be easier to find matching interests with peers
slightly older or younger than the target child or of the opposite gender. School
staff can often be helpful and recommend several children who have shown inter-
est in the child with ASD, exhibit frequent unprompted prosocial and empathic
behaviors (e.g., helping others, sharing), and may make good play partners. In
298 Applications of NDBI Strategies

addition, generally speaking, the more inclusive activities in which the child is
involved, the easier it will be to find peers for practice. One helpful strategy is to
linger before and after activities in order to naturally connect and socialize with
parents of peers before and after school or to offer to drive carpool. Bringing extra
snacks to share and bringing games for multiple players to the park to entice peers
to join the activity while waiting can also foster connections.
Children with ASD may initially show a lack of interest in playing with
peers. Pairing peers with strong reinforcers such as favorite snacks and toys may
increase interest. It is important to prompt the child with ASD primarily to make
simple requests from peers to pair direct natural reinforcement with peer initia-
tions and to initially have a high level of reinforcement combined with low task
demand. Parallel play near a peer with the occasional exchange of toy material
can also be a good starting point, and teaching can build toward longer, recipro-
cal interactions.

Peer-Mediated Interventions
Because the use of adult partners to train social skills does not generalize eas-
ily to peer social skills, teaching social skills directly through peer-mediated ap-
proaches has particular promise. Peer-mediated interventions typically involve
training peers to implement an intervention directed toward a child with a dis-
ability (Chan et al., 2009), often by teaching persistence in initiating specific play
behaviors (sharing, helping, giving affection and praise; Rogers, 2000). Though this
approach tends to be underutilized in practice (Rogers, 2000), there are manualized
and highly effective approaches for peer-mediated intervention (Wang, Cui, & Par-
rila, 2011; Zhang & Wheeler, 2011). For instance, school-age peers have been taught
to implement PRT in order to increase social-communication behaviors (including
both initiations and responses) of children with ASD (Harper, Symon, & Frea, 2008;
Kuhn, Bodkin, Devlin, & Doggett, 2008; Pierce & Schreibman, 1995, 1997a, 1997b).
The procedures for the peer coaches included instruction and modeling with an
adult trainer, role play with an adult and other peer coaches, and intermittent feed-
back during play sessions with children with ASD. Collateral changes in language
and joint attention (and toy play) have been reported (Pierce & Schreibman, 1995,
1997b). Peer tutoring has also been used to teach peers IT techniques (McGee,
Almeida, Sulzer-Azaroff, & Feldman, 1992), with improvements in reciprocal so-
cial behavior, social initiations, and peer acceptance. Evidence suggests that par-
ents can also teach siblings to use peer-mediation strategies (Strain & Danko, 1995;
Strain, Kohler, Storey, & Danko, 1994).
One of the first models for peer-mediated intervention was developed by
Odom and Strain (1984) and involved behaviorally based training of peers to
increase social initiations and responses of the children with ASD. Another such
approach comes from the integrated play groups model (Wolfberg & Schuler,
1993), where peers are guided to encourage toy play by children with ASD by
directing attention, modeling symbolic play, and embedding the behaviors of chil-
dren with ASD into their broader play theme (Zercher, Hunt, Schuler, & Webster,
2001). This model involves many components consistent with an NDBI approach,
including conducting the intervention within natural integrated and devel-
opmentally appropriate play settings, using consistent routines and toys with
interactive potential to provide a context that is conducive to interaction, and
 Improving Social Skills and Play 299

emphasizing child-initiated behaviors through adult scaffolding. These strate-

gies have been shown to result in more functional, symbolic, and social play and
decreases in nonfunctional object manipulation and isolated play (Wolfberg &
Schuler, 1993). More recently, Kasari and colleagues (2012) demonstrated lasting
changes in school social networks following a relatively brief (6-week) peer train-
ing intervention.

Facilitated Playdates
Playdates hosted by parents of children with ASD are a natural context for building
peer relationships and enhancing social skills. Research evidence has repeatedly
shown that children with ASD are more likely to have reciprocal friendships if
their parents actively set up and facilitate opportunities for peer contact outside
school, such as playdates and get-togethers (Frankel, Gorospe, Chang, & Sugar,
2011; Frankel & Myatt 2003; Ladd, Hart, Wadsworth, & Golter, 1988). Research has
indicated that naturalistic strategies can be used to increase spontaneous social
interactions with adults and peers (Kohler et al., 2001). Common features of suc-
cessful approaches include both motivational strategies (i.e., incorporating the
child’s interests, environmental arrangement, contingent reinforcement) and sys-
tematic prompting of play targets according to a developmental sequence (Hwang
& Hughes, 2000; Jung & Sainato, 2013). For instance, Kohler and colleagues (2001)
demonstrated that when teachers received coaching in specific naturalistic strate-
gies (using novel materials, joining play activity, incorporating choice, arranging
the environment, expanding language, drawing attention to peers), preschool chil-
dren increased their unprompted social interaction.

Following the Child’s Lead When applied to peer interactions, the NDBI
strategies of using child-preferred activities and following the child’s lead mean
that the activity selected for the playdate should be of interest to both children
involved (i.e., the child with ASD and the peer). Not only are children more likely
to engage with each other when they are enjoying a mutually reinforcing activity,
but child-preferred activities also provide an optimal context for teaching skills.
That way, if one child struggles to interact appropriately at first, the activity will
continue to capture his or her interest while the adult facilitator works to support
improved interaction. Of course, to ensure the activity is highly preferred for the
child with ASD, general activities can be slightly modified to incorporate specific
interests. For example, if both children like playing Bingo but the child with ASD
loves animals, then animal Bingo may be an excellent choice. Likewise, if both
children like basketball but the game is a little hard for the child with ASD, perhaps
playing basketball with balloons may be easier and thus more preferred.

Cooperative Arrangements For effective social facilitation, activities must

be structured to ensure that the children (and especially the child with ASD) re-
ceive contingent and natural reinforcement as often as possible for their use of ap-
propriate social skills. Reinforcement for interaction should ideally come directly
from the peer. For instance, if the activity involves constructing a puzzle, the
child with ASD could be prompted by an adult to request, “Can you pass one of
the puzzle pieces?” from the peer, and the adult can then ensure that the peer pro-
vides contingent natural reinforcement for that appropriate request. The easiest
300 Applications of NDBI Strategies

way to do this systematically is to deliberately engineer the activities to include

cooperative arrangements, in which interaction is necessary to complete the ac-
tivity and directly results in reinforcement for one or both children. Coopera-
tive arrangements can be thought of as one type of environmental arrangement,
in which the emphasis is on making sure the peer has control of the materials
necessary for the child with ASD to complete the desired task. Cooperative ar-
rangements can easily be established by an adult facilitator in school classrooms,
on playgrounds, during extracurricular activities, or during playdates and get-
togethers at home.

Shared Control in Cooperative Arrangements One way to set up initial

cooperative arrangements is to start activities with children having shared con-
trol of the materials necessary for the activity. For instance, if the chosen activity
involved having children make pizzas, the adult could ask each child to bring a
favorite topping to share. When the child who brought pepperoni decides that he
or she wants pineapple to add to his or her pizza, the child can be prompted (if
necessary) to request some from his or her peer. In this way, motivation to interact
initially is built into the structure of the activity. The benefit of cooperative ar-
rangements is that once children learn the skill of making appropriate requests,
they will no longer need adult prompting to interact as long as cooperative ar-
rangements are in place.
Likewise, activities or games can be designed specifically around a child’s
strengths so that the child will immediately become a valued member of the game.
For instance, a child with ASD who reads well can be put in charge of reading clues
to other children on a treasure hunt. A child who swims well can be put in charge
of diving for pool toys to distribute to his or her friends. A child who loves num-
bers can be made the caller in a Bingo game. Finally, cooperative arrangements can
be reestablished continually by an adult facilitator so that the children continue to
be highly motivated to cooperate and communicate with each other. Other exam-
ples of how to use cooperative arrangements to encourage peer interaction during
different types of activities include the following:
• When it is time for a snack, give all the plates and cups to the child with ASD
and all the snacks to the peer. Encourage the child with ASD to ask his or her
friend which color plate and cup he or she wants. Once the child has passed
out the plates, he or she can request snacks from the peer. In this way, the
child will receive direct natural reinforcement for initiating to his or her peer.
Children can also be encouraged to prepare snacks for each other so that they
get practice asking questions about which, where, and how much food another
child would like.
• If the children want to play with trains, place the desirable parts of the train set
in clear containers or bags and distribute them among the children so that no
one child has a sufficient number of items to construct a track and play alone.
Remind the children to look at what the other children have and ask to trade if
they want an item a friend is holding. This will encourage children to practice
initiating requests to peers for toys when highly motivated. To encourage chil-
dren to practice play acts with peers, the adult can prompt the target child to
imitate a peer’s use of toys before taking a turn.
 Improving Social Skills and Play 301

• When introducing an activity such as an art project, set the expectation that the
children will work together to complete a single project. This creates a reason
for ongoing interaction and negotiation about what the project should look
like. For instance, if the children are making a puppet together (rather than
each child making his or her own puppet), the adult can encourage them to
talk with each other about what it should look like and to ask and answer ques-
tions about the color of the hair, type of clothes, and facial features until they
come to a shared decision. Materials for completing the project (scissors, glue,
ribbon) can be moved around the table by the adult facilitator to keep creating
new reasons for the children to interact by asking for what they need from a
friend. Having only one pair of scissors or one container of glue will further
ensure that the children have to take turns and ask for the items frequently.
• Physical games and sports can also be designed to include cooperative arrange-
ments. This may often involve changing the rules slightly, but if introduced at
the start of the game, new rules that also make the game more fun will often be
well received. For instance, putting two buddies in charge of calling out “red
light, green light” will mean that the two children will have to discuss when
to call which instruction. Shooting baskets can be made cooperative by setting
a timer and having the children work together to get as many baskets as pos-
sible in 2 minutes, perhaps even with balls worth different numbers of points.
• During a cooking activity, a child with strong reading skills can be put in charge
of the recipe, and other children can be prompted to ask questions about what
steps need to be completed next. In a large group, each ingredient can be given
to a different child so that the child holding the mixing bowl gets repeated
practice requesting the items he or she needs. For children who are ready to
practice conversation skills (beyond requesting), the adult can encourage the
children to ask questions and share comments about their favorite foods, mak-
ing sure to time prompts for these challenging tasks right before the target
child’s turn to receive the next ingredient (the natural reinforcer for trying con-
versation). When the food has been prepared, the children can enjoy eating it
together. Box 12.5 provides some general tips related to playdates.

CONCLUSION
This chapter focused on using NDBI to enhance meaningful social skills, that
is, those skills that have potential to make lasting differences in the quality of
a child’s relationships over time. The focus also was on teaching strategies that
can be used in the natural environment with the child’s natural play partners,
whether those are parents of very young children or typically developing peers.
These strategies are intended to promote better engagement and also greater
independence through self-monitoring. One of the key advantages of the NDBI
approach is the emphasis on making the treatment interaction enjoyable for the
child. Whether teaching initiations during sensory social routines, teaching func-
tional or symbolic play, or teaching advanced cooperative play skills, the use of
motivational strategies such as following a child’s interests can be particularly
powerful for teaching social skills because the core purpose of socialization is to
have fun.
302 Applications of NDBI Strategies

Ready, Set, Implement!

BOX 12.5: Tips for playdates
• Make sure playdates are initially short. A short successful playdate is
much more valuable than a longer playdate that ends with the children
ignoring each other—or worse, engaging in challenging behaviors.
• For a quick play encounter, offer to carpool to school or events, and give
the children a few minutes to play before or after the car ride.
• Going out for an ice cream after school can be a playdate; it is short and
sweet and can help establish the peer as a reinforcer. Even having a
snack with a peer on the playground after school is a social activity.
• Tell peers in advance about the planned activity so they can come excited
to participate and can even bring materials to contribute (e.g., pizza or
ice cream toppings, craft supplies), which gives you initial cooperative
arrangements.
• If the kids are sensitive about having an adult around when playing at
home, do an activity in the kitchen requiring cutting or cooking, or take
them somewhere outside the home where adult supervision is required
(e.g., swimming, bowling, rock climbing wall at the local gym).
• Think about how you position children at a table, making sure the kids face
each other but are not close enough to grab materials from each other.
• Be sure to provide feedback and prompting to both children during the
playdate.
• Intersperse snacks, and set them up using cooperative arrangements.
• Coordinate with the other family to find out what the peer’s favorite
snacks and/or activities are.
• Intersperse a physical activity to get some of the wiggles out.
• Pick activities that have a clear beginning and end.

REFERENCES
Baker, M. J. (2000). Incorporating the thematic ritualistic behaviors of children with autism
into games: Increasing social play interactions with siblings. Journal of Positive Behavior
Interventions, 2(2), 66–84.
Bellini, S., & Peters, J. K. (2008). Social skills training for youth with autism spectrum disor-
ders. Child and Adolescent Psychiatric Clinics of North America, 17(4), 857–873.
Belsky, J., & Most, R. K. (1981). From exploration to play: A cross-sectional study of infant
free play behavior. Developmental Psychology, 17(5), 630–639.
Berger, N. I., & Ingersoll, B. (2013). An exploration of imitation recognition in young chil-
dren with autism spectrum disorders. Autism Research, 6(5), 411–416.
Berger, N. I., & Ingersoll, B. (2015). An evaluation of imitation recognition abilities in typi-
cally developing children and young children with autism spectrum disorder. Autism
Research, 8(4), 442–453.
Carpenter, M., Pennington, B. E., & Rogers, S. J. (2002). Interrelations among social-cognitive
skills in young children with autism. Journal of Autism and Developmental Disorders, 32(2),
91–106.
 Improving Social Skills and Play 303

Casby, M. W. (2003). The development of play in infants, toddlers, and young children. Com-
munication Disorders Quarterly, 24(4), 163–174.
Chan, J. M., Lang, R., Rispoli, M., O’Reilly, M., Sigafoos, J., & Cole, H. (2009). Use of peer-
mediated interventions in the treatment of autism spectrum disorders: A systematic
review. Research in Autism Spectrum Disorders, 3(4), 876–889.
Charman, T., Baron-Cohen, S., Swettenham, J., Baird, G., Drew, A., & Cox, A. (2003). Pre-
dicting language outcome in infants with autism and pervasive developmental disorder.
International Journal of Language & Communication Disorders, 38(3), 265–285.
Colozzi, G. A., Ward, L. W., & Crotty, K. E. (2008). Comparison of simultaneous prompting
procedure in 1:1 and small group instruction to teach play skills to preschool students
with pervasive developmental disorder and developmental disabilities. Education and
Training in Developmental Disabilities, 43(2), 226–248.
Contaldo, A., Colombi, C., Narzisi, A., & Muratori, F. (2016). The social effect of “being imi-
tated” in children with autism spectrum disorder. Frontiers in Psychology, 7, 726.
Dawson, G., & Adams, A. (1984). Imitation and social responsiveness in autistic children.
Journal of Abnormal Child Psychology, 12(2), 209–225.
Dawson, G., & Galpert, L. (1990). Mothers’ use of imitative play for facilitating social responsive-
ness and toy play in young autistic children. Development and Psychopathology, 2(2), 151–162.
Ezell, S., Field, T., Nadel, J., Newton, R., Murrey, G., Siddalingappa, V., . . . Grace, A. (2012). Imi-
tation effects on joint attention behaviors of children with autism. Psychology, 3(9), 681–685.
Field, T., Ezell, S., Nadel, J., Grace, A., Allender, S., & Siddalingappa, V. (2013). Reciprocal
imitation following adult imitation by children with autism. Infant and Child Development,
22(6), 642–648.
Frankel, F. D., Gorospe, C. M., Chang, Y., & Sugar, C. A. (2011). Mothers’ reports of play dates
and observation of school playground behavior of children having high-functioning
autism spectrum disorders. Journal of Child Psychology and Psychiatry, 52, 571–579.
Frankel, F., & Myatt, R. (2003). Children’s friendship training. New York, NY: Brunner-
Routledge.
Gates, J. A., Kang, E., & Lerner, M. D. (2017). Efficacy of group social skills interventions for
youth with autism spectrum disorder: A systematic review and meta-analysis. Clinical
Psychology Review, 52, 164–181.
Gengoux, G. W. (2015). Priming for social activities: Effects on interactions between children
with autism and typically developing peers. Journal of Positive Behavior Interventions, 17(3),
181–192.
Gulsrud, A. C., Hellemann, G., Shire, S., & Kasari, C. (2016). Isolating active ingredients in
a parent-mediated social communication intervention for toddlers with autism spectrum
disorder. Journal of Child Psychology and Psychiatry, 57(5), 606–613.
Hancock, T. B., & Kaiser, A. P. (2006). Enhanced milieu teaching. In S. F. Warren & M. E. Fey
(Series Eds.) & R. J. McCauley & M. E. Fey (Vol. Eds.), Communication and language inter-
vention series: Treatment of language disorders in children (pp. 203–236). Baltimore, MD: Paul
H. Brookes Publishing Co.
Harper, C. B., Symon, J. B. G., & Frea, W. D. (2008). Recess is time-in: Using peers to improve
social skills of children with autism. Journal of Autism and Developmental Disorders, 38(5),
815–826.
Harrist, A. W., & Waugh, R. M. (2002). Dyadic synchrony: It’s structure and function in chil-
dren’s development. Developmental Review, 22, 555–592.
Harrop, C., Gulsrud, A., Shih, W., Hovsepyan, L., & Kasari, C. (2017). The impact of caregiver-
mediated JASPER on child restricted and repetitive behaviors and caregiver responses.
Autism Research, 10, 983–992.
Hwang, B., & Hughes, C. (2000). The effects of social interactive training on early social
communicative skills of children with autism. Journal of Autism and Developmental Disor-
ders, 30(4), 331–343.
Ingersoll, B., Berger, N., Carlsen, D., & Hamlin, T. (2017). Improving social functioning and
challenging behaviors in adolescents with ASD and significant ID: A randomized pilot
feasibility trial of reciprocal imitation training in a residential setting. Developmental Neu-
rorehabilitation, 20(4), 236–246.
Ingersoll, B., & Dvortcsak, A. (2010). Teaching social communication to children with autism:
A practitioner’s guide to parent training. New York, NY: Guilford Press.
304 Applications of NDBI Strategies

Ingersoll, B., & Gergans, S. (2007). The effect of a parent-implemented imitation intervention
on spontaneous imitation skills in young children with autism. Research in Developmental
Disabilities, 28(2), 163–175.
Ingersoll, B., & Lalonde, K. (2010). The impact of object and gesture imitation training on
language use in children with autism spectrum disorder. Journal of Speech, Language, and
Hearing Research, 53(4), 1040–1051.
Ingersoll, B., Lewis, E., & Kroman, E. (2007). Teaching the imitation and spontaneous use of
descriptive gestures in young children with autism using a naturalistic behavioral inter-
vention. Journal of Autism and Developmental Disorders, 37(8), 1446–1456.
Ingersoll, B., & Schreibman, L. (2006). Teaching reciprocal imitation skills to young children
with autism using a naturalistic behavioral approach: Effects on language, pretend play,
and joint attention. Journal of Autism and Developmental Disorders, 36(4), 487–505.
Ingersoll, B., Walton, K., Carlsen, D., & Hamlin, T. (2013). Social intervention for adolescents
with autism and significant intellectual disability: Initial efficacy of reciprocal imitation
training. American Journal on Intellectual and Developmental Disabilities, 118(4), 247–261.
Ishizuka, Y., & Yamamoto, J. (2016). Contingent imitation increases verbal interaction in
children with autism spectrum disorders. Autism, 20(8), 1011–1020.
Jarrold, C., Boucher, J., & Smith, P. K. (1996). Generativity defects in pretend play in autism.
British Journal of Developmental Psychology, 14(3), 275–300.
Jones, E. A., Carr, E. G., & Feeley, K. M. (2006). Multiple effects of joint attention intervention
for children with autism. Behavior Modification, 30(6), 782–834.
Jordan, R. (2003). Social play and autistic spectrum disorders: A perspective on theory,
implications and educational approaches. Autism, 7(4), 347–360.
Jung, S., & Sainato, D. M. (2013). Teaching play skills to young children with autism. Journal
of Intellectual and Developmental Disability, 38(1), 74–90.
Kaiser, A. P., & Trent, J. A. (2007). Communication intervention for young children with dis-
abilities: Naturalistic approaches to promoting development. In S. L. Odom, R. H. Horner,
M. E. Snell, J. Blacher, S. L. Odom, R. H. Horner, . . . J. Blacher (Eds.), Handbook of develop-
mental disabilities (pp. 224–245). New York, NY: Guilford Press.
Kasari, C., Freeman, S., & Paparella, T. (2006). Joint attention and symbolic play in young
children with autism: A randomized controlled intervention study. Journal of Child Psy-
chology and Psychiatry, 47(6), 611–620.
Kasari, C., Gulsrud, A. C., Wong, C., Kwon, S., & Locke, J. (2010). Randomized controlled
caregiver mediated joint engagement intervention for toddlers with autism. Journal of
Autism and Developmental Disorders, 40(9), 1045–1056.
Kasari, C., Paparella, T., Freeman, S., & Jahromi, L. B. (2008). Language outcome in autism:
Randomized comparison of joint attention and play interventions. Journal of Consulting
and Clinical Psychology, 76(1), 125–137.
Kasari, C., Rotheram-Fuller, E., Locke, J., & Gulsrud, A. (2012). Making the connection: Ran-
domized controlled trial of social skills at school for children with autism spectrum dis-
orders. Journal of Child Psychology and Psychiatry, 53(4), 430–439.
Kasari, C., Sigman, M., Mundy, P., & Yirmiya, N. (1990). Affective sharing in the context of
joint attention interactions of normal, autistic, and mentally retarded children. Journal of
Autism and Developmental Disorders, 20(1), 87–100.
Koegel, L. K., Koegel, R. L., Shoshan, Y., & McNerney, E. (1999). Pivotal response interven-
tion II: Preliminary long-term outcomes data. Journal of the Association for Persons with
Severe Handicaps, 24(3), 186–198.
Koegel, R. L., Sze, K., Mossman, A., Koegel, L. K. & Brookman-Frazee, L. (2006). First words:
Getting verbal communication started. In R. L. Koegel & L. K. Koegel (Eds.), Pivotal
Response Treatments for autism: Communication, social and academic development (pp. 141–164).
Baltimore, MD: Paul H. Brookes Publishing Co.
Koegel, R. L., Vernon, T. W., & Koegel, L. K. (2009). Improving social initiations in young
children with autism using reinforcers with embedded social interactions. Journal of
Autism and Developmental Disorders, 39(9), 1240–1251.
Kohler, F. W., Anthony, L. J., Steighner, S. A., & Hoyson, M. (2001). Teaching social interac-
tion skills in the integrated preschool: An examination of naturalistic tactics. Topics in
Early Childhood Special Education, 21(2), 93–103.
 Improving Social Skills and Play 305

Kuhn, L. R., Bodkin, A. E., Devlin, S. D., & Doggett, R. A. (2008). Using pivotal response
training with peers in special education to facilitate play in two children with autism.
Education and Training in Developmental Disabilities, 43(1), 37–45.
Ladd, G. W., Hart, C. H., Wadsworth, E. M., & Golter, B. S. (1988). Preschoolers’ peer net-
works in nonschool settings: Relationship to family characteristics and school adjustment.
In S. Salzinger, J. S. Antrobus, & M. Hammer (Eds.), Social networks of children, adolescents,
and college students (pp. 61–92). Hillsdale, NJ: Lawrence Erlbaum Associates.
Liber, D. B., Frea, W. D., & Symon, J. B. G. (2008). Using time-delay to improve social play
skills with peers for children with autism. Journal of Autism and Developmental Disorders,
38(2), 312–323.
Lifter, K., Ellis, J., Cannon, B., & Anderson, S. R. (2005). Developmental specificity in tar-
geting and teaching play activities to children with pervasive developmental disorders.
Journal of Early Intervention, 27(4), 247–267.
Lifter, K., Sulzer-Azaroff, B., Anderson, S. R., & Cowdery, G. E. (1993). Teaching play activi-
ties to preschool children with disabilities: The importance of developmental consider-
ations. Journal of Early Intervention, 17(2), 139–159.
Longhi, E., & Karmiloff-Smith, A. (2004). In the beginning was the song: The complex mul-
timodal timing of mother–infant musical interaction. Behavioral and Brain Sciences, 27(4),
516–517.
Lydon, H., Healy, O., & Leader, G. (2011). A comparison of video modeling and pivotal
response training to teach pretend play skills to children with autism spectrum disorder.
Research in Autism Spectrum Disorders, 5(2), 872–884.
Martins, M. P., & Harris, S. L. (2006). Teaching children with autism to respond to joint
attention initiations. Child & Family Behavior Therapy, 28(1), 51–68.
Mason, S. A., McGee, G. G., Farmer-Dougan, V., & Risley, T. R. (1989). A practical strategy for
ongoing reinforcer assessment. Journal of Applied Behavior Analysis, 22(2), 171–179.
Masur, E. F., & Rodemaker, J. E. (1999). Mothers’ and infants’ spontaneous vocal, verbal, and
action imitation during the second year. Merrill-Palmer Quarterly, 45(3), 392–412.
McGee, G. G., Almeida, M. C., Sulzer-Azaroff, B., & Feldman, R. S. (1992). Promoting reciprocal
interactions via peer incidental teaching. Journal of Applied Behavior Analysis, 25(1), 117–126.
McGee, G. G., Morrier, M. J., & Daly, T. (1999). An incidental teaching approach to early
intervention for toddlers with autism. Journal of the Association for Persons with Severe Hand-
icaps, 24(3), 133–146.
Meek, S. E., Robinson, L. T., & Jahromi, L. B. (2012). Parent–child predictors of social com-
petence with peers in children with and without autism. Research in Autism Spectrum Dis-
orders, 6(2), 815–823.
Meltzoff, A. N., & Moore, M. K. (2000). (a) Imitation of facial and manual gestures by human
neonates (b) Resolving the debate about early imitation. In D. Muir & A. Slater (Eds.),
Infant development: The essential readings (pp. 167–181). Malden, MA: Blackwell Publishing.
National Research Council. (2001). Educating children with autism. Washington, DC: National
Academies Press.
Odom, S. L., & Strain, P. S. (1984). Peer-mediated approaches to promoting children’s social
interaction: A review. American Journal Of Orthopsychiatry, 54(4), 544–557.
Pierce, K., & Schreibman, L. (1995). Increasing complex social behaviors in children with
autism: Effects of peer-implemented pivotal response training. Journal of Applied Behavior
Analysis, 28(3), 285–295.
Pierce, K., & Schreibman, L. (1997a). Multiple peer use of pivotal response training social
behaviors of classmates with autism: Results from trained and untrained peers. Journal of
Applied Behavior Analysis, 30(1), 157–160.
Pierce, K., & Schreibman, L. (1997b). Using peer trainers to promote social behavior in
autism: Are they effective at enhancing multiple social modalities? Focus on Autism and
Other Developmental Disabilities, 12(4), 207–218.
Rieth, S. R., Stahmer, A. C., Suhrheinrich, J., Schreibman, L., Kennedy, J., & Ross, B. (2014).
Identifying critical elements of treatment: Examining the use of turn taking in autism
intervention. Focus on Autism and Other Developmental Disabilities, 29, 168–179.
Rogers, S. J. (2000). Interventions that facilitate socialization in children with autism. Journal
of Autism and Developmental Disorders, 30(5), 399–409.
306 Applications of NDBI Strategies

Rogers, S. J. (2005). Play interventions for young children with autism spectrum disorders.
In L. A. Reddy, T. M. Files-Hall, & C. E. Schaefer (Eds.), Empirically based play interventions
for children (pp. 215–239). Washington, DC: American Psychological Association.
Rogers, S. J., & Dawson, G. (2010). Early Start Denver Model for young children with autism: Pro-
moting language, learning, and engagement. New York, NY: Guilford Press.
Rogers, S. J., Dawson, G., & Vismara, L. A. (2012). An early start for your child with autism:
Using everyday activities to help kids connect, communicate, and learn. New York, NY: Guilford
Press.
Sallows, G. O., & Graupner, T. D. (2005). Intensive behavioral treatment for children with
autism: Four-year outcome and predictors. American Journal on Mental Retardation, 110(6),
417–438.
Sandbank, M., Woynaroski, T., Watson, L. R., Gardner, E., Keçeli Kaysili, B., & Yoder, P.
(2017). Predicting intentional communication in preverbal preschoolers with autism spec-
trum disorder. Journal of Autism and Developmental Disorders, 47(6), 1581–1594.
Schreibman, L., Dawson, G., Stahmer, A. C., Landa, R., Rogers, S. J., McGee, G. G., . . .
Halladay, A. (2015). Naturalistic developmental behavioral interventions: Empirically
validated treatments for autism spectrum disorder. Journal of Autism and Developmental
Disorders, 45(8), 2411–2428.
Sigman, M., & Ruskin, E. (1999). Continuity and change in the social competence of children
with autism, Down syndrome, and developmental delays. Monographs of the Society for
Research in Child Development, 64(1), v–114.
Slaughter, V., & Ong, S. S. (2014). Social behaviors increase more when children with ASD
are imitated by their mother vs. an unfamiliar adult. Autism Research, 7(5), 582–589.
Smith, T., Klorman, R., & Mruzek, D. W. (2015). Predicting outcome of community-based
early intensive behavioral intervention for children with autism. Journal of Abnormal Child
Psychology, 43(7), 1271–1282.
Stahmer, A. C. (1995). Teaching symbolic play skills to children with autism using pivotal
response training. Journal of Autism and Developmental Disorders, 25(2), 123–141.
Stahmer, A. C., Ingersoll, B., & Carter, C. (2003). Behavioral approaches to promoting play.
Autism, 7(4), 401–413.
Stone, W. L., Ousley, O. Y., & Littleford, C. D. (1997). Motor imitation in young children with
autism: What’s the object? Journal of Abnormal Child Psychology, 25(6), 475–485.
Stone, W. L., & Yoder, P. J. (2001). Predicting spoken language level in children with autism
spectrum disorders. Autism, 5(4), 341–361.
Strain, P. S., & Danko, C. D. (1995). Caregivers’ encouragement of positive interaction
between preschoolers with autism and their siblings. Journal of Emotional & Behavioral Dis-
orders, 3, 2–12.
Strain, P. S., Kohler, F. W., Storey, K., & Danko, C. D. (1994). Teaching preschoolers with
autism to self-monitor their social interactions: An analysis of results in home and school
settings. Journal of Emotional and Behavioral Disorders, 2(2), 78–88.
Strain, P. S., & Schwartz, I. (2001). ABA and the development of meaningful social relations
for young children with autism. Focus on Autism and Other Developmental Disabilities, 16(2),
120–128.
Thiemann-Bourque, K., Brady, N. C., & Fleming, K. K. (2012). Symbolic play of preschoolers
with severe communication impairments with autism and other developmental delays:
More similarities than differences. Journal of Autism and Developmental Disorders, 42(5),
863–873.
Thorp, D. M., Stahmer, A. C., & Schreibman, L. (1995). Effects of sociodramatic play train-
ing on children with autism. Journal of Autism and Developmental Disorders, 25(3), 265–282.
Topál, J., Gergely, G., Miklósi, Á., Erdőhegyi, Á., & Csibra, G. (2008). Infants’ perseverative
search errors are induced by pragmatic misinterpretation. Science, 321(5897), 1831–1834.
Toth, K., Munson, J., Meltzoff, A. N., & Dawson, G. (2006). Early predictors of communica-
tion development in young children with autism spectrum disorder: Joint attention, imi-
tation, and toy play. Journal of Autism and Developmental Disorders, 36(8), 993–1005.
Vernon, T. W., Holden, A. N., Barrett, A. C., Bradshaw, J., Ko, J. A., McGarry, E. S., . . . German,
T. C. (2019). A pilot randomized clinical trial of an enhanced pivotal response treatment
approach for young children with autism: The prism model. Journal of Autism and Develop-
mental Disorders, 1–16. https://doi.org/10.1007/s10803-019-03909-1
 Improving Social Skills and Play 307

Wainer, A. L., & Ingersoll, B. R. (2013). Disseminating ASD interventions: A pilot study of
a distance learning program for parents and professionals. Journal of Autism and Develop-
mental Disorders, 43(1), 11–24.
Wainer, A. L., & Ingersoll, B. R. (2015). Increasing access to an ASD imitation intervention
via a telehealth parent training program. Journal of Autism and Developmental Disorders,
45(12), 3877–3890.
Wainer, A. L., Pickard, K., & Ingersoll, B. R. (2017). Using web-based instruction, brief work-
shops, and remote consultation to teach community-based providers a parent-mediated
intervention. Journal of Child and Family Studies, 26(6), 1592–1602.
Walton, K. M., & Ingersoll, B. R. (2012). Evaluation of a sibling-mediated imitation interven-
tion for young children with autism. Journal of Positive Behavior Interventions, 14(4), 241–253.
Wang, S., Cui, Y., & Parrila, R. (2011). Examining the effectiveness of peer-mediated and
video-modeling social skills interventions for children with autism spectrum disorders:
A meta-analysis in single-case research using HLM. Research in Autism Spectrum Disor-
ders, 5(1), 562–569.
Westby, C. (2000). A scale for assessing development of children’s play. In K. Gitlin-Weiner,
A. Sandgrund, & C. Schaefer (Eds.), Play diagnosis and assessment (pp. 15–57). Hoboken, NJ:
John Wiley & Sons.
Whalen, C., & Schreibman, L. (2003). Joint attention training for children with autism using
behavior modification procedures. Journal of Child Psychology and Psychiatry, 44(3), 456–468.
White, P. J., O’Reilly, M., Streusand, W., Levine, A., Sigafoos, J., Lancioni, G., . . . Aguilar,
J. (2011). Best practices for teaching joint attention: A systematic review of the intervention
literature. Research in Autism Spectrum Disorders, 5(4), 1283–1295.
Williams White, S., Keonig, K., & Scahill, L. (2007). Social skills development in children
with autism spectrum disorders: A review of the intervention research. Journal of Autism
and Developmental Disorders, 37(10), 1858–1868.
Wolfberg, P. J., & Schuler, A. L. (1993). Integrated play groups: A model for promoting the
social and cognitive dimensions of play in children with autism. Journal of Autism and
Developmental Disorders, 23(3), 467–489.
Wolfberg, P. J., & Schuler, A. L. (2006). Promoting social reciprocity and symbolic represen-
tation in children with autism spectrum disorders: Designing quality peer play interven-
tions. In T. Charman, W. Stone, T. Charman, & W. Stone (Eds.), Social and communication
development in autism spectrum disorders: Early identification, diagnosis, and intervention
(pp. 180–218). New York, NY: Guilford Press.
Wong, C. S. (2013). A play and joint attention intervention for teachers of young children
with autism: A randomized controlled pilot study. Autism, 17(3), 340–357.
Wong, C., & Kasari, C. (2012). Play and joint attention of children with autism in the pre-
school special education classroom. Journal of Autism and Developmental Disorders, 42(10),
2152–2161.
Zercher, C., Hunt, P., Schuler, A., & Webster, J. (2001). Increasing joint attention, play and
language through peer supported play. Autism, 5(4), 374–398.
Zhang, J., & Wheeler, J. J. (2011). A meta-analysis of peer-mediated interventions for young
children with autism spectrum disorders. Education and Training in Autism and Develop-
mental Disabilities, 46(1), 62–77.
13
Supporting Behavior,
Self-Regulation, and Adaptive Skills
Mendy B. Minjarez, Yvonne Bruinsma, and Rosy Matos Bucio

C
ompared to their typically developing peers, individuals with autism
spectrum disorder (ASD) have increased rates of challenging behaviors,
including aggression, self-injury, noncompliance, and tantrums. Research-
ers generally agree that this occurs due to skill deficits (e.g., poor communication
skills), sensory sensitivities, rigid behavior patterns, and lack of supports available
in many settings where individuals with ASD work, learn, and play. Like their
typically developing peers, individuals with ASD must learn to self-regulate their
behavior and to engage in positive behaviors, such as staying on task and using
skills appropriate to the setting. This chapter focuses on strategies for support-
ing appropriate and adaptive behaviors and skills, including self-regulation. It
discusses both strategies for remediating skill deficits, with a focus on adaptive
behavior and self-regulation skills, as well as environmental supports that can be
used to reduce challenging behaviors and assist individuals with ASD in partici-
pating in a variety of activities.
Positive behavior is a broad term and may vary by context; by age; and dependent
on an individual’s family system, cultural values, life experiences, and background.
In this chapter, positive behaviors are defined as those that are developmentally
appropriate for the particular developmental stage the individual is in and that
support improvements in functioning and quality of life and movement toward
less restrictive settings. In contrast, challenging behaviors pose great risk to long-term
well-being and quality of life and are cited as one of the primary reasons individu-
als with ASD fail to successfully participate in many community settings (Carr,
2011). Challenging behavior also is one of the leading causes of stress for families
of individuals with ASD (Bristol, 1984; Koegel, Schreibman, et al., 1992; Lucyshyn,
Dunlap, & Albin, 2002) and often leads to living in restrictive environments, poten-
tially limiting quality of life. As such, a portion of the field of Applied Behavior
309
310 Applications of NDBI Strategies

Analysis (ABA) focuses on developing scientifically validated technological proce-

dures for reducing challenging behavior in individuals with ASD and intellectual
disabilities while also teaching functional, adaptive replacement skills.
Systematic and direct instruction may be necessary for individuals with ASD
to learn skills such as waiting, asking for a break when frustrated, politely taking
turns, preparing a healthy meal, or living on a budget. All these skills must be
practiced, shaped, and reinforced over time. Consistent with Naturalistic Develop-
mental Behavioral Intervention (NDBI) models, strategies for shaping such skills
must be practical, socially valid, and designed for implementation in the natural
environment. Tools such as functional behavioral assessments (FBAs) are criti-
cal in determining the functions of behavior, identifying functionally equivalent
replacement behaviors, and ultimately providing the information needed to con-
struct comprehensive positive behavior support (PBS) plans. When supporting
individuals with ASD struggling with challenging behavior, NDBI rely on the sci-
ence of ABA, including PBS (Carr et al., 2002; Horner, Dunlap, Koegel, & Carr, 1990).

NDBI AND CHALLENGING BEHAVIOR

Several NDBI discuss specific frameworks for addressing challenging behav-
ior (e.g., Early Start Denver Model [ESDM], Pivotal Response Treatment [PRT];
however, PRT relies on the principles of ABA and PBS [e.g., Project ImPACT (Im-
proving Parents as Communication Teachers)]). For example, ESDM uses a step-
wise approach to addressing challenging behavior that relies on principles of ABA
(Rogers & Dawson, 2010). These steps include the following:
1. Describe behavior and gather frequency data.
2. Collaborate with a behavior analyst to conduct an immediate functional assess-
ment if the behaviors are unsafe (e.g., aggression, self-injury).
3. Seek the input of the primary care physician to rule out biological causes if the
onset of behavior was sudden.
4. Continue to monitor behavior, including topography, function, and frequency
while implementing the ESDM treatment plan if the behavior is not unsafe and
it is unclear whether a behavior plan is needed.
5. When needed, develop a behavior plan based on functional assessment data,
implement it along with the regular ESDM treatment plan, take data on prog-
ress, and monitor closely for 8–12 weeks.
6. After 8–12 weeks, if the behavior plan has not been effective, consult with a
behavior analyst.
Project ImPACT notes that if the clinician has appropriate skills for assess-
ing and intervening with challenging behavior (i.e., background in ABA), parent
training can focus on reducing challenging behavior before moving into more
specific training in the Project ImPACT model. Clinicians who do not have this
skill set should work with colleagues with ABA expertise (Ingersoll & Dvortcsak,
2010). ESDM also notes that children with challenging behaviors tend to recruit
decreasing positive attention from adults over time, making it important to provide
noncontingent positive attention to these children during activities in which the
 Supporting Behavior, Self-Regulation, and Adaptive Skills 311

probability of problem behavior is low. This strategy is consistent with the general
notion, shared by many NDBI, that positive affect and interactions are an impor-
tant component of intervention.
In PRT, principles such as functional assessment, antecedent interventions,
self-management, and multicomponent treatment packages are used to reduce chal-
lenging behaviors (Koegel, Koegel, Boettcher, Harrower, & Openden, 2006; Koegel,
Koegel, Hurley & Frea, 1992), and self-management, transfer stimuli, and compet-
ing reinforcement are used to reduce interfering behaviors, such as stereotypy and
restricted interests (Koegel, Talebi, & Koegel, 2006). ESDM also uses teaching func-
tionally similar replacement behaviors to reduce stereotypy (e.g., teach appropriate
object play with objects the child uses repetitively) and use of children’s restricted
interests and repetitive behaviors as reinforcement for engaging in periods free of
such behavior (Rogers & Dawson, 2010). These strategies are consistent with the
broader ABA literature, which has demonstrated that use of stereotyped or repeti-
tive behavior as reinforcement enhances learning and does not lead to increases
in this behavior (Charlop, Kurtz, & Casey, 1990; Charlop-Christy & Haymes, 1998).
Some NDBI models, such as Joint Attention, Symbolic Play, Engagement, and Regu-
lation (JASPER), also rely on additional strategies for targeting self-regulation, such
as adult matching and modeling of appropriate affect. Strategies that are consistent
with most NDBI that can be used to target challenging behaviors are outlined next.

RELEVANT APPLIED BEHAVIOR ANALYSIS INTERVENTIONS

A number of general ABA principles apply when addressing challenging behav-
iors using an NDBI framework. Behavior should be addressed systematically using
principles of functional assessment with an emphasis on prevention (antecedent
interventions) and teaching functional replacement behaviors. Interventions
for challenging behavior should also incorporate principles that are emphasized
in PBS, including focusing on inclusion, providing environmental supports to
decrease challenging behavior, and teaching functional skills to enhance quality
of life. That is, sometimes it is as much about the setting’s lack of readiness to meet
the needs of an individual with ASD as it is about that individual needing to gain
skills to function in the setting.

Functional Approach to Challenging Behavior

Most NDBI embrace a functional approach to challenging behavior, which relies
on the notion that all behavior serves a communicative function. Identification of
function then leads to treatment planning, which includes strategies for teaching
functionally equivalent replacement behaviors. There are a number of approaches
for assessing behavior to determine function, including functional assessment
(Durand, 1990; Matson & Minshawi, 2007; Matson & Nebel-Schwalm, 2007) and
functional analysis (Hanley, Iwata, & McCord, 2003). Functional assessment, typi-
cally done through observation of behavior and data collection on the antecedent-
behavior-consequence (A-B-C) sequence or by interviews, such as the Functional
Analysis Interview Form (O’Neill, Horner, Albin, Storey, & Sprague, 1990), are more
commonly used in NDBI than is functional analysis. Functional assessment pro-
cedures rely on observation of behavior in the natural environment or interviews
about naturally occurring antecedents and contingencies; this approach is more
312 Applications of NDBI Strategies

consistent with NDBI principles than functional analysis procedures, which often
take place in clinic settings using highly structured procedures. More recently,
however, procedures have been developed for conducting functional analyses in
the natural environment (e.g., trial-based or classroom-based functional analysis)
(Bloom, Iwata, Fritz, Roscoe, & Carreau, 2011; Larkin, Hawkins, & Collins, 2016),
which may also be used in conjunction with NDBI procedures.
The functional approach is recommended because research supports that
intervention plans based on behavioral function are more effective than those that
are not. Important information that can be derived from the functional assessment
process may include 1) information about antecedents that lead to challenging
behavior or increase the probability of occurrence, 2) information about maintain-
ing consequences that may need to be altered, 3) information about skill deficits that
may lead to selecting replacement behaviors to be taught, and 4) information about
environmental variables that may affect the probability of behavior (e.g., setting,
time of day, presence of certain individuals who are preferred or nonpreferred).
Because most behavior typically serves either an “obtain” (e.g., to obtain attention
or tangible objects) or “avoid” (e.g., to avoid demands or aversive sensory input)
function, which are the opposite of one another, understanding function prior to
designing interventions is considered key in ABA.

Prevention of Challenging Behavior (Antecedent Interventions)

It has often been written that the most effective time to address challenging behav-
iors is when they are not occurring, meaning prevention is key (Bambara & Kern,
2005; Schwartz, Ashmin, McBride, Scott, & Sandall, 2017). Those who work with in-
dividuals with ASD (e.g., parents, teachers, therapists) can often prevent challeng-
ing behaviors by arranging the environment to support and teach behaviors that
increase participation, self-regulation, and successful demonstration of skills and
give individuals increased control (Schwartz et al., 2017). Antecedent interventions
can be blended with most NDBI interventions (because they are focused on strate-
gies for supporting individuals in the natural environment); are often essentially
prompts that can be faded over time; and often incorporate use of choice, sharing
control, and following the child’s lead. Antecedent interventions used for optimiz-
ing learning opportunities are also discussed in detail in Chapter 7.

Universal Antecedent Interventions Antecedent interventions can take many

forms, and some could be considered universal best practice for supporting all chil-
dren’s successful participation in their daily routines and age-appropriate settings
(e.g., educational, child care, community). Universal antecedent strategies perhaps
lend themselves the best to use in conjunction with NDBI because they can be im-
plemented routinely in the natural environment for all children and do not require
specialized supports for one individual. Schwartz and colleagues have published
extensively on this topic (e.g., Sandall et al., 2019; Schwartz et al., 2017). Although
these resources are geared toward the classroom setting, they can be easily adapted
to any natural environment; thus, the reader may find them useful for pairing with
NDBI strategies in addressing challenging behavior. Some examples of universal
antecedent strategies include 1) following a consistent daily routine, 2) setting clear
behavioral expectations and rules, 3) focusing on positive adult–child interactions
(e.g., as mentioned with regard to the ESDM approach to challenging behavior),
 Supporting Behavior, Self-Regulation, and Adaptive Skills 313

4) embedding strategies for consistent contingent reinforcement of appropriate

child behaviors (e.g., reinforcement systems as well as incidental reinforcement,
such as “catching them being good”), 5) designing the physical setting to support
positive behavior and discourage challenging behavior (e.g., avoid long pathways
that facilitate elopement or furniture clusters that promote children chasing each
other in circles), and 6) providing opportunities for children to make choices (e.g.,
designing the setting or the schedule so that the child can easily make choices about
materials to be used or the order in which to complete tasks).

Individualized Antecedent Interventions Even with universal antecedent

interventions in place, some children may experience behavioral challenges, in
which case individualized prevention strategies are helpful. These strategies can
take a number of different forms (see Box 13.1), such as the use of priming, visual
cues, environmental and physical strategies, and removal or avoidance of stimuli
that increase the probability of challenging behavior (e.g., an activity that leads to
repetitive behavior or an object that leads to challenging behavior when access is
denied). Many of these can be effectively incorporated with NDBI because they
focus on altering the natural environment to better support the child. Because
antecedent interventions need to be individualized for the child, the challenging
behaviors, and the setting, they can take many different forms and are often com-
bined to increase the probability that behavior is prevented. Antecedent interven-
tions are most useful when based on functional assessment and may include some
of the following examples.
Priming Used just prior to when a skill is required or when the probability of a
challenging behavior is increased, priming is defined as any strategy that is a pre-
view designed to prepare the child for the expectation or help the child understand
what is coming next. Priming can take many different forms. For example, it can
include reminders about appropriate skills to use (e.g., remember to find a friend to
play with at recess) or a verbal review of expectations (e.g., at school you are expected
to sit quietly). Priming can also incorporate visual cues, such as reviewing a visual

Ready, Set, Implement!

BOX 13.1: Antecedent interventions
Antecedent interventions are any strategy designed to prevent challenging
behavior, including the following:
• Visual cues
• Warnings for transitions
• Priming for expected behaviors
• Placement or removal of objects associated with behavior
• Placement of adults in proximity to child
• Pairing preferred with nonpreferred activities to increase compliance or
participation
314 Applications of NDBI Strategies

schedule or Social Story for appropriate behavior in the store prior to shopping.
Warnings, whether visual or verbal, are also common priming strategies (e.g., for
transitions, changes in routine, or removal of preferred objects). “Start” directions,
meaning directions that tell the child what to do, as opposed to what the child should
stop doing, can be a useful priming strategy to promote expected behaviors (e.g., a
teacher might say, “Remember your walking feet,” “Here is the ball,” “Let’s share
with our friends,” or “It’s time for lunch; let’s sit while we eat”).
Visual Cues Although there are many forms of priming, visual cues are com-
monly used and can take many forms. Visual schedules can be used to review
daily routines (e.g., the steps in the morning routine) and schedules (e.g., the pe-
riods in the school day), as well as more extended schedules (e.g., events across
the week). Common schedules may include the school day routine, the therapy
schedule, when the child will see certain people or family members, Mom’s house
or Dad’s house for two-household families, or a calendar countdown to a preferred
activity (e.g., trip to the amusement park, vacation). Another form of visual sched-
ule depicts the steps in completing a skill or single routine (e.g., getting dressed,
going to the bathroom, steps in an employment task). These schedules are often
developed in conjunction with task analysis procedures and are used to support
skill development and compliance.
Visual cues are also often used to prepare individuals for transitions, such as
a cue depicting one more minute, time to clean up, or what activity is coming next.
Although extensively detailing types of visual cues is outside the scope of this
chapter, there are several resources available about the many ways in which visual
cues can be developed and used (e.g., Hodgdon, 2016, 2017). When using visual
cues in the capacity described here, consider how they fit with the NDBI strategies
being used, how effectively they can be embedded across natural environments,
and whether they are being used in conjunction with other strategies (e.g., teaching
replacement behaviors) so that they can eventually be faded.
Environmental and Physical Strategies It is often useful to consider how
characteristics in the physical environment may be associated with increased risk
for challenging behavior. For example, are preferred objects in view during times
when they cannot be accessed? Are there clear cues for which activities are avail-
able versus not available (i.e., choice/not a choice)? Does the child need a visual in-
dication of where to sit or stand in line? Are objects available that lead to repetitive
behaviors? Is the space large and open so that it promotes running back and forth
and crashing against the walls in a self-injurious manner? Careful consideration of
how the physical environment may be contributing to challenging behavior may
be useful when developing individualized antecedent interventions. Visual cues
may also be combined with environmental and physical strategies, for example,
placing preferred objects into a bin that is clearly marked “all done” when they are
no longer a choice.
Although there may be endless environmental or physical antecedent inter-
ventions that are useful, common ones include the following:
1. Cues for where to sit or stand (e.g., a line on the floor at the door where children
should line up, dots on the floor for each child during circle time, a special
chair at the dinner table to indicate where to sit, a picture of the child in their
expected location)
 Supporting Behavior, Self-Regulation, and Adaptive Skills 315

2. Cues for whether objects are available or not (e.g., bins with clear visual cues
that depict whether objects are a “choice” or “not a choice,” “all done” bins or
locations, for example, placing the iPad or cell phone on a specific shelf at home
when it is not a choice)
3. Removal of objects that are all done, not a choice, or do not promote functional
behavior (e.g., objects that promote self-stimulatory behavior)
4. Use of furniture and organization systems that automatically restrict access to
preferred objects when they are not available (e.g., shelving that can close when
it is time to go to bed or come to the table in a classroom, use of bins with lids)
5. Partitions, furniture arrangements, or assignment of a child to a certain part
of the room or area of the house that works well for that child (e.g., arrange
shelving to create smaller spaces, limit open spaces for individuals with sig-
nificant hyperactivity, place the child’s bedroom away from the noisiest part of
the house)
6. Strategic placement of reinforcement to encourage desired or expected behav-
iors (e.g., a rule that snacks must stay at the table to promote eating at the table,
preferred items at circle time to promote remaining present)

Replacement Behaviors
Although antecedent interventions are designed to prevent challenging behavior,
the functional approach to behavior necessitates teaching functionally equivalent
replacement behaviors that allow the individual with ASD to have his or her needs
met in more adaptive ways. Understanding the communicative function of the
behavior allows clinicians to select replacement behaviors that serve the same
function. Although teaching skills that serve other functions may be useful to the
individual, these new skills are unlikely to assist with a reduction in challenging
behavior unless they serve the same function.
Replacement behaviors can be selected from a range of skills that serve the
same function as the challenging behavior. Because social-communication chal-
lenges are a core feature in ASD, replacement behaviors will often fall into this
category. Skills for requesting objects, gaining attention, initiating and sustaining
social interactions, appropriate refusing and protesting, requesting breaks, and
gaining access to help are common social-communication replacement behaviors.
Chapters 11 and 12 discuss teaching communication and social skills. Additional
replacement behaviors, such as self-regulation behaviors and adaptive skills, are
addressed next.

Selecting Efficient Replacement Behaviors There are several key factors to

consider when selecting replacement behaviors, such as response match, efficiency,
acceptability, and recognizability (Durand, 2012; see Box 13.2). First, as stated,
when considering response match, the new skill must serve the same function as
the challenging behavior (e.g., teaching appropriate skills for gaining attention or
social initiation if challenging behavior is to gain attention from peers; teaching
requesting objects, tolerating delayed access to reinforcement, and tolerating re-
moval of preferred objects if behavior is for access to preferred items). The new skill
must also be as or more efficient as the challenging behavior. That is, the new skill
316 Applications of NDBI Strategies

Ready, Set, Implement!

BOX 13.2: Replacement behaviors
Replacement behaviors must
• Serve the same function as the challenging behavior (response match)
• Work as well or better than the disruptive behavior in gaining access to
reinforcement (efficiency)
• Be recognizable to a range of individuals across settings
• Be acceptable and functional for the context or setting
• Be generalizable across appropriate individuals, settings, and so forth
• Be socially valid for the individual, context, family, setting, and so forth

must result in natural reinforcement and should be associated with low response
effort. Because new behaviors are often not associated with low response effort
by definition, the child may need to initially be taught the behavior explicitly and
reinforced systematically to build mastery. Such behaviors should be taught out-
side the context in which challenging behavior occurs. Once mastery is achieved,
generalization of these behaviors can be systematically reinforced, until, finally,
the child can be prompted to use the behavior in the actual context in which the
challenging behavior previously occurred.
Consider the simple example of a child who does not have a communication
skill to request objects and instead uses whining and crying to get something
out of reach. Pointing to objects could first be taught during one-on-one interac-
tions with a therapist in which preferred objects are used to enhance motivation
to request and physical prompts are used to evoke pointing behavior. At the same
time, parents, teachers, and therapists can use prompts to help the child point to
the desired item as soon as the child notices he or she wants it (before the crying)
and reward that behavior quickly. Once this skill is mastered, more opportunities
can be provided throughout naturally occurring routines (e.g., meals, play in the
home setting), and prompts can be reduced in all settings. Again, at first the point
needs to be rewarded in all environments as quickly as possible; otherwise, the
child will go back to crying because it works quicker. Once the pointing is clearly
established, the child can learn to wait, be told “not right now,” and so forth.

Selecting Functional, Generalizable, Socially Valid Replacement Behaviors

The new skill or replacement behavior should also be functional across settings
and easy to recognize. All settings in which the child must function should be
considered when selecting replacement behaviors. A behavior that is functional in
one setting but not another may hinder generalization of reductions in challenging
behavior. For example, teaching a child to use a communication device that is only
available in the therapy setting but not the home setting has limited utility. Re-
placement behaviors should also be socially valid from the perspective of the child
and relevant stakeholders, meaning it should be functional but also acceptable. For
example, if a parent is focused on the child learning a communication skill that
 Supporting Behavior, Self-Regulation, and Adaptive Skills 317

does not require keeping track of any materials or augmentative and alternative
communication (AAC) devices, it may be more useful to teach pointing, reaching,
or gesturing than use of picture cards or a device. Finally, replacement behaviors
must be as universally recognizable as possible so they are functional no matter
who the communication partner is. Teaching skills that are not easy for others to
recognize may limit their effectiveness and may limit opportunities for movement
toward less restricted environments and inclusion. For example, teaching a child
to use a picture communication system may be more effective than teaching signs
to communicate because pictures are universally recognizable, whereas signs may
not be. If the new skill is too hard, does not result in reinforcement, is difficult to
generalize across settings, or is not recognizable to everyone who interacts with
the child, it is not likely to take the place of the challenging behavior because the
behavior will still be more effective.

Using Task Analysis Procedures Some replacement behaviors, particularly

adaptive skills, are actually complex chains of behaviors that may need to be bro-
ken down for teaching. The field of ABA has developed helpful tools, such as task
analysis, for teaching these complex behaviors. A task analysis helps break down
complex behaviors or skills into smaller, more manageable steps. The process of
the task analysis also provides an opportunity for identifying where chaining and
shaping can be used during skill building. The information gathered from the task
analysis can then be used to systematically teach each new adaptive skill step by
step. When using task analysis, modeling the skill is often the first step before
providing the individual with ASD with the opportunity to practice. With each
step, assistance (prompting) should be provided when necessary and then faded,
instead of allowing the individual to struggle or make mistakes.

Consequence Strategies
Examination of maintaining consequences is an essential part of any functional
assessment procedure. Functional assessment results may indicate that it is nec-
essary to alter consequences to attain reductions in challenging behavior. How-
ever, consequence strategies alone are not likely to lead to long-lasting behavior
changes and should be used in conjunction with a comprehensive positive support
behavior plan, including antecedent strategies and plans for teaching replacement
behaviors. Consequence interventions in NDBI are outlined in Chapter 9 and are
briefly discussed here in relation to challenging behaviors. Consequences should
be examined to determine whether challenging behaviors are being inadvertently
reinforced, in which case this contingency will need to be altered. Furthermore,
appropriate replacement behaviors may not be present or consistently reinforced,
especially if the child’s skill deficits result in productions of appropriate behavior
that are impaired or approximations. If these challenges are present, consequences
will need to be altered so that challenging behavior is not reinforced and appropri-
ate replacement behaviors are. Several ABA principles apply here.

Reinforcement of Replacement Behaviors As discussed previously, re-

placement behaviors will not be effective unless they are reinforced. Ensuring
they are functional, generalizable, and socially valid will increase the likelihood
of reinforcement for these behaviors across settings. The NDBI principle of natural
318 Applications of NDBI Strategies

reinforcement almost always applies when teaching replacement behaviors be-

cause these behaviors are selected to be functional and result in reinforcement in
the natural environment. Many NDBI also incorporate reinforcement of reason-
able behavioral attempts, which is especially relevant when teaching replacement
behaviors. Because children may have difficulty producing appropriate behaviors
when upset or frustrated, accepting and reinforcing any approximation of the
replacement behavior can be a useful strategy for building motivation and skills
over time.

Extinction Extinction is defined as the removal of previously available rein-

forcement, resulting in a decrease in probability of the occurrence of the behavior.
Extinction is often used when reinforcement was inadvertently being applied to
negative behaviors. For example, consider the case of a child who always screams
when his or her mother is cooking dinner. The behavior is reinforced when the
mother leaves the kitchen to provide the child with attention, snacks, and activities
to try and keep him or her busy while she finishes cooking. When this behavior
is placed on extinction, the child’s mother will no longer leave the kitchen and
will ignore the child while he or she continues screaming. Those who have used
this intervention before will be familiar with the concept of the extinction burst,
the classic initial and temporary sharp increase in behavior under these circum-
stances before learning occurs and the behavior decreases (discussed further in
Chapter 8). Because some behaviors are difficult to place on extinction (e.g., those
that are unsafe) and this intervention may not be suitable in all settings (e.g., public
places, such as the grocery store), extinction is frequently used in conjunction with
antecedent interventions to prevent the behavior as well as replacement behaviors
that can be proactively prompted in an additional effort to prevent the behavior.

Self-Management
Individuals with ASD may demonstrate skills in a certain set of circumstances but
not in another or may struggle to use skills across communicative partners. For
instance, a child may struggle with social initiations in the classroom but not on
the playground at recess; another child may carry a conversation with adults but
struggle to converse with peers. Furthermore, individuals may struggle with skill
initiation or fluency, leading to skills that are acquired but not well generalized.
Self-management, defined as monitoring one’s own target behavior production,
data collection, and recruitment of reinforcement, is a valuable, evidence-based
tool that can be useful in addressing these performance issues. Teaching an indi-
vidual to take charge of his or her own behavior may also lead to empowerment,
thus decreasing dependence on adults (Lee, Simpson, & Shogren, 2007).
Research supports the use of self-management to increase or decrease a range
of skills for students of all ages and most skill levels (National Autism Center,
2015). A comprehensive overview and in-depth discussion of this literature is not
provided here but is available in three literature reviews (Aljadeff-Abergel et al.,
2015; Lee, Simpson, & Shogren, 2007; Southall & Gast, 2011) and in the National
Standards Project, Phase 2 report (National Autism Center, 2015). For children who
are accustomed to adult-implemented token reward systems, self-management is
often an easy adjustment, with the main difference being teaching the child to
independently monitor his or her own behavior. For children who are still learning
 Supporting Behavior, Self-Regulation, and Adaptive Skills 319

Ready, Set, Implement!

BOX 13.3: Self-management steps
• Identify the behavior
• Develop a measurement strategy
• Select reinforcement
• Implement discrimination training
• Practice the target behavior
• Learn to record the target behavior and recruit reinforcement
• Make the transition from training to self-managing behaviors
• Generalize self-management

to count or learning how to wait for reinforcement, it is often helpful to start with a
simple target behavior (e.g., a behavior the child can already perform). The measure-
ment system can also be simplified to help the child learn how self-management
works. For example, the child might earn reinforcement after just two or three suc-
cessful instances of a simple behavior. Often stickers or small tokens (e.g., balls,
marbles, pennies) can be more motivating and concrete for young children just
learning self-management. Bingo stampers or dot art markers can be a good substi-
tute for children with minimal writing skills or children who are averse to writing
instruments.
There are a number of steps in teaching self-management that are briefly
reviewed in the sections that follow (see Box 13.3). Correct implementation of
self-management procedures is relatively easy if the planning stages have been
completed carefully.

Identify the Behavior The first step in teaching self-management is to identify

what behavior will be targeted for decrease or increase and then describe it in as
much detail as possible. The level of detail is important for data collection but even
more important to ensure the person with ASD can learn exactly what behavior is
being targeted during discrimination training. It is best to target a positive behav-
ior rather than describe the challenging behavior to be decreased (e.g., “safe hands”
versus “no hitting”). During initial discrimination training, the adult must explain
the target behavior to the child with ASD; it is helpful if the name is child friendly
and short (e.g., “taking turns with friends,” “staying on topic,” “being flexible”). No
matter what behavior is selected, the adult should collect baseline data to establish
the current level of performance. The adult can then set goals just slightly above
the baseline level to ensure initial success.

Develop a Measurement Strategy Once the behavior has been identified, the
adult must develop a plan for measuring it. This plan should address if measure-
ment will be based on the presence or the absence of the target skills (e.g., intervals
without hitting, intervals with peer interaction). Counting positive behavior is often
more effective. Both frequency and duration data can be appropriate, depending
320 Applications of NDBI Strategies

on the behavior being measured. For example, is it a frequency count of how many
times the child initiated to a peer during recess or an interval recording where the
student is marking on-task behavior every 5 minutes?
A variety of options are available for behaviors counted as a frequency. The
student can simply make a mark on paper with a pencil, a dot art marker, or a
marker. Or the student can cross out a picture showing a thumbs-up or a star.
However, because frequency counting needs to take place in the natural environ-
ment (e.g., in social settings), a number of other unobtrusive solutions may be a bet-
ter match, including commercially available counters, bracelets and rubber bands
that are moved from one wrist to the other, or electronic solutions on tablets and
phones. Target behaviors counted in duration can be measured by clocks or timers
(e.g., wristwatch, phone, tablet, kitchen). Special gadgets are also available that can
be set for a certain interval and carried in a pocket to alert the student that an inter-
val has passed (e.g., MotivAider). For some children, it can be helpful if the mea-
surement system includes visual reminders of the target behavior. For example, the
system might include a picture card to represent “brain working” or “safe hands.”

Select Reinforcement Once the behavior is defined and the measurement

method is selected, the adult should designate what the child will earn for engag-
ing in the identified target behaviors. Although NDBI place high value on the use
of natural reinforcement, self-management systems usually require artificial rein-
forcers in the beginning of the program. Nevertheless, from the beginning, a plan
should be in place to transfer reinforcement from artificial to natural as the child
gains skills. For example, when increasing social initiations on the playground,
having more friends to play with during recess may eventually serve as reinforce-
ment. As with any reinforcer, it must be defined by the individual; however, it is
also important to assess feasibility (e.g., it is not feasible to give large reinforcers
when first teaching self-management because many trials will be required). Every
time reinforcement is delivered, it should be paired with behavior-specific praise
(e.g., “Great job being flexible!”).

Implement Discrimination Training Once the preparation is completed, dis-

crimination training can begin. In this phase, the main objective is to teach the
individual what the target behavior is and what it is not. The quality of the descrip-
tions completed in the behavior definition phase will help to determine how eas-
ily the child will understand the nuances of the target behavior. When beginning
discrimination training and introducing the target behavior, it may be appropriate
to briefly explain the importance of the behavior (e.g., being flexible is important
because sometimes other people like to be the ones who get to make decisions).
The next step in discrimination training is to model the correct target behavior,
which is most often done in person but can also be done through video modeling.
Modeling should begin with explicit and obvious models to increase the likelihood
of correct responding and can then fade to more subtle models. The child with ASD
will then be asked to identify the behavior in the model before learning to identify
it in him- or herself. If the child provides the correct response, the adult should
immediately provide reinforcement with behavior-specific social praise. If the
child incorrectly identifies the behavior, the adult should explain why this is incor-
rect and try again, but the adult should make sure to reinforce with social praise
for trying. If the child has multiple errors in a row, the discrimination training
 Supporting Behavior, Self-Regulation, and Adaptive Skills 321

may need to be terminated and evaluated. Once the child has responded correctly
across several trials, then it is time to introduce the incorrect target behavior using
the same discrimination training strategies. Identification of correct and incorrect
responses should be practiced until the child is at least 80% accurate or has met
other specified mastery criteria.

Practice the Target Behavior Once the child reliably identifies the correct
and incorrect target behavior in others, it is important for him or her to practice
giving correct and incorrect responses. If the child does not want to engage in
incorrect responding (e.g., being off task if the target behavior is staying on task) or
if this is not appropriate (e.g., in the case of aggression), the adult can just wait until
the incorrect response occurs naturally and then ask the child to self-evaluate.
After each occurrence of behavior, the child should be prompted to evaluate his
or her performance. All correct identifications of the child’s own behavior should
be reinforced. When practicing the target behavior, the goal should be set at an
attainable level because the child is learning a new skill. For example, if teach-
ing staying on task, the child should be expected to stay on task for a short pe-
riod (e.g., 30–60 seconds) initially in order to earn immediate reinforcement. The
child should also receive reinforcement for all attempts at the target behavior at
this stage because he or she is just learning a new skill. The goal at this stage is not
to increase the rates of behavior but rather to teach the system, which will sustain
long-term performance change.

Learn to Record the Target Behavior Once the child can correctly identify
the target behavior for at least 80% of all trials, measurement can be introduced as
the next step. The child must be taught to use the measurement system. Many chil-
dren find it exciting to take data for themselves; they may enjoy having a special
pencil or a bingo stamper in their favorite color. At first, the child can receive rein-
forcement for providing the correct response and recording the response correctly.
The first few times, the child may need prompting to record the correct response.
It is helpful to fade these prompts very quickly to ensure that the individual be-
comes independent in his or her measurement. Once the child can independently
identify and record correctly at least 80% of trials, he or she is generally ready to
begin self-management.
While the child is learning to discriminate and accurately record behavior,
reinforcement should be frequent because the child is learning a new skill. Fading
of reinforcement should not begin until after self-management has actually begun
and the child is consistently providing correct responses and correctly measur-
ing the target behavior without prompting. Although the adult is likely still
controlling access to reinforcement during this phase, the child must be actively
evaluating whether he or she has met the goal in order to learn self-recruitment of
reinforcement.

Make the Transition From Training to Self-Managing Behaviors Once the

child has learned to discriminate and accurately record behaviors, he or she can
begin to self-manage. First, the child will practice self-management with moni-
toring from an adult to allow prompting as needed. Prompting initially may be
required both for correct production and discrimination of the behavior as well
as for correct recording. Once the child is at or above 80% accuracy, prompting
322 Applications of NDBI Strategies

can be faded. The goal is to fade prompting to the point that an adult can check in
with the child at certain points during a specified time period to review the self-
monitoring.
If the child will earn reinforcement multiple times per session or day, it may
be necessary to teach him or her to notify an adult when reinforcement has been
earned, rather than waiting for a designated check-in time. Children can also be
taught to access reinforcement independently. The amount of control transitioned
will depend greatly on the child’s cognitive abilities, the child’s self-control, and
the setting in which the behavior is ultimately going to be self-managed. When
increasing independence with self-management, it is important to note that the
child’s accuracy of discrimination and recording does not have to be perfect. When
children are above 80% accuracy, their behavioral change is typically comparable
to those with higher accuracy. As such, those who are teaching self-management
to individuals with ASD can be comfortable reinforcing attempts as long as they
meet this threshold.

Generalize Self-Management Many behaviors taught with self-management

will ultimately have to be generalized to other settings or social partners. Other
providers and staff should be made aware of the treatment plan so that they can
provide initial encouragement to use the skill. Also, the tracking system should
be feasible and socially valid across settings. Once the child is able to use the self-
management system on his or her own, adult support can be faded. It is often still
helpful to have the adult check in periodically to make sure the self-management
system is being used appropriately. For instance, an adult can occasionally rate
the child’s behavior and compare to the child’s ratings to check for accuracy. The
child can even earn extra points for accurate ratings. However, as noted previously,
100% accuracy in recording is not necessary for the child to demonstrate general
improvement in the target skill. If the child is able to do the skill without self-
management, it may be time to take the self-management system away. Often chil-
dren forget to use the system but continue to show the target skill, which is a sign
that the intervention has worked and the self-management system can be faded.

NDBI STRATEGIES FOR TEACHING

SELF-REGULATION AND ADAPTIVE SKILLS
Many behaviors may be appropriate to teach as replacement behaviors when in-
tervening on challenging behaviors. Clinicians should consider many of the social
and communication strategies discussed elsewhere in this book when developing
behavior plans that include replacement behaviors. Although the range of possible
replacement behaviors is broad, two other common areas to address include self-
regulation and adaptive skills. This section addresses NDBI strategies for teaching
these skills, and subsequent sections discuss examples of skills that may be useful
to teach in each domain.

Provide Clear Cues and Prompts

As with any behavior, clear cues and prompts are used when teaching self-
regulation and adaptive skills. Because many of these skills can be abstract (e.g.,
having good hygiene, being flexible), it can be helpful to give them concrete names
 Supporting Behavior, Self-Regulation, and Adaptive Skills 323

to ensure that cues for the behavior are clear. For example, being flexible could
be called “doing things differently” or “staying cool when things change,” and
hygiene behaviors could be called “having a clean body.”
Because many of the behaviors discussed in this chapter are either complex
behaviors or chains of behavior, adults should carefully consider the use of prompts
in teaching. It is likely to take time and patience to teach many of these behaviors,
and adult prompts may be necessary for quite some time to ensure success. As a
result, adults should systematically address the need for prompt fading to ensure
these adult prompts do not become habit and to increase independence over time.

Provide Modeling
Modeling is often helpful when teaching self-regulation and adaptive skills and can
take many forms. As discussed previously, modeling is a key step in discrimination
training when teaching self-management. In this type of modeling intervention,
the skills are modeled purposely and often out of context to teach an individual to
identify correct and incorrect behavior. Similar modeling can be used when teach-
ing self-regulation skills, such as waiting calmly or staying on task. Modeling can
also be incidental, such as modeling self-talk during unexpected events for a child
with flexibility goals (e.g., “I wasn’t expecting the stickers to be gone, but I can
make another choice”). Video modeling is also commonly used to teach adaptive
and other skills (Bellini & Akullian, 2007; Charlop-Christy, Le, & Freeman, 2000;
Keen, Brannagan, & Cuskelly, 2007; Shipley-Benamou, Lutzker, & Taubman, 2002).

Incorporate Child-Selected Materials and Choices

When possible, it can be useful to incorporate child-preferred materials when
teaching self-regulation and adaptive skills. When teaching adaptive skills, adults
may find it difficult to incorporate natural reinforcement for some behaviors (e.g.,
toilet training, brushing teeth), but with a little creativity, they can build in child-
selected materials and choices. One way to accomplish this is to incorporate a child’s
interests even if those interests cannot serve as the natural reinforcer. For example,
the child might select a toothbrush that looks or feels a certain way or shampoo
that smells a certain way. For toilet training, the child might select stickers with his
or her favorite character on them. The adult may place pictures of the child’s favor-
ite characters, books, toys, or shows in the area where the skill will be taught (e.g.,
on the bathroom door, on the dresser when targeting dressing). Another way to
build in child preference is to teach adaptive skills within routines where desired
activities naturally follow the skill being targeted. For example, teeth-brushing
could be followed by reading the child’s favorite bedtime book, or getting dressed
can be followed by going outside to play. The proximity of these events within the
child’s routine can lead to a broader form of natural reinforcement.
When teaching self-regulation, adults may find it easier to incorporate the
child’s preferred activities in a way that is consistent with NDBI practices. For
example, when teaching flexibility, adults can create opportunities to practice
the associated skills during a preferred activity (e.g., interrupting or blocking the
child’s play) and then provide access to the activity as reinforcement. Many target
behaviors in the area of flexibility are outlined next, with examples of how to teach
each within child-selected activities.
324 Applications of NDBI Strategies

Use Natural Reinforcement

Following from the previous discussion of child-selected materials and choices,
reinforcement for self-regulation and adaptive skills should be natural and directly
connected to the behavior when possible. Some adaptive skills are easier than oth-
ers to accomplish this. For example, it is easy to build natural reinforcement into
teaching money skills because the individual with ASD can purchase a desired
item or activity (even if it’s through role-playing at home). Finding the natural
reinforcement for making a bed might be trickier because a tidy room may not be
a strong natural reinforcer. In these cases, the strategies discussed for incorporat-
ing child-selected materials or embedding the skill in routines in which preferred
activities follow may be useful. For example, adults could use visual cues for bed
making on an iPad, followed by access to the iPad for a specified period of time.
If natural reinforcement is difficult for a specific adaptive skill, self-management
(discussed previously) may also be useful. Although natural reinforcement is ideal,
reinforcement in some form is essential!

Reinforce Attempts
Many self-regulation and adaptive skills are complex skills or combinations of
skills; therefore, significant time and practice may be required to gain mastery and
build fluency of these skills. As such, use of reinforcing attempts and shaping may
be useful because reinforcing successive approximations of skills is an excellent
strategy for both facilitating skill building and enhancing motivation. This strat-
egy may be particularly important in terms of motivation because the individual
with ASD is likely to become frustrated if required to practice a difficult skill for
long periods of time without reinforcement. Consider the child who is just learn-
ing how to wait. Waiting nicely may need to be shaped over time so that the child
initially receives reinforcement for waiting for a brief period, even if he or she is not
quiet or is displaying negative affect without engaging in more severe challenging
behavior (e.g., aggression). If the expectations are set to high from the beginning,
the child may never have a chance to begin learning the contingency.

Provide Prompt Fading

As with most skills, prompt fading is essential in teaching self-regulation and
adaptive skills because these skills are most useful when used flexibly and inde-
pendently in the natural environment. Self-regulation skills can be challenging to
teach because they are often required under frustrating circumstances, and adap-
tive skills can be challenging because they often require sequences of multiple
behaviors (e.g., getting dressed, using the bathroom, taking the bus). Given these
challenges, prompt fading many need to be carefully planned to ensure skills are
maintained and generalize. In addition to typical prompt-fading strategies, self-
management strategies may be helpful in building independence. Furthermore, it
may be useful to consider prompts that are not delivered by another person, such
as visual cues (e.g., task analysis for making lunch), lists (e.g., a permanent grocery
shopping list that is kept on the individual’s phone), and calendars. Some of these
prompts may not even need to be faded because they are consistent with strate-
gies that are used by many individuals to organize their lives (e.g., calendars, lists,
planners).
 Supporting Behavior, Self-Regulation, and Adaptive Skills 325

Technology can be another helpful tool in prompt fading. For example, cal-
endars can be set up with daily and weekly reminders or alarms for specific
adaptive skills. These strategies can be particularly useful with adolescents and
adults who may be resistant to adult prompts. It is also important to consider that
adult prompts may set individuals apart from others their age and create stigma,
although use of an electronic device is a completely acceptable behavior. There are
countless apps for chores, homework organizers, reminders, cooking, and budget-
ing. Given the popularity of videos, older children, teens, or adults can work with
family members and staff to create video models of specific adaptive skills that
can be saved onto their smartphones or tablets and used for priming or referenc-
ing at any point. Although technology is definitely a motivator and advantageous
teaching tool, monitoring its use is also important.

Consider Adult Affect

Several NDBI have increased focus on the role of adult affect in intervention.
For example, ESDM and JASPER focus on both matching the child’s affect, when
appropriate, and modeling appropriate affect when trying to help the child reg-
ulate. As such, the role of adult affect should be considered when addressing
challenging behaviors and teaching skills such as self-regulation and adaptive
functioning. Several affective strategies may be useful, including matching, mod-
eling, and use of positive affect to enhance motivation and engagement. Matching
affect is most appropriate when the child is demonstrating appropriate affect that
the adult wishes to reinforce or sustain. For example, if a child is calmly practicing
independent work, verbal praise in a low but positive tone of voice would be more
appropriate than using a high-affect energetic voice. Likewise, if a child is attempt-
ing to calm down during a tantrum, using a lower and slower voice to provide
verbal prompts or direction would be more appropriate than an excited voice or a
stern voice.
Modeling affect is appropriate when the adult is trying to promote changes in
the child’s affect. For example, if a child is becoming frustrated with having to be
flexible and is beginning to escalate, it would be most appropriate to model calm
affect even when acknowledging the child’s frustration. Finally, the adult may wish
to use a high level of positive affect in order to increase motivation and engagement.
For example, if a child is low energy and is becoming bored, which might be an
antecedent for challenging behavior, the adult may want to use a high level of posi-
tive affect to energize and engage the child. Or in a really high-energy game, if a
child becomes overly excited, which may be an antecedent for aggression, the adult
may want to slow down and become calmer. Use of varied affect to enhance inter-
actions is a general strategy that is incorporated into most NDBI.

Embed Practice in Daily Routines

As discussed, self-regulation and adaptive behaviors can be complicated to teach
and may require direct instruction. When possible, embedding this instruction
into daily routines and the natural environment is ideal, although these may need
to be taught outside of daily routines before being generalized. When behaviors are
taught within daily routines, it is important to remember that they may be time con-
suming to execute until they can be emitted fluently. For example, when targeting
326 Applications of NDBI Strategies

self-advocacy behaviors (e.g., saying “that’s mine”), adult coaching may be required
for the child to engage in the skill, which may be frustrating because the coaching
will cause this interaction to take longer, delaying reinforcement. Likewise, when
targeting adaptive skills, behaviors may be emitted quite slowly, especially when
they are actually chains of behavior. For example, making a sandwich or count-
ing money will take much longer when these skills are not fluid. As a result, it is
important to consider what preteaching might be necessary before moving into
the natural environment and/or to proactively plan when skills will be targeted to
ensure there is time to do so. Teaching breakfast making may be better targeted on
a weekend than a busy weekday morning.

PROMOTING SELF-REGULATION IN INDIVIDUALS WITH ASD

In the simplest of terms, self-regulation refers to the ability to direct and manage
behavioral as well as emotional responses to the environment (Bronson, 2000). Self-
regulation is a skill set that includes a number of different subskills, such as being
able to calm down when something upsetting has happened; being flexible; and
tolerating disappointment, frustration, and delayed reinforcement (Arain et al.,
2013). Children and individuals who struggle with self-regulation are more likely
to demonstrate challenging behaviors, such as aggression (Raaijmakers et al.,
2008), and tend to experience more anxiety and depression (Martel et al., 2007).
Self-regulation is necessary in all contexts, including school, and researchers have
found that students who have more advanced self-regulation skills develop bet-
ter academically (McClelland & Wanless, 2012). Children at all ages and abilities,
including children with ASD, may benefit from instruction in this developmental
domain (Bronson, 2000).
Although difficulties with self-regulation are not reflected in the diagnostic
criteria for ASD, they are frequently major areas of challenge for this population
and often cause significant family stress as well (Hepburn & Wolff, 2013; Ostfeld-
Etzion, Feldman, Hirschler-Guttenberg, Laor, & Golan, 2016). As such, providing
systematic teaching and opportunities to practice self-regulation with support is
often part of treatment for individuals with ASD. With intervention, individuals
can learn a range of self-regulation skills that will greatly affect their quality of life.
The acquisition and use of behavior regulation skills requires instruction, practice,
and reinforcement (Bronson, 2000), just like any other skill set. Self-management
(discussed previously) is an especially useful intervention when teaching self-
regulation skills because of its emphasis on self-evaluation and self-reinforcement
(Todd, Reid, & Butler-Kisber, 2010).
Skills related to self-regulation are especially relevant in the reduction of chal-
lenging behaviors because self-regulation helps prevent challenging behavior, and
many skills related to this domain can be taught as replacement behaviors. Several
examples of self-regulation behaviors commonly taught in NDBI are discussed next.

Selecting Self-Regulation Targets

Often self-regulation behaviors are relevant when developing behavior interven-
tion plans because they can become part of antecedent interventions and can be
taught as replacement behaviors (e.g., teaching flexibility and then priming for
flexibility and related coping skills in relevant contexts). These skills should be
 Supporting Behavior, Self-Regulation, and Adaptive Skills 327

selected using the general guidelines discussed for selecting appropriate replace-
ment behaviors (e.g., functional, generalizable, socially valid). Skills such as tol-
erating delayed reinforcement and removal of objects and flexibility may have
a significant impact in the reduction of challenging behaviors. Like most skills
taught using NDBI, these skills can be taught by either creating opportunities in
the natural environment or capitalizing on those that naturally occur. The teach-
ing strategies reviewed throughout this book, such as using prompts and prompt
fading, teaching within child-selected activities, sharing control, using balanced
turns, using natural reinforcement, and reinforcing attempts, can all be used to
teach self-regulation skills.

Teaching Self-Regulation Skills Using NDBI

It can be tempting to avoid situations that are difficult for individuals with ASD.
Doing so prevents triggers to challenging behavior and reduces stress for everyone
involved. Although this antecedent strategy can be effective, it may only provide a
short-term reprieve because the underlying challenges with self-regulation persist.
Providing a safe and supportive framework in which individuals can be coached
through their self-regulation challenges is likely to result in more durable long-term
improvements in self-regulation skills and decreases in challenging behavior. If a
child typically yells and cries during mealtimes at family get-togethers, instead of
avoiding these events all together, caregivers can learn to scaffold by teaching the
child to calmly ask to be “all done” when relatives start to sit down. As this improves,
the caregiver could have the child sit with a timer on his or her chair for a few sec-
onds before asking to be done. The caregiver can then slowly and systematically in-
crease what the child practices, using motivation to avoid as a natural consequence
for having the child politely leave the area instead of melting down. Two examples
(targeting flexibility and teaching waiting) are outlined in detail next, with addi-
tional self-regulation behaviors and examples outlined in Table 13.1.

Targeting Flexibility Behavioral flexibility consists of a number of skills, in-

cluding the ability to adjust to and tolerate changes in routines, activities, and ex-
pectations; a willingness to compromise; the ability to remain calm when things
do not go one’s way; and the capability to solve problems in new ways. Individuals
with ASD have a tendency to adhere to routines and seek sameness in activities
(American Psychiatric Association, 2000), which can interfere with daily function-
ing. Deviation from familiar routines or a disruption in activities can easily lead to
challenging behaviors, stress, or anxiety.
Research on flexibility has addressed a range of areas, for example, play (Baker,
2000), conversation (Koegel, Park, & Koegel, 2014), and food choices (Dominick,
Davis, Lainhart, Tager-Flusberg, & Folstein, 2007; Koegel et al., 2012). NDBI strat-
egies commonly used to address this challenge include arranging the environ-
ment, reinforcing attempts, natural reinforcement whenever possible, and practice
in everyday routines and activities. Several strategies are commonly used when
teaching self-regulation skills, such as flexibility and waiting. These are outlined
next and are also integrated into the behavior-specific examples in Table 13.1.
1. Operationally define and label flexibility for the child or individual with ASD
(e.g., “trying new foods,” “staying calm when changes happen”).
328 Applications of NDBI Strategies

Table 13.1. Example self-regulation behaviors categorized by function

Example target
Behavior Description behaviors Teaching example

Function: Access to tangibles

Tolerating Child remains calm Remain calm. Create learning opportunities

removal of when preferred Use coping skills, by removing objects, moving
preferred objects are such as self-talk from least to most preferred.
objects removed from (e.g., “I can have Begin with short intervals (e.g.,
possession. it later”). 1–3 seconds), and reinforce
Accept alternatives. with access to the object
contingent on tolerating delay.
Increase length of delay over
time until the child can tolerate
total removal.
Accepting Child remains calm Remain calm. Create learning opportunities by
denied access when access to Use coping skills, denying access to objects and
to preferred preferred objects such as self-talk. then following the procedures
activities or is denied. Accept alternatives. listed previously.
objects

Function: Escape or avoidance

Requesting a Child uses Verbally ask for a Create learning opportunities

break communication break. by instructing the child to
strategy (e.g., Use a visual cue to engage in adult-directed
verbal, visual, request a break. activities and then prompting
gestural) to behavior to request a break.
indicate a break Provide natural reinforcement
is needed. in the form of a break. Begin
with short intervals of adult-
directed activities, and extend
the time the child can sustain
before requesting a break over
time.
Protesting Child uses Verbally say “no” Create opportunities by offering
communication or “I don’t want nonpreferred objects and
strategy (e.g., to.” prompting the child for the
verbal, visual, Push away objects. target protest skill. Reinforce
gestural) to Shake head “no.” by removing the objects
indicate he or Gesture, such as contingent on use of the
she does not hold up hand appropriate protest behavior.
want something with palm facing
or does not out to indicate
want to do “no.”
something.
Requesting help Child uses Verbally say “help” Create opportunities by putting
communication or “help me.” the child in situations in which
strategy (e.g., Give objects to help is required (e.g., place
verbal, visual, others for help. objects in containers with
gestural) to Point to an object tight lids, present snacks in
indicate help is to indicate help. unopened packages). Prompt
needed. the child for the target skill,
and reinforce by providing
help.
 Supporting Behavior, Self-Regulation, and Adaptive Skills 329

Table 13.1. (continued)

Example target
Behavior Description behaviors Teaching example

Self-advocacy Child uses Verbally advocate, Create opportunities by

communication such as saying, interrupting the child, gently
strategy (e.g., “Move please,” removing objects, or blocking
verbal, visual, “That’s mine,” or the child’s play. Prompt the
gestural) to “I don’t like that.” target skill, and then reinforce
advocate for Gesture to self to by removing the interruption.
needs or wants. indicate “that’s
mine.”
Persisting with Child persists with Try for a specified Create opportunities, as done
difficult tasks task for specified period of time in requesting help trials (see
period of time before or after previous example), and then
without giving asking for help prompt the child for the target
up or asking for (before actually behavior (e.g., persisting,
help. receiving help). trying another way). Gradually
Try other strategies increase the amount of
before asking for persistence required before
help. providing reinforcement.
Reinforce by providing help or
a break.

Function: Tangible, escape or avoid, or attention due to rigidity (flexibility training)

Accepting Child accepts Remain calm. Create opportunities by

interruptions interruptions Accept interrupting activities, moving
and and unexpected interruptions, from least-to-most preferred
unexpected changes without and move on. activities. Begin with brief
changes challenging May protest, but interruptions, and gradually
(often behaviors and do not engage increase. Reinforce by
tangible moves on. in challenging providing access to the activity
function) behavior. contingent on tolerating the
interruption.
Tolerating Child accepts Remain calm. Create opportunities by creating
when things unexpected Accept the unexpected outcomes (e.g.,
do not go outcome (e.g., outcome, and set up a game where winning
as expected losing a game, move on. or losing can be controlled by
(often something May protest the adult), moving from least
tangible breaking) verbally, but to most difficult. Reinforce by
or escape without do not engage either providing the outcome
or avoid challenging in challenging the child expected or desired or
function) behaviors and behavior. giving access to other preferred
moves on. Use self-talk (e.g., activities if the child moves on.
“It’s no big deal.
I can try again”)
or other coping
strategies.
(continued)
330 Applications of NDBI Strategies

Table 13.1. (continued)

Example target
Behavior Description behaviors Teaching example

Tolerating Child accepts Make the transition Create opportunities by placing

transitions transition without demands for transitions. Begin
(often without displaying with transitions that are set
tangible and/ challenging challenging up just for practice and are
or escape behavior and behavior. not actually part of the daily
or avoid moves on. Accept the routine. Use the following
function) outcome, and hierarchy as a guideline:
move on. • Nonpreferred to high-
May protest preferred activity
verbally. • Low preferred to high
Use self-talk (e.g., preferred
“I can always • Preferred to preferred
finish that later”) (matched)
or other coping • Low preferred to
strategies. maintenance nonpreferred
• Low preferred to acquisition
nonpreferred
• High preferred to
maintenance nonpreferred
• High preferred to acquisition
nonpreferred
Initially require only brief periods
with the new activity, and
gradually expand the time
frame. Reinforce by allowing
the child access to the high-
preferred activity after making
the transition and staying
with the new activity for the
specified time period.
Tolerating Child accepts Remain calm. Create opportunities by having
others others’ actions Attend to the adults insert themselves into
entering play or involvement actions or ideas the child’s play, beginning with
or activities in play and/or of others. less-preferred activities and
with the child responds to the Respond to the brief insertions and gradually
or wanting ideas or actions actions or ideas increasing to preferred
to direct the of others in play of others. activities and longer insertions.
play (often (rather than Remain calm if Prompt the child using first,
tangible or directing it). others do not then language (e.g., first the
attention follow one’s dinosaur will eat and then you
function) directions. can make him play). Reinforce
by allowing the child to direct
the play following compliance
with demand.

2. Break down the targeted “flexibility” behavior into hierarchical, teachable steps.
The easiest steps should be targeted first, and subsequent steps can work up the
hierarchy. For example, when targeting making transitions, begin with making
transitions away from less-preferred activities before working up to those that
are highly preferred. Likewise, when targeting waiting or tolerating removal of
items, begin with brief time intervals and expand to longer intervals.
3. Systematically increase the degree of flexibility before the child or student
earns his or her reinforcement. For example, initially the child may only
need to demonstrate flexibility with turn taking once before earning his or
 Supporting Behavior, Self-Regulation, and Adaptive Skills 331

her reinforcement. As the child is successful, the requirement for contingent

reinforcement can be increased to two, then three, then four, and so forth.
4. Practice flexibility goals by creating opportunities where skills are required.
These opportunities are often contrived at first to allow the child to practice
outside of the actual situation and ensure they can be targeted systematically
and with enough repetition to lead to learning. Prompt behaviors explicitly,
and use errorless instruction when possible to promote initial success.
5. Reinforce attempts across people, settings, and activities to enhance motivation.
6. Try to use natural reinforcement when possible, even if this means going back
to the child’s preferred activity or way of doing things. For example, a child can
be reinforced by being able to direct the play after allowing someone else to
direct it for a brief period.
7. Determine if a self-management program would be beneficial, especially when
fading adult prompts. For example, it may be useful to train a child to monitor
whether he or she was flexible in play and accepted and responded to the ideas
and actions of other people in order to earn reinforcement at the end of a brief
(e.g., 5-minute) play session.
8. Begin by teaching these skills during adult–child interactions before targeting
them during peer interactions.
9. Be sure it is necessary to teach flexibility for the specific area of concern and
that the new skills are functional.
Once the target skill has been explicitly taught, it can be practiced incidentally,
for example, by changing game rules or routines on a regular basis. For example,
during dinner, parents might change where everyone sits once or twice a week.
Bath time could be switched from after dinner to before dinner. Varying or modi-
fying rules and routines on a regular basis helps children and adolescents learn
that small changes are part of everyday life and are manageable.

Teaching Waiting One of the most practical and easiest self-regulation skills
parents, clinicians, and teachers can teach children with ASD is waiting (i.e., toler-
ating delayed reinforcement). Opportunities to teach waiting can be incorporated
into natural activities and routines just as any behavior being taught using NDBI.
As with any skill, waiting can be effectively taught in situations in which the child
wants access to an object or activity and the adult has shared control over avail-
able reinforcement. When the child indicates a desire for access to reinforcement,
a cue to wait can be given (e.g., “wait,” “1 minute,” a gesture such as raising the
index finger), a brief waiting period can be required (e.g., a few seconds for a child
who is just learning this skill), and natural reinforcement can then be provided in
the form of access to the object or activity. The duration of waiting time can then
be gradually and systematically increased until the child can wait for a functional
time period such as 1–2 minutes. Several additional simple strategies may be useful
when teaching waiting. These are outlined in Table 13.2

Considering Commonly Taught Self-Regulation Behaviors The behaviors

listed in Table 13.1 can be taught using similar strategies and may be useful in
332 Applications of NDBI Strategies

Table 13.2. Strategies to support teaching waiting

Strategy Description

Use auditory cues (e.g., counting)
Use visual cues
Use natural opportunities, even
when waiting is not required
Counting is a very practical way of signifying the
passage of time. Use a calm, neutral voice, and count
out a predetermined set of numbers so the child has
a way to understand progress toward the goal.
Visual cues can also be helpful, for example, counting
on fingers or the use of visual timers once the time
intervals become longer.
Children make many requests throughout the day.
Purposely practice waiting some of the time before
providing natural reinforcement to increase the
frequency of opportunities to practice this skill.

improving self-regulation and decreasing challenging behaviors. Children often

need to learn multiple behaviors in this category at one time. Furthermore, many
of these behaviors can go together, and it may be important to consider how one be-
havior may be a requirement for or support another. For example, it may be helpful
to teach waiting prior to teaching removal of objects so that the child has already
learned that objects will be returned after waiting.

TEACHING ADAPTIVE SKILLS

Adaptive skills include a broad range of behaviors related to daily, functional, and
self-care activities, such as hygiene, dressing, cooking, money management, timeli-
ness, and leisure. These types of daily living skills are essential to independent liv-
ing and quality of life. Adaptive skills for individuals with ASD have been a topic
of great interest for decades. In fact, some of the earliest intervention studies for
individuals with ASD focused on teaching adaptive skills (Wolf, Risley, Johnston,
Harris, & Allen, 1967; Wolf, Risley, & Mess, 1964). More recent studies have found
that even individuals with ASD who have average cognitive abilities frequently
demonstrate low levels of adaptive functioning, making the transition into adult-
hood challenging (McGovern & Sigman, 2005).
As with other developmental areas, NDBI emphasize teaching adaptive skills
in the natural environment. Furthermore, essential to adaptive functioning is gen-
eralization of skills across settings, people, and activities. Because generalization
is automatically embedded into NDBI instruction, NDBI may be particularly well
suited for supporting adaptive skill development. Teaching adaptive skills can also
be important in the reduction of challenging behaviors, particularly when chal-
lenging behavior emerges in response to difficult daily routines in which skill defi-
cits may be present (e.g., dressing, bathing).

Selecting Adaptive Skill Targets

Like self-regulation behaviors, adaptive skills are important when developing be-
havior intervention plans because they can be addressed using antecedent inter-
ventions (e.g., visual schedules for compliance daily routines) and can be taught
as replacement behaviors (e.g., teaching skills, such as dressing and bathing, that
are required in daily routines but may be associated with challenging behaviors).
These skills should be selected using the general guidelines discussed previously
 Supporting Behavior, Self-Regulation, and Adaptive Skills 333

for selecting appropriate replacement behaviors (e.g., functional, generalizable,

socially valid). Skills such as dressing, brushing teeth, bathing, self-feeding, and
keeping track of belongings may have a significant impact on the reduction of chal-
lenging behaviors. Like most skills taught using NDBI, these skills can be taught
by creating opportunities in the natural environment. The teaching strategies re-
viewed throughout this book, such as use of prompts and prompt fading, teaching
within child-selected activities, sharing control and using balanced turns, and use
of natural reinforcement and reinforcing attempts, can all be effectively used to
teach adaptive skills.
Many skills fall into the adaptive category, and systematic assessment may be
useful. A range of assessment tools may be useful in assessing adaptive skills, such
as standardized measures (e.g., Vineland Adaptive Behavior Scales, Third Edition;
Sparrow, Cicchetti, & Saulnier, 2016) and developmental checklists (e.g., the DATA
Model Skills Checklist; Schwartz et al., 2017). Once adaptive skill deficits have
been identified, it may also be useful to conduct a task analysis to further evalu-
ate exactly which parts of a behavior need to be explicitly taught. For example, a
child who cannot drink from an open cup may have difficulty picking up the cup
but may actually drink from it just fine, or vice versa. Careful assessment of adap-
tive skills is recommended before developing goals in this domain. Table 13.3 lists
examples of adaptive skills across skill domains and developmental levels. Because
this table is by no means exhaustive, it should not be used in place of a thorough
assessment.

Teaching Adaptive Skills Using NDBI

Once adaptive functioning targets have been selected, they can be taught using
many NDBI strategies. One example (teaching dressing) is outlined in detail next,
with additional adaptive skills and examples outlined in Table 13.4.
Adaptive skills vary greatly in the number of steps that may be involved
and the complexity of the behavior. A skill such as spearing food with a fork and
putting it in one’s mouth is much simpler than a skill composed of a number of
steps (e.g., dressing) or a skill that requires cognitive ability, background knowl-
edge and experience, or judgment about safety (e.g., cooking items based on the
appropriate amount of time required). A number of behavior analytic strategies
are useful when targeting adaptive skills goals (e.g., chaining, backward chaining,
shaping), yet these skills can nonetheless be taught in the natural environment
using NDBI strategies. For example, adaptive skills are easily taught in the natural
environment and can be taught in preferred contexts using natural reinforcement.
Modeling, prompting, and prompt fading are also commonly used.
For example, getting dressed is a complex behavior. First, the developmental
level of the child must be considered because the expectations for independence
in a 3-year-old may differ from the expectations in a high school student. Once the
target behaviors have been identified, it may be useful to use procedures such as task
analysis to break them down and develop strategies for teaching such as forward or
backward chaining. A prompt hierarchy and prompt fading strategy are also likely
to be useful. Appropriate context for teaching and natural reinforcement should
then be considered; for example, will the skills be taught during the actual daily
routines or during a time of day designated for practice until a specified level of mas-
tery is attained? Once context is determined, natural reinforcement can be identified;
334 Applications of NDBI Strategies

Table 13.3. Example adaptive behaviors across the life span

Behavior Example target behaviors

Mealtime or feeding

Drinking from an open cup
Using a spoon or fork
Sitting at the table
Clearing dishes
Making simple food
Making food that requires
multiple steps
Making a meal
Takes a sip from a cup held by an adult.
Picks up the cup and puts it to his or her lips.
Picks up cup and takes one sip.
Takes food from a fork or spoon held by an adult.
Scoops the food with spoon.
Spears the food with a fork.
Scoops or spears independently and moves food into mouth.
Sits in a high chair or booster for a specified time period.
Sits in a chair for specified time period (beginning with short
intervals and systematically increasing).
Puts a dish in a “dirty dishes” bin at the table.
Takes the dish to the counter.
Clears food from the dish into the trash.
Makes toast.
Pours cereal and adds milk.
Puts cheese and crackers on a plate.
Makes a sandwich.
Uses the microwave.
Makes instant oatmeal.
Heats soup.
Makes eggs, toast, and coffee.
Makes pasta and salad.
Makes a sandwich and fruit.

Hygiene or self-care

Toilet training Successfully voids in the toilet on a schedule (habit trained).

Initiates using the toilet by telling an adult.
Initiates using the toilet by going independently.
Washing hands Turns on water and adjusts temperature.
Turns off water.
Gets soap.
Rinses hands.
Dries hands.
Throws away paper towels.
Brushing teeth Allows an adult to brush.
Holds brush and puts it in his or her mouth.
Brushes teeth for an appropriate time period.
Brushes all parts of teeth consistently.
Puts own toothpaste on brush.
Bathing Tolerates being bathed by adult.
Helps wash self.
Helps dry self.
Washes own body.
Washes own hair.
Dries self.
Dressing Puts on shirt, pants, underwear, socks, or shoes.
Takes off items.
Ties shoes.
Managing menstrual cycle Identifies when period is starting.
Changes own pad based on schedule.
Changes own pad based on judgment of needing to change.
 Supporting Behavior, Self-Regulation, and Adaptive Skills 335

Table 13.3. (continued)

Behavior Example target behaviors

School behaviors

Keeping track of materials Keeps appropriate materials in backpack.

Keeps appropriate materials where they belong in his or her
desk.
Takes lunch box to lunch and returns it to the appropriate
place.
Places jacket in the appropriate place and takes it at the end
of the day.
Using classroom materials Knows how to use scissors, pencils, pencil sharpeners,
markers, glue, and erasers.
Walking with peers in line Walks immediately behind the teacher.
Walks in any place in line.
Keeps hands to self.
Attends to the teacher’s verbal instructions.
Completing independent work Works for short period of time.
Works for period of time using a self-management system.
Works independently on preferred, and later a nonpreferred,
activity.
Requests help.
Requests a break.

Executive functioning behaviors

Staying on task for a specified Stays on task for a short period of time.
time period Stays on task for a period of time using a self-management
system.
Following multiple steps in an Follows two short related steps (e.g., get your pencil, and
activity start your work).
Follows two short unrelated steps (e.g., finish your work, and
choose a book to read).
Follows increasing number of steps with longer duration.
Finishing an activity, cleaning Completes an activity and puts one item away.
up, and moving on Completes an activity and cleans up.
Completes an activity, cleans up, and chooses a preferred
activity.
Persisting with difficult tasks Persists for a specified period of time with difficult activities
before requesting help.
Tries multiple strategies before asking for help.
Asks a peer, rather than an adult, for help when appropriate.

Community behaviors

Counting money Identifies coins by name.

Counting change
Reading bus schedules
Identifies coins by value.
Recognizes dollars by value.
Adds dollar amounts from varied bills.
Adds change amounts from varied coins.
Adds dollars and cents.
Counts change in dollars.
Counts change in cents in round numbers.
Counts change in cents in any increment.
Counts change in dollars and cents.
Reads the schedule of arrivals and departures, where the
correct route is already identified.
Finds the correct route on a schedule.
Searches the Internet for the correct bus schedule web site.
Searches the bus schedule web site for the correct route.
336 Applications of NDBI Strategies

Table 13.4. Example adaptive behaviors and teaching examples

Description or Example target

Behavior example overall goal behaviors Teaching example

Mealtime or feeding

Sitting at the Child can sit at Sit at the table for a Create learning opportunities
table the table for short time. by prompting the child to
an appropriate Sit for an increasing sit for very short periods of
amount of time length of time. time, followed by access to
based on the meal Say, “All done.” preferred activities that are
(e.g., shorter for natural to the setting. Begin
snack, longer for this goal by requiring sitting
meals). with preferred foods only, and
later move to nonpreferred
foods. Systematically increase
the amount of time. Once the
child can sit for a short period,
teach “all done” and reinforce
it no matter how long the
child has been sitting.
Combine with the waiting
goal to increase the amount
of time the child is required
to sit before “all done” is
reinforced.
Making a snack Individual can Make toast. Create learning opportunities by
prepare three Pour cereal and add having the individual select
simple snacks for milk. preferred snacks to learn
self that do not Put presliced to make. Incorporate visual
require cooking. cheese and cues, chaining, and other
crackers on a Applied Behavior Analysis
plate. (ABA) teaching methods as
needed. Teach in the natural
context with appropriate
prompt levels, and fade
prompts over time. Provide
natural reinforcement in the
form of eating the snack once
prepared.

Hygiene and self-care

Bathing Individual can Tolerate being Develop a clear and consistent

participate bathed by adult. routine using visual
in bathing at Help wash self. cues, adult prompts, and
developmentally Help dry self. prompt fading as needed.
appropriate Wash own body. Teach specific skills using
level (up to Wash own hair. ABA methods if needed.
independent Dry self. Incorporate choice and
bathing if Adjust the water following the individual’s
appropriate). temperature. lead by allowing children
to choose bath toys and
adolescents or adults to
choose bath products if
interested. Provide natural
reinforcement by providing
bath toys contingent on
compliance with washing or
by following a bath routine
with a preferred activity (e.g.,
preferred snack or meal, toy
or game, or story depending
on the time of day).
 Supporting Behavior, Self-Regulation, and Adaptive Skills 337

Table 13.4. (continued)

Description or Example target

Behavior example overall goal behaviors Teaching example

School behaviors

Walking with Individual can walk Walk immediately Create opportunities to practice
peers in line in line in front of behind teacher. this behavior, beginning
or behind peers Walk in any place with very short walks and
from one place to in line. then increasing duration.
another. Keep hands to self.Use ABA strategies, such
Attend to as prompting and prompt
teacher’s verbal fading, to target the skill.
instructions. Begin by walking to preferred
locations and following
appropriate walking with
natural reinforcement in the
form of preferred activities.
Then, make the transition
to walking to nonpreferred
locations, followed by
preferred locations as natural
reinforcement.
Independent Individual can work Work for a short Create opportunities to
work without adult period of time. practice this behavior,
support for a Work for a period beginning with very short
specified period of of time using a periods of independent
time. self-management work on maintenance
system. tasks, followed by access to
Work independently preferred activities as natural
on a preferred, reinforcement. Increase to
and later a longer periods of work on
nonpreferred, acquisition tasks or multiple
activity. tasks in a row. Incorporate
Request help. choice when possible (e.g.,
Request a break. order of tasks, materials
to be used). Once the child
can work for a period of
time, begin incorporating
requests for help or a break,
followed by the natural
reinforcement of receiving the
corresponding outcome.

Executive functioning behaviors

Persisting with Individual persists Persist for a Create opportunities to practice

difficult tasks with a difficult specified period this behavior in the natural
task for a specified of time with environment by presenting
period of time difficult activities difficult tasks or those that
and then uses before requesting may require help. Incorporate
appropriate help. child choice and following
problem-solving Try multiple the child’s lead by targeting
strategies if the strategies before this skill during preferred
task cannot be asking for help. activities (e.g., place marbles
completed. Ask a peer, rather for a marble ramp in a tightly
than adult, sealed container). Reinforce
for help when the child for persistence by
appropriate. providing access to materials.
Eventually incorporate other
skills, such as asking for help
or trying two strategies before
asking for help.
(continued)
338 Applications of NDBI Strategies

Table 13.4. (continued)

Description or Example target

Behavior example overall goal behaviors Teaching example

Community behaviors

Counting Individual can count Identifies coins by Create opportunities to practice

money bills and coins name. this skill in the natural
when required to Identifies coins by environment by going to
do so to make a value. stores that sell small preferred
purchase. Recognizes dollars items and are conducive to
by value. practicing (e.g., small store,
Adds dollar amount not crowded). Incorporate
from varied bills. choice by allowing the
Adds change individual to select the store
amount from and item to purchase. Begin
varied coins. with easy amounts of money
Adds dollars and to count, and gradually
cents. increase the difficulty. Provide
access to the item as natural
reinforcement.
Reading bus Individual can Read the schedule Create opportunities to practice
schedules correctly use the of arrivals and this skill in the natural
bus schedule departures in environment by planning bus
to get from which the correct outings to preferred locations.
one location to route is already Incorporate choice by having
another at a level identified. the individual select where
appropriate for Find the correct to go. Plan the trip using the
his or her current route on a targeted skills (e.g., reading
independence schedule. the bus schedule). Practice
(e.g., some Search the Internet additional skills during the
individuals for the correct ride (e.g., paying the driver).
may need more bus schedule web Provide natural reinforcement
supervision than site. in the form of access to the
others in this Search the bus preferred location upon
process for safety schedule web site arrival. Incorporate multiple
reasons). for the correct opportunities to practice by
route. going to several destinations
before going home if
appropriate.

for example, is there a preferred activity that might naturally follow the routine (e.g.,
choosing favorite breakfast food after completing morning dressing routine)?
Consider the case of Abdul, a 5-year-old boy who could not dress himself.
He had tantrums most mornings when his mother laid out his clothing, gave
him instructions to get dressed, and left the room to make breakfast. His mother
reported significant tantrums each morning but did not connect these challenges
to his lack of dressing skills until Abdul’s therapist completed a functional assess-
ment interview. She identified the dressing routine and then completed a task anal-
ysis. She determined that, for his developmental level, Abdul should be able to put
on underwear, sweat pants (no buttons or zippers), and shirts without buttons as
long as the clothing was laid out for him to avoid putting it on backward.
Because Abdul was highly motivated to choose his breakfast foods and have
his favorite Lightning McQueen plate and cup, the therapist made a first-then
visual to cue him that he would be reinforced with these choices upon completion
of getting dressed. She also gave him the opportunity to select his clothing, thus
 Supporting Behavior, Self-Regulation, and Adaptive Skills 339

building in choice and shared control. She then taught his mother how to use
backward chaining, starting with providing full assistance with all aspects of the
routine except the final step of pulling up his sweatpants. Once Abdul was inde-
pendent with this step and understood the routine of being reinforced following
its completion, the therapist developed a visual schedule that included the multiple
steps in the routine. This was then used in place of adult prompts as they were
faded within the process of backward chaining until Abdul could independently
complete all steps in the routine in order to earn reinforcement.
When teaching adaptive skills within daily routines, it may be useful to think
of natural reinforcement as being “natural” because it involves reinforcement that
would naturally occur next within the daily routine (e.g., receiving dessert after
dinner, playing a game after homework) rather than in the more concrete sense
as discussed elsewhere throughout this book. This definition of natural reinforce-
ment may also include use of the Premack Principle (discussed in Chapter 8),
which states that the opportunity to engage in a high-probability behavior con-
tingent on the occurrence of a low-frequency behavior will function as reinforce-
ment for the low-frequency behavior (Cooper, Heron, & Heward, 2013). Although
Abdul’s example relies heavily on the use of ABA intervention strategies, the use
of shared control, natural reinforcement, and emphasis on teaching in the natural
environment are consistent with most NDBI. For additional examples of adaptive
behaviors being taught using NDBI, please see Table 13.4.

TIPS FOR TEACHING SELF-REGULATION AND ADAPTIVE SKILLS

Like social-communication skills, self-regulation and adaptive skills are com-
plex sets of behavior with many intertwined components. The complex nature
of these skill sets and the many components that must be taught may challenge
even the best clinicians, especially when disruptive behaviors are also present.
Following are a few tips that may increase success when teaching self-regulation
and adaptive skills.

Be Patient and Provide Time

Teaching self-regulation and adaptive skills can be challenging when children
are used to having their maladaptive behaviors reinforced or having others do
these tasks for them. Remind yourself that these behaviors take time and practice
to develop. Some may require more explicit teaching and practice before they are
fully generalized than others. Do not introduce opportunities to practice a self-
regulation or adaptive skill if you are going to be rushed. For example, if you are
working on shoe tying, do not ask the child to practice in the morning when there
is less time and more urgency to leave. Rather, wait and provide an opportunity
before going outside to play in the afternoon or on the weekend.

Maintain the Focus on Motivational Strategies

As mentioned previously, the skills discussed in this chapter can be challenging
to learn and may take time. As a result, these skills may also be frustrating for the
individual with ASD to practice. Furthermore, because the rationale for learning
many of these skills relates to social norms that may not motivate the individual
with ASD (e.g., others are more likely to interact with someone who is clean), a
340 Applications of NDBI Strategies

focus on incorporating motivational strategies into teaching these skills is critical.

Strategies such as choice, following the child’s lead, prompting, reinforcing at-
tempts, and natural reinforcement are particularly important to incorporate into
teaching strategies. Prompts and prompt fading may also be important because
many target behaviors discussed in this chapter are actually complex sets of be-
havior or steps in a sequence. Making sure the appropriate amount of adult sup-
port is available to create success (errorless instruction) and then fading over time
is one important strategy for enhancing motivation. Reinforcing attempts is also an
important strategy to consider when teaching complex chains of behavior because
the individual may perform some steps more easily than others but will become
frustrated and unmotivated if reinforcement cannot be earned until all steps are
performed with the same level of fluency.

Consider the Natural Environment

As discussed throughout this chapter, many self-regulation and adaptive skills are
difficult, complex, and include multiple behaviors rather than just one. As a re-
sult, these behaviors are more likely to require careful consideration of prerequisite
skills, as well as appropriateness for teaching in the natural environment versus
teaching skills out of context first before generalizing to the natural setting. For
example, if an individual has never seen money or the bus schedule before, it is
probably not appropriate to introduce these skills in the natural environment. Or if
a child cannot wait for even 3 seconds, he or she is not likely to be successful wait-
ing in line at the grocery store before purchasing a preferred item. Instruction for
self-regulation and adaptive skills should be carefully and systematically planned.
When possible, teaching in the natural environment with a high level of
prompting is desirable to avoid having to generalize skills later; however, when
there are barriers to the success of this approach, skills should first be taught out of
context and then generalized. Even when teaching out of context, however, NDBI
strategies can be used. For example, when teaching waiting, the child can be taught
to wait briefly before being given access to preferred items. Or when teaching
money skills, the individual can be taught within the context of role-plays in which
they purchase preferred items from the therapist.

Incorporate Parent Coaching

Teaching adaptive skills and self-regulation may present challenges for parents or
caregivers who are less likely to be present when teaching other skills. Self-regulation
skills are likely to need targeting during times of frustration or in contexts in which
challenging behaviors are or were previously present. Likewise, adaptive skills are
likely to be or have been sources of challenge and frustration for parents because
they often lead to challenging behaviors that interrupt routines and lead to other is-
sues, such as being late. As such, teaching these behaviors is likely to be associated
with frustration or negative emotions for parents and caregivers.
When targeting these skills, it may be useful to assess the impact of this nega-
tive history on the present teaching interactions and troubleshoot with parents. For
example, incorporating strategies for two parents in a family to support each other
(e.g., one backing up the other during challenging behavior), teaching self-regulation
strategies to parents, and teaching parents how to use noncontingent reinforcement
 Supporting Behavior, Self-Regulation, and Adaptive Skills 341

to enhance positive parent–child interactions may all be helpful. In some cases,

parents may also benefit from additional parent training or mental health treat-
ment to assist them in learning skills for managing their own self-regulation when
trying to teach these skills to their children. With plenty of research to support that
children with ASD can learn from modeling, it is important to be sure parents are
modeling desirable behaviors.

Case Example: Jonas

Jonas is a 12-year-old boy with a diagnosis of ASD and attention-deficit/hyperactivity
disorder (ADHD). He has average cognitive and language ability and primarily is in
general education classes at school, with supports through an individualized education
program (IEP). Given his many age-appropriate skills, Jonas has the potential to do
well in many areas (e.g., academic achievement); however, he is currently struggling a
great deal. Jonas has significant impulsivity and challenges with self-regulation. These
difficulties result in daily behavioral and emotional outbursts that include behaviors
such as yelling, screaming, cursing, banging his fists, kicking furniture and people, and
elopement. Outbursts are more frequent at school and last longer, although they hap-
pen in home and community settings as well. Frequency of outbursts is two to three
times per day. Duration ranges broadly, from a few minutes to a half hour. Jonas was
previously in ongoing ABA therapy but eventually stopped because his parents felt he
was doing better in terms of social-communication skills, which had been his primary
treatment targets. After a particularly long and intense outburst at school that lasted
about 45 minutes and necessitated clearing the other children from the classroom,
Jonas’s teacher called a team meeting to discuss next steps in how to support Jonas.
The team, including the parents, discussed the current concerns and agreed to
start with a functional assessment of behavior at school. Jonas’s parents also decided
to contact his previous ABA provider to see if the provider could assist with a func-
tional assessment in the home and community settings, which the provider agreed to
do. Once the functional assessment was completed, the team reconvened to discuss
next steps. Results were very similar across settings. Both parents and service
providers noticed that Jonas was struggling with a significant increase in rigid adher-
ence to routines (e.g., wanting to finish things before moving on), was more easily
frustrated by transitions (e.g., when he was not finished yet, when moving away from
preferred activities), was avoidant of demands being placed on him (e.g., activities
of daily living, homework, school work), and was struggling to stay organized and on
task with the increased expectations of sixth grade. Given these challenges, the pri-
mary functions of his behavior were task avoidance, tangible (e.g., when required to
make the transition from preferred activities), and attention, although the latter was
primarily a secondary function that emerged when Jonas was upset in the context of
another function (e.g., task avoidance).
Given these challenges, the team began to develop a behavior plan for Jonas
across settings. First, they introduced a number of antecedent interventions. At
school, they first considered universal antecedent interventions because Jonas was
in a general education classroom. For example, the teacher agreed that all sixth-
grade students could benefit from some improvements in their organization skills and
342 Applications of NDBI Strategies

implemented a homework tracking system that was tied to the existing classroom
behavior goals system. If all students turned in their homework and checked their
completion off on the tracking sheet, the class received a point toward its overall
behavioral goals. The teacher also began priming all students during periods where
Jonas was at risk for behavioral challenges, for example, reminding all students to
raise their hands if they needed help.
Individualized antecedent interventions were also implemented, such as priming
Jonas for transitions at home and at school. Priming was developed for both transition
scenarios that were challenging for Jonas, including warnings that a preferred activity
was about to end and warnings that he might not have time to finish something but
could make a plan for finishing it later. As Jonas gained skills for remaining calm when
frustrated, his parents, teachers, and therapists also implemented a priming plan for
reminding him to use his coping strategies during times of risk for behavioral outburst.
Although Jonas had many strong skills (e.g., verbal and cognitive ability), the
team agreed that there were several skills he should be taught as replacement
behaviors. Because Jonas often became upset when demands were placed on
him, the team taught him asking for help and asking for a break. These were initially
taught using naturalistic opportunities during his ABA therapy sessions (e.g., working
on homework during ABA, reinforcing requests for a break with 2 minutes of free
time) and were eventually generalized to the school setting. When these skills were
generalized to school, the teacher also used priming to remind Jonas he could request
short breaks and help from teachers or peers to decrease risk of behaviors.
The team also taught Jonas coping skills for managing frustration. He learned
skills such as coping statements (e.g., “It’s okay. I can finish my work later”), count-
ing exercises, and deep breathing, first during ABA therapy and eventually at school
or during parent–child interactions at home and in the community. These skills
were taught using modeling, prompting, and natural reinforcement (e.g., access to
preferred activities if he could tolerate finishing his work later), which were eventually
faded. In conjunction with learning these coping skills, Jonas’s ABA team began
working on practicing waiting, making transitions from preferred activities, and having
preferred activities removed from him. These skills were initially targeted by setting
up many transitions during therapy sessions and providing Jonas with natural rein-
forcement (e.g., regaining access to his preferred activities) contingent on his ability
to remain calm and tolerate the targeted skill (i.e., waiting, coming away, removal of
preferred activities). The skills eventually were targeted across settings and reinforce-
ment was faded so that Jonas could tolerate longer delays and denied access before
receiving access to reinforcement again. Because Jonas was being taught coping
skills in conjunction, he was also encouraged to use these skills to remain calm while
practicing these targeted behaviors.
Once Jonas learned to tolerate delayed access to reinforcement and transitions,
he used self-management to maintain his use of the coping skills he had learned.
Jonas learned to track instances where his frustration was triggered and when he
used his coping skills. He kept track using a simple application on his phone, so his
friends were not aware that he had an individualized behavior plan. He would then
show the data to his mother after school to confirm whether his goals had been met
and reinforcement had been earned.
 Supporting Behavior, Self-Regulation, and Adaptive Skills 343

Several consequence interventions were also put in place by the team. The team
was in agreement that Jonas’s avoidance behavior was often inadvertently reinforced,
especially if his behavior was so escalated that the classroom had to be cleared.
With the use of antecedent interventions and teaching replacement behaviors, the
frequency of high-intensity outbursts decreased at school, but the team also agreed
to bring in adult support during outbursts, rather than clearing the room, which would
allow teachers to follow through with demands. At home, his parents and therapists
agreed to wait him out and then follow through, as long as access to reinforcement
was removed in the meantime. This strategy was feasible because Jonas was not
severely aggressive or destructive during outbursts. Upon further discussion, the
team also realized that most of the adults who interacted with Jonas during his
tantrums were providing attention, especially because Jonas yelled and used a great
deal of foul language during these episodes, which adults found to be stressful.
Parents and teachers realized that they were being reactive even when they did
not intend to. As such, the team defined a clear set of adult behaviors for ignoring
outbursts, including turning one’s body away, not speaking, not crossing arms, and
not making eye contact. The team also agreed on a time interval of calm behavior that
was required before reinforcement (e.g., attention, help, access to tangibles) would
be offered to Jonas.
Because Jonas was being educated in a general education classroom and had
age-appropriate intelligence and verbal skills, the team prioritized implementing
his interventions in a developmentally appropriate and naturalistic manner. As
much as possible, replacement behaviors were taught during typical daily routines
(e.g., homework, schoolwork, getting ready in the morning). When necessary, they
were taught first by his ABA therapists, but they still focused on teaching during
natural routines and activities. As mentioned, the self-management program was
tracked using Jonas’s phone so it could remain private from his peers. Over time,
with the combination of universal and individualized antecedent interventions,
replacement behaviors, and changes in consequences, the frequency of behavioral
challenges decreased. Nonetheless, these behaviors would sometimes emerge
again, especially with changes in routines or new stressors (e.g., new school year).
To continue addressing these concerns, Jonas’s ABA team continued to consult as
needed, and they re-introduced strategies such as self-management and priming in
order to maintain previous skills or assist with generalization of new skills.

CONCLUSION
The big picture for ASD intervention should include systematic and program-
matic opportunities for developing positive behavior, self-regulation, and adaptive
skills. Learning to cooperate with less preferred situations, deal with frustration,
be flexible, wait, and manage daily living skills is essential to living a well-rounded
life. These are also skills that have a high likelihood of contributing to the reduc-
tion of challenging behavior, which, in turn, increases opportunities for success
in natural environments. The strategies used in NDBI are particularly well suited
for teaching these skills, and when used in conjunction with ABA approaches to
reducing challenging behavior, the opportunity for enhanced quality of life and
participation in the least restrictive environment can be maximized.
344 Applications of NDBI Strategies

REFERENCES
Aljadeff-Abergel, E., Schenk, Y., Walmsley, C., Peterson, S. M., Frieder, J. E., & Acker, N.
(2015). The effectiveness of self-management interventions for children with autism—
A literature review. Research in Autism Spectrum Disorders, 18, 34–50.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders
(4th ed., text revision). Arlington, VA: Brookes.
Arain, M., Haque, M., Johal, L., Mathur, P., Nel, W., Rais, A., . . . Sharma, S. (2013). Maturation
of the adolescent brain. Neuropsychiatric Disease and Treatment, 9, 449–461.
Baker, M. J. (2000). Incorporating the thematic ritualistic behaviors of children with autism
into games: Increasing social play interactions with siblings. Journal of Positive Behavior
Interventions, 2, 66–84.
Bambara, L. M., & Kern, L. (2005). Individualized supports for students with problem behaviors:
Designing positive behavior support plans. New York, NY: Guildford.
Bellini, S., & Akullian, J. (2007). A meta-analysis of video modeling and video self-modeling
interventions for children and adolescents with autism spectrum disorders. Exceptional
Children, 73, 261–284.
Bloom, S. E., Iwata, B. A., Fritz, J. N., Roscoe, E. M., & Carreau, A. B. (2011). Classroom appli-
cation of a trial-based functional analysis. Journal of Applied Behavior Analysis, 44(1), 19–32.
Bristol, M. M. (1984). Family resources and successful adaptation to autistic children. In
E. Schopher & G. B. Mesibov (Eds.), The effects of autism on the family (pp. 289–310). New
York, NY: Kluwer/Plenum Publishers.
Bronson, M. B. (2000). Self-regulation in early childhood: Nature and nurture. New York, NY:
Guilford Press.
Carr, E. G. (2011). Positive behavior support and problem behavior. In D. G. Amaral, G.
Dawson, & D. H. Geschwind (Eds.), Autism spectrum disorders (pp. 1144–1155). Oxford,
United Kingdom: Oxford University Press.
Carr, E. G., Dunlap, G., Horner, R. H., Koegel, R. L., Turnbull, A. P., Sailor, W., . . . Fox, L.
(2002). Positive behavior support: Evolution of an applied science. Journal of Positive Behav-
ior Interventions, 4(1), 4–16, 20.
Charlop, M. H., Kurtz, P. F., & Casey, F. G. (1990). Using aberrant behaviors as reinforcers for
autistic children. Journal of Applied Behavior Analysis, 23(2), 163–181.
Charlop-Christy, M. H., & Haymes, L. K. (1998). Using objects of obsession as token reinforc-
ers for children with autism. Journal of Autism and Developmental Disorders, 28(3), 189–198.
Charlop-Christy, M. H., Le, L., & Freeman, K. (2000). A comparison of video modeling with
in vivo modeling for teaching children with autism. Journal of Autism and Developmental
Disorders, 30, 537–552.
Cooper, J. O., Heron, T. E., & Heward, W. L. (2013). Applied behavior analysis (2nd ed.). New
York, NY: Pearson.
Dominick, K. C., Davis, N. O., Lainhart, J., Tager-Flusberg, H., & Folstein, S. (2007). Atypical
behaviors in children with autism and children with a history of language impairment.
Research in Developmental Disabilities, 28, 145–162.
Durand, V. M. (1990). Severe behavior problems: A functional communication training approach.
New York, NY: Guilford Press.
Durand, V. M. (2012). Functional communication training: Treating challenging behavior.
In P. A. Prelock & R. J. McCauley (Eds.), Treatment of autism spectrum disorders: Evidence-
based intervention strategies for communication and social interactions (pp. 107–138). Baltimore,
MD: Paul H. Brookes Publishing Co.
Hanley, G. P., Iwata, B. A., & McCord, B. E. (2003). Functional analysis of problem behavior:
A review. Journal of Applied Behavior Analysis, 36, 147–185.
Hepburn, S. L., & Wolff, B. C. (2013). Self-regulation in persons with autism spectrum dis-
orders. In K. C. Barrett, N. A. Fox, G. A. Morgan, D. J. Fidler, & L. A. Daunhauer (Eds.),
Handbook of self-regulatory processes in development: New directions and international perspec-
tives (pp. 429–452). New York, NY: Psychology Press.
Hodgdon, L. (2016). Visual strategies for improving communication: Practical supports for autism
spectrum disorders. Troy, MI: QuirkRoberts Publishing.
Hodgdon, L. (2017). Solving behavior problems in autism: Improving communication with visual
strategies. Troy, MI: QuirkRoberts Publishing.
 Supporting Behavior, Self-Regulation, and Adaptive Skills 345

Horner, R. H., Dunlap, G., Koegel, R. L., & Carr, E. G. (1990). Toward a technology of
“nonaversive” behavioral support. Journal of the Association for Persons with Severe Handi-
caps, 15(3), 125–132.
Ingersoll, B., & Dvortcsak, A. (2010). Teaching social communication to children with autism:
A manual for parents. New York, NY: Guilford Press.
Keen, D., Brannagan, K. L., & Cuskelly, M. (2007). Toilet training for children with autism: The
effects of video modeling. Journal of Developmental and Physical Disabilities, 19(4), 291–303.
Koegel, L. K., Koegel, R. L., Boettcher, M. A., Harrower, J., & Openden, D. (2006). Combin-
ing functional assessment and self-management procedures to rapidly reduce disrup-
tive behaviors. In R. L. Koegel & L. K. Koegel (Eds.), Pivotal Response Treatments for autism
(pp. 245–259). Baltimore, MD: Paul H. Brookes Publishing Co.
Koegel, L. K., Koegel, R. L., Hurley, C., & Frea, W. D. (1992). Improving social skills and
disruptive behavior in children with autism through self-management. Journal of Applied
Behavior Analysis, 25, 341–354.
Koegel, L. K., Park, M. N., & Koegel, R. L. (2014). Using self-management to improve the
reciprocal social conversation of children with autism spectrum disorder. Journal of
Autism and Developmental Disorders, 44(5), 1055–1063.
Koegel, R. L., Bharoocha, A. A., Ribnick, C. B., Ribnick, R. C., Bucio, M. O., Fredeen, R.
M., & Koegel, L. K. (2012). Using individualized reinforcers and hierarchical exposure to
increase food flexibility in children with autism spectrum disorders. Journal of Autism and
Developmental Disorders, 42(8), 1574–1581.
Koegel, R. L., Schreibman, L., Loos, L. M., Dirlich-Wilhelm, H., Dunlap, G., Robbins, F. R., &
Plienis, A. J. (1992). Stress profiles for mothers and fathers of children with autism. Journal
of Autism & Developmental Disorders, 22, 205–216.
Koegel, R. L., Talebi, J. L., & Koegel, L. K. (2006). Reducing ritualistic behaviors and broaden-
ing children’s interests. In R. L. Koegel & L. K. Koegel (Eds.), Pivotal Response Treatments for
autism (pp. 217–229). Baltimore, MD: Paul H. Brookes Publishing Co.
Larkin, W., Hawkins, R. O., & Collins, T. (2016). Using trial-based functional analysis to
design effective interventions for students diagnosed with autism spectrum disorder.
School Psychology Quarterly, 31(4), 534–547.
Lee, S.-H., Simpson, R. L., & Shogren, K. A. (2007). Effects and implications of self-
management for students with autism: A meta-analysis. Focus on Autism and Other Devel-
opmental Disabilities, 22(1), 2–13.
Lucyshyn, J. M., Dunlap, G., & Ablin, R. W. (Eds.). (2002). Families and positive behavior
support: Addressing problem behavior in family contexts. Baltimore, MD: Paul H. Brookes
Publishing Co.
Martel, M. M., Nigg, J. T., Wong, M. M., Fitzgerald, H. E., Jester, J. M., Puttler, L. I., . . . Zucker,
R. A. (2007). Childhood and adolescent resiliency, regulation, and executive functioning
in relation to adolescent problems and competence in a high-risk sample. Development and
Psychopathology, 19(2), 541–563.
Matson, J. L., & Minshawi, N. F. (2007). Functional assessment of challenging behavior:
Toward a strategy for applied settings. Research in Developmental Disabilities, 28(4), 353–361.
Matson, J. L., & Nebel-Schwalm, M. (2007). Assessing challenging behaviors in children with
autism spectrum disorders: A review. Research in Developmental Disabilities, 28(6), 567–579.
McClelland, M. M., & Wanless, S. B. (2012). Growing up with assets and risks: The importance
of self-regulation for academic achievement. Research in Human Development, 9(4), 278–297.
McGovern, C. W., & Sigman, M. (2005). Continuity and change from early childhood to
adolescence in autism. Journal of Child Psychology and Psychiatry, 46(4), 401–408.
National Autism Center. (2015). National Standards Project, Phase II. Randolph, MA: Author.
O’Neill, R. E., Horner, R. H., Albin, R. W., Storey, K., & Sprague, J. R. (1990). Functional analy-
sis of problem behavior: A practical assessment guide. Sycamore, IL: Sycamore.
Ostfeld-Etzion, S., Feldman, R., Hirschler-Guttenberg, Y., Laor, N., & Golan, O. (2016). Self-
regulated compliance in preschoolers with autism spectrum disorder: The role of tem-
perament and parental disciplinary style. Autism, 20(7), 868–878.
Raaijmakers, M. A. J., Smidts, D. P., Sergeant, J. A., Maassen, G. H., Posthumus, J. A., van
Engeland, H., & Matthys, W. (2008). Executive functions in preschool children with aggres-
sive behavior: Impairments in inhibitory control. Journal of Abnormal Child Psychology,
36(7), 1097–1107.
346 Applications of NDBI Strategies

Rogers, S. J., & Dawson, G. (2010). Early Start Denver Model for young children with autism: Pro-
moting language, learning, and engagement. New York, NY: Guilford Press.
Sandall, S. R., Schwartz, I. S., Joseph, G. E., Gauvreau, A. N., Horn, E. M., Lieber, J., & Odom,
S. L. (2019). Building blocks for teaching preschoolers with special needs (3rd ed.). Baltimore, MD:
Paul H. Brookes Publishing Co.
Schwartz, I. S., Ashmin, J. A., McBride, B., Scott, C., & Sandall, S. R. (2017). The DATA Model
for teaching preschoolers with autism: Blending approaches to meet individual needs. Baltimore,
MD: Paul H. Brookes Publishing Co.
Shipley-Benamou, R., Lutzker, J. R., & Taubman, M. (2002). Teaching daily living skills to
children with autism through instructional video modeling. Journal of Positive Behavior
Interventions, 4(3), 166–177.
Southall, C. M., & Gast, D. L. (2011). Self-management procedures: A comparison across
the autism spectrum. Education and Training in Autism and Developmental Disabilities, 46(2),
155–171.
Sparrow, S. S., Cicchetti, D. V., & Saulnier, C. A. (2016). Vineland Adaptive Behavior Scales,
Third Edition. San Antonio, TX: Pearson.
Todd, T., Reid, G., & Butler-Kisber, L. (2010). Cycling for students with autism: Self-regulation
promotes sustained physical activity. Adapted Physical Activity Quarterly, 27(3), 226–241.
Wolf, M., Risley, T., Johnston, M., Harris, F., & Allen, E. (1967). Application of operant condi-
tioning procedures to the behavior problems of an autistic child: A follow-up and extension.
Behaviour Research and Therapy, 5(2), 103–111. Retrieved from https://search.proquest
.com/docview/84454450?accountid=14522
Wolf, M., Risley T., & Mess, H. (1964). Application of operant conditioning procedures to the
behaviour problems of an autistic child. Behaviour Research and Therapy, 1, 305–312.
14
Implementing NDBI in Schools
Aubyn C. Stahmer, Jessica Suhrheinrich, and Laura J. Hall

O
ne of the primary purposes of the Individuals with Disabilities Educa-
tion Improvement Act of 2004 (PL 108-446) was to support high-quality
in-service preparation and professional development for all personnel
to ensure that they have the knowledge and skills to improve the academic
achievement and functional performance of children with disabilities. This
includes knowledge and skills in the use of scientifically based instructional
practices (Yell, 2016). As a result of federal legislation, there has been growing
demand for use of evidence-based practices by educators. Research reviews by
the National Professional Development Center on Autism Spectrum Disorders
and National Standards Project identified specific evidence-based practices and
established treatments, such as Naturalistic Developmental Behavioral Interven-
tions (NDBI), that are key for use by special educators (National Autism Center,
2015; Wong et al., 2014, 2015).
Although NDBI have been identified as evidence-based, limited information
is available about how to use these strategies in group settings or how to use these
strategies to teach academic tasks—two challenges teachers face each day. In their
review, Wong and colleagues (2014) did not find any research using NDBI (natural-
istic interventions [NI]) that targeted “school readiness,” and they found research
focused on “academic” outcomes only for children ages birth to 5 years. However,
there was research using peer-mediated interventions (PMI) targeting “school
readiness” for young children birth to 5 years and targeting “academics” for stu-
dents ages 6–22 years (Wong et al., 2014, p. 28). Some of the PMI included strategies
from NDBI.
Educators in the majority of the United States are using standards based on
the Common Core State Standards (CCSS; http://www.corestandards.org). CCSS
emphasize teaching children problem-solving skills using multiple means to find
the best answer rather than focusing on learning the only correct response, which

347
348 Applications of NDBI Strategies

is compatible with the common instructional strategies used in NDBI. For example,
NDBI strategies that are aligned with CCSS include responding to varied cues and
opportunities; using multiple materials and examples; rewarding attempts; and
using teaching strategies that support generalization, independence, and problem
solving. In addition, the emphasis on using real-world contexts when teaching the
academic skills that are part of the CCSS is compatible with the focus on arranging
the environment as a common element of NDBI.
Most NDBI programs have been studied in the context of one-to-one interven-
tion, parent-implemented intervention, or a comprehensive program that incorpo-
rates NDBI (see Chapter 5 on inclusion for examples). Many teachers reported that
NDBI components fit with their idea of “good teaching” and make sense to them
(Stahmer, Suhrheinrich, Reed, & Schreibman, 2012). In addition, they reported that
these strategies help children with autism spectrum disorder (ASD) generalize new
skills to broader environments. These teacher opinions align with the available
scientific literature on NDBI as well (e.g., McGee, Krantz, & McClannahan, 1985).
However, specific intervention components and factors related to the instructional
environment also influence use. Teachers find some NDBI components—including
keeping instructions and opportunities clear, simple, and relevant to the child;
gaining the child’s attention; ensuring there is a direct relationship between the
reinforcer and behavior; and rewarding goal-directed attempts—to be part of what
they would consider good teaching.
In contrast, teachers may find the following three areas to be somewhat dif-
ficult to implement in classroom settings. These include 1) shared control and turn
taking; 2) the use of direct reinforcement, and in some cases, even the use of tangible
reinforcement; and 3) the translation of broad learning goals to specific tasks and
activities. Often, it can be difficult to determine, for example, a natural reinforcer
that links directly to certain academic tasks, such as math or geography. Teachers
also say that they do not always have something tangible to provide in a group
setting, but instead they use praise to provide feedback to students. Other con-
cerns include how to best incorporate student-specific interests and turns (includ-
ing modeling) into daily academic lessons and how to take the skills originally
designed for one-on-one and use them with groups of multiple children, especially
in settings such as circle time, in large-group activities, and without adequate staff
support.
This chapter provides ideas for overcoming these barriers to using NDBI in
academic settings, with a focus on incorporating NDBI in group activies common
to most classrooms and addressing academic and individualized education pro-
gram (IEP) goals.

INCLUDING NDBI COMPONENTS

IN GROUP OR ACADEMIC SETTINGS
Setting up the teaching environment for NDBI is similar to setting up any good
teaching environment for children with ASD. For specific lessons, educators should
place teaching materials (including favorite materials if possible) and linked rein-
forcers in areas that are easily accessible to them but that are out of reach of the
students. Having a place to keep extra toys and materials can be useful if students’
motivation changes and the lesson plan needs to shift as a result. Lessons can be
 Implementing NDBI in Schools 349

conducted anywhere, based on the goal of the lesson; however, expectations should
be clear for the student within that space. For instance, for a lesson that involves
standing in a circle on the playground, it may help to draw a chalk line to indicate
where students should stand.
Educators can also set up the environment to provide opportunities for
students to use their skills naturally throughout the school day (environmental
arrangements). For example, a teacher could put art materials and games in a cup-
board that may require students to ask for the specific game, label the color of
marker they need, use prepositions, or complete sentences to ask for materials,
toys, or activities. Giving students specific jobs can encourage peer interaction. For
example, one student can be in charge of passing out paper for an assignment or
keeping track of who has completed their work. Other students may need to ask
him or her for materials or indicate to the leader when they are ready for the next
activity.

Motivation Is the Key

One of the main reasons to use NDBI is to increase student motivation to learn.
NDBI offer many ways to do this, so when using NDBI in the classroom, educa-
tors should consider their students and what motivators will be most powerful
for them or best-suited to the activity. Not all of the strategies need to be used at
the same level in each interaction. Table 14.1, the motivational strategies menu, can
help teachers decide which strategy may be most effective and when.

Shared Control, Choice, or Child-Preferred Activities

Shared control occurs when an activity is neither completely teacher led nor com-
pletely student led. Rather, teachers and students work together to keep high mo-
tivation and engagement in the learning process. Teachers often indicate that this
particular strategy is difficult to implement in practice. However, because it also
has the potential to improve student motivation, when teachers are successful at
incorporating shared control, they often report fewer behavior difficulties and
greater engagement from students.
Shared control can be used in a variety of ways during academic tasks. Teach-
ers might include student-preferred materials, for example, a math lesson that
includes counting pieces of a preferred toy (e.g., legos), which can then be used
afterward as reinforcement. They can enhance teaching materials, for example, by
adding pictures of animals whose names start with the letter a student is learning
to write. Teachers can provide students with a large degree of control in choosing
their activities for the day, topics of writing assignments, or leading activities. As an
alternative, teachers may offer choices that provide a sense of control to the student
with only limited changes to the lesson (see Box 14.1). Examples include a choice
of taking a quiz or doing a problem-solving worksheet during a math session, a
choice of which center to start with for the day, or a choice of writing in cursive or
printing. Teachers often find it helpful to incorporate favorite themes into activi-
ties and assignments to motivate students. Shared control can also include turn
taking so that appropriate behaviors can be modeled, and students can practice
this back-and-forth type of interaction. Depending on the student and the activity,
turns can occur with the teacher or with other students.
350 Applications of NDBI Strategies
Table 14.1. Motivational strategies menu
Motivational strategy It is especially good
Use favorite materials
Individual preferred For one-on-one activity
materials For group activities in which most
children enjoy the materials
For materials that fit the goals
When the child is very hard to
motivate
When there is limited resistance to
giving up the materials during the
learning interaction
Play-based materials When materials can be used to reach
goals (e.g., social, language, colors,
counting, play)
When materials fit the child’s age and
developmental level
When the child needs a great deal of
reward and the play materials are
motivating
When the child is motivated for
play materials and/or use of these
materials is a specific goal
Enhanced academic For children who have difficulty
materials attending to academic tasks
For children who need to learn to
complete worksheets and other
activities for a group environment
For homework
Give choices
Between activities: For children who are very difficult to
Guided motivate or at times when it is easy
to allow greater control (e.g., free
play, recess, one-to-one activities)
When the child can determine the
type and length of the activity
Between activities: When choices need to be limited but
Limited more than one activity or set of
materials can be used to meet the
goals of the activity
Within activities For group activities
When the material or activity is set
Choose effective rewards
Use real rewards: When you use rewards the child really Mix with praise or token
Timing and value likes and can see and feel when he
or she needs the most motivation
When you use real rewards more often
when the child is hard to motivate
During nonpreferred activities
When a child is learning a new skill
Reward attempts When you reward some attempts When you reward fewer
during each activity
When you reward more attempts
when the child is difficult to
motivate or is frustrated with the
task
It may not be as great
For group activities in which
children have very different
interests
For materials that do not fit
the goals
When the child loves the
items so much he or she
does not pay attention to
the teaching instructions
For specific goals that require
non–play-based materials
When favorite topics,
characters, and so forth
cannot be incorporated
into the task
When these topics lead to
distraction, rather than
engagement and attention
For activities where only
certain materials, activities,
or topics are appropriate or
available
When the length of the
activity is fixed
For specific tasks in which
only one activity choice is
available
When a child has poor
motivation for the activity
when the child is easier
to motivate; during
motivating tasks; when you
are practicing skills that are
pretty easy for the child
attempts if the child is
motivated for the activity
and seems to enjoy the
challenge of learning new
skills
 Implementing NDBI in Schools 351

Ready, Set, Implement!

BOX 14.1: Adding choices
A simple way to add choices to most academic lessons is to allow students
to choose what they will write with. They can choose to use a pen, pencil,
or colored marker to complete a worksheet. This simple choice is easy
for teachers and can make students feel more motivated to complete the
lesson. Many other similar types of choices can be easily embedded into the
classroom.

Examples of how to use shared control to teach academic skills include the
following:
• If Sarah enjoys numbers, having her label the dates during a calendar activity
and place today’s date on the calendar may increase her motivation to attend
during circle. Allowing other students to go first and providing Sarah a turn
contingent on good attention may further increase her ability to attend to the
entire activity.
• Perhaps the group is working on forming a paragraph with a topic sentence,
supporting sentences, and a concluding sentence. Allow the students to choose
the topic either as a group or individually. They may choose to write about a
favorite game or activity they often play in the classroom. If students like dif-
ferent games, they can take turns choosing the topics, or the group could write
a story that incorporates fun parts of several games.
• If students are working on handwriting, they may choose between pictures
representing the letters or words they are learning to write. Examples include
trains delivering apples, airplanes, and alligators for the letter A or a favorite
cartoon character using different objects such as a ball, a car, or a cup for chil-
dren learning to write simple words.
• When working in groups of students, work on social skills and turn taking
while incorporating choices. For example, one child can be in charge of scis-
sors; another, glue sticks; and another, colored pencils for an art project. Chil-
dren can ask for the item they want and trade when they have finished with
their turn.
• Social skills and math can be a focus during a game in which students have
half a circle, square, or triangle placed on their shirt and they have to find their
other half in the group. They then tell their peers who has the other half and
what shape they make together (e.g., “Dan has the other half, and together we
make a rectangle”).
• Turns can also be used to model skills between students. For example, students
who excel at math or writing can take a turn first to model the skill for other
students.
352 Applications of NDBI Strategies

• Larger group activities may provide opportunities for cooperative action. For
example, the entire group may decide on a food to prepare for snack. This
activity could focus on literacy by following a recipe to make the snack, as well
as group cooperation and social skills, with different students contributing by
preparing each of the ingredients. When they are done, they get to eat the
snack (reinforcement!).

Contingent or Direct Reinforcement

Educators often find success using reinforcement appropriately when working with
small groups of students. When the student behaves appropriately by responding
correctly or making a reasonable attempt, the teacher provides a reward. When the
student is incorrect or inappropriate, the teacher ignores the behavior, corrects the
behavior, or asks the student to try again. If another student in the group (who is
not working directly with the teacher) does something appropriate, such as asking
for a new crayon, he or she can also be rewarded for the appropriate behavior.
Providing rewards in a larger group environment can be a bit more difficult. Yet,
with some creative thinking, the teacher can think of ways for the whole group to
earn rewards. If specific students are trying hard or responding appropriately while
other students are not listening, the educator can reward those students who are
doing a good job. Then, he or she can provide the group as a whole a chance to try
again or to earn a new reward. As another group reward, a teacher could use cotton
balls to represent snow during circle time. As the class discusses the winter weather,
the teacher can hand out snowballs to students who are listening well. Likewise,
students can collect small animals, numbers, or letters during lessons on these topics.
They can then use the items they collect to make something during free time later on.
Direct reinforcement strategies can be more challenging for academic tasks.
Throughout the school day, however, educators have the opportunity to require
language in naturalistic situations and can provide direct reinforcement. For exam-
ple, a student may want to use scissors from the cupboard, go to the rest room, or
play with a toy from a high shelf. These are all opportunities to provide direct rein-
forcement for appropriate language use. Incorporating favorite items in the tasks
can also be helpful. For example, educators can require language in naturalistic
situations through activities such as the following:
• Learning to count trains can lead to playing with trains.
• Copying letters related to a favorite movie title might be rewarded with being
allowed to talk about the movie with a classmate.
• Reading the labels for items in containers correctly can lead to using the items
(e.g., color of markers, size of Lego pieces, materials needed to put a plant in
a pot).
• Placing the date on the calendar after naming the number may be rewarding
for some students.
• Earning game tokens or pieces for writing a paragraph about a game can lead
to using them to play the game when the activity is over.
• Asking for food items cut in pieces by halves or quarters during snack or
breakfast can lead to eating the items.
 Implementing NDBI in Schools 353

Clear Instructions
Use of clear instructions involves both providing developmentally appropriate in-
structions that students can understand and providing uninterrupted instructions.
In some classrooms, variability in student skills and language comprehension can
make it difficult to provide instructions that everyone can understand. It may be
necessary to use multiple methods to give an instruction; for example, a teacher
might use verbal instructions and hold up a picture that illustrates what is coming
next. Sometimes, providing an instruction in two ways can help. Teachers can also
give a group instruction for those who can follow it and then get the attention of
students who have more difficulty understanding and present the instruction to
them individually. One of the biggest challenges with providing clear instructions
in the classroom is the likelihood that the teacher will be interrupted in between
the time the instruction is given and when the student responds. When working
with a group of students, interruption and distraction are much more likely. Strate-
gies to ensure that instructions to students are clear and not interrupted during
group activities include the following:
• Teachers can help students anticipate when to pay particular attention to the
instructor and when it will be their turn by using a rhythm or pattern when
giving instructions. For example, the teacher asks each student to count a cer-
tain number of favorite objects using the same rhythm to make it easier for
them to anticipate how and when they should respond.
• Keeping students busy when it is not their turn is also helpful. For example,
the teacher can show students how to label colors and shapes and then trace,
draw, or color in a shape (depending the student’s skill level) while the teacher
asks the same of the next student.
• When giving a group instruction, such as asking students to get their materials
out for social studies, the instructor can make sure he or she is ready to give the
instructions before getting everyone’s attention. If a disruptive student is inter-
rupting, the teacher can follow through with the group first and then manage
that student’s behavior.
Of course, interruptions will occur. If that happens, educators should simply
provide the instruction or opportunity again when follow through can be completed.
The following are examples of how to adapt an instruction for different stu-
dents. Perhaps the lesson includes doing a science experiment and working on math
skills. The teacher can adapt the instructions to include a more challenging task for
students with higher math skills and less challenging task for students who have
fewer math skills. Some students may be asked to divide in order to get the correct
amount of sulfur to add to the mixture (Instruction 1), whereas another student
may be asked to measure the sulfur and place it in the bowl (Instruction 2). Like-
wise, a group of students who are working on writing have decided to write about
their favorite movies. The teacher might first provide an instruction verbally for
those students with better language skills that requires them to write a paragraph
about the film. For example, “Joey, Shana, and Sue, please write a five-sentence
paragraph about your favorite movie.” For other students, the teacher might pro-
vide pictures of various movie examples known to be popular with the class and
a list of specific questions to answer about the movie. For example, “Who is this
354 Applications of NDBI Strategies

movie about?” Other students may simply need to choose a picture of a favorite
movie and copy the title of the film. In this way, students of varying skill levels can
work together on the same task.

Broad Attentional Focus

Lessons should use different materials and methods to teach the same concept in
order to give the student a broad understanding of the concept and how to use it in
different settings. For example, if only picture flashcards are used when teaching
a child to label items, the child may think that “car” is the name of the picture of
the blue sedan with four doors; he or she may not understand the broader concept
of cars. Therefore, using a variety of materials—photographs and cartoons of cars,
remote-controlled cars, real cars, and toy cars—is important to teach the child a
more general idea of the concept of car. The same is true when teaching new words,
phrases, and play activities.
Broadening a child’s attention involves use of varied instructions. Varied
instructions mean asking the same thing in slightly different ways. Instructions
can vary across seven types of opportunities (see Table 14.2), and the goal is for
children to respond to all types of opportunities because that is what they will
encounter in the world. For example, if a teacher would like a child to learn to
report his or her address, the educator will need the child to respond to the ques-
tion asked in several ways (e.g., “Where do you live?” “Where is your house?”
“What is your address?”) rather than only responding if someone says, “Tell me
your address.” The teacher also may put the address on an iPad or place a photo of
the child’s house with the address in the student’s backpack so that the student can
pull it out if someone asks. Another example would apply in teaching addition; for
example, a teacher could use jacks, dice, balls, worksheets, crayons, and flashcards
to illustrate the concept of addition. Assuming the most complex of these instruc-
tions is at the child’s developmental level, then using all of these opportunities to
respond is considered using varied instructions.
Educators can also implement differentiated instruction for students with dif-
ferent skill levels by creating a variety of materials. For example, when teaching
map reading to a child who is not yet reading, the teacher might provide a small
map with stickers of buildings at several points on the map (e.g., a sticker of a house

Table 14.2. Example opportunities and cues

Opportunity Description Teacher behavior

Gesture/play model Model the action. Feed a doll with a spoon.

Verbal model Model exactly what you want
your student to say.
Instruction Give an instruction telling the
student what to do.
Question Ask a question.
Facial expression Wait expectantly with eyes
open wide.
Comment Make a leading comment.
Situational Set up situations to elicit a
specific behavior.
Say “spoon” when the student is
reaching for the spoon.
Say, “Feed the boy.”
Say, “Should the boy eat peas or
yogurt?”
Hold up the doll, and look expectantly
at the student.
Say, “The boy is hungry.”
Put a doll, spoon, and bowl on the
table near the student.
 Implementing NDBI in Schools 355

on one end and a school on another, stickers of a farm and a fire station in between).
The teacher could then ask the student to move a doll from “home” to “school” on
the map and state the directions along the way. The student could then say some-
thing such as, “The boy leaves home, goes down this street, past the farm, then
turns right at the fire station until he gets to school.” Another child who is reading
might be given a list of written instructions about how to get from home to school
(e.g., go up two blocks, then right four blocks, then cross the street). He or she could
then use those instructions to move the doll along a real map from home to school.
Both students are learning the concept of map reading but at their own ability
level. Table 14.2 describes a variety of forms that can be used as a cue.

Generalization and Maintenance of Skills

A focus on maintenance of skills over time and generalization of skills with differ-
ent people, with different materials, and within different settings and activities is
a common instructional strategy of NDBI. Maintenance and generalization are ini-
tially targeted through intentional use of varied cues, use of natural reinforcement,
and teaching in the natural environment. In fact, the cues that are likely to be used
in the natural environment should be identified and embedded at the beginning
of any lesson planning (Mayer, Sulzer-Azaroff, & Wallace, 2014). It is important
that students have the opportunity to practice any skills across environments and
in different contexts to help them master the concept. Instead of assessing frac-
tions using blocks only, for instance, a teacher should assess the use of fractions
with food, during time telling, and on math worksheets. Children may also benefit
from specific assessment of maintenance and generalization to identify any areas
of weakness. This can be done by asking a student to use newly learned skills with
new materials or a new person. For example, if the child has learned to follow
instructions from the teacher during math, have the speech therapist give similar
instruction during language time and see if the student still responds.

SCHOOL-BASED ACTIVITIES MOST SUITED FOR NDBI

NBDIs can be used throughout the school day during a wide variety of activities.
To identify activities that are a good fit for NBDI use, educators should consider the
following questions.
• Do I know my student’s preferences or interests and target skills?
An important part of using NBDI successfully in the classroom is planning. If
an educator does not know what motivates the students, it helps to watch what
they do during free play, ask their family members, or conduct a formal prefer-
ence assessment (see Chapter 6 and Box 14.2).
• Do I have the opportunity to share control with my students during this
activity?
Sharing control means there is some flexibility in how the lesson will run or what
materials can be used. Some activities, such as recess or free choice time, may
have very little structure. In these situations, the teacher can easily follow the
student’s lead for maximal child choices. The teacher still has specific learning
goals (e.g., requesting a turn, counting to 10, writing a descriptive paragraph),
356 Applications of NDBI Strategies

Ready, Set, Implement!

BOX 14.2: Incorporating Children’s Interests Into Theme-Based Teaching
NDBI strategies can be used during theme-based teaching. For example, if
the theme is community helpers, you can talk about the vehicles used by
fire fighters, mail carriers, and garbage collectors as a way to incorporate
motivating materials for a student interested in cars and use these vehicles as
a natural reward for answering questions during the discussion.

but the way in which the goals are taught is flexible. Consider Table 14.3 with
examples of how to address the same goals in activities of decreasing structure.
• Will I be able to provide regular feedback and natural reinforcement?
Students will learn best when given regular and related feedback about their
behavior. When teachers are working with only one child, this is no problem.
However, providing feedback becomes more difficult as the group size grows.
When choosing activities for NDBI, a teacher must consider how to give atten-
tion to each student in the group (or the group as a whole) to provide meaningful
feedback. Individual students will likely need varied amounts of reinforcement
to keep them engaged. See Table 14.4 for examples of ways to provide whole-
group reinforcement and individual reinforcement within a group setting.

Table 14.3. Examples of different levels of structure

Structured
Highly structured activity with Semi-structured
activity with a required academic or
set goals and sequence of steps play-based Unstructured
Goals procedures or materials activity activity

Ava will Mrs. Chavez The number While passing At recess,

independently prepares several of the week out materials Mrs. Chavez
count small cups is 5. During a for an art finds Ava
quantities with different group circle activity, playing in
up to 10 quantities of small time activity, Mrs. Chavez the sandbox.
on 80% of blocks (1–10) Mrs. Chavez asks Ava, Mrs. Chavez
opportunities. in each. During places five “How many says,
a small-group beanbags in crayons do I “Let’s put
math activity, her bucket. She have?” When five scoops
Mrs. Chavez asks asks Ava, “How Ava responds in your
Ava to “count many beanbags correctly, bucket. You
the blocks.” do I have?” Mrs. Chavez count.” She
Mrs. Chavez When Ava lets Ava choose blocks the
alternates her responds, she the colors bucket until
attention between gets to pass out she wants. Ava says
the three students beanbags to She repeats each number,
in the group, and hear friends to this process then moves
each student gets use during the with scissors, her hand
to build with the next song. glue sticks, so Ava can
blocks between and other dump the
turns. materials. sand in the
bucket.
 Implementing NDBI in Schools 357

Table 14.4. Examples of reinforcement

Activity Whole-group reinforcement Individual reinforcement

Multiplication with white The group earns a marker Students who respond correctly
boards: Each student for each problem everyone or make a good attempt get
writes his or her answer completes correctly (or their choice of extra marker
on a personal white attempts). When the group colors to draw on the white
board and holds it above earns 10 markers, everyone board between problems,
his or her head so the gets to play a Pictionary allowing the teacher to work
teacher can review the math game. individually with those who
answer. answered incorrectly.
Mr. Neilson wants to When Mr. Neilson asks a When Mr. Neilson “catches” a
encourage his students question and all students student doing good listening,
to raise their hands either raise a hand to answer he praises him or her and
before speaking and or sit quietly, the class earns says, “You get to choose a
listen while others are 1 minute of song time. song!”
talking during circle Likewise, when all students
activities. The students’ listen while another student
favorite part of circle time answers, the class earns
is song time at the end. 1 minute of song time.

EXAMPLES OF ACTIVITIES AND LESSONS

Table 14.5 includes examples of how to use one NDBI strategy, Classroom Pivotal
Response Teaching (CPRT), to address IEP goals and specific curriculum areas.
The table describes three students, Jose, Sara, and Darren, who attend the same
K–2 special day class. Their IEP goals and examples of how their teacher uses NDBI
strategies to meet their communication and math goals during classroom activities
are included. NDBI strategies also have been used to increase motivation and fa-
cilitate homework completion. In particular, providing choices (even somewhat su-
perficial choices such as order of task completion), incorporating simple problems
with more difficult ones, and rewarding attempts have all been used successfully
(Koegel, Tran, Mossman, & Koegel, 2006).

CONCLUSION
Research has looked at the use of NDBI strategies in schools, typically in com-
bination with other evidence-based interventions (e.g., Stahmer, Suhrhenrich, &
Rieth, 2016; Young, Falco, & Hanita, 2016). Teachers share that these strategies make
sense to them and fit well with teaching students with ASD and other students in
their classrooms.
One teacher learning to use NDBI said, “Once you get used to implement-
ing the choices, shared control, and the rewards for attempts, it makes teaching so
much easier for all involved, and we end up with so much more.” Another teacher
said, “I found my students did learn the skills presented, and they seemed to have
fun while learning (and I did, too!).”
We hope these strategies are both fun and useful in the classroom. There
are some resources that will provide more information about the use of NDBI
in schools. For example, the National Professional Development Center on ASD
offers professional development materials, such as the Autism Focused Inter-
vention Resources and Modules (AFIRM) for planning, using, and monitoring
27 evidence-based practices for learners with ASD, including NI, Pivotal Response
Treatment (PRT), and PMI.
358 Applications of NDBI Strategies
Table 14.5. Meeting individual goals using Classroom Pivotal Response Training (CPRT)
Kindergarten/first grade
Student profile
Jose is a 6-year-old boy who attends a
K–2 special day class. He has some
intelligible phrase speech, which he uses
to request and at times to comment, but
he does not yet use sentences. He can
match uppercase letters but does not
name them. Jose is at the beginning level
of reading sight words. Jose counts to 20
and can give objects up to 10 from a field
of 12–15 with 80% accuracy. He requires
visuals to augment learning. Jose has
difficulty interacting with other students
and is often alone on the playground and
at lunch.
Sara is a first grader in the same special
day class as Jose. She is a 7-year-old girl
who uses five- to six-word sentences
but does not always express herself well
to get her needs met. Sara knows all of
the upper- and lowercase letters and the
sound each letter makes. She is learning
to recognize simple words in print. She
prints her first and last names. Sara
knows how to do addition for single-digit
numbers. She is currently working on
subtraction skills. Sara has many friends
but still has difficulty sharing materials
during class activities.
Darren is a first grader. He primarily
uses gestures to communicate and
makes some inconsistent attempts
at single words. He is able to use a
Picture Exchange Communication
System to make requests with an
open-handed prompt. Darren rote sings
the ABC song (using approximations)
but does not recognize the letters of
the alphabet. Darren rote counts to 5
(using approximations) but has not yet
developed numeral recognition. Darren
parallel plays near peers but has little
to no interaction with them. He is often
alone and ignores those around him.
Individualized education program goals or
curriculum area
1. Jose will name the uppercase letters when
they are presented in random order, with
100% accuracy on four of five opportunities.
2. Jose will demonstrate the ability to complete
addition sums in single digits with visual
support, during four of five opportunities.
3. Within 1 school year, Jose will spontaneously
use simple sentences five times in each
school day on 6 out of 8 days.
4. Jose will join a group appropriately (e.g., by
spontaneously waving, saying hello, asking
to play) and will remain in proximity to other
students during small group and lunch for
15 minutes over 4 of 5 school days.
1. Sara will decode simple consonant-vowel-
consonant words when shown a variety of
printed materials, with 8 out of 10 words
correct as measured by interim assessment
on four out of five occasions.
2. Sara will demonstrate the ability to
do single-digit subtraction problems
independently with at least 80% correct
on 4 of 5 school days.
3. When at an activity with plenty of materials,
Sara will be able to share with her peers
spontaneously for up to five turns on 4 of
5 school days.
1. Darren will match the letters of the uppercase
alphabet when given two sets of letters with
100% accuracy on four of five opportunities.
2. Darren will point to the requested numerals
to 10 with 100% accuracy during four of
five opportunities.
3. Darren will use words or pictures to
communicate at least 20 times without
prompting throughout the school day to
request objects or activities on 4 of 5 school
days.
4. Darren will interact with peers during
structured play by turn taking and sharing
materials during daily activities with teacher
facilitation on 70% of opportunities on
3 days.
 Implementing NDBI in Schools 359

Table 14.5. (continued)

Kindergarten/first grade

Using CPRT at language arts with Jose, Sara, and Darren

Activity: Letter and word recognition
Materials: Letter cards, character stickers, writing or matching boards for students, toy animals
The students, Jose, Sara, and Darren, are seated at a small round table with the teacher. She
reviews the alphabet with the students by showing them letter cards of all the letters and
naming them.
Jose: The teacher shows Jose a letter card. “What letter is this, Jose?” She holds up an S.
Jose looks at it and says, “S” (Goal 1). “Good,” says the teacher and gives him the letter,
which has a Superman sticker on it. (He likes superheroes.)
Next, the teacher takes a turn and models a more advanced skill. She writes “all” on her
white board and places the “B” card in front of it. “B goes with a-l-l to spell ball.”
Sara: Sara is working on “at” words (e.g., bat, cat, hat) and has a board with a blank space
followed by “at.” The teacher asks Sara if B can be put in front of at to make a word. Sara
looks at her board and puts the B in front. “What does it say, Sara?” Sara replies, “B-at.
Bat!” (acquisition skill, Goal 1). “That’s great,” the teacher tells her. “It spells bat!” She asks
Sara if she would like to take another turn or share her letter with Darren. Sara chooses to
give the letter to Darren (Goal 3).
Darren: Darren has a matching board for the capital letters. He places the B from Sara on the
correct corresponding letter (Goal 1). He is rewarded by being allowed to choose and play
with a toy animal that begins with the same letter.
The teacher continues the lesson in this manner, allowing Jose to name the letters (being
rewarded with the embedded stickers), Sara to test them with the “at” board (being
rewarded by allowing her to choose to take a turn or share), and Darren to match them to
his board (rewarding him with animal toys that begin with the same letter he is matching).
The teacher models as needed and gives praise throughout the session.
Using CPRT at math with Jose, Sara, and Darren
Activity: Number recognition, addition, and subtraction
Materials: Number cards, addition and subtraction folder templates (three squares printed
horizontally with + or − and an = between them)
The teacher shows and labels each number card and allows the students the choice of
whispering or yelling as they repeat each number after her (maintenance skill). She knows
that “being the teacher” is motivating for all her students, so she uses this role to reinforce
the students’ behavior during a math activity.
Darren: Then, the teacher holds up two numbers (3 and 5) and says, “Darren, tell us what
numbers these are” (Goal 3). He labels both numbers correctly, and she gives him the
corresponding number cards and says, “Okay, Darren is the teacher.” She helps Darren
pass out the numbers. He chooses to give the number 3 to Jose and the number 5 to Sara
(Goal 4). Next, she holds up two more numbers (1 and 2) for Darren and asks, “Where
is number 2?” Darren takes the 2 card and, smiling, gives it to Sara (Goals 2 and 4). The
teacher wants to reward his spontaneous sharing. “That was great, Darren!” she says, “You
picked the correct number and even gave it to Sara without being asked! You may choose
two animals.”
Sara: Sara’s folder has a subtraction sign between the first two boxes. The teacher tells Sara,
“Put your number 5 here” and points to the first box, “and your number 2 here” and points
to the second box. She then asks, “What is the answer?” and points to the third box. Sara
says, “Five minus two equals three.” The teacher announces, “Great job! Now Sara is the
teacher.” With the teacher’s help, Sara gives Jose the number 2 card and tells him to do his
math problem.
Jose: Jose makes a nice attempt by reading the numbers on his folder without solving the
problem (Goal 2). The teacher praises his effort, and he is allowed to flick the number cards
with his fingers. The teacher says, “Now I will take a turn” and solves an addition problem
on another folder.
The lesson continues in this manner until math time is over.
Source: Stahmer, 2011.
360 Applications of NDBI Strategies

Books that may be useful include the following:

Delmolino, L. (2015). Solve common teaching challenges in children with
autism: 8 essential strategies for professionals and parents (topics in autism).
Bethesda, MD: Woodbine House.
Hall, L. J. (2018). Autism spectrum disorders: From theory to practice (3rd ed.).
New York, NY: Pearson.
Leach, D. (2012). Bringing ABA to home, school and play for young children
with autism spectrum disorders and other disabilities. Baltimore, MD: Paul H.
Brookes Publishing Co.
Stahmer, A., Suhrheinrich, J., Reed, S., Schreibman, L., & Bolduc, C. (2011).
Classroom pivotal response teaching for children with autism. New York, NY:
Guilford Press.

REFERENCES
Individuals with Disabilities Education Improvement Act (IDEA) of 2004, PL 108-446, 20
U.S.C. §§ 1400 et seq.
Koegel, R. L., Tran, Q. H., Mossman, A., & Koegel, L. K. (2006). Pivotal response treatments for
autism: Communication, social, and academic development. Baltimore, MD: Paul H. Brookes
Publishing Co.
National Autism Center. (2015). National Standards Project, Phase 2. Randolph, MA: Author.
Mayer, G. R., Sulzer-Azaroff, B., & Wallace, M. (2014). Behavior analysis for lasting change.
Cornwall-on-Hudson, NY: Sloan.
McGee, G. G., Krantz, P. J., & McClannahan, L. E. (1985). The facilitative effects of incidental
teaching on preposition use by autistic children. Journal of Applied Behavior Analysis, 18(1),
17–31.
Stahmer, A. C., Suhrheinrich, J., Reed, S., & Schreibman, L. (2012). What works for you?
Using teacher feedback to inform adaptations of pivotal response training for classroom
use. Autism Research and Treatment, 2012, 1–11. (Article ID 709861)
Stahmer, A. C., Suhrheinrich, J., & Rieth, S. R. (2016). Classroom pivotal response teaching:
A pilot examination of the adapted protocol. Journal of the American Academy of Special
Education Professionals, Winter, 119–139.
Stahmer, A., Suhrheinrich, J., Reed, S., Schreibman, L., & Bolduc, C. (2011). Classroom pivotal
response teaching for children with autism. New York, NY: Guilford Press.
Wong, C., Odom, S. L., Hume, K., Cox, A. W., Fettig, A., Kucharczyk, S., . . . Schultz, T. R.
(2014). Evidence-based practices for children youth and young adults with autism spectrum disor-
der. Chapel Hill: The University of North Carolina, Frank Porter Graham Child Develop-
ment Institute, Autism Evidence-Based Practice Review Group.
Wong, C., Odom, S. L., Hume, K. A., Cox, A. W., Fettig, A., Kucharczyk, S., . . . Schultz, T. R.
(2015). Evidence-based practices for children, youth, and young adults with autism spec-
trum disorder: A comprehensive review. Journal of Autism and Developmental Disorders,
45(7), 1951–1966.
Yell, M. L. (2016). The law and special education (4th ed.). New York, NY: Pearson.
Young, H. E., Falco, R. A., & Hanita, M. (2016). Randomized, controlled trial of a compre-
hensive program for young students with autism spectrum disorder. Journal of Autism and
Developmental Disorders, 46, 544–560.
15
Collecting Data in NDBI
Mendy B. Minjarez, Melina Melgarejo, and Yvonne Bruinsma

L
ike all interventions grounded in behavior analysis, data collection is a
critical component of Naturalistic Developmental Behavioral Interventions
(NDBI). Not only have data supported the efficacy of NDBI in numerous pub-
lished research studies, but consistent with data-based decision making as a cor-
nerstone of Applied Behavior Analysis (ABA), data guide treatment planning by
demonstrating the effects of ongoing treatment programs for individual learners.
Data provide the information needed for developing goals and planning interven-
tion programs, ensuring the intervention is implemented accurately, monitoring
progress, guiding treatment decisions, facilitating communication across team
members, and evaluating the program’s overall effectiveness. Although the details
of data collection vary depending on the specific intervention and target skill, all
NDBI incorporate a system of data collection.
Ongoing collection of skill and behavior data allows for the tracking of progress
without judgment based on temporary bias or misinterpretation of singular events.
For example, if a parent experiences a tough weekend of challenging behaviors, he
or she may get discouraged and think that progress is not being made when the
data actually may continue to show an improving trend. Or, if a teacher observes
a student engage in a new skill, he or she may determine the goal is met without
realizing that the skill is only produced in the teacher’s presence and more work is
needed before the student uses that skill with others. In NDBI programs, data help
clinicians track whether the skills taught are 1) firmly assimilated into the child’s
repertoire or if the child needs additional instruction and practice; 2) used fluently,
flexibly, and in meaningful ways or are difficult to produce or rigidly applied;
3) used in situations that have not been directly taught or limited to a particular
teaching context (i.e., generalization); and 4) maintained over time.
As described in Chapter 16, use of a clear system of data collection to guide the
intervention is one of the quality indicators of NDBI programs. Data provide essential
feedback on clinical strategies and guide clinical programming and goal development.

361
362 Applications of NDBI Strategies

GENERAL FRAMEWORK FOR DATA COLLECTION

All NDBI emphasize the importance of data collection, but there is great variability
in how specifically the models outline strategies for doing so. The data collected
must be reliable (precise enough to be replicated) and valid (accurate); otherwise
they may be misleading (see Box 15.1 for complete definitions of reliability and
validity). Because data are used to drive clinical decision making, their reliability
and validity are of utmost importance.
Several NDBI programs have outlined important considerations for develop-
ing data collection strategies in their manuals (e.g., Classroom Pivotal Response
Teaching [CPRT], Project DATA [Developmentally Appropriate Treatment for
Autism]). Clinicians may find it helpful to think about the following questions
when developing data collection methods (Schwartz, Ashmun, McBride, Scott, &
Sandall, 2017; Stahmer, Suhrheinrich, Rieth, Schreibman, & Bolduc, 2011):
• What information are you trying to capture? That is, will your data provide
you with the information you need to answer the question you have? Will your
method be valid, meaning it measures what you intend it to measure?
• Will the method be reliable, meaning it is precise enough to achieve inter-
observer reliability?
• What measurement criteria are written into the goal?
• What data are required in the setting (e.g., schools, for insurance)?
• Will the data collection system be manageable, be practical, and make sense for
those who will be collecting the data?
• What information do you need to evaluate progress and make program
changes?
Additional considerations for developing and using data collection methods may
include deciding 1) where to collect data (setting), 2) how often to collect data,
3) who will collect the data, and 4) how to measure behavior change. For some
behaviors, it may be important to consider whether data from multiple settings is
necessary. For example, if a child has tantrums minimally at school but often at
home, measurement of tantrums in the school setting may not capture this child’s
baseline functioning or progress during treatment at home in a valid manner.
Next, clinicians should decide how often data will be collected. For example,
will data collection be continuous across treatment sessions or collected in probes?

BOX 15.1: Reliable and valid data collection

Reliability: Reliability refers to whether results are precise enough to be
consistently replicated. In ABA, the most important kind of reliability is
interobserver agreement, defined as more than one person arriving at
the same result when data are collected.
Validity: Validity refers to the accuracy of data, meaning whether you are
measuring what you intend to measure.
 Collecting Data in NDBI 363

This will depend on how often the behavior occurs and how quickly it is expected
to change. It is also important to clearly determine who is monitoring the data.
Likely there will be more than one person in each setting, which is why reliability
of data recording is important. It is also important to consider what type of data
is relevant based on how the goal is written. For example, if the goal states that
mastery criteria are based on frequency during a 10-minute probe, the data collec-
tion method must match that criterion. Likewise, if the goal states that duration of
tantrums will decrease, the data collection method must focus on duration rather
than frequency or rate.
There are many other considerations for selecting what type of data is appro-
priate, depending on what behaviors are being measured. These are discussed in
more detail later in the chapter but are also well-elaborated in the ABA literature
(e.g., Cooper, Heron, & Heward, 2013).
Once these decisions have been made, clinicians can design a data sheet. There
are many data sheets available in ABA and NDBI books, manuals, and texts, as well
as online. Clinicians may find some of these easier to adapt than others, and they
often may also wish to develop their own data sheets for specific areas. Many pro-
grams routinely follow established treatment procedures or guidelines and often
have a core set of data sheets so that a new data sheet is not developed every time
a goal is written. Nonetheless, to gather reliable and valid data, clinicians should
ensure their data sheets capture what they are trying to measure.
Once a data collection method is determined, clinicians must also decide on
data summary and analysis methods. Many NDBI programs use straightforward
ABA graphing methods, but some use other methods such as summary face sheets
and matrices. Treatment teams must decide on methods that are feasible, efficient
for the setting, and effective in progress monitoring and data-based decision mak-
ing. When determining these methods, it is also important to determine who will
be overseeing data analysis and using this information to make program changes
(e.g., teacher, lead Board Certified Behavior Analyst [BCBA], therapist) and how
and when this person will review the data. Data are only helpful if summarized,
analyzed, and used effectively to monitor treatment.

DATA COLLECTION ACROSS NDBI MODELS

NDBI target a wide variety of skills across the various domains of development (e.g.,
communication, social, play, behavior, motor, self-help, cognitive). Although some
programs may be more focused and others more comprehensive, each one targets
socially significant skills that help children actively and meaningfully participate
in the world around them. With an understanding of developmental and behav-
ioral perspectives, and considering social- and age-appropriateness, clinicians pri-
oritize the most critical skills for intervention and track them via data collection.
All NDBI models focus on data collection in order to evaluate treatment
progress and guide treatment planning; however, there is considerable variabil-
ity across models. The next section provides a review of data collection methods
across a sample of NDBI models. NDBI models with more explicit and detailed
data collection systems are reviewed first, followed by those that rely on broader
strategies available in the ABA and developmental literature. The data collection
methods reviewed here pertain primarily to skills acquisition because most NDBI
use standard ABA data collection methods for taking data on challenging behavior.
364 Applications of NDBI Strategies

Early Start Denver Model

In the Early Start Denver Model (ESDM), specific data sheets include fields for data
collection on targets that are most commonly generated from the ESDM curricu-
lum checklist. Although the targets themselves can be flexible, the general data
collection method is set. Daily data are collected on the Daily Data Sheet, typically
on acquisition skills as well as maintenance skills. Data are then used to modify
teaching within sessions and track progress across sessions. Within sessions, data
are used to track which skills have been targeted so clinicians can monitor whether
teaching needs to be adjusted over the course of a session to ensure they have
worked on all goals. These data can also provide information about how to adjust
teaching based on performance. For example, if a child does not perform well on
a maintenance skill, teaching an acquisition skill may need to be temporarily put
on hold until the maintenance skill can be confirmed. Across sessions, data are
summarized and transferred to a Data Summary Sheet so overall progress can be
effectively monitored. The ESDM manual does not specify any other data sum-
mary methods, such as graphing; however, many sites graph data over time for
ease of review. Once data are summarized, the information is used to make deci-
sions regarding treatment format and structure based on decision trees available
in the manual.
ESDM specifies an interval recording procedure in which the clinician stops
briefly every 15 minutes and documents presence or absence of correct respond-
ing on skills that were targeted. In this way, targeted skills are recorded four times
during a 1-hour session, yielding a uniform data set that can be evaluated across
sessions. Detailed information is provided in the ESDM manual about how to code
behaviors based on child performance (e.g., nonresponse, incorrect response, cor-
rect response; Rogers & Dawson, 2010).
As with all NDBI, ESDM’s naturalistic approach means that data collection
must be feasible in the natural environment. This data collection method is used
because it only requires brief pauses in treatment every 15 minutes, and otherwise,
the clinician can focus solely on intervention. Such an approach may be particu-
larly useful when working with very young children whose high energy level and
rapidly shifting attention can make the pacing of intervention quite fast.
There are several advantages to the data collection method used in ESDM.
Because it was developed specifically for use in the natural environment, it is very
user friendly. It uses premade data sheets, and it can be used across developmental
domains (i.e., it is not just focused on one developmental area, such as language). It
also includes a simple way to track both maintenance and acquisition tasks.
Challenges with this data collection method may include concerns about
areas where it lacks specificity. For example, this method does not include
detailed information about any error correction methods used. Its lack of trial-
by-trial information makes it challenging to evaluate learning, error patterns,
and trajectories. For example, a child may demonstrate a skill once within a
15-minute time interval over multiple days, thus getting credit for the skill but
not actually increasing the frequency or duration with which that skill is used.
However, because all data collection methods have pros and cons, it may be use-
ful to consider the ESDM method as being very feasible and user friendly while
also remaining open to adding other more specific data collection methods when
needed.
 Collecting Data in NDBI 365

Classroom Pivotal Response Teaching

CPRT has a comprehensive data collection system in its manual, both with meth-
ods for daily use and methods for tracking progress over time in accordance
with individualized education program (IEP) standards (Stahmer et al., 2011). Al-
though this model is adapted for the school setting, much can be learned from
how these procedures are modified for use in the natural environment, as well
as the varied types of data they can be used to collect. As discussed previously,
the CPRT manual encourages clinicians to think about the following questions
when developing data collection methods: 1) What information are you trying to
capture? 2) What measurement criteria are written into the goal? 3) What data are
required in your setting (e.g., school, insurance)? 4) What is manageable for those
who will have to collect data? and 5) What information do you need to evaluate
progress and make program changes? (Stahmer et al., 2011). These general tenets
of data collection are similar to those put forth in the Project DATA manual, dis-
cussed later.
As with ESDM, the CPRT manual contains both data sheets for summarizing
progress, as well as those for daily data collection methods. Progress can be sum-
marized at any interval that is relevant for the treatment setting, the broadest of
which is quarterly, in keeping with how often IEP goals are typically reviewed. The
CPRT manual is an excellent resource for a number of types of data sheets, includ-
ing those that can be used to summarize progress over various periods of time,
those that range from structured (i.e., forced choice format) to unstructured (i.e.,
with fields to fill in), those that document presence or absence of a skill versus trial
by trial, and those that can be used to take data on multiple children at one time
in group settings (Stahmer et al., 2011). Again, although these methods have been
developed for the school setting, they can also be adapted for use in other settings
and represent one of the more comprehensive sets of data collection examples that
is available across NDBI models.
Advantages of the data collection methods reviewed in the CPRT manual
include the multiple choices of data sheets that can be reproduced and used based
on the needs of the activity and goals. Because they were developed for use in
naturalistic intervention, they are also fairly easy to complete, although some do
require becoming familiar with measurement systems that clinicians may not be
accustomed to using. However, with some practice, these resources can prove use-
ful in a number of settings for different goals and skill sets.

Developmentally Appropriate
Treatment for Autism in Toddlers (Project DATA)
Although Project DATA is not reviewed as an NDBI program in Chapter 2, it is
mentioned in multiple places as an intervention that is consistent with most tenets
of NDBI models. Indeed, review of the Project DATA manual quickly reveals that
it has merit in terms of its data collection methods, which have broad applicabil-
ity in any NDBI (Schwartz et al., 2017). The Project DATA manual first highlights
the reasons data are collected, including to monitor progress, evaluate program-
ming, communicate with others about the child’s performance, identify phases
of learning (mastery, generalization, maintenance), and maintain compliance or
practice standards. Certainly, these are uses that would apply to all NDBI models.
366 Applications of NDBI Strategies

Much like CPRT, Project DATA emphasizes that any data collection must be inten-
tionally selected with the earlier discussed questions in mind.
Project DATA notes that regular and reliable data collection is important and
that data should be analyzed soon after they are collected through effective sum-
marization methods. Although this program has a focus on visual inspection of
graphs, the summarization method must be feasible; therefore, tables, matrixes,
and other forms of summarizing data may also be acceptable as long as the data
are displayed in such a way that they can be used for regular data-based deci-
sion making. In Project DATA, at least five data points are required before making
programming changes, and 5–10 data points are recommended before making the
subsequent set of changes.
The Project DATA manual includes a number of data sheets that can be used
for a variety of purposes, including trial-based daily data sheets with and with-
out graphing, a daily data sheet (not trial-based), a task analysis data sheet, and a
weekly data sheet (Schwartz et al., 2017). Each of these forms of data collection may
serve different purposes; the manual encourages clinicians to think about the fol-
lowing questions when developing a data sheet:
• Where will the data sheet be used?
• What is the best way to organize the data sheet to meet the data collection need
(e.g., by day, by activity, by behavior or goal)?
• What will the data sheet look like?
• Does the data sheet make sense to those who will use it?
Like CPRT, an advantage of the data collection systems reviewed in the Project
DATA manual includes the large number of reproducible data sheets that can be
used across settings to track a broad range of behaviors. The format of these data
sheets would likely be familiar to most clinicians with an ABA background and is
also easy to learn. The data sheets that track a number of behaviors on one page
lend themselves particularly well to the natural environment because no flipping
between data sheets is required. Disadvantages of the data methods proposed in
Project DATA include that most of the methods are trial by trial, which can be la-
borious in the natural environment, and that graphing appears to be the best sum-
marization method, which can pose challenges in some settings.

Project ImPACT
Project ImPACT (Improving Parents as Communication Teachers) does not include
as much detail regarding data collection methods as other NDBI, such as ESDM.
The manual states that a range of data collection methods can be relied on, and it
includes an example data sheet for recording child performance on specified learn-
ing targets within a treatment session (Ingersoll & Dvortcsak, 2010a, 2010b). The
primary data collected on this sheet are goals targeted, child performance, and
type of prompt used. How child performance should be evaluated (e.g., trial by
trial, probe) is not specified, leaving the details up to individual clinicians or par-
ents. As such, similar to Enhanced Milieu Teaching (EMT) and Pivotal Response
Treatment (PRT), this model relies more heavily on clinician experience with data
collection and analysis procedures.
 Collecting Data in NDBI 367

Because Project ImPACT is heavily focused on parent training, there are two
parent treatment fidelity data sheets in the manual that provide significantly more
detail than the child-focused data sheet (Ingersoll & Dvortcsak, 2010a, 2010b). These
data sheets require clinicians to make ratings of parent performance on a 5-point
Likert scale, ranging from low to high treatment fidelity, across a large number of
specific skills that are associated with treatment techniques. For example, within
the area of following the child’s lead, parents are rated on specific skills, including
1) lets the child choose the activity, 2) is face to face with the child, and 3) joins in
the child’s play. Two treatment fidelity data sheets are provided: one that is used
when parent training is conducted individually and one for group-based parent
training. Other NDBI, such as CPRT, also include data sheets to assess treatment
fidelity.
The manual for Project ImPACT also notes that although live data collection is
important, it can also be challenging when working in the natural environment. In
this NDBI model, periodic videos of treatment should be made, and treatment time
should be spent reviewing these videos with parents for training purposes. When
this more detailed review is taking place without the child present, treatment fidel-
ity data can be collected more easily in addition to any child target behaviors the
clinician may wish to score during this video review session.
Because a broad range of data collection methods are used to track child tar-
get behaviors in Project ImPACT, pros and cons can only be discussed in terms of
the treatment fidelity measures used in this model. Much like ESDM and CPRT, a
significant advantage of the treatment fidelity measures in this model is that they
are premade, user friendly, easy to understand, and generally efficient because
they do not require trial-by-trial scoring. Parent treatment fidelity measures are
also relatively rare in both NDBI and the broader field of ABA, making these tools
unique and useful in a modified form for scoring treatment fidelity of similar NDBI
models. The primary disadvantage of this treatment fidelity scoring system is the
lack of trial-by-trial data, which can yield more specific information that is helpful;
however, in our experience, these data are so challenging to obtain during parent
training that the advantages of this checklist make it a very efficient tool.

Enhanced Milieu Teaching

In the literature on EMT, data collection methods used in research are the primary
focus, although some methods that are more clinician friendly are also discussed
(Hancock & Kaiser, 2012). Given the focus on communication targets, most data
collection in EMT is focused on these goals. In research, EMT uses comprehen-
sive assessment methods (e.g., standardized measures, parent report measures) as
well as complicated language analyses methods, such as the Systematic Analysis
of Language Transcripts (SALT), which relies on transcription of language samples
and then calculation of variables such as mean length of utterance (MLU; Hancock
& Kaiser, 2012).
Although these methods are too labor intensive and complex for clinical prac-
tice, EMT clinicians have adapted certain portions of them to be more user friendly
and efficient. For example, data are routinely collected during treatment sessions
on spontaneous, imitated, and prompted communication using operational defi-
nitions. Functional use of language is sometimes evaluated by asking parents to
368 Applications of NDBI Strategies

identify rote or stereotyped speech so it can be eliminated from the analysis, espe-
cially when calculating MLU. Data are collected by listing communication targets
and then either recording examples of each target or tallying frequency. The com-
bination of both types of data has advantages because it provides information on
both frequency and variety in speech. Depending on individual child goals, data
may also be collected on variables such as communication function (e.g., comment
vs. request) and other characteristics of language (e.g., scripted vs. spontaneous
speech). Because most data are collected using frequency recording, graphing is
then used to summarize the data and make programming decisions. In EMT, data
are often collected on both parent use of treatment strategies (treatment fidelity)
and child communication targets.
Although EMT data collection is not as clearly spelled out as some of the data
collection methods discussed previously, it is nonetheless an intuitive and straight-
forward approach to data collection that is consistent with ABA intervention over-
all. It is also very similar to the strategies used in PRT, which are discussed next.

Pivotal Response Treatment

PRT uses data collection methods that are very similar to those outlined for EMT
(Koegel & Koegel, 2006). PRT data are most commonly taken on operationally
defined target behaviors, such as spontaneous, imitated, prompted, and stereotyped
speech. Representative samples of behavior or probes are more commonly gathered
in PRT than trial-by-trial data across a treatment session. For example, a common
method used in PRT is to transcribe a 10-minute language sample and code the
language in vivo by function (e.g., behavior regulation vs. joint attention), includ-
ing prompt levels (e.g., independent vs. [model] prompted), variation (e.g., num-
ber of different words used vs. frequency of functional utterances), and frequency
(e.g., number of words or number of utterances). As in EMT, these procedures are
also readily adapted depending on child goals. Because PRT sometimes consists of
weekly parent training sessions, data collection methods may be adapted to this
session frequency. For example, a language sample such as the one described previ-
ously may provide broader data that are more useful than trial-by-trial data from
week to week. Parent-collected data are also commonly used in PRT because clinic
sessions may only occur weekly. Data collection procedures may need to be modi-
fied to make them user friendly for parents. For example, it may be more feasible for
a parent to take data on one target behavior for a short time period (e.g., 10 minutes)
than to have him or her monitor a behavior throughout the day. In PRT, data are
typically graphed or visually represented in some way, similar to EMT.
PRT also incorporates measures of parent treatment fidelity, which can be
scored during sessions or later by video review. There are several parent treatment
fidelity measurement strategies outlined in the literature, including procedures for
coding videos for the PRT intervention strategies and checklists such as the one
described in the Project ImPACT manual. Parents may also be able to take data
on treatment fidelity using checklists or treatment logs. For example, checklists
that ask parents to rate their use of the PRT strategies have been used, as have logs
where parents give a broad estimate of how many trials they provided during each
major routine of the day (e.g., getting ready in the morning, after school, bedtime
routine). Parents have also been asked to take data on 10 minutes of PRT practice
per day as one way to get a representative sample of their PRT treatment fidelity.
 Collecting Data in NDBI 369

Like EMT, PRT data collection is straightforward and primarily relies on use
of ABA procedures in the natural environment. PRT does not have any published
or widely used data collection methods, and clinicians will need to develop their
own data sheets and data analysis methods when using these treatment models.

Joint Attention, Symbolic Play,

Engagement, and Regulation (JASPER)
Data collection methods for JASPER (Joint Attention, Symbolic Play, Engagement,
and Regulation) are not as clearly spelled out in the literature as other models
(Kasari, Paparella, Freeman, & Jahromi, 2008). There are some general guidelines
available; however, at this time, clinicians targeting the joint attention and play
skills addressed in this model need to rely on data collection methods from other
models or from the field of ABA. JASPER specifies that the mastery criteria for treat-
ment goals are typically uniform across joint attention targets and are set at inde-
pendent performance of the behavior three times across two sessions. Skills with
less frequency or that require more prompting are considered emerging. Data are
collected as a frequency count during sessions, and prompt levels are also recorded.
One data collection procedure unique to JASPER is that it suggests that clini-
cians take data on targeted and emerging skills simultaneously (Kasari et al., 2008).
That is, if a skill that is not yet part of the treatment plan is observed, it should be
recorded. In this way, a broad inventory of the child’s existing and emerging skills
is maintained over the course of treatment. This method may be useful across
NDBI and could be applied in a more targeted way when appropriate. For example,
when teaching skills that may rapidly generalize to other areas, data collection on
untargeted areas may be useful (e.g., when teaching pointing for joint attention, it
may be useful to take data on any pointing that occurs for the function of request-
ing). JASPER suggests that generalization should be evaluated by having an inde-
pendent observer, such as a parent or teacher, evaluate carryover of skills to other
settings. Alternatively, if this is not feasible, a clinician can visit other settings to
collect these data.

WHEN AND WHY DATA ARE COLLECTED

Across NDBI and the field of ABA there are many types of data that may be rele-
vant and many methods for collecting those data. In NBDI, the focus is on practical
data collection strategies that can inform treatment in the natural environment and
demonstrate the effectiveness of intervention strategies in both skill acquisition
and behavioral reduction. Over the course of intervention, data are collected at dif-
ferent times and for different purposes (see Box 15.2). Data collection begins before
treatment starts in order to gather baseline data that allow providers to evaluate
treatment progress. It continues during treatment, both to evaluate treatment ef-
fects and to take baseline on new skills as goals are added to programming. It
is also common for new reasons for data collection to emerge, such as the emer-
gence of challenging behavior that requires functional assessment and ongoing
data collection to monitor effects of subsequent treatments. Data on maintenance
and generalization are considered key. The following section provides a number
of considerations that may be helpful when writing treatment plans and thinking
about data collection.
370 Applications of NDBI Strategies

Ready, Set, Implement!

BOX 15.2: Key contexts for data collection
Data should be taken for the following phases or situations:
• Initial assessment and/or baseline
• Acquisition skills
• Emergence of challenging behaviors
• Maintenance skills
• Generalization
• Treatment fidelity

Initial Assessment
Most treatment programs begin with some sort of initial assessment. Described in
Chapter 10, many tools are commonly used during initial assessments (e.g., behav-
ioral observation methods, standardized assessments, checklists, curricular ma-
terials), and these can be used effectively for treatment planning and goal setting.
Because these tools may not yield the kind of data behavior analysts use to evaluate
treatment effects, clinicians should also collect baseline data on target behaviors
being addressed in treatment. For example, using a standardized intelligence or
achievement test may provide useful information, but it will not yield information
that will facilitate evaluation of treatment effects during the first weeks of treat-
ment. Initial assessment tools can provide rich information across a broad range
of developmental domains, and once clinicians set treatment goals, they should
collect baseline data before implementing specific interventions.

Baseline
Although part of treatment planning may involve taking baseline data on individ-
ual target behaviors, baseline data are not necessarily only collected at the begin-
ning of treatment. Any time a new skill is introduced or a new behavior emerges
that is the focus of behavioral reduction procedures, clinicians must first collect
baseline data. There are many strategies for taking baseline data and for deciding
on criteria before moving into the treatment phase for a given goal. For example,
for some skills, baseline can be assessed once (e.g., across one treatment session),
and if it does not meet criteria (e.g., 80%), treatment is initiated. In contrast, it may
be more useful to take baseline data across multiple sessions for some behaviors to
demonstrate stability of data before moving on to treatment. The nuances of how
to select baseline data collection measures are well covered in the ABA literature.
Most important, baseline data must not be overlooked in order to evaluate the ef-
fects of NDBI treatments as they are introduced.
Once the intervention is underway, data are systematically collected on an
ongoing basis throughout the duration of the program. These progress data, cap-
turing the child’s performance on specific target skills, are used to monitor learn-
ing and make any necessary adjustments to the intervention.
 Collecting Data in NDBI 371

Data on Skill Acquisition Target Behaviors

Once a program has started, data should be collected during ongoing treatment in
order to monitor progress on skill acquisition and evaluate the response to treat-
ment. As a recap, skills that are new or continue to be difficult for the child are
called acquisition skills. Data collection methods for skill acquisition may include
trial-by-trial recording of a child’s response to each opportunity, interval record-
ing of child progress during a session, or probes of specific behaviors to examine
progress at specific time periods. The method of data collection should be linked
to the child’s goals and then used to adapt the intervention to the specific needs
of the child and family. Several methods for collecting data during treatment are
outlined later in the chapter. For other considerations and uses of data collection,
see Box 15.3.

Data Collection for Use Within Versus Across Sessions As described pre-
viously, data collection can serve several functions and, therefore, can be used both
during sessions and across sessions. One prominent way data are used during a
session is to assess what level of prompting should be used or if prompting should
be adjusted depending on the child’s response pattern. In ESDM, data are used
during sessions to track which skills have been targeted so clinicians can moni-
tor whether teaching needs to be adjusted over the course of a session to ensure
all goals are worked on. Data are also used to track progress on target behaviors
across sessions. Across sessions, data collection informs about the overall effective-
ness of the treatment and allows for the determination of when goals are met or not
met and when treatment should be adapted or ended.

Data on Prompt Type and Level Data on prompt type and level are often
collected to track progress toward independence. For example, when utilizing
most-to-least prompting procedures where assistance is systematically reduced
from session to session (or trial to trial) until the antecedent stimuli reliably evoke
the target behavior, data on prompts are essential to guide the intervention. Many
of the NDBI models, including ESDM, Project IMPACT, EMT, and CPRT, include
prompt type in their data sheets.
In addition to the type of prompt used, the prompt level is often also recorded.
The level of prompting is usually differentiated as a full or partial prompt, which

BOX 15.3: Data collection during ongoing treatment

Data collection during ongoing treatment is used for the following:
• Evaluating response to intervention
• Troubleshooting when treatment is not working
• Monitoring skill acquisition versus generalization
• Deciding when a goal is met
• Adjusting treatment sessions (planning the session, as in ESDM, or
modifying the prompt level according to progress)
372 Applications of NDBI Strategies

primarily applies to physical prompt-

Prompt level:
F, full; Prompts ing. A partial physical prompt indicates
P, partial guidance is provided to help the child
F / P Ph V Vs G I
complete a portion of a step, whereas
Prompt type: in a full physical prompt, guidance is
Ph, physical; F / P Ph V Vs G I
V, verbal provided to complete the entire step.
Vs: visual; F / P Ph V Vs G I Recording prompt level allows for
G, gestural additional detail, which is especially
I, independent F / P Ph V Vs G I
(no prompt) useful when focused on prompt fad-
ing. Figures 15.1 and 15.2 illustrate how
Figure 15.1. Sample Data Sheet for recording of prompt
level and type.
prompt level and type can be recorded
as part of data collection.

Data on Maintenance of Skills

Once the student meets initial mastery criteria, clinicians should collect data on
maintenance of target behaviors. Tasks that the student has mastered and can pro-
duce consistently and easily are called maintenance tasks, and maintenance refers
to the lasting change in behavior after intervention ends. Maintenance of target
behaviors can be monitored through probes.
Probes are used occasionally but systematically to assess the maintenance and
generalization of skills or target behaviors. Probes can occur during intervention or
after intervention has ended. Probing during instruction can assist the practitioner
or parent in assessing the generalization or maintenance of a skill and adjusting
instruction if needed. Probes after intervention ends help to determine the mainte-
nance of target behaviors. When deciding when to conduct probes, several factors
may influence the timing and frequency, including the severity of the behavior and
the maintenance of the behavior to date. Most data sheets used in ABA allow for
the collection of both skill acquisition data and maintenance data, making it easy to
collect acquisition data on one skill and maintenance data on a separate skill on the
same data sheet. An example of a trial-by-trial data sheet that allows for the selec-
tion of maintenance or acquisition skill is illustrated in Figure 15.3, and an example
of a less structured data sheet is shown in Figure 15.4.

Trials 1 2 3 4 5 6 7 8 9 10
+ + + + + + + + + +
Select
− − − − − − − − − −
One
NR NR NR NR NR NR NR NR NR NR
Prompt
Level/ PP FP G FV PV
Type

Prompt
F = Full V Vs G P
Level/
P = Partial Verbal Visual Gestural Physical
Type

NR = No Response

Figure 15.2. Sample Data Sheet for recording prompt level and type by trial.
 Collecting Data in NDBI 373

Acquisition skill:

Maintenance skill:

Trial 1 2 3 4 5 6 7 8 9 10
Target M M M M M M M M M M
A A A A A A A A A A
Response + + + + + + + + + +
_ _ _ _ _ _ _ _ _ _

NR NR NR NR NR NR NR NR NR NR
Prompt

KEY:
M, Maintenance Skill; A, Acquisition Skill;
NR, No Response.

Figure 15.3. Sample Data Sheet to record one Acquisition Skill and one
Maintenance Skill simultaneously.

Data on Generalization of Skills

Generalization refers to whether the target behavior is exhibited in settings other
than where the instruction or intervention occurred. This means that a child who
can use certain skills under one set of circumstances is able to use the same skills
under different conditions.
Data must ultimately reflect
Data Sheet
that the child can produce
the same response indepen- +
Most frequent
+

dently across contexts in var-

Acquisition prompt level/type Maintenance
Date skills − (If any) skills −

ied ways.
Data collection on gen-
eralization can be obtained
through generalization probes
or by collecting data as treat-
ment is implemented by vari-
ous individuals (e.g., teachers,
parents, staff) and in various
settings (e.g., school, home,
community). Some NDBI,
such as CPRT, include a spe-
cific data sheet to collect data
on generalization of skills.
The CPRT generalization
probe allows for the observer KEY:

to select three materials or

+ = Responds independently to all or almost all (at least 80%) opportunities
√ = Responds independently to most opportunities (50%) but requires support for some opportunities
− = Requires support to respond to all or almost all opportunities.

activities, three settings, and Prompt level:

three partners as important F, full; P, partial.

for the generalization of the

Prompt type:
Ph, physical; V, verbal; Vs, visual; G, gestural.

skill. The observer selects the Figure 15.4. Sample Data Sheet with record for multiple acquisition
Naturalistic Developmental Behavioral Interventions in the Treatment of Children with Autism Spectrum Disorder

material, the setting, and the and maintenance skills.

edited by Yvonne Bruinsma, Mendy B. Minjarez, Laura Schreibman, and Aubyn C. Stahmer.
Copyright © 2020 by Paul H. Brookes Publishing Co., Inc. All rights reserved.
374 Applications of NDBI Strategies

Generalization Data Sheet

partner and collects data on
Indicate the date, setting, and communicative partner, which you will probe the skill. Circle the child’s response as 1) whether the skill is correct,
2) whether the skill is incor-
C, correct ; I, incorrect ; NR, no response.

Skill: rect, or 3) whether no response

Communicative occurred. Generalization data
collection can be obtained
Date Setting Partner Child response

C I NR
with data sheets used for
C I NR
skills acquisition or with spe-
cific data sheets such as the
C I NR one in Figure 15.5.

C I NR
Data on
C I NR Challenging Behaviors
Data collection is usually C I NR

ongoing for challenging be-

haviors and may include fre- C I NR

quency, duration, intensity,

and rate of challenging be- C I NR

haviors. In addition, more

detailed information is col-
C I NR

lected by taking A-B-C C I NR

data (antecedent-behavior-
Figure 15.5. Sample Generalization Data Sheet across settings and
consequence). A common
Naturalistic Developmental Behavioral Interventions in the Treatment of Children with Autism Spectrum Disorder
edited by Yvonne Bruinsma, Mendy B. Minjarez, Laura Schreibman, and Aubyn C. Stahmer.

way of collecting A-B-C data

Copyright © 2020 by Paul H. Brookes Publishing Co., Inc. All rights reserved.

communicative partners.
is to note the start and end
time of the behavior, along with detailed notes from which antecedents and con-
sequences can be extracted later (see Figure 15.6). Alternatively, data sheets can
be prepopulated with common antecedents and consequences to allow for easy
checking off (Figure 15.7). Many other data collection methods for challenging be-
havior exist in the ABA literature and may include strategies that are specific to fre-
quency, duration, and/or intensity data, depending on the behavior being targeted.

Data on Treatment fidelity

It is imperative that data are collected on intervention fidelity, or the extent to
which the treatment is implemented as designed. This means no changes or omis-
sions to the planned intervention occur during treatment. Data on treatment fi-
delity are often measured with checklists in which all components or steps of
an intervention are listed. The observer then checks off all the components used
or steps taken, and a percentage can be calculated by dividing that by the total
number of components or steps in the intervention. A more sophisticated way of
measuring treatment fidelity is by rating each treatment component or strategy on
a Likert scale and setting criterion for achieving treatment fidelity, as illustrated
in Figure 15.8.
It is important to collect treatment fidelity data for anyone implementing
treatment, including professionals, parents, teachers, and staff. As previously
mentioned, some of the NDBI models, such as Project ImPACT and PRT, include
data sheets specifically designed to obtain parent treatment fidelity data, and these
 Collecting Data in NDBI 375

sheets can easily be modi- Antecedent-Behavior-Consequence Data Sheet

fied to take treatment fidelity
data on other implementers.
Antecedents Behavior Consequences
Activity/ What happened right What the behavior What happened
Date/Time Setting Event before the behavior looked like after the behavior

Taking treatment fidelity Date:

data helps identify whether Start:

the parents, teachers, or staff Stop:

have sufficient training to

Date:

implement the intervention

Start:

independently or if more
Stop:

Date:

training and support are Start:

required. Stop:

In addition to checklists Date:

and Likert scales, treat- Start:

ment fidelity has also been Stop:

scored using trial-by-trial Date:

scoring in models such as Start:

PRT (e.g., Hardan et al., Stop:

2015). In trial-by-trial scor- Date:

ing, each trial is scored for Start:

each treatment component, Stop:

and then a percentage of cor- Date:

rect implementation for each Start:

component is calculated, as Stop:

well as a percentage for the Naturalistic Developmental Behavioral Interventions in the Treatment of Children with Autism Spectrum Disorder
edited by Yvonne Bruinsma, Mendy B. Minjarez, Laura Schreibman, and Aubyn C. Stahmer.

overall correct implementa- Figure 15.6. Sample A-B-C Data Sheet with fill in the blanks.
Copyright © 2020 by Paul H. Brookes Publishing Co., Inc. All rights reserved.

tion. Although this method

has been successful in research, in practice it is time consuming and challenging
unless very clear operational definitions of each behavior are available. A recent
study found that more general rating scales, such as those described previously,
have very high agreement with trial-by-trial coding and therefore may be sufficient
for clinical settings (Suhrheinrich et al., 2019). As such, it may be more practical to
use trial-by-trial scoring in special circumstances only. For example, if a child was
struggling to gain a skill and the clinician felt there were inconsistencies in parent
treatment adherence but could not pinpoint them, trial-by-trial scoring could be
useful as a clinical tool to further assess these challenges.

TYPES OF DATA AND MEASUREMENT SYSTEMS

Measurement systems for data collection are extensively described in the ABA lit-
erature (e.g., Cooper et al., 2013), and this chapter can only provide a brief overview
of types of data and measurement decisions. Table 15.1 contains common types of
data that are collected when using behavior analytic interventions that may lend
themselves well to use with NDBI.

Frequency
It is important to calculate both correct and incorrect response rates in order to
assess skill development. Increasing rates of correct responding may indicate
a child is improving, but only if the rate of incorrect responses is decreasing.
 376 Applications of NDBI Strategies

Antecedent-Behavior-Consequence Data Sheet

Child Code Operational Definition:

Behavior

Behavior
Date: Antecedent Observable, specific Consequence
Start Time What happened before description What happened after End time
Date: Given instruction or
qq Yelling
qq Additional prompts
qq End time:
prompt Whining
qq Blocked physical
qq
Asked to wait
qq Throwing
qq aggression
Start time:
Redirected
qq Spitting
qq Blocked self-injurious
qq
Told no
qq behavior
Walked away
qq
Given praise
qq Ignored
qq
Eloped
qq
Physical touch
qq Moved away
qq
Aggression:
qq
(hug/high five) Given item or activity
qq
Given preferred item
qq Self-injurious
qq Removed item or
qq
Given non-preferred
qq behavior: activity
item Other:
qq
Unintentional ignoring
qq Property Destruction:
qq
Intentional ignoring
qq
Other:
qq

Date: Given instruction or

qq Yelling
qq Additional prompts
qq End time:
prompt Whining
qq Blocked physical
qq
Asked to wait
qq Throwing
qq aggression
Start time:
Redirected
qq Spitting
qq Blocked self-injurious
qq
Told no
qq behavior
Walked away
qq
Given praise
qq Ignored
qq
Eloped
qq
Physical touch
qq Moved away
qq
Aggression:
qq
(hug/high five) Given item or activity
qq
Given preferred item
qq Self-injurious
qq Removed item or
qq
Given non-preferred
qq behavior: activity
item Other:
qq
Unintentional ignoring
qq Property Destruction:
qq
Intentional ignoring
qq
Other:
qq

Naturalistic Developmental Behavioral Interventions in the Treatment of Children with Autism Spectrum Disorder
edited by Yvonne Bruinsma, Mendy B. Minjarez, Laura Schreibman, and Aubyn C. Stahmer.
Copyright © 2020 by Paul H. Brookes Publishing Co., Inc. All rights reserved.

Figure 15.7. Sample A-B-C Data Sheet with prepopulated checkboxes.

 Collecting Data in NDBI 377

Fidelity Data Sheet

To achieve fidelity, the adult (therapist, parent) must receive a score of 4 or 5 on each of the technique summary
scores that are being measured.

Low fidelity High fidelity

1 2 3 4 5
Not implemented Implemented Implemented up Implemented a Implemented
throughout session occasionally but to half of the time majority of the time throughout the
misses majority of but misses many but misses some session
opportunities opportunities opportunities

Intervention technique Fidelity Notes

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

Summary 1 2 3 4 5

Naturalistic Developmental Behavioral Interventions in the Treatment of Children with Autism Spectrum Disorder
edited by Yvonne Bruinsma, Mendy B. Minjarez, Laura Schreibman, and Aubyn C. Stahmer.
Copyright © 2020 by Paul H. Brookes Publishing Co., Inc. All rights reserved.

Figure 15.8. Sample Treatment Fidelity Data Sheet for multiple NDBI techniques.
378 Applications of NDBI Strategies

Table 15.1. Types of data

Type of data Definition Uses Example

Frequency The number of Used for behaviors with The number of times a
occurrences of a discrete beginnings and child initiated during a
behavior endpoints 10-minute probe
Rate The number of Used for behaviors with The number of words read
occurrences of a discrete beginnings and per minute across probes
behavior identified endpoints when the of varying lengths
in a ratio of time length of sessions varies
Duration The amount of Used for behaviors with How much time passes
time in which a discrete beginnings between the beginning
behavior occurs and endpoints and the and the end of a tantrum
primary concern is the
length of time a child
engages in a behavior
Latency The measure of the Used for behaviors with The time elapsed between
time between the discrete beginnings and the onset of the question
presentation of endpoints when the “Hi, what is your name?”
a stimulus and clinician is interested in and the response “My
the start of the how long a child takes name is Emily”
response to begin performing a
particular behavior once
the opportunity has been
presented
Intensity The force with which Most often used to Measuring severity of
a response is measure the intensity or aggressive behaviors:
emitted severity of behaviors caused no injury, caused
minor injury but did not
break the skin, caused
minor injury but drew
blood, caused major
injury that required
medical attention

For example, when toilet training, increased voiding in the toilet in the presence
of increasing accidents as well does not represent the same type of progress as in-
creasing voids without accidents.

Rate
Rate is a commonly used measurement in ABA and is calculated by taking the fre-
quency of a behavior and dividing that by the length of time of an observation, re-
sulting in a ratio. A general guideline is that the unit of time stays consistent across
observations so that rates can be compared; however, length of observation periods
can vary. For example, if a student initiates conversations with peers three times
during a 20-minute recess period and five times during a 45-minute recess period,
the rates of initiation would be 0.15 per minute and 0.11 per minute, respectively.
When lengths of observation periods vary, clinicians should annotate the duration
of the observation period as well in order to have a complete understanding of
performance. For example, two children can both perform jumping jacks at a rate
of 0.25 per minute. However, one student is performing at this rate over the course
of 10 minutes, whereas the other student is performing at this rate for 2 minutes.
 Collecting Data in NDBI 379

Duration
There are two common ways to measure duration: duration per session and du-
ration per occurrence. For duration per session, the total amount of time a child
engages in behavior is recorded. For example, if in an hour session, a child engages
in tantrums for 6 minutes, 8 minutes, and 4 minutes, the total duration of the tan-
trum behavior would be 18 minutes. Another way to use duration measures is to
measure per occurrence of behavior. For example, a child might have a goal to stay
seated for dinnertime but frequently gets up. The amount of time the child stays
seated before getting up could be recorded. This may better inform whether stay-
ing seated is increasing over time.

Latency
Latency is used to measure how long it takes for a child to respond once an oppor-
tunity has been presented. Latency is often reported as the average of the latency
measure per observation period. For example, if a child responds within 1 second,
2 seconds, and 3 seconds to a question from a peer within the observation period,
the average latency would be 2 seconds.

Intensity
Intensity is sometimes referred to as severity, or the magnitude or force of a be-
havior. Intensity can be helpful in measuring various behaviors, including self-
injurious behaviors. For example, clinicians might measure the frequency of biting
occurrences, but measuring intensity can provide valuable information about the
severity of the biting. Did the biting leave a red mark or did it break skin? Intensity
may also be used to measure the voice volume of responding. Was the child barely
audible? If so, does that count as an occurrence of responding?
Another way to think about intensity is to ask, “To what degree is the behavior
present?” When measuring intensity, it is important that guidelines are put in place
that clarify levels of intensity so that measurement is consistent across observers.
To the extent possible, these guidelines should consist of clear operational defi-
nitions. For example, clinicians might define biting severity, as mentioned previ-
ously, by defining amount or type of tissue damage associated with the behavior
(e.g., red mark that is gone within a minute is low intensity, whereas broken skin
is high intensity).

Methods of Measurement
Once the type of data to be collected is selected, it is time to choose a measurement
system. Careful selection is less of an issue when using rate and frequency because
these can simply be tallied without any additional tools. For measurements such
as duration and latency, instruments such as stopwatches or phone applications
are generally used. Technology continues to advance, and collecting and graph-
ing data on tablets, phones, and laptops is becoming more common. Once the data
collection method has been selected, clinicians must address additional questions,
such as whether data will be measured on each trial (trial by trial), on a sample of
trials, or a number of other ways, outlined in Table 15.2.
380 Applications of NDBI Strategies

Table 15.2. Method of measurement

Method of
measurement Definition Uses Example

Permanent This method involves It is used when the Clinician calculates

product selecting a product or observer cannot words read per
result that indicates always be present minute from an audio
the occurrence of the when the behavior recording of a child
target behavior, and a occurs. reading aloud.
response is recorded if
the product is or is not
produced.
Time This is a variation of It is used because the If a child is out of his or
sampling interval recording in observer does not have her seat at any time
which the behavior is to observe the behavior during an interval,
recorded if it occurs for the entire interval, it is counted as one
at any time during the just a portion of the occurrence of out-of-
interval. interval or at a specific seat behavior.
time in the interval.
Interval This method documents It is used for behaviors Whole interval: A child
recording whether a behavior with no clear independently played
occurred during a beginning or end during an entire
particular period. (continuous) and/or 30-second interval.
There are two types that occur at a high Partial interval: A child
of interval recording: frequency. independently played
whole and partial during 15 seconds of a
interval. 30-second interval.
Task analysis The process of It is used to break Clinician breaks down
breaking a skill complex tasks into a each step involved in
down into smaller, sequence of smaller tying the child’s shoes
more manageable steps or actions. It or brushing his or her
components. is used for many teeth.
skills, including daily
living skills and
desensitization.
Rating scale This method estimates It is used for rating Motivational rating
the degree to which the severity of the scales are used to
a symptom or behavior. measure symptoms.
characteristic is present.
It is typically presented
with a Likert scale.

Continuous Versus Discontinuous Methods of collecting data are gener-

ally either continuous or discontinuous measurement. Collecting data on every
trial (trial by trial) is a form of continuous measurement, which provides the most
complete description of an individual’s performance. However, collecting data
on every trial might not be feasible across professionals, teachers, and parents.
In addition, collecting data on every trial can have other setbacks, such as increas-
ing the duration of sessions and decreasing a child’s overall exposure to teaching
(i.e., time spent in data collection is not spent teaching) and interrupting reciprocity
of interactions during treatment. Continuous data collection can also be challeng-
ing in the natural environment. Discontinuous measurement, on the other hand,
involves recording data on only a subset of trials. For example, instead of recording
every response during a 10-trial session, clinicians may record data on only the
first 3 trials or on only a portion of an interval. Although discontinuous measure-
ment might be more feasible, it can produce an incomplete record of performance.
 Collecting Data in NDBI 381

Permanent Product Permanent product measurement refers to the measure-

ment of real or concrete objects or outcomes resulting from a behavior after the be-
havior has occurred. All of the types of measurement described in this chapter can
be used in permanent product measurement. In a classroom, a permanent product
might be the number of worksheets completed in a week or an audio recording
of the student reading. At home, this may be the number of dishes washed or the
number of puzzles completed. This type of measurement might be especially help-
ful for teachers who have to attend to all students during instruction but can judge
a student’s performance by how much work the student completed.
There are several advantages to this type of measurement, including that it
provides a more complete picture of the observation, and data for several behaviors
can be collected by reviewing the permanent product multiple times. However,
there are some factors to consider before using permanent product measurement.
If treatment decisions occur during a session (e.g., level of prompting), then real-
time measurement is necessary. Clinicians must also consider how the permanent
product might affect the behavior, for example, if a video recording affects how a
child interacts with the therapist.

Time Sampling (Interval Recording) Time sampling is used when it is not

feasible to continuously observe a child. There are three types of time sampling:
whole-interval recording, partial-interval recording, and momentary time sam-
pling. Whole-interval recording is used to measure continuous behaviors, such as
on-task behavior. An observation period is divided into small intervals, and then
the observer records whether the behavior was present for the entirety of each
interval. For example, if an interval lasted 10 seconds and the student was on-task
for 8 seconds, that interval would not be recorded for on-task behavior. The clini-
cian reports the percentage of intervals in which the target behavior was present
for the entire duration. For example, if a student was on-task for 7 out of 10 inter-
vals, his or her percentage would be 70%. Because any deviation from the target
behavior during an interval results in the entire interval being scored as negative,
whole-interval recording often underestimates the actual percentage of time spent
engaged in the target behavior.
Partial-interval recording is used when the observer is interested in measur-
ing if the target behavior occurs during any point of the interval. For example,
if a student exhibits social engagement behaviors for 2 seconds of a 10-second
interval, the observer would record that interval as correct. Partial-interval record-
ing is useful for behaviors that may be challenging to count but where pauses in
the behavior are appropriate (e.g., remaining engaged in conversation). Because
credit for the entire interval is given if the behavior is present at all, partial-interval
recording may overestimate the actual percentage of time spent engaged in the
target behavior.
Momentary time sampling is used to measure if the target behavior occurs at
the end of each interval. The difference between this type of sampling and whole-
or partial-interval recording is that the observer must continuously pay attention
in whole- and partial-interval recordings, whereas in momentary time sampling,
the observer only records if the behavior occurs at the end of the interval. Momen-
tary time sampling is a useful tool in NDBI because continuous observation can be
challenging while also trying to watch the time interval and record data accurately.
382 Applications of NDBI Strategies

Interval Recording Data Sheet

Behavior

Whole interval: + = Behavior is continuous during the interval

Partial interval: + = Behavior occurs even once during the interval

Momentary: + = Behavior occurs at the end of the interval

Date

Interval Length

Intervals:

10

Activity

Figure 15.9. Sample Interval Recording Data Sheet.

For example, when collecting data on sitting during circle time, data could be col-
lected by rating the behavior every 5–10 seconds, which allows the rater to observe
the child, watch the stopwatch, and code data simultaneously. Figure 15.9 illustrates
how the different methods of time sampling can be used with the same data sheet.
Naturalistic Developmental Behavioral Interventions in the Treatment of Children with Autism Spectrum Disorder
edited by Yvonne Bruinsma, Mendy B. Minjarez, Laura Schreibman, and Aubyn C. Stahmer.
Task Analysis Task analysis
Copyright © 2020 by Paulis the Publishing
H. Brookes process ofrightsbreaking
Co., Inc. All reserved. a skill down into
smaller, ordered components, which can then be taught to an individual (see
Chapter 13 for a detailed description). Task analysis is frequently used to teach
self-help skills (e.g., brushing teeth, washing hands), to teach adaptive skills (e.g.,
counting money, buying groceries), and for desensitization (e.g., going to the den-
tist). When developing a task analysis, the clinician should remember the skill level
of the person so the number of steps and wording match the individual’s develop-
mental level. Once a task analysis is developed, there are a number of chaining pro-
cedures that can be used to teach the skill that are beyond the scope of this chapter
but are readily available elsewhere (e.g., Cooper et al., 2013). Task analysis data
 Collecting Data in NDBI 383

collection and measurement provides ongoing determination of components of the

chain that have reached mastery level. In the single-opportunity method, the clini-
cian assesses the individual’s ability to perform each step in the chain in the correct
order; if only the first 3 steps of a 10-step task analysis are performed correctly, the
teacher stops the assessment, and the rest of the steps are marked as incorrect. In
the multiple-opportunity method, the teacher assists the student in completing the
step if it is performed incorrectly and allows for the student to continue with the
chain; subsequent steps that are performed correctly would be marked as correct.
Example data sheets for task analysis are shown in Figures 15.10 and 15.11.

Rating Scales Rating scales are considered indirect assessments of behavior

and can be used for several purposes, including as part of a functional assessment.
Rating scales are often used in school settings to obtain information from several
informants, including teachers and parents. Rating scales typically assess a wide
range of behaviors and should have strong psychometric properties. In addition to
rating behaviors, rating scales usually include items that assess the extent to which
certain behaviors impede the quality of life of the individual or family. A disadvan-
tage of rating scales is that there is no direct measurement of behavior, potentially
limiting the usefulness and applicability. Box 15.4 summarizes some of the general
reminders to think about when thinking about data collection.

DATA COLLECTION IN THE NATURAL ENVIRONMENT

Though NDBI can be provided in a clinic setting, they are designed for the individ-
ual’s natural environments, and as such, data collection also takes place in natural
environments. Over the course of intervention, data are collected in a variety of
contexts to ensure the child is learning the necessary skills when and where those
skills are needed. In other words, it is important to collect data on the child’s per-
formance in different settings (e.g., home, school, clinic, community), with different
individuals (e.g., parent, siblings, teacher, therapists), across various activities (e.g.,
free play time, bath time, mealtime, structured tasks) and situations within the
same environment (e.g., one-on-one with an adult vs. in a group, when the room
is noisy vs. when it is quiet), and during transitions (e.g., from mealtime to bath
time, from the classroom to the playground, from one play activity to the next).
This helps the team assess whether discrepancies exist between the skills the child
is (and is not) using and the skills needed for successful functioning in varied,
everyday environments.
There are a number of challenges to data collection in naturalistic programs.
The very nature of NDBI is that they are provided in natural settings. Living rooms,
kitchens, backyards, local parks, school, playdates, and the grocery store are all
therapeutic settings to teach skills. In addition, in NDBI, activities are fluid and
shift to accommodate ongoing routines. Trying to collect sufficient data on a single
skill can be difficult when the parent is playing with trains in the living room, then
kicking a soccer ball in the backyard, followed by making a snack in the kitchen,
before going on a shopping trip to the local store. Ensuring the adult has collected
sufficient opportunities or trials to measure progress on a skill in a specific context
can require careful thought about data collection methods and creativity in how
treatment is implemented. Following are some considerations that may be helpful
when collecting data in the natural environment.
 384 Applications of NDBI Strategies

Task Analysis Data Sheet

Target Skill: Dates:

% Independent

Prompting Hierarchy:
I, Independent M, Modeling
VP, Verbal Prompt PP, Physical Prompt
IVP, Indirect Verbal Prompt NR, No Response/Refused
GP, Gestural Prompt

Naturalistic Developmental Behavioral Interventions in the Treatment of Children with Autism Spectrum Disorder
edited by Yvonne Bruinsma, Mendy B. Minjarez, Laura Schreibman, and Aubyn C. Stahmer.
Copyright © 2020 by Paul H. Brookes Publishing Co., Inc. All rights reserved.

Figure 15.10. Blank Sample Task Analysis Data Sheet.

 Collecting Data in NDBI 385

Task Analysis Data Sheet

Target Skill: Shirt on Dates:

2/12 2/15 2/18 2/21

Find tag in neck VP VP I

Put shirt down with neck up and tag on top GP VP VP

Put head in shirt I GP I

Pull head through hole PP PP M

Bring right arm through I I I

Bring left arm through I I I

Pull shirt down I I I

% Independent 57% 43% 71%

Prompting Hierarchy:
I, Independent M, Modeling
VP, Verbal Prompt PP, Physical Prompt
IVP, Indirect Verbal Prompt NR, No Response/Refused
GP, Gestural Prompt

Naturalistic Developmental Behavioral Interventions in the Treatment of Children with Autism Spectrum Disorder
edited by Yvonne Bruinsma, Mendy B. Minjarez, Laura Schreibman, and Aubyn C. Stahmer.
Copyright © 2020 by Paul H. Brookes Publishing Co., Inc. All rights reserved.

Figure 15.11. Sample Task Analysis Data Sheet with example of “shirt on”.
386 Applications of NDBI Strategies

Ready, Set, Implement!

BOX 15.4: Data collection strategies
• Use probing and sampling when appropriate.
• Use video data collection when time is available to score the videos.
• Develop clear and concise data sheets that appropriately measure the
target behaviors.
• Keep data sheets simple, and collect data on multiple goals on one sheet
of paper to reduce flipping through data sheets.
• Ensure data are summarized and analyzed frequently to help guide the
intervention.

Goodness of Fit
Acceptability of assessments and data collection methods is key to their success.
Acceptability can be considered from several viewpoints. First, it is important that
the methods being used are acceptable to those who will be collecting the data. Cli-
nicians must consider and balance variables such as effort required, understand-
ing of the method, and compatibility with other responsibilities. For example, if a
method is easy to understand, but is too time consuming to allow the clinician to
collect data simultaneously while conducting intervention, it is likely to have low
acceptability. Likewise, if a method uses a relatively simple data sheet but requires
complex judgements about behaviors in the moment, it may also have low accept-
ability. When developing data collection methods, these variables should be dis-
cussed with those who will be collecting the data to ensure goodness of fit.
Acceptability must also be considered from a social validity perspective. That
is, because NDBI are implemented in the natural environment, the data collection
method must not be stigmatizing or interfere with the intervention. One way to
assess social validity of data collection methods is to ask the family or involved
individuals about the acceptability of the procedures. Clinicians can also compare
the child with peers in the treatment context and evaluate how much the data col-
lection methods will stand out from the activities of the peers and the adults who
are interacting with them. How obvious data collection methods are should also
be considered from a confidentiality perspective. A child at the park who is being
shadowed by a clinician with a clipboard is very likely to be labeled as receiv-
ing support, which may allow others to be privy to the child’s special needs sta-
tus. In these instances, discreet data collection methods are often useful, as well
as data collection methods that can be conducted on common devices such as
smart phones.

Feasibility
As mentioned throughout this chapter, the feasibility of data collection needs to
be assessed before and throughout treatment because it will also influence accept-
ability. Feasibility and acceptability are closely related, but feasibility may require
 Collecting Data in NDBI 387

some additional assessment. For example, clinicians must consider the skills of the
individual collecting data. Minimally trained classroom aides will have far fewer
skills for handling complex data collection methods than experienced behavior
technicians. Session length may also affect feasibility. For example, it may not be
feasible to take trial-by-trial data across a 3-hour session, but this level of attention
to detail may be easier to maintain across a 1-hour session. Likewise, frequency
of behavior may influence feasibility so that high-frequency behaviors are more
challenging to document than those that are low frequency. The setting in which
data must be collected is also an important factor to consider. For example, data
collection in the living room may be easier than data collection at the park. Fur-
thermore, even within a setting, the activity may affect the data collection. Data
collection on waiting in line for the slide may be much easier than data collection
during a game of Frisbee in which the clinician is the social play partner.

Parent Data Collection in Naturalistic Programs

Caregiver involvement and empowerment are integral components of NDBI. After
parents or other caregivers learn strategies they can use within their daily routines,
it is important that they understand how they can measure their child’s progress.
Parents can begin to identify skills or behaviors to change and may be able to target
those skills independently. Data collected by parents provide the treatment team
with information about how the child is performing without the support of a clini-
cian; it allows the team to assess generalization and maintenance without the need
for clinician presence. When using parent-mediated interventions, it can also be
useful for parents to take intervention fidelity data. For example, in PRT, parents
are sometimes asked to estimate the number of trials implemented within daily
routines as a way of obtaining an estimate of treatment dose.
For some parents, data collection comes easily, and they quickly hang data
sheets on the refrigerator, carry a notebook to record data, or start making notes
on their smartphone. For other parents, however, the task of data collection can be
daunting and may actually seem aversive. It takes months or years to become adept
at implementing NDBI while simultaneously collecting accurate data; expecting
parents to master this skill set while also tending to their child’s needs and other
daily responsibilities may be unreasonable. As such, special considerations may
be helpful when assessing feasibility and goodness-of-fit of data collection proce-
dures to be used by parents.
A first step in engaging caregivers in the data collection process is having
them actively participate in development of their child’s goals. Stakeholder buy-in
is also discussed in Chapter 10. The clinician may review the intervention plan
and ensure the caregiver understands each goal, why it is included in the program,
and how data will be collected. It may be useful to have the parent prioritize those
skills or behaviors that are most important to the family’s quality of life and select
priority goals for parent-collected data, especially because it may only be feasible
for a parent to track one or a small number of behaviors at a time. It may also be
helpful to select behaviors that will show rapid progress, especially initially, so the
parent can see the value in the data he or she is collecting. Skills or behaviors that
are likely to take a long time to change or are severe in nature may be less motivat-
ing for parents to track.
388 Applications of NDBI Strategies

Feasibility and goodness-of-fit considerations should be evaluated with par-

ents just as with clinicians and may include questions such as where the data
sheets will be kept, whether data will be collected on paper or electronically (e.g.,
in a smartphone), what type of data a parent feels will be easiest or make the most
sense (e.g., tallies in categories of behavior vs. writing a narrative), how often a
parent feels he or she can take data, and how many goals the parent feels he or she
can track at one time. When thinking about how the data will be collected, clini-
cians should first determine with parents if it will be on paper or electronic. Many
parents prefer smartphone use because they tend to have their phones available
most of the time.
Once the format is decided, the clinician and parent can collaboratively deter-
mine the type of data (e.g., tallies, checkboxes, or coding on a predetermined data
sheet vs. written narrative that a clinician can derive the data from). Although cer-
tain behaviors may lend themselves best to a certain data collection method, flex-
ibility may be required in order to accommodate parent needs and increase parent
adherence to the selected data collection method. For example, using a functional
assessment data sheet with predetermined antecedents and consequences may be
an easier way to immediately see the patterns in behavior; however, parents may
have a hard time knowing how to categorize the behaviors they are seeing. In this
case, a written narrative of A-B-Cs may be more accurate, and a clinician can then
derive the A-B-Cs and transfer them to another functional assessment data sheet
to summarize the data.
How much data a parent will collect is another important consideration.
Unlike clinicians, who are solely focused on the child they are working with, par-
ents have many competing demands in the natural environment. Depending on
the behavior, continuous data collection may be more desirable than probe data
collection from the clinician perspective; however, parents may not be able to take
data continuously unless the behavior is low frequency or only occurs in a narrow
context. As such, it may be more feasible to have parents take probe data, which
can then either be analyzed as frequency within a set time frame (e.g., 10 minutes)
or rate if the time frame varies. When asking parents to collect probe data, clini-
cians should work with the parents to define when the data will be collected. For
example, some parents may easily make independent decisions from day to day to
take data during an appropriate period, whereas other parents may be more suc-
cessful with a clearly defined time or routine for taking data (e.g., every day after
dinner for 10 minutes of play, daily during the bath routine).
When considering the burden on parents of data collection, clinicians should
also consider the number of goals being tracked. Some parents may be able to track
several behaviors at once, whereas others may need to focus on one behavior at
a time. How often the behavior occurs may affect how many goals a parent can
take data on at once; for example, collecting data across one behavior that occurs
30 times versus three behaviors that each occur 10 times provides data on 30 behav-
iors either way.
The most important part when helping parents to learn data collection meth-
ods is a focus on setting them up for success. Unlike direct teaching methods that
result in immediate successful responses for the child and thus reinforcement of
parent behavior, data collection may yield more delayed reinforcement for par-
ents. As discussed, feasibility and goodness of fit are of utmost importance, as is
 Collecting Data in NDBI 389

BOX 15.5: Examples of practical questions for parents

Use the following questions to create a feasible data collection method that
will be a good fit for a parent, caregiver, or family.
• Do you prefer to take data on paper or on a smartphone or device?
• If paper, where will you keep your data sheets? For example, on
the fridge, in a notebook, or on the counter? Will a pen or pencil be
accessible?
• Do you prefer a data sheet with checkboxes or coding procedures that
might require some training during treatment sessions first or would you
rather write down what happened in narrative form?
• What is your estimate of how often this behavior will occur? Do you think
it is feasible or makes sense to record every instance of the behavior? If
we only recorded it for a short period of time (e.g., 5–15 minutes), would
it occur? (Note: Depending on the behavior, clinicians may already know
the answers to these questions.)
• Depending on how often each behavior may be happening, do you think
we can/should take data on more than one behavior at a time?

setting reasonable expectations. Starting with an “anything is better than nothing”

mentality can be helpful so parents can feel successful and eventually build up
to more consistent data collection. Working collaboratively to determine the best
methods can also build buy-in and success. Box 15.5 provides a practical list of
questions clinicians can ask parents in order to develop successful data collection
methods for home and community settings.

CONCLUSION
All NDBI place emphasis on the importance of data collection, although data col-
lection methods may differ. The goal of this chapter was to review data collec-
tion methods and types of data commonly used and collected in ABA but also to
provide a number of variables to consider when developing data collection meth-
ods for use in NDBI. Although clinical expertise is required to develop data collec-
tion methods from scratch, the content in this chapter should be useful in helping
clinicians to build this skill set, especially as applied to interventions in the natural
environment.

REFERENCES
Bruinsma, Y., & McNerney, E. K. (2012). Pivotal Response Treatment. In P. A. Prelock & R. J.
McCauley (Eds.), Treatment of autism spectrum disorders: Evidence-based intervention strate-
gies for communication and social interactions (pp. 281–312). Baltimore, MD: Paul H. Brookes
Publishing Co.
Cooper, J. O., Heron, T. E., & Heward, W. L. (2013). Applied behavior analysis (2nd ed.). Upper
Saddle River, NJ: Pearson/Merrill-Prentice Hall.
Hancock, T. B., & Kaiser, A. P. (2012). Implementing enhanced milieu teaching with children
who have autism spectrum disorders. In M. E. Fey & A. G. Kamhi (Series Eds.) & P. A.
390 Applications of NDBI Strategies

Prelock & R. J. McCauley (Vol. Eds.), Communication and language intervention series. Treat-
ment of autism spectrum disorders: Evidence-based intervention strategies for communication and
social interactions (pp. 163–188). Baltimore, MD: Paul H. Brookes Publishing Co.
Hardan, A. Y., Gengoux, G. W., Berquist, K. L., Libove, R. A., Ardel, C. M., Phillips, J., . . .
Minjarez, M. B. (2015). A randomized controlled trial of pivotal response treatment group
for parents of children with autism. Journal of Child Psychology and Psychiatry, 56(8), 884–892.
Ingersoll, B., & Dvortcsak, A. (2010a). Teaching social communication to children with autism:
A manual for parents. New York, NY: Guilford Press.
Ingersoll, B., & Dvortcsak, A. (2010b). Teaching social communication to children with autism:
A practitioner’s guide to parent training. New York, NY: Guilford Press.
Kaiser, A. P., & Hampton, L. H. (2016). Enhanced milieu teaching. In R. McCauley, M.
Fey, & R. Gilliam (Eds.), Treatment of language disorders in children (2nd ed., pp. 87–120).
Baltimore, MD: Paul H. Brookes Publishing Co.
Kasari, C., Fannin, D. K., & Goods, K. S. (2012). Joint attention intervention for children with
autism. In P. A. Prelock & R. J. McCauley (Eds.), Treatment of autism spectrum disorders:
Evidence-based intervention strategies for communication and social interactions (pp. 139–162).
Baltimore, MD: Paul H. Brookes Publishing Co.
Kasari, C., Paparella, T., Freeman, S., & Jahromi, L. B. (2008). Language outcome in autism:
Randomized comparison of joint attention and play interventions. Journal of Consulting
and Clinical Psychology, 76(1), 125–137.
Koegel, R. L., & Koegel, L. K. (2006). Pivotal response treatments for autism. Baltimore, MD:
Paul H. Brookes Publishing Co.
Rogers, S. J., & Dawson, G. (2010). Early Start Denver Model for young children with autism: Pro-
moting language, learning, and engagement. New York, NY: Guilford Press.
Schwartz, I. S., Ashmun, J., McBride, B., Scott, C., & Sandall, S. R. (2017). The DATA Model for
teaching preschoolers with autism: Blending approaches to meet individual needs. Baltimore, MD:
Paul H. Brookes Publishing Co.
Stahmer, A. C., Suhrheinrich, J., Rieth, S., Schreibman, L., & Bolduc, C. (2011). Classroom piv-
otal response teaching for children with autism. New York, NY: Guilford Press.
Suhrheinrich, J., Dickson, K., Chan, N., Chan, J. C., Wang, T., & Stahmer, A. C. (2019). Fidelity
assessment in community programs: An approach to validating simplified methodology.
Behavior Analysis in Practice, online First, 1–11. https://doi.org/10.1007/s40617-019-00337-6
16
Identifying Quality
Indicators of NDBI Programs
Aubyn C. Stahmer, Sarah R. Rieth, Brooke Ingersoll, Yvonne Bruinsma, and Aritz Aranbarri

T
he quality of community programs serving children with autism spectrum
disorder (ASD) can be quite variable. Some programs are using evidence-
based strategies and have mastered using them with fidelity in their programs,
and others may not have the training and experience needed to use Naturalistic
Developmental Behavioral Intervention (NDBI) strategies effectively. This chapter
provides information about how to decide if an NDBI program is high quality. The
intention is to help programs ensure that they have in place the pieces of a high-
quality program that are known to be most effective for children and families.

QUALITY INDICATORS VERSUS COMMON FEATURES

This book describes the common features necessary for a program to be considered
an NDBI program (see Chapter 2 for a review). Having those common features is
necessary, but not sufficient, to ensure a program is effective for children and fami-
lies. Each feature or strategy must be completed competently and consistently. This
chapter provides simple ways to ensure that NDBI features are implemented with
high quality by identifying specific quality indicators (see Box 16.1). Quality indi-
cators are defined, evidence-based measures of program quality that can be used
to measure and track clinical performance and outcomes. For a more thorough
description of a specific procedure, refer to the relevant chapter.

SPECIFIC PROGRAM ELEMENTS TO

LOOK FOR IN A QUALITY NDBI PROGRAM
A quality NDBI program must have defined procedures, treatment fidelity mea-
surement procedures, individualized programs for the child and family, clearly
defined treatment goals, progress tracking, and quality staff training.

391
392 Applications of NDBI Strategies

BOX 16.1: Elements of a quality NDBI program

1. Defined procedures: Does the program have an intervention manual
available?
2. Treatment fidelity measurement procedures: Does the program have a
way to measure how well providers use NDBI?
3. Individualized programs for the child and family: Are families included as
partners in developing the NDBI program and treatment goals?
4. Clearly defined treatment goals: Are goals developed based on an
assessment of the child’s developmental level?
5. Progress tracking: Are data collected regularly and used to make changes
to goals and programs?
6. Quality staff training: Does the program have a clear training plan that
includes active learning, coaching, and ongoing supervision?

Defined Procedures
For an intervention to be considered an NDBI, its procedures must be clearly de-
scribed and written down so that everyone using the intervention is doing roughly
the same thing. This process, called manualization, is a key aspect of evidence-
based practice and is important for accurate training and implementation of an
NDBI (Durlak & DuPre, 2008; Fixsen, Naoom, Blase, & Friedman, 2005). Having
clearly described NDBI procedures ensures that everyone is using the intervention
the same way and has the same ideas about the essential features of the interven-
tion. Although referencing the manual by itself can increase a clinician’s skill in
using an intervention, additional training and feedback are typically necessary to
achieve treatment fidelity (Herschell et al., 2009). Treatment fidelity means the in-
tervention is being used as it was designed (see next section). Thus, the existence
of a manual and clearly specified procedures is necessary, but not sufficient, for
appropriate and effective implementation of NDBI (Durlak & DuPre, 2008; Fixsen
et al., 2005).
In line with evidence-based practice, all NDBI have clearly defined proce-
dures and associated methods for measuring and ensuring treatment fidelity for
the intervention strategies used with the child. In addition, some parent-mediated
NDBI also include clearly defined procedures for conducting parent coaching (e.g.,
Project ImPACT). Some NDBI also include additional support materials, such as
checklists, video examples, visual reminders, and self-monitoring tools designed
to help community clinicians and families use the program more successfully.
As of the writing of this chapter, the Early Start Denver Model (ESDM), Pivotal
Response Treatment (PRT), Classroom Pivotal Response Training (CPRT), and
Project ImPACT (Improving Parents as Communication Teachers) manuals have
each been published and can be purchased directly by clinicians or parents. Other
NDBI manuals are forthcoming or may currently only be available through partici-
pation in a training program or directly from the intervention developer.
Key quality indicator: When determining the quality of a community program,
one simple item to look for is whether the teacher, clinician, or supervisor has a
copy of the intervention manual available. Does it seem as if the program is using
 Identifying Quality Indicators of NDBI Programs 393

the manual when training staff, tracking use of the intervention, and making adap-
tations for individual children? If a program says it is using a specific NDBI pro-
gram but does not have a manual available, this might be cause to question the
program’s use of the strategies it reports are being used.

Treatment Fidelity Measurement Procedures

One of the main measures of quality is whether the NDBI procedures are being
used correctly during treatment sessions. This is called treatment fidelity, or the
degree to which the intervention is implemented as it was intended by the de-
velopers (Gresham, MacMillan, Beebe-Frankenberger, & Bocian, 2000). When an
intervention is studied in a research setting, the individuals using the intervention
are required to maintain high levels of treatment fidelity. That is, as part of the
research procedures, they make sure they are doing each step as planned. These
procedures are used in the studies that showed the intervention to be effective. In
community care, however, treatment fidelity is not often measured, so it is hard to
know if the intervention is being used as planned.
Oftentimes, treatment fidelity in the community is not measured because
there is not a feasible way to do it. Researchers traditionally have used compli-
cated and time-consuming methods of checking how well their procedures are
being implemented, which is not practical in the real world. However, researchers
have begun to develop new, simpler ways of checking how well intervention proce-
dures are being used. For example, the National Professional Development Center
for Autism’s (NPDC) Autism Focused Intervention Resources and Modules (AFIRM)
include implementation checklists for each evidence-based practice (https://afirm
.fpg.unc.edu). Even though it may take extra time, measuring treatment fidelity is
important for several reasons (Hume et al., 2011).
First, treatment fidelity affects child outcomes (Durlak & DuPre, 2008; Gresham
et al., 2000; Stahmer & Gist, 2001; Strain & Bovey, 2011). Educators, practitioners,
clinicians, and other professionals want to make a difference for children. With-
out accurate measurement of how intervention components are being used (or not
used), they cannot draw clear conclusions about how the pieces of the intervention
affect children. If a child is not making progress, providers do not know if it is
because the child is not responding well to the intervention, because the interven-
tion is not being done correctly, or because important pieces of the intervention
are being left out. The use of a treatment fidelity checklist can tell providers which
components are being used well and where providers might need to improve. By
checking the treatment fidelity of their intervention, providers can safely say that
good child outcomes are likely because of the intervention they are using. If chil-
dren are not making good progress, providers may need to try something new.
Second, without some type of measurement of treatment fidelity, providers
have no way to know if the procedures are being used with high quality. In fact,
providers do not know if most of the steps of an intervention are being used at all.
When providers are looking for quality indicators of a program, treatment fidelity
to whatever practice they are using is essential.
Third, treatment fidelity measurement is very important for training. Just as
they develop measureable goals for children, adults learning new skills also need a
way to measure and track their progress. Treatment fidelity measurement can help
supervisors know where support is needed, and it can help providers know when
to ask for help or where to put their practice efforts. Tracking treatment fidelity can
394 Applications of NDBI Strategies

also let a program manager know when it is okay to have a new provider work
independently with a child in a successful way. It may also be important to have
clear treatment fidelity measures to document that therapists have received appro-
priate training. Many more insurance companies are beginning to require clear
documentation of therapist training and many states are beginning to have state
licenses or credentials that therapists must obtain. As the onus is often on agencies
and providers to take responsibility for the appropriate training and credentialing
of their therapists, clear treatment fidelity procedures, measures, and documenta-
tion are important in this context.
Fourth, treatment fidelity is important for making sure the intervention prac-
tices are used well over the long term. Oftentimes there will be drift in practices as
individuals go back to old habits or begin to adapt strategies. Periodically measur-
ing treatment fidelity can keep everyone on track and make sure everyone uses
strategies consistently over time. Finally, measuring treatment fidelity can help
users effectively individualize intervention, which is discussed later in this chapter.
Most NDBI programs have some measure of treatment fidelity, at least for
research purposes. These usually measure procedural treatment fidelity (or the
use of key ingredients of the intervention) and therapist competence (the level of
skill and judgment used in executing the treatment; Schoenwald et al., 20l1) and
give a guideline for a minimum level of treatment fidelity needed to be considered
competent. The specific level that is “good enough” to see clinical improvement in
children is often arbitrary. There have been limited studies determining the level
needed to ensure positive outcomes. In research, 80% correct use of strategies is
often the benchmark. This may not be necessary for good outcomes, but research
does not yet have this information.
The other piece that is important is intensity. A provider can be great at using
NDBI strategies, but if he or she never actually uses a strategy, that does not help
much! Although researchers do not know how much is enough for most inter-
ventions, they do know that using NDBI consistently leads to better outcomes
(Pellecchia et al., 2015). So, how can providers track these things in practice?
As mentioned previously, the NPDC (http://autismpdc.fpg.unc.edu/) devel-
oped treatment fidelity measures for many of the evidence-based practices, includ-
ing some NDBI. These use a rating scale format so that each step of the intervention
is rated on a 3-point scale, indicating that a step was not implemented, partially imple-
mented, or implemented. Items on the NDBI treatment fidelity list include “choosing
motivating materials/activities to engage learners and promote the use of target
skills,” “following the learner’s lead,” and “expanding the response and provid-
ing the requested material (if the learner gives the target response).” In this way,
providers see which components they are implementing well and which are more
challenging. This can be done both as a self-assessment and as part of a supervisor
or peer feedback session. Few of these brief treatment fidelity formats have been
validated, but there is some new research in NDBI looking at how to simplify this
process for community providers.
In a project looking at PRT, teams compared a research-based treatment fidel-
ity tool to a rating scale format and found good agreement for determining pass-fail
for each component strategy (Suhrheinrich et al., 2019). The authors are currently
working with providers to simplify this process even further into a checklist for-
mat that includes simple ways to provide feedback during training (see Figure 16.1).
 Identifying Quality Indicators of NDBI Programs 395

CPRT Checklist
Name: Date:
Activity:
Easy tasks: Learning goals:
Use the scale below to score your use of each component of CPRT. Then, fill in the narrative boxes with your coach.

− √ +
Did not use this component (Oops!) Used this component sometimes Rocked it; used this component
There were some ways it could often.
have been used better.

Teacher self-
assessment
Antecedent components (CREATE) −/ /+ Notes
1. Ensures student is paying attention before providing a cue

2. Provides clear and developmentally appropriate cues

3. Varies instructions

4. Intersperses learning goals with easy tasks

5. Uses preferred q Individual q Play-based q Enhanced academic
materials
6. Varies materials

7. Gives choices q Between activity q Within activity

8. Follows the student’s lead

9. Takes turns when q Modeling q Social interactions q Turns with peer(s)
appropriate
Waits 5–10 seconds for child to respond (PAUSE)

Consequence components (RESPOND)

10. When rewards are provided, they are direct

11. Provides contingent rewards for appropriate responses

12. Provides reinforcement for good trying (attempts)

Preparation and general session management

1. Identifies effective rewards

2. Amount of reinforcement maintains student motivation

3. Manages distractions from the teaching environment
Eliminates distractions from the teaching environment
4. Maintains control of instructional materials

5. Varies prompt level appropriately

Naturalistic Developmental Behavioral Interventions in the Treatment of Children with Autism Spectrum Disorder
edited by Yvonne Bruinsma, Mendy B. Minjarez, Laura Schreibman, and Aubyn C. Stahmer.
Copyright © 2020 by Paul H. Brookes Publishing Co., Inc. All rights reserved.

Figure 16.1. Classroom Pivotal Response Teaching checklist.

396 Applications of NDBI Strategies

Projects such as these may simplify this process for providers. In the meantime,
when considering whether a program is measuring treatment fidelity, ask how the
program or school decides if a provider is using the NDBI correctly.
Key quality indicator: Does the program have a systematic way to measure how
well the providers are using the NDBI program? Do providers regularly measure
treatment fidelity procedures during provider training and periodically over time?

Individualized Programs for the Child and Family

All children with ASD and their families are different, and even though programs
may have operationalized procedures and high-quality interventions, experienced
clinicians need to understand how to use the strategies in ways that are individual-
ized to each child and family’s needs. Providers should not confuse individualiza-
tion with a decrease in treatment fidelity. A clinician should first learn to use all the
strategies well so that individualization can be thoughtful and systematic. Then,
assessment of child and family needs, coupled with collaborative goal develop-
ment, should be used to adapt the NDBI program to meet the needs of individual
children as well as to ensure fit of the program within the family system, culture,
values, and routine.
There are many ways that programs can be individualized to fit the needs of
the family system, culture, values, and routines. For example, active parent involve-
ment in intervention is a recommended component of NDBI. If goals and strate-
gies that are targeted with the NDBI meet the needs of the family, parents will be
more motivated to participate, and children will make better progress (Brookman-
Frazee & Koegel, 2004; Schreibman & Koegel, 1996). Does the provider collaborate
with families on choosing goals that are important to them? In addition, any use
of NDBI strategies needs to fit into the family context. For example, in some cul-
tures, praising children by saying things such as, “Great job!” and “Way to go!”
does not feel natural. Does the provider work with the parents to understand what
social rewards might be more in keeping with the family culture? In some cultures,
mealtime is a sit-down time with family, whereas for others, children choose when
and where they would like to eat or eat separately from adults. Does the provider
tailor ideas and recommendations about using NDBI strategies during mealtimes
and other routines in a way that matches the family’s day-to-day reality? Quality
treatment plans respect these differences when determining natural rewards and
strategies.
When using NDBI, it is also important to understand family routines because
one of the hallmarks of these programs is using the strategies in natural con-
texts. Generalization of strategies to daily routines can be challenging for families
because most practitioners have caregivers learn in the context of play or other
structured activities. Effective providers will talk with families about how to inte-
grate strategies into usual family routines and activities, which vary by family,
and help problem-solve challenges in different contexts. In this way, families and
providers work together to make the NDBI strategies fit the family, not the other
way around.
In addition, there is some research to indicate that parent-implemented inter-
vention may not be as effective for families who are under very high levels of stress.
This may mean clinician-implemented treatment is a better place to start. High-
quality programs may also consider creative ways to include multiple caregivers
 Identifying Quality Indicators of NDBI Programs 397

through offering flexible times for training, video recording sessions, and conduct-
ing phone meetings with caregivers who cannot attend sessions. Experienced cli-
nicians also understand that different caregivers have different interaction styles
and will adapt the intervention based on that style. For example, some parents may
wish to focus on interaction with toys, whereas others may wish to focus on large
motor or self-help activities. A good program will adapt to these needs and con-
sider the family context in developing an intervention program.
When considering individualization for a specific child, clinicians should use
the data about a child’s current skill level and goal progress to decide which strate-
gies to start with and when to change strategies. For example, a child may be mak-
ing progress on production of nouns but may not be making progress in following
directions using typical NDBI strategies within daily routines and play. A provider
might add more structure, such as visual supports or practicing the specific behav-
ior in a more structured way, to try to help the child learn to follow directions. This
does not mean that more structure should also be added to noun production. Once
the skill is learned in the structured setting, supports might be faded to ensure
independence and generalization. ESDM, for example, has a decision tree that can
be used to help understand when to add more structure when a child needs it
(Rogers & Dawson, 2010). Data on progress should guide these types of changes.
High-quality programs will vary their use of NDBI strategies for individual goals
to maximize child progress and will base any changes on data.
Key quality indicator: Does the program or provider include the family as
a partner in the development of goals and choice of strategies? Are parents and
caregivers (and the person with ASD, if appropriate) integrated into the program
in a meaningful way as an equal part of the intervention team? Does the provider
respect the culture and context of the family as treatment goals and programs are
developed?

Clearly Defined Treatment Goals

One way to determine whether a program is of high quality is to ask about the
process of goal development. Based on research indicating that teaching within a
developmental framework has both long- and short-term benefits, NDBI use this
framework to guide the selection of intervention targets based on child-specific
development, with a particular focus on social-communication. For example, typi-
cally developing infants begin using gestures and other nonverbal communicative
behaviors prior to using words. Thus, when working with a child who is nonverbal
or preverbal, the adult will encourage gesture use prior to language. This is one
way programs can be individualized to the needs of the child.
The types of goals chosen may depend on the specific NDBI program being
used. Although all NDBI target early social-communication development, they
vary on the specific social-communication skills that they emphasize, as well as
whether they include instruction in a broader range of skills. For example, some
NDBI (e.g., reciprocal imitation training [RIT]; Joint Attention, Symbolic Play,
Engagement, and Regulation [JASPER]) focus primarily on nonverbal behaviors
(imitation, joint attention, symbolic play), whereas others, such as enhanced milieu
teaching (EMT), focus more explicitly on language. NDBI also differ in the extent
to which they focus on social-communication development or whether they target
a broader range of developmental skills. For example, Project ImPACT focuses on
398 Applications of NDBI Strategies

social-communication development in the areas of social engagement, communica-

tion, imitation, and play. ESDM uses a comprehensive developmental curriculum
that also targets self-regulation, self-care and independence skills, and preacademic
concepts. A high-quality program will specify developmentally appropriate goals
that fit with the intervention.
An assessment is needed to determine which goals are appropriate. NDBI use
various assessment methods for identifying goals. Some NDBI, such as ESDM, have
a formal assessment process that is directly tied to their curriculum. For example,
ESDM uses a clinician-administered curriculum checklist that is completed within
the context of a 1- to 1.5-hour play-based interaction with the therapist and the
child. The therapist uses specific play-based materials and activities designed to
evoke a defined set of skills across developmental areas, including social, commu-
nication, cognitive, and motor skills. The therapist then develops individualized
goals based on the child’s performance on the curriculum checklist and input from
the parent and other professionals, if relevant.
Parent-mediated NDBI are often more focused on the assessment of child skill
use with the parent. For example, Project ImPACT uses a developmental skills
checklist and naturalistic observation as part of a collaborative goal setting pro-
cess between the parent and clinician. Both the parent and clinician complete the
checklist based on their knowledge of the child’s skills and the observation of a
parent–child and clinician–child interaction. The parent and the clinician then
work together to identify appropriate goals in the areas of social engagement,
communication, imitation, and play.
Other NDBI use less formalized approaches for setting goals that may include
a combination of naturalistic observation, standardized assessment, and parent
report of skills. Some, such as PRT, recommend using existing curricula to deter-
mine the child’s current skill level and form developmentally appropriate goals. If
goals are chosen without an assessment or standard process of some kind, teaching
may not be happening within a developmental framework.
A high-quality goal-setting assessment process should include opportunities
to identify what the child can do not only during a standardized assessment but
also in daily routines. As discussed previously, the assessment and goal develop-
ment should occur in collaboration with parents and caregivers to ensure that any
goals selected match the values and beliefs of the family. Research demonstrates
benefits for both parents and children when clinicians and parents collaborate to
set goals and implement treatment (Brookman-Frazee & Koegel, 2004). Of course,
in using NDBI, the aim is for children to meet their initial goals and move toward
more complex ones, meaning goal setting should be an ongoing and continual pro-
cess in any good treatment program.
Key quality indicator: Does the program use an assessment or curriculum to help
determine the child’s current skill level? Are goals grounded in a developmental
framework and based on the assessment of the child’s skills? Are goals developed
in collaboration with the family?

Progress Tracking
All NDBI emphasize the importance of ongoing measurement of child skill use
to determine progress toward goals and to guide treatment methods. Although
standardized assessments of language and developmental skills are important for
 Identifying Quality Indicators of NDBI Programs 399

evaluating long-term outcomes, they are not as useful for measuring regular prog-
ress toward goals within the time frame needed to monitor and modify treatment
goals and procedures. Progress should typically be monitored about monthly to
quarterly, and standardized assessments often are not recommended to be admin-
istered that frequently. In addition, standardized assessments are usually focused
on broad domains (e.g., receptive language, expressive language) rather than the
type of specific, measureable goals that are part of high-quality treatment. Thus,
NDBI use a variety of behavioral methods for tracking child progress toward goals.
The ongoing interaction between the child and adult inherent in NDBI can
make session-by-session data collection more challenging than more structured
Applied Behavior Analysis approaches (see Chapter 15 for a detailed description
of data collection strategies for NDBI). However, some programs, such as ESDM,
have developed methods for tracking skill use within the session. Other programs
collect session data from video so as not to interrupt the ongoing interaction.
Although possibly more accurate and less challenging than collection within the
session, video-based data collection is time consuming and thus tends to be less
practical for community settings. Other approaches involve periodic tracking of
child skill uses (rather than session by session) using naturalistic observation or the
re-administration of curriculum checklists, usually no less frequently than every
3 months. Multiple data collection methods may be appropriate, and the AFIRM
modules developed by the NPDC offer data sheets for various NDBI (https://afirm
.fpg.unc.edu). Data collection is essential for knowing when a set of strategies is not
working to help a child meet his or her goals and requires summarization methods
(e.g., graphing or summary face sheets) to be effective, as discussed in Chapter 15.
The data collection procedures should clearly link to the child’s goals so the pro-
vider can use the data over time to change strategies, add new goals, and improve
individualization of the program (Simpson, 2005).
Key quality indicator: How are goals developed and tracked? How are data
being summarized and reviewed? Is there a way to measure goal progress over
time and make changes to the program and strategies based on goal progress? Pro-
grams should have an assessment protocol and progress-monitoring system that
can be reviewed to know what skills the program is designed to address, whether
goals are developmentally appropriate, and what progress is being made.

Quality Staff Training

The quality of the training that clinicians receive has a significant impact on their
ability to use NDBI effectively. Although some training likely occurs in the pro-
cess of formal schooling and licensure (where applicable), the majority of service
providers report that most of their training takes place on the job, once they have
begun working clinically. Many clinicians providing the actual service to children
with ASD are paraprofessionals, often not licensed, who are under the supervision
of a licensed, experienced, or specialized clinician. In this service model, the di-
rect services providers ideally receive training and supervision from experienced
and specialized clinicians within their program to ensure service quality. As men-
tioned above, this training is also increasingly required for insurance billing or
state licensing and credentialing.
The presence of formal training for direct services roles within agencies is
crucial because there is significant variety in the amount and content of training
400 Applications of NDBI Strategies

received before service. Providers come to their job with varying backgrounds and
levels of experience. Similar clinical roles (e.g., behavioral therapist) may serve
different populations depending on the organization or setting. To address the full
range of learning needs related to using NDBI, training may be needed on ASD
specifically, on the age or developmental level of children served, on the actual
strategies that compose the approach, or on broader contextual factors of a job, such
as how to work collaboratively with parents and other service providers. For exam-
ple, a provider who previously worked with middle school children with ASD who
is moving into an early intervention program may be familiar with the behavioral
principles and practices that partially compose NDBI, but he or she may need more
instruction on developmentally appropriate strategies for working with young
children or including extended family members in the intervention sessions. Giv-
ing providers background knowledge of the reasoning behind specific practices
and the foundational theories of NDBI (i.e., principles from developmental science
and Applied Behavior Analysis) may facilitate providers’ learning of how to imple-
ment individual strategies and thus may be an important content area for training
(Rieth et al., 2018).
The range of training content for learning to use NDBI is wide. However, clini-
cians typically come to the job with some ability and knowledge on which they can
build. A modularized approach to training, which includes assessment of what cli-
nicians already know and can use and then provides needed training accordingly,
may be a useful and optimally efficient approach for preparing direct services
staff. The skills necessary to use an NDBI strategy can be broken down into several
smaller pieces, and therapists can only be taught those pieces they do not know.
Prior knowledge ideally would be determined by a combination of self-report from
the trainee as well as observation of current clinical skills in practice by a knowl-
edgeable supervisor.
The method in which training is delivered is equally as important as the con-
tent covered. Literature from adult learning theory and health care provider behav-
ior change has identified several effective practices for supporting the learning and
implementation of new strategies by clinical practitioners. Based on this literature,
high-quality training in NDBI should include 1) a manualized procedure with clear
criteria for implementing the intervention; 2) initial training that includes didactic
presentation, model demonstrations of target skills, and opportunities to practice
with coaching; 3) mastery criteria that are related to the provider implementing the
new skills in routine practice and are assessed on a routine basis; and 4) regular and
ongoing supervision that includes structured assessment of treatment fidelity. Taken
together, these elements compose adequate preparation and ongoing support to pro-
viders delivering services to individuals with ASD and their families. Behavioral
skills training, a set of training procedures clearly described in the Applied Behavior
Analysis literature, is a useful framework when developing plans for training staff.
A formal, initial intensive training period is a common approach across
organizations providing behavioral services (LaVigna, Christian, & Willis, 2005).
Research indicates that delivery of the initial content should occur in both verbal
and written form in order to have a maximal impact on knowledge and perfor-
mance (Macurik, O’Kane, Malanga, & Reid, 2008). Advancements in technology
have allowed for initial didactic instruction to occur either in-person or online,
thus potentially decreasing training costs and time commitments for agencies as
 Identifying Quality Indicators of NDBI Programs 401

well as potentially expanding the audience who receives training. Comparisons of

training methods indicate that technology-based (e.g., web-based, video presen-
tations) initial training is equally as effective as or more effective than in-person
information delivery for acquiring knowledge of the content (Macurik et al., 2008).
Regardless of format, several important features of initial training should be
present in high-quality programs. These include opportunities for active learn-
ing (Birman, Desimone, Porter, & Garet, 1995; Garet, Porter, Desimone, Birman,
& Yoon, 2001), reflection and collaboration (Joyce & Showers, 1995; Lieberman &
Pointer Mace, 2008; McLaughlin & Darling-Hammond, 1995), and alignment with
provider needs (Desimone, 2009; Garet et al., 2001). Active learning means that
trainees are not simply passive recipients of information (e.g., watching a pre-
sentation, slide show, or video) but also contribute, act, and respond throughout
the initial training process (Banilower & Shimkus, 2004; Bonwell & Eison, 1991;
Borko, 2004; Darling-Hammond, 1998). Likewise, opportunities for collaboration
and reflection should be present that give trainees a chance to connect the train-
ing content to their own personal experiences and prior background. Last, align-
ment with provider needs ensures that the training offered to providers matches
the skills they need to acquire and fits the individuals and families that they will
serve (Desimone, 2009; Garet et al., 2001). These features (active learning, opportu-
nities for reflection or collaboration, and alignment with provider needs) all serve
as strong quality indicators for the initial training that interventionists receive to
prepare them for work with individuals and families.
Even the best initial training in NDBI strategies, however, is unlikely to be
sufficient to fully support clinicians’ use of an intervention in practice. Research
demonstrates that coaching is crucial in order to promote active and correct use
of the material learned (Beidas & Kendall, 2010; Miller, Yahne, Moyers, Martinez,
& Pirritano, 2004; Odom, 2009; Scheuermann, Webber, Boutot, & Goodwin, 2003;
Sholomskas et al., 2005; Stahmer, Suhrheinrich, & Rieth, 2016; Suhrheinrich, 2011).
In education, support from a coach has been shown to make it 13 times more likely
that a teacher will use an intervention (Driscoll, Mcardle, Plumlee, & Proctor, 2010).
Coaching typically involves an expert, supervisor, or mentor observing a clinician
using an intervention and then providing specific feedback on the strengths and
weaknesses of what the clinician is doing (Lee, Frey, Herman, & Reinke, 2014).
The most important part of coaching appears to be receiving performance
feedback because this is the piece that is consistently related to the clinician using
the intervention as it was intended (Reinke et al., 2014). This may take the form of
formal, structured feedback (e.g., a treatment fidelity checklist on NDBI compo-
nents or a structured observation), or it may be informal and semi-structured (e.g.,
pointing out what went well and what to improve for next time). The presence of
coaching in a program’s training plan for new providers is a quality marker that
increases the likelihood that providers are receiving training and information that
they will actually be able to use in practice.
After high-quality initial training, it is important to ensure ongoing quality
and sustained use of specific practices over time. Drift inevitably occurs in how
providers use strategies, and direct services providers will undoubtedly encounter
difficult cases or unfamiliar territory in how to apply interventions. Receiving ongo-
ing feedback is important for improving and maintaining treatment integrity and
providers’ confidence in their ability to use the intervention (Bush, 1984; Cornett
402 Applications of NDBI Strategies

Quality Indicator Checklist

Quality elements
Defined procedures
& Knight, 2009). This type
of ongoing feedback is use-
ful from a supervisor, but it
Quality questions Indicators
1.1. Does the program have an intervention manual available?

can also be from peers or col-

leagues because the process
Fidelity measurement 2.1. Does the program have a way to measure how well
providers use NDBI during training and over time?

Staff training of watching another person

3.1. Does the program have a clear training plan for teaching

use strategies and providing

new staff the intervention?

semi-structured feedback
3.2. Does the training include active learning, coaching,
and collaboration?

(e.g., via a treatment fidelity

3.3. Does the program provide ongoing supervision?

Individualized checklist) is likely to improve

4.1. Are families included as partners in developing the
treatment treatment goals?
practice for the observer as
well as the recipient of the
4.2. Are caregivers taught to integrate intervention strategies
into natural routines?

feedback. The presence of

4.3. Are intervention strategies adapted to fit the family
context and culture?

ongoing coaching can also

address the need for training
Treatment goals 5.1. Are goals developed based on an assessment of the
child’s developmental level?

to span a sufficient duration

5.2. Are goals clearly defined and measurable?

of time, meaning it is spread

out over multiple months
5.3. Are goals functional for the child and family?

Progress tracking or contacts with supervi-

6.1. Are data collected regularly to track progress?

sors or trainers, rather than

occurring in a single-shot
6.2. Are these data summarized and reviewed regularly by a
lead therapist (e.g., Board Certified Behavior Analyst)?

intensive workshop or pre-

6.3. Are these data used to make changes to goals and

sentation (Desimone, 2009;

programs?

Guskey, 1994; Supovitz &

Naturalistic Developmental Behavioral Interventions in the Treatment of Children with Autism Spectrum Disorder

Turner, 2000) because this is

edited by Yvonne Bruinsma, Mendy B. Minjarez, Laura Schreibman, and Aubyn C. Stahmer.

Figure 16.2. Quality Indicator Checklist for NDBI.

Copyright © 2020 by Paul H. Brookes Publishing Co., Inc. All rights reserved.

known to be best practice.

Programs should have training that focuses broadly on the multiple skills
necessary to deliver NDBI (e.g., intervention strategies, developmental appropri-
ateness, ASD, behavioral principles, working with families, parent training) and
involves ongoing monitoring and support. Training should not be a one-time bar
to clear but rather an evolving and continual process of improvement. Regular and
(at least) semi-structured feedback on their use of intervention strategies and their
work with children and families should be consistently available to therapists,
either from a supervisor or a peer.
Key quality indicator: Does the program have a clear training plan for new staff
with didactic training that features active learning, opportunities for reflection or
collaboration, and alignment with provider needs? Is coaching with feedback until
a provider meets mastery criteria part of the program’s training plan? Does the
program have ongoing supervision practices in place to ensure continued quality
after initial training?
Figure 16.2 provides a reproducible checklist that can be used when evaluat-
ing NDBI programs.

CONCLUSION
The goal of this book is to provide practical information about how to use NDBI
to support individuals with ASD from diverse backgrounds, across a variety of
community settings, and to teach a range of skills. The use of high-quality NDBI
 Identifying Quality Indicators of NDBI Programs 403

strategies, regardless of the brand name of the intervention, is motivating for learn-
ers with ASD, improves social relationships and engagement, and increases the
generalization and natural use of new skills. Involving parents and other caregiv-
ers can extend intervention intensity and increase learning opportunities as well
as support family functioning and parental well-being. NDBI strategies were de-
signed specifically for families to use during daily activities and highlight integra-
tion of family input into all aspects of goal development, intervention delivery, and
progress monitoring. Social-communication, as a key challenge for individuals
with ASD, is often the focus of NDBI. Incorporating peers into NDBI programs fur-
ther helps individuals with ASD by supporting both their own social development
and peers’ understanding of how to interact with diverse learners. NDBI strategies
are best used in coordination and with high treatment fidelity to ensure effective
outcomes in individuals with ASD. By understanding the theory behind the strate-
gies; using the examples provided across settings, ages, goals, and skills; and moni-
toring quality indicators, practitioners can use NDBI to enhance the developmental
potential of the individuals with ASD they serve.

REFERENCES
Banilower, E. R., & Shimkus, E. S. (2004). Professional development observation study. Retrieved
from http://www.pdmathsci.net/reports/banilower_shimkus_2004.pdf
Beidas, R. S., & Kendall, P. C. (2010). Training therapists in evidence-based practice: A criti-
cal review of studies from a systems-contextual perspective. Clinical Psychology: Science
and Practice, 17(1), 1–30. https://doi.org/10.1111/j.1468-2850.2009.01187.x
Birman, B. F., Desimone, L., Porter, A. C., & Garet, M. S. (1995). Designing professional devel-
opment that works. Retrieved from http://www.ascd.org/ASCD/pdf/journals/ed_lead
/el200005_birman.pdf
Bonwell, C. C., & Eison, J. A. (1991). Active learning: Creating excitement in the classroom.
Washington, DC: George Washington University, School of Education and Human Devel-
opment. Retrieved from https://eric.ed.gov/?id=ED336049
Borko, H. (2004). Professional development and teacher learning: Mapping the terrain. Edu-
cational Researcher, 33(8), 3–15. https://doi.org/10.3102/0013189X033008003
Brookman-Frazee, L., & Koegel, R. L. (2004). Using parent/clinician partnerships in parent
education programs for children with autism. Journal of Positive Behavior Interventions, 6(4),
195–213. https://doi.org/10.1177/10983007040060040201
Bush, R. N. (1984). Effective staff development in making schools more effective: Proceedings of three
state conferences. San Francisco, CA: Far West Laboratory.
Chan, N., Wang, T., Suhrheinrich, J., Lee, H., & Stahmer, A. (2015, May). Improving fidelity
measurement of pivotal response training to increase systematic use. Poster presented to the
International Meeting for Autism Research (IMFAR), Salt Lake City, Utah.
Cornett, J., & Knight, J. (2009). Research on coaching. In J. Knight (Ed.), Coaching: Approaches
and perspectives (pp. 192–216). Thousand Oaks, CA: Sage.
Darling-Hammond, L. (1998). Doing what matters most investing in quality teaching. New York,
NY: National Commission on Teaching & America’s Future. Retrieved from https://eric
.ed.gov/?id=ED415183
Desimone, L. M. (2009). Improving impact studies of teachers’ professional development:
Toward better conceptualizations and measures. Educational Researcher, 38(3), 181–199.
https://doi.org/10.3102/0013189X08331140
Driscoll, S. K., Mcardle, M. E., Plumlee, M. H., & Proctor, D. (2010). Evaluation of hexavalent
chromium in sediment pore water of the Hackensack River, New Jersey, USA. Environ-
mental Toxicology and Chemistry, 29(3), 617–620. https://doi.org/10.1002/etc.93
Durlak, J. A., & DuPre, E. P. (2008). Implementation matter: A review of research on the
influence of implementation on program outcomes and the factors affecting implemen-
tation. American Journal of Community Psychology, 41(3–4), 327–350. Retrieved from http://
onlinelibrary.wiley.com/doi/10.1007/s10464-008-9165-0/full
404 Applications of NDBI Strategies

Fixsen, D. L., Naoom, S. F., Blase, K. A., & Friedman, R. M. (2005). Implementation research:
A synthesis of the literature. Tampa: University of South Florida, Louis de la Parte Florida
Mental Health Institute, The National Implementation Research Network.
Garet, M. S., Porter, A. C., Desimone, L., Birman, B. F., & Yoon, K. S. (2001). What makes
professional development effective? Results from a national sample of teachers. American
Educational Research Journal Winter, 38(4), 915–945. Retrieved from http://journals.sagepub.
com/doi/pdf/10.3102/00028312038004915
Gresham, F. M., MacMillan, D. L., Beebe-Frankenberger, M. E., & Bocian, K. M. (2000). Treat-
ment integrity in learning disabilities intervention research: Do we really know how treat-
ments are implemented? Learning Disabilities Research and Practice, 15(4), 198–205. https://
doi.org/10.1207/SLDRP1504_4
Guskey, T. R. (1994, April). Professional development in education: In search of the optimal mix.
Retrieved from https://eric.ed.gov/?id=ED369181
Herschell, A. D., McNeil, C. B., Urquiza, A. J., McGrath, J. M., Zebell, N. M., Timmer, S. G.,
& Porter, A. (2009). Evaluation of a treatment manual and workshops for disseminating,
parent–child interaction therapy. Administration and Policy in Mental Health and Mental
Health Services Research, 36(1), 63–81. https://doi.org/10.1007/s10488-008-0194-7
Hume, K., Boyd, B., McBee, M., Coman, D., Gutierrez, A., Shaw, E., . . . Odom, S. (2011).
Assessing implementation of comprehensive treatment models for young children with
ASD: Reliability and validity of two measures. Research in Autism Spectrum Disorders, 5(4),
1430–1440. https://doi.org/10.1016/j.rasd.2011.02.002
Joyce, B., & Showers, B. (1995). Learning experiences in staff development. The Developer, 3.
LaVigna, G. W., Christian, L., & Willis, T. J. (2005). Developing behavioural services to meet
defined standards within a national system of specialist education services. Pediatric Reha-
bilitation, 8(2), 144–155. https://doi.org/10.1080/13638490400024036
Lee, J., Frey, A. J., Herman, K., & Reinke, W. (2014). Motivational interviewing as a frame-
work to guide school-based coaching. Advances in School Mental Health Promotion, 7(4),
225–239. https://doi.org/10.1080/1754730X.2014.949515
Lieberman, A., & Pointer Mace, D. H. (2008). Teacher learning: The key to educational reform.
Journal of Teacher Education, 59(3), 226–234. https://doi.org/10.1177/0022487108317020
Macurik, K. M., O’Kane, N. P., Malanga, P., & Reid, D. H. (2008). Video training of support
staff in intervention plans for challenging behavior: Comparison with live training. Behav-
ioral Interventions, 23(3), 143–163. https://doi.org/10.1002/bin.261
McLaughlin, L., & Darling-Hammond, M. W. (1995). Policies that support professional
development in an era of reform. The Phi Delta Kappan, 76, 597–604. https://doi.org
/10.2307/20405410
Miller, W. R., Yahne, C. E., Moyers, T. B., Martinez, J., & Pirritano, M. (2004). A randomized
trial of methods to help clinicians learn motivational interviewing. Journal of Consulting
and Clinical Psychology, 72(6), 1050–1062. https://doi.org/2004-21587-015[pii]\r10.1037/0022
-006X.72.6.1050
Odom, S. L. (2009). The tie that binds. Topics in Early Childhood Special Education, 29(1), 53–61.
https://doi.org/10.1177/0271121408329171
Pellecchia, M., Connell, J. E., Beidas, R. S., Xie, M., Marcus, S. C., & Mandell, D. S. (2015). Dis-
mantling the active ingredients of an intervention for children with autism. Journal of Autism
and Developmental Disorders, 45(9), 2917–2927. https://doi.org/10.1007/s10803-015-2455-0
Reinke, W. M., Stormont, M., Herman, K. C., Wang, Z., Newcomer, L., & King, K. (2014). Use
of coaching and behavior support planning for students with disruptive behavior within
a universal classroom management program. Journal of Emotional and Behavioral Disorders,
22(2), 74–82. https://doi.org/10.1177/1063426613519820
Rieth, S. R., Haine-Schlagel, R., Burgeson, M., Searcy, K., Dickson, K. S., & Stahmer, A. C.
(2018). Integrating a parent-implemented blend of developmental and behavioral inter-
vention strategies into speech-language treatment for toddlers at risk for autism spec-
trum disorders. Seminars in Speech and Language, 39, 1–11.
Rogers, S. J., & Dawson, G. (2010). Early Start Denver Model for young children with autism: Pro-
moting language, learning and engagement. New York, NY: Guilford Press.
Scheuermann, B., Webber, J., Boutot, E. A., & Goodwin, M. (2003). Problems with personnel
preparation in autism spectrum disorders. Focus on Autism and Other Developmental Dis-
abilities, 18(3), 197–206. https://doi.org/10.1177/10883576030180030801
 Identifying Quality Indicators of NDBI Programs 405

Schoenwald, S. K., Garland, A. F., Chapman, J. E., Grazier, S. K., Sheidow, A. J., & Southam-
Gerow, M. A. (2011). Toward the effective and efficient measurement of implementation
fidelity. Administration and Policy in Mental Health and Mental Health Services Research, 38(1),
32–43.
Schreibman, L., & Koegel, R. L. (1996). Fostering self-management: Parent-delivered pivotal
response training for children with autistic disorder. In E. D. Hibbs & P. S. Jensen (Eds.),
Psychosocial treatments for child and adolescent disorders: Empirically based strategies for clinical
practice (pp. 525–552). Washington, DC: American Psychological Association.
Sholomskas, D. E., Syracuse-Siewert, G., Rounsaville, B. J., Ball, S. A., Nuro, K. F., & Carroll,
K. M. (2005). We don’t train in vain: A dissemination trial of three strategies of train-
ing clinicians in cognitive-behavioral therapy. Journal of Consulting and Clinical Psychology,
73(1), 106–115. https://doi.org/10.1037/0022-006X.73.1.106
Simpson, R. (2005). Evidence-based practices and students with autism spectrum disorders.
Focus on Autism and Other Development Disabilities, 20(3), 140–149. Retrieved from http://foa
.sagepub.com/cgi/content/long/20/3/140
Stahmer, A., Suhrheinrich, J., & Rieth, S. (2016). A pilot examination of the adapted proto-
col for Classroom Pivotal Response Teaching. Journal of the American Academy of Special
Education Professionals. Retrieved from http://aasep.org/aasep-publications/journal-of-the
-american-academy-of-special-education-professionals-jaasep/jaasep-winter-2016/a
-pilot-examination-of-the-adapted-protocol-for-classroom-pivotal-response-teaching
/index.html
Stahmer, C., & Gist, K. (2001). The effects of an accelerated parent education program on
technique mastery and child outcome. Journal of Positive Behavior Interventions, 3(2), 75–82.
https://doi.org/10.1177/109830070100300203
Strain, P. S., & Bovey, E. H. (2011). Randomized, controlled trial of the LEAP model of early
intervention for young children with autism spectrum disorders. Topics in Early Childhood
Special Education, 31(3), 133–154. https://doi.org/10.1177/0271121411408740
Suhrheinrich, J. (2011). Training teachers to use pivotal response training with children with
autism: Coaching as a critical component. Teacher Education and Special Education: The Jour-
nal of the Teacher Education Division of the Council for Exceptional Children, 34(4), 339–349.
https://doi.org/10.1177/0888406411406553
Suhrheinrich, J., Dickson, K., Chan, N., Chan, J. C., Wang, T., & Stahmer, A. C. (2019). Fidel-
ity assessment in community programs: An approach to validating simplified methodol-
ogy. Behavior Analysis in Practice, 1–11. https://doi.org/10.1007/s40617-019-00337-6
Supovitz, J. A., & Turner, H. M. (2000). The effects of professional development on science
teaching practices and classroom culture. Journal of Research in Science Teaching, 37(9),
964–980.
17
Considering Future Directions in NDBI
Laura Schreibman, Mendy B. Minjarez, and Yvonne Bruinsma

A
s demonstrated throughout this book, Naturalistic Developmental Behav-
ioral Interventions (NDBI) were developed with both behavior analytic and
developmental conceptual and theoretical foundations. NDBI enjoy strong
empirical support, demonstrated by a substantial and broad body of research. This
research has shown that NDBI are highly effective with children with autism spec-
trum disorder (ASD) and that they can be implemented with treatment fidelity by a
variety of individuals (e.g., clinicians, parents, teachers) and in a variety of settings,
including the clinic, home, community, and school.
The early studies in the area were primarily single subject design studies
(e.g., Koegel, Camarata, Koegel, Ben-Tall, & Smith, 1998; Koegel, Dyer, & Bell, 1987;
Laski, Charlop, & Schreibman, 1988; Pierce & Schreibman, 1995, Stahmer, 1999),
and this methodology is still employed regularly. In addition, more recent studies
of NDBI have tested their effects via larger randomized controlled trials utiliz-
ing group research designs (e.g., Dawson et al., 2010; Hardan et al., 2015; Kasari,
Kaiser, et al., 2014; Kasari, Lawson, et al., 2014; Landa, Holman, O’Neill, & Stuart,
2011). In essence, NDBI owe their existence to sound single subject design research
that teased out some of the effective components and underlying mechanisms.
Research then systematically advanced these interventions to allow increased
refining of strategies so that NDBI became increasingly effective, efficient, and
tailored to the specific needs of the children with whom they are applied. It is
the nature of all intervention science to continue this improvement and refine-
ment process. Therefore, we have identified the following research directions as
important for future investigation of NDBI (see Schreibman et al., 2015, for a more
comprehensive discussion) as well as future directions for dissemination of NDBI
interventions.

407
408 Applications of NDBI Strategies

RESEARCH FUTURE DIRECTIONS

Although researchers know a lot about NDBI and the effectiveness of NDBI strate-
gies, they can still learn more. This section offers an inventory of six broad areas
that need further exploration and scrutiny. We propose the following future
research directions.
• Increased focus on larger scale and more contemporary pragmatic random-
ized controlled trials (RCTs) to allow for the study of moderators and media-
tors of treatment effectiveness and efficiency in community settings.
The first RCTs addressing NDBI focused on young children with ASD with
the goal of preventing or ameliorating the early social and communication in-
dicators of the disorder (i.e., early intervention) and/or testing the efficacy of
a particular intervention. The effectiveness of NDBI with older children with
ASD or with children who fail to respond to other types of early intervention
has yet to be sufficiently addressed by research (e.g., Kasari, Kaiser, et al., 2014).
In addition, larger RCTs will help identify important mediators and moderators
of treatment, which will help to further tailor treatments to individual children.
For example, Sherer and Schreibman (2005) identified a specific behavioral pro-
file that predicted the effectiveness of Pivotal Response Treatment (PRT). This
study focused on observable behaviors exhibited by the children. Further re-
search must also specify the characteristics of participants in terms of ASD
diagnostic status, particularly communication and social abilities.
Another important focus is on treatment dosage. Future RCTs should
focus on the dosage (hours of treatment) applied and assess child response
over time as a means of investigating outcome effects associated with specific
dosages and time in intervention. Dosage is particularly important in terms of
dissemination of NDBI because many geographic areas experience a shortage
of treatment providers, and information about the lower limits of effective dos-
ing is relevant for developing service models that can serve a larger number of
individuals effectively.
• Measurement of intervention outcomes to evaluate change that is truly
meaningful
Earlier studies of the effectiveness of intervention strategies demonstrated im-
provements in IQ score but more limited changes in core symptoms of ASD and
limited assessment of long-term social functioning. For instance, in Lovaas’s
(1987) early intervention study, determination of “normal” functioning was de-
fined as an IQ score in the average range and successful placement in first grade.
However, IQ score and classroom placement are only two limited measures of a
child’s response to treatment because it is possible to meet both of these criteria
and still have ASD and/or experience ongoing functional impairments. Thus,
it is important to extend outcome assessments to include both proximal and
distal estimates of truly functional changes in the child’s behavior in a variety
of natural social contexts (e.g., interactions with parents and others, behavior
in the classroom, peer interactions). Such studies should include generalization
and maintenance of acquired behavior across settings, people, and time. Com-
mon, standardized measures of social functioning examining changes in ASD
core deficits would also be beneficial.
 Considering Future Directions in NDBI 409

• Empirical analysis of the active components within multicomponent

interventions
All NDBI are composed of multiple components, or elements, as part of an in-
tervention package. Although empirical validation of the packages has been
obtained, the contribution of each embedded element frequently has not been
determined. Also, one or more of the embedded elements may not be required
in order for positive outcomes to be achieved. In order to sort out these types of
questions, dismantling studies, in which individual components are separately
evaluated, are required. Clinicians need to know under what circumstances,
for whom, at what level, and if a particular element is important to include in
the package. Given the renowned heterogeneity of expression of ASD, child
characteristics likely will have a substantial impact on such findings.
The ability to tailor treatments to individual children in a wider variety of
contexts will be enhanced with such studies and a clearer understanding of the
role of treatment package components. Researchers have only begun to explore
these issues in NDBI (e.g., Gulsrud, Hellemann, Shire, & Kasari, 2015). This
will be even more important as treatments are transferred into community set-
tings because community adoption is more likely if interventions are easier to
implement and methods for adoption in different settings with individual chil-
dren are clearly specified. Last, the field would greatly benefit from studies that
establish both conceptual and empirical links between active ingredients and
outcomes, both at the behavioral level and the level of underlying functional
brain activity (Dawson, 2008; Sullivan, Stone, & Dawson, 2014).
• Understanding the necessary procedural treatment fidelity of both treatment
packages and their individual components
The next stage of research in NDBI must involve independent replication of
intervention effects by researchers who were not involved in the treatment’s
development. In addition, procedures often need to be altered and adapted for
cultural and community contexts. Clinicians need to know how NDBI can be
altered for individual children or contexts while retaining their effectiveness.
Means for assessing treatment fidelity for packages as well as components must
be clearly described and available for researchers and providers. Although treat-
ment fidelity measures exist for most NDBI models, these are primarily focused
on treatment fidelity within research studies rather than treatment fidelity of
clinical implementation. Furthermore, for those models that do use treatment
fidelity measurement as part of clinical implementation, the proposed treat-
ment fidelity methods have not been studied for their reliability or validity, nor
have they been compared to alternative ways of measuring treatment fidelity.
Given the pressures on community-based intervention providers to be efficient
with time and justify how it is spent to insurance or other payers, user-friendly
treatment fidelity measures for use in clinical settings are warranted.
• Developing new methodological approaches for testing intervention strate-
gies for improving outcomes of NDBI for all children, including children who
show slower response to a specific intervention.
A substantial advantage of a systematic approach to developing and evaluat-
ing the effectiveness of NDBI is continued research aimed at refining strategies
410 Applications of NDBI Strategies

and understanding how specific NDBI, and their components, interact with dif-
ferent children. Researchers need to more fully understand how existing, and
future, NDBI might be altered or combined to increase the overall positive out-
come rate for all children with ASD. This includes finding strategies to improve
outcomes for children who prove to be the most challenging in terms of treat-
ment response. Researchers studying ASD have begun to explore new research
designs that allow better understanding of how to combine and individualize
interventions (Almiral, Kasari, McCaffrey, & Nahum-Shani, 2018).
• Employing innovative methods to implement and sustain research-based
NDBI in community programs serving children with ASD
As noted previously, research into expanding the use of NDBI in community
settings in which children are more likely to have access to them is an impor-
tant priority. Researchers can develop the most effective treatments possible,
but if these treatments are not accessible to the children and families who
would most benefit, then they have achieved little. Although researchers have
demonstrated the effectiveness of NDBI in laboratory studies, the fact remains
that NDBI are not yet widely delivered in community settings (Hess, Morrier,
Heflin, & Ivey, 2008; Stahmer et al., 2005).
We suggest innovative models of intervention implementation that shift
from the more traditional “uni-directional” model of transferring research-
based intervention into community settings to a more “bi-directional” or recip-
rocal model involving researchers and community providers working together
to establish effective community implementation (Bondy & Brownell, 2004;
Meline & Paradiso, 2003; Weisz, Chu, & Polo, 2004). NDBI may be particularly
well suited for public intervention systems because of their focus on early child
development and the naturalistic strategies required by early intervention leg-
islation. Future research must address the challenges posed by the complexity
of interventions, the cost of high-intensity treatment implementation, and the
demands of training and ongoing support and monitoring (especially in areas
where resources are limited).

DISSEMINATION AND IMPLEMENTATION: FUTURE DIRECTIONS

The need for research regarding community implementation of NDBI also raises
some pressing questions regarding dissemination of NDBI models. NDBI were de-
veloped at universities across the country, and like many other areas of science, the
gap between discovery of knowledge and practical implementation can be many
years. Given the increase in prevalence of ASD and the tremendous lack of avail-
able service providers, a focus on strategies to improve dissemination is warranted.
The following strategies may be helpful to accelerate community implementation.
• Incorporating NDBI training into existing undergraduate and graduate
programs
Undergraduate and graduate degrees and areas of academic focus could be ap-
propriate places to focus efforts in training future clinicians and educators in
NDBI models. Board Certified Behavior Analysts and behavior technicians are
often thought of as the primary agents of intervention for core symptoms for
 Considering Future Directions in NDBI 411

children with ASD. Training programs in behavior analysis are variable in the
extent to which they provide training in naturalistic forms of behavior analysis.
In addition, many programs are quite brief (e.g., 1 year), resulting in a primary
focus on education in core behavioral principles without ample time to cover
NDBI models and strategies in depth.
To expand NDBI use into the schools more effectively, special education
programs could also begin to incorporate coursework regarding the delivery of
such interventions in classroom settings. Psychology and counseling programs
could do the same, especially in light of the focus on the parent training compo-
nents of these interventions. Improvements in the research base, as discussed
previously, are one important step, but educators and community intervention
providers must then carry the findings over into academic training programs.
• Working with community-based providers and educators to implement
treatment
An alternative to inclusion into existing undergraduate and graduate programs
may be to offer NDBI training through continuing education programs on a
wider scale for professionals already licensed or certified. This would provide
an opportunity for more in-depth training and allow for training to meet qual-
ity measures such as treatment fidelity. Although postgraduate certification is
now available through some of the NDBI models, this type of certification is
often research oriented and very expensive. Community providers are often
unable to reimburse these training programs, especially in light of the high
turnover in the industry as a whole.
Clinicians and researchers with NDBI background may also consider how
to develop partnerships with their local service systems, such as early interven-
tion Birth to Three programs, state organizations that support individuals with
developmental disabilities, and school districts. Some NDBI models (e.g., Joint
Attention, Symbolic Play, Engagement, and Regulation [JASPER]; Enhanced
Milieu Teaching [EMT]; PRT) have done research in settings such as schools
and have developed models for school-based dissemination (e.g., Classroom
Pivotal Response Teaching [CPRT]). Continuing both the research and dissemi-
nation efforts focused on public service systems will aid in much wider access
to services for children with ASD, especially those who live in areas where ac-
cess to private treatment agencies is limited.
• Exploring novel service-delivery models that maximize effective implementation
Research and implementation through novel service-delivery models is also
warranted. Although many NDBI rely on clinician expertise, others are partially
or completely parent-mediated. Novel service-delivery methods may include
parent training groups, web-based training, applications that use artificial in-
telligence and smart bots to guide parents through coursework, and telehealth.
Technology can be leveraged to expand access to services, particularly those
that are parent-mediated. Several NDBI have been studied using novel meth-
ods, such as group PRT and Internet-based training in the Early Start Denver
Model (ESDM) and Project ImPACT (Improving Parents as Communication
Teachers). Further work in this area will also enhance access to services.
412 Applications of NDBI Strategies

• Increasing access to published documentation

Although most NDBI have published manuals, dissemination may be acceler-
ated by access to more published documentation, including, but not limited to,
curricula (especially for older children and adults), guides to parent training
(especially for older children and adults), workbooks, data sheets, and check-
lists. These types of intervention supports, guidelines, and instructions will
ensure knowledge is not lost when intervention is disseminated into the com-
munity. Furthermore, considering more bi-directional research that brings to-
gether communities and universities, research institutions may want to engage
with community providers to test the materials they have developed to aid
their implementation.

CONCLUSION
In conclusion, we feel the concept of NDBI provides for parsimony of distinct inter-
vention models (e.g., PRT, ESDM, JASPER) and allows for a clearer appreciation and
understanding by families, professionals, insurance carriers, and other consumers.
Researchers and clinicians must self-identify their intervention as an NDBI strat-
egy. To be identified as such, however, requires that the intervention has strong
empirical support and incorporates the requirements described in this book. Vari-
ous ASD treatment consumers can then have confidence that an intervention has
met the qualifications and requirements of NDBI. We are hopeful that our field will
continue to advance and collaborate. This book is likely only the beginning of a
movement to bring research and practice together and into the communities where
these interventions are needed most. We hope this book is one positive way to help
practitioners and others understand and use NDBI.

REFERENCES
Almiral, D., Kasari, C., McCaffrey, D. F., & Nahurn-Shani, I. (2018). Developing optimized
adaptive interventions in education. Journal of Research on Educational Efficiency, 11(1), 27–34.
Bondy, E., & Brownell, M. T. (2004). Getting beyond the research to practice gap: Research-
ing against the grain. Teacher Education and Special Education: The Journal of the Teacher Edu-
cation Division of the Council for Exceptional Children, 27, 47–56.
Dawson, G. (2008). Early behavioral intervention, brain plasticity, and the prevention of
autism spectrum disorder. Development and Psychopathology, 20, 775–803.
Dawson, G., Rogers, S., Munson, J., Smith, M., Winter, J., Greenson, J., . . . Varley, J. (2010).
Randomized, controlled trial of an intervention for toddlers with autism: The Early Start
Denver Model. Pediatrics, 125, 17–23.
Hardan, A. Y., Gengoux, G. W., Berquist, K. L., Libove, R. A., Ardel, C. M., Phillips, J., . . .
Minjarez, M. B. (2015). A randomized controlled trial of a Pivotal Response Treatment
group for parents of children with autism. Journal of Child Psychology and Psychiatry, 56,
884–892. doi:10.1111/jcpp.12354
Hess, K. L., Morrier, M. J., Heflin, L. J., & Ivey, M. L. (2008). Autism treatment survey: Ser-
vices received by children with autism spectrum disorders in public school classrooms.
Journal of Autism and Developmental Disorders, 38, 961–971.
Gulsrud, A., Hellemann, G., Shire, S., & Kasari, C. (2015). Isolating active ingredients in a
parent-mediated social communication intervention for toddlers with autism spectrum
disorder. Journal of Child Psychiatry and Psychology, 57(5), 606–613.
Kasari, C., Kaiser, A., Goods, K., Nietfeld, J., Mathy, P., Landa, R., . . . Almirall, D. (2014).
Communication interventions for minimally verbal children with autism: A sequential
multiple assignment randomized trial. Journal of the American Academy of Child and Adoles-
cent Psychiatry, 53, 635–646.
 Considering Future Directions in NDBI 413

Kasari, C., Lawton, K., Shih, W., Landa, R., Lord, C., Orlich, F., . . . Senturk, D. (2014).
Caregiver-mediated intervention for low-resourced preschoolers with autism: An RCT.
Pediatrics, 134, e72–e79.
Koegel, R. L., Camarata, S., Koegel, L. K., Ben-Tall, A., & Smith, A. E. (1998). Increasing
speech intelligibility in children with autism. Journal of Autism and Developmental Disor-
ders, 28, 241–251.
Koegel, R. L., Dyer, K., & Bell, L. K. (1987). The influence of child preferred activities on
autistic children’s social behavior. Journal of Applied Behavior Analysis, 20, 243–252.
Landa, R. J., Holman, K. C., O’Neill, A. H., & Stuart, E. A. (2011). Intervention targeting
development of socially synchronous engagement in toddlers with autism spectrum dis-
order: A randomized controlled trial. Journal of Child Psychology and Psychiatry, 52(1), 13–21.
Laski, K., Charlop, M. H., & Schreibman, L. (1988). Training parents to use the natural lan-
guage paradigm to increase their autistic children’s speech. Journal of Applied Behavior
Analysis, 21, 391–400.
Lovaas, O. I. (1987). Behavioral treatment and normal educational and intellectual function-
ing in young autistic children. Journal of Consulting and Clinical Psychology, 55, 3–9.
Meline, T., & Paradiso, T. (2003). Evidence-based practices in schools: Evaluating research
and reducing barriers. Language, Speech, and Hearing Services in Schools, 34, 273–283.
Pierce, K., & Schreibman, L. (1995). Increasing complex social behaviors in children with
autism: Effects of peer-implemented pivotal response training. Journal of Applied Behavior
Analysis, 283, 285–295.
Schreibman, L., Dawson, G., Stahmer, A. C., Landa, R., Rogers, S. J., McGee, G. G., &
Halladay, A. (2015). Naturalistic Developmental Behavioral Interventions: Empirically
validated treatments for autism spectrum disorder. Journal of Autism and Developmental
Disorders, 45, 2411–2428.
Sherer, M. R., & Schreibman, L. (2005). Individual behavioral profiles and predictors of
treatment effectiveness for children with autism. Journal of Consulting and Clinical Psychol-
ogy, 73, 525–538.
Stahmer, A. C. (1999). Using pivotal response training to facilitate appropriate play in chil-
dren with autism spectrum disorders. Child Language Teaching and Therapy, 15, 29–40.
Stahmer, A. C., Leslie, L. K., Hurlburt, M., Barth, R. P., Webb, M. B., Landsverk, J., & Zhang,
J. (2005). Developmental and behavioral needs and service use for young children in child
welfare. Pediatrics, 116, 891–900.
Sullivan, K., Stone, W. L., & Dawson, G. (2014). Potential neural mechanisms underlying the
effectiveness of early intervention for children with autism spectrum disorder. Research in
Developmental Disabilities, 35, 2921–2932.
Weisz, J. R., Chu, B. C., & Polo, A. J. (2004). Treatment dissemination and evidence-based
practice: Strengthening intervention through clinician-researcher collaboration. Clinical
Psychology: Science & Practice, 11, 300–307.
Glossary

AAC Augmentative and alternative communication. All systems and ways

individuals communicate without speaking. AAC may include picture systems,
tablet systems, and speech-generating devices.
A-B-C sequence Antecedent-behavior-consequence sequence. See also three-
term contingency.
abolishing operations Reduction in value of a reinforcer due to satiation.
acquisition tasks Tasks that are new.
active listening Technique in which the listener fully hears what the other person
says and conveys interest by using nonverbal and verbal messaging.
affective engagement The interactive relationship with positive emotions
between caregiver and child.
affective reciprocity The emotional experience in back-and-forth interactions,
usually between a parent and a child.
affective sharing Automatic mirroring of the other person’s emotional state.
antecedent Preceding event or stimulus that sets the occasion for and influences
the actions or behaviors that follow.
antecedent interventions Strategies that focus on the events or stimuli that
precede a behavior in order to reduce the likelihood of challenging behavior.
backward chaining Instruction begins with the last step of the sequence.
balanced turns Back-and-forth exchanges in activities or with objects in which
both people have more or less the same number of turns.
behavior regulation communicative intents Behaviors that regulate the
behavior of another person.
behavioral momentum Increasing the likelihood of responding by presenting
easier or already acquired tasks to establish a pattern of responding before
presenting the more difficult or newer task.
cascading effect A cumulative effect on development whereby acquisition of
lower level skills propels spreading effects toward other skills.

415
416 Glossary

chaining Breaking a target behavior down into component steps and teaching
the steps individually in sequence; when these steps are performed in sequence,
the target behavior is achieved.
contingent/contingency Dependent and/or temporal relations between operant
behavior and its controlling variables.
continuous reinforcer schedule Every correct response is reinforced.
cooperative arrangements Arrangements of materials so that peers need each
other to complete the activity.
differential reinforcement Reinforcing a specific class of behavior while
withholding reinforcement for other classes of behavior.
directive coaching Telling the parent what to do.
discrete trial training A method of teaching based on Applied Behavior Analysis
principles, where skills are broken into smaller subsets and taught one at a time.
discriminative stimulus A stimulus in the presence of which a particular
response will be reinforced.
dyadic synchrony A regulated, reciprocal, and harmonious interaction between
two people.
echolalia Repetition of noises, words, or phrases.
ecological validity The extent to which research findings can be generalized
to everyday real life. Intervention studies with strong ecological validity are
conducted in a fashion that mimics real life as much as possible. This term
clinically refers to whether interventions are feasible in the natural environment
and whether context-specific barriers have been taken into account, such as
parental involvement and cultural factors.
emotional attunement Being aware and responsive to the other person’s
emotions and non verbal cues.
enticing strategies Animation, narration, imitation, or humor used to increase
the likelihood of child engagement.
environmental arrangement Purposeful planning of a learning environment
and the materials in order to increase the likelihood of appropriate behaviors
and decrease the likelihood of challenging behaviors.
errorless learning Using prompting from most to least intrusive to ensure the
child’s successful responding and high levels of reinforcement.
establishing operations (EO) Environmental event that increases the value of a
stimulus due to deprivation, in this case a consequence.
evidence-based interventions Treatments supported by empirical evidence as
effective.
expansions Response to a child utterance in which something is added to the
child’s language.
 Glossary 417

extinction Removing previously provided reinforcement, decreasing the

likelihood of subsequent behavior. Also called planned ignoring.
extinction burst Temporary increase in the strength of a behavior after extinction
is first employed.
fixed interval schedule of reinforcement The time interval after which rein-
forcement is provided is consistent.
fixed ratio schedule of reinforcement The number of responses between rein-
forcements is consistent.
forward chaining Instruction begins at the beginning of the complete response.
free operant preference assessment Allowing a child free access to all types of
materials (but typically not food) to identify potential positive reinforcers.
function of the behavior The reason a behavior occurs.
functional behavior assessment (FBA) Assessment that identifies and opera-
tionalizes target behaviors—identifies their function or purpose and what
maintains them.
functional communication Practical and meaningful communication skills that
the child can use to be more independent.
functional skills Practical skills that allow individuals to be more independent.
functionally equivalent replacement behaviors New behavior that serves the
same purpose (function) as the previous behavior.
generalization Use of skills across various people, places, and materials.
goodness of fit Contextual fit; the treatment plan works well for stakeholders
in the natural environment (home, school, community), which improves the
likelihood of its long-term use.
IEP Individualized education program. A written education plan designed to
meet a child’s learning needs.
imitation A behavior controlled by any physical movement that serves as a
novel model, has formal similarity with the model, and immediately follows the
occurrence of the model. The model must serve as a controlling variable for the
imitative behavior.
inclusion Including individuals with disabilities in everyday activities
and encouraging them to have roles similar to their peers who do not have
disabilities.
instructional cue Providing an action to assist or encourage the desired response
from the individual. Also see discriminative stimulus.
interval schedule of reinforcement The reinforcer is delivered after a specified
amount of time. Reinforcement is delivered after the first correct response upon
the interval ending.
418 Glossary

joint activity routines Play activities in which both partners have key roles
and build on each other’s contributions. Parents build on child behavior in a
predictable manner and add variation to increase learning opportunities.
joint attention Ability to coordinate attention between objects and people.
Sometimes called triadic attention. Is typically divided into response to joint
attention bids by others and initiations of joint attention bids by the individual.
joint attention initiation Directing another’s attention to an object or event of
interest using eye gaze to share interest and/or pointing and/or giving and/or
showing.
learned helplessness Lack of understanding of the contingency relationship
between responses and reinforcement; this occurs when an individual no longer
responds because he or she no longer associates a response with a consequence.
learning opportunities Teaching trials consisting of antecedents, behaviors, and
consequences.
maintenance tasks Tasks that have been mastered.
mastery criteria The specified standard used to determine whether a new skill
is considered acquired.
modeling Adult demonstration of appropriate responses or behaviors, typically
demonstrating the target skill the child is to perform.
morphology Small units of meaning within words.
motivating operations Environmental variables that strengthen or weaken the
effect of a consequence.
natural environment The context in which the individual lives, goes to school,
works, and/or engages in social or extracurricular activities.
natural reinforcement Reinforcer that has a direct relationship to the behavior
and task; in other words, the consequence is logically related to the response.
negative punishment Positive stimulus is avoided or removed, decreasing the
likelihood of this behavior subsequently.
negative reinforcement Undesirable stimulus or event is removed, stopped, or
avoided after a behavior, which strengthens the behavior, making it more likely
to occur again.
noncontingent reinforcement Reinforcement that is provided independent of
the target behavior.
nonverbal mirroring Term used in enhanced milieu teaching (EMT) to describe
an adult imitating his or her child’s actions.
one-up rule When speaking to children, using one more word than the number
of words the child is using.
operant conditioning Method of learning in which associations are made
between behavior and consequences.
 Glossary 419

operant learning Method of learning that occurs through rewards and

punishments for behavior. Through operant conditioning, an association is
made between a behavior and a consequence for that behavior. Also called
operant conditioning.
operational definitions Clear and specific definitions of behavior that are written
to ensure individuals can reproduce treatment procedures and/or code the same
thing when measuring behavior.
overgeneralization Error as the result of a behavior being under the control of a
stimulus class that is too broad.
paired choice preference assessment Assessment that provides a hierarchy of a
child’s preferences by providing choices.
parent empowerment Providing parents with the resources, tools, and supports
needed to be successful.
PECS Picture Exchange Communication System. A systematic comprehensive
way to teach communication through the use of small cards with simple icons
or photos in six consecutive phases.
peer-mediated intervention Therapy that uses the person’s peers to deliver
treatment.
person-centered planning An ongoing collaborative process in which
stakeholders (e.g., treatment providers, parents, caregivers, school personnel)
partner with the individual with autism spectrum disorder (or any developmental
or medical condition) to develop and actualize that person’s vision for his or her
life and future.
phonology Rules about speech sounds.
pivotal areas Areas that, when targeted, result in widespread gains in untargeted
areas of behavior.
positive behavior support Set of evidence-based strategies used to increase
quality of life and decrease challenging behavior by teaching new skills and
making changes in a person’s environment.
positive punishment An aversive stimulus follows a response and decreases the
likelihood of this behavior subsequently. Also called punishment by application.
positive reinforcement Desirable stimulus or event that occurs after a behavior
and strengthens the behavior, making it more likely to reoccur.
pragmatics Rules for communication through language.
Premack Principle Positioning a higher probability behavior after (or contingent
on) the occurrence of a lower probability behavior in order to increase the
likelihood of the lower probability behavior’s occurrence. Also called first, then.
priming Behavioral intervention involving the presentation of upcoming
activities in a low-demand context with high levels of reinforcement prior to
when the appropriate behavior is expected to be performed.
420 Glossary

prompt Type of antecedent; an additional cue that can be delivered with or after
the initial instructional cue; provides extra support to elicit a correct response.
prompt dependence Pattern in which the child does not engage in the behavior
without prompts or assistance. In other words, the child may become reliant on
prompts to complete a skill rather than gaining the ability to perform the skill
independently.
prompt fading Systematic reduction to less-intrusive prompting with the goal
of independence.
prompting Systematic way of providing and removing assistance to help an
individual learn a skill.
randomized controlled trials Research designs in which individuals are
randomly allocated to groups and compared to each other after implementation
of an independent variable (e.g., a specific treatment).
ratio schedules of reinforcement Every response is not followed by a reinforcer,
but rather reinforcement delivery is determined by the number of responses
that have occurred since the last reinforcement.
recasting Repeating the child’s response. Can be used to expand the child’s
response by adding on to what the child did or said, often along with providing
reinforcement.
reinforcement When an event occurs (is perceived, received, or removed) that
follows and strengthens a behavior, making it more likely to reoccur.
reinforcing attempts Providing reinforcement not only for correct responses but
also for a goal-directed attempt in the right direction.
reliability Whether results are precise enough to be consistently replicated.
replacement behaviors Skills taught to take the place of the challenging behavior.
To be successful, the selected skills must be a response match, be efficient, be
acceptable, and be recognizable.
responsive interaction Ability of the parent or therapist to connect with the
child emotionally. Following the child’s lead, mirroring nonverbal actions
(sometimes referred to as synchronization), and turn taking are examples of
responsive interactions that provide the context and the interaction in which
teaching is optimized.
self-management Monitoring and rewarding of one’s own behavior.
semantics The meaning of words (vocabulary).
sensory social routines Social game made up of a sequence of back-and-forth
actions by parent and child in which repeated actions and affect sharing combine
to enhance social interaction and joint attention.
setting event Prior events or conditions, internal or external to the individual,
that increase the likelihood that an antecedent will evoke a response.
 Glossary 421

shaping Reinforcing successive approximations to the target response.

single subject design studies Research design in which the subject serves as his
or her own control.
social motivation hypothesis of autism spectrum disorder Suggests that
the social reward system in the brain is compromised, resulting in children
with autism spectrum disorder receiving limited reinforcement from social
engagement, which leads to less learning from the environment.
social orienting Develops before joint attention and consists of a child directing
attention to another person: turning to and responding to naturally occurring
social stimuli.
social validity Social importance and acceptability of treatment goals or target
behaviors, intervention procedures, and treatment outcomes. A well-rounded
view of social validity takes into account the acceptability from the perspective
of the client, the treatment provider, and society; however, the client and family
view is often most emphasized.
stimulus discrimination Extent to which a stimulus evokes a specific response
to the exclusion of others.
stimulus generalization When related or similar stimuli evoke the same
response.
stimulus overselectivity Attentional deficit in some children with autism
spectrum disorder wherein a child’s behavior might only be affected by a small
portion of a compound stimulus.
strength of the behavior Behavior’s frequency (how often it occurs, e.g., how many
tantrums in a day), latency (how soon after the antecedent the behavior occurs, e.g.,
how quickly the child says “daddy” when his or her father appears), and magnitude
(with how much force the behavior occurs, e.g., decibel level of screaming).
synchronization Mirroring nonverbal actions.
syntax Rules that govern sentence structure, including word order.
task analysis Process that breaks a complex multistep behavior down into a
sequence of smaller steps or actions.
task variation Providing a mix of targets within a sequence (as opposed to the
same task repeatedly).
three-term contingency Each behavior can be understood and broken down into
what happened before (antecedent or discriminative stimulus), the behavior
(operant response), and the consequence (reinforcer or punisher).
time delays Prompts used to transfer stimulus control from adult prompts to
naturally occurring stimuli by increasing the time between the discriminative
stimulus and the prompt.
topography Description of a behavior without values or expectation.
422 Glossary

treatment fidelity Sometimes called fidelity of implementation or treatment

adherence: the degree of accuracy with which a procedure or a set of strategies
is implemented or used.
validity Represents something accurately and completely.
variable interval schedule of reinforcement Time interval after which
reinforcement is provided varies.
variable ratio schedule of reinforcement Number of responses varies between
reinforcements.
Index
References to tables, figures, and boxes are indicated with a t, f, and b, respectively.
Abolishing operation (AO), 125b
in consequence strategy, 197, 197b
Academic setting, see School setting
Acceptability, see Goodness of fit
Acquisition tasks, 14, 23, 32
data collection and, 371, 371b
social skills and, 248, 266t, 282t, 297
Activities
child-selected, 133–134, 134b, 135t
Classroom Pivotal Response Teaching
(CPRT) examples, 357, 358t–359t
group-based, 61
planning of, 156–160, 157b, 158t–159t
school setting and, 355–357, 356b,
356t–359t
self-regulation behavior and, 323, 327, 333
Adaptive behavior
bathing and, 332–333, 334t, 336t
cooking and, 318, 325, 332–333, 336t
dinnertime meal and, 314, 318, 331, 339
maladaptive behavior and, 10, 339
selecting targets of, 332–333
self-regulation and, 322–326
teaching of, 333–341, 334t–338t
Vineland Adaptive Behavior Scales
and, 52
see also Challenging behavior;
Naturalistic Developmental Behavioral
Interventions
Adaptive Behavior Assessment System
(ABAS), 52, 106
Adult affect, 325
Adult imitation, 11b, 15, 78, 131–132, 284
Affective engagement, 7–8
Affective reciprocity, 7
Affective sharing, 7–8
Affect-laden interactions, 123–124
Age appropriateness, 312
case example of, 114–115, 341, 343
data collection and, 363
of goals, 54, 228, 231
of peers, 109
play development and, 286–288, 287t–288t
of toys, 155
Aggression, 195
in antecedent-behavior-consequence
(A-B-C) data sheet, 376f
self-regulating behavior and, 309–310,
324–326
Aikido, martial art, 68
Alexa’s Playful Learning Academy for
Young Children (PLAYC), 62–63
inclusion and, 102, 112–113
Alternative communication, see
Augmentative and alternative
communication
Americans with Disabilities Act (ADA) of
1990 (PL 101-336), 100
Antecedent, behavior, and consequence
(A-B-C) framework, 6, 23
antecedent-based intervention and,
151–152, 152b
in communication development, 241–242
consequence strategies and, 193, 210
data sheet for, 374, 375f–376f
learning opportunities and, 175–177
sharing control and, 140
Antecedent-based intervention
behavioral momentum in, 166–167
case example of, 171–172
child’s attention in, 166
conclusion on, 172
Early Start Denver Model (ESDM) and,
154–155, 160, 165
engaging and enticing in, 164–165
Joint Attention, Symbolic Play,
Engagement, and Regulation (JASPER)
and, 154–155, 165
routines in, 164–167, 168t–170t
in self-regulation, 311–315, 313b, 318,
341–343
setting events and, 151–152, 152b, 156
423
424 Index
Antecedent-based intervention—continued
shared control in, 167, 168t–170t
task variation in, 166–167
teaching and
see also Naturalistic Developmental
Behavioral Interventions
Antecedents, 31
Applied Behavior Analysis (ABA)
challenging behavior and, 309–322, 313b,
316b, 319b
consequence strategies and, 193, 197, 208,
210
curriculum checklists and, 220–221
data collection and, 361–363, 362b,
366–375, 389
empowering parents and, 85, 91
learning opportunities and, 177, 191
Naturalistic Developmental Behavioral
Interventions (NDBI) and, 3–17, 11b
progress tracking and, 399–400
in social initiations, 278
Assertiveness, 26
Assessment
curriculum-based, 13, 54
free operant preference, 160
functional behavioral assessment (FBA),
310
in goal development, 218–224, 221t, 223t
initial assessment and, 66, 221, 370, 370b
paired choice preference, 160
published curricula and, 53–54
standardized assessments, 219–220
Verbal Behavior Milestones Assessment
and Placement Program (VB-MAPP),
54, 222
Assessment Evaluation and Programming
System for Infants and Children (AEPS®),
54, 222
Assessment of Basic Language and
Learning Skills (ABLLS), 54, 222
Attentional focus, 11b, 15–16, 30, 35t
case example of, 229
inclusion and, 109
in school settings, 354–355, 354t
Attention-deficit/hyperactivity disorder
(ADHD), 341–343
Auditory cues, 332t
Augmentative and alternative
communication (AAC)
device, 188–189
nonverbal individuals and, 253–254
prompting and, 183, 188–189
replacement behavior and, 317
teaching strategies in, 253–254
Autism education associates (AEA), 112
Autism Focused Intervention Resources and
Modules (AFIRM), 357, 393, 399–400
Autism Research Foundation, 100
Autism Society of America, 100
Autism Speaks, 5
Autism spectrum disorder (ASD), 3
communication development and,
237–338
defined, 4–5
developmental science and, 7–10
earliest symptoms of, 7
history of intervention, 5–7
National Professional Development
Center on, 347, 357
social motivation hypothesis of, 22
see also Applied Behavior Analysis;
Naturalistic Developmental Behavioral
Interventions
Autistic Self-Advocacy Network (ASAN), 100
Autoimmune disease, 80
Autosymbolic play, 287t
Aversive sensory input, 61
Backward chaining, 201
Baer, D.M., 11–12, 58
Balanced turns, 78, 91, 92t, 109
motivation and, 141–144, 143t
in social skills, 285, 295–296
Balloons, 135t, 159t, 259t–260t, 282t, 293t
Baseline data, 370
Bathing, 50, 169t, 204t, 291
adaptive behavior and, 332–333, 334t, 336t
Bayley Scales of Infant and Toddler
Development (BSID), 52, 219–220
Behavior, see Adaptive behavior;
Challenging behaviors
Behavior regulation communicative
intents, 251
Behavioral momentum, 137t, 144, 166–167
Behavioral observation, 53
in goal selection, 222–224, 223t
Behavioral Skills Training, 85
Bingo game, 299–300, 319, 321
Board Certified Behavior Analyst (BCBA),
10, 23, 33, 363, 402f, 410–411
Board games, 64, 227, 292, 292b, 296
Body movements, imitation of, 132
Brainstorming, with parents, 84–86, 84t
Brown’s Stages of Language Development,
239
Brushing teeth, 334t
Bubbles
bath time and, 169t
communication behavior and, 250, 260t,
264t
expanding interest and, 135t
goal development and, 227–228
instructional cues and, 181, 184t
 Index
recasting and, 243
time delay strategies and, 283
word vocalization of, 131t, 145–146, 202
Bus schedule, 335t, 338t, 340
Camp settings, 61
Caregiver buy-in, 225–226, 226b
Carolina Curriculum for Infants and
Toddlers with Special Needs, 54
Cascading effect, 8, 230–231
Celebrity advocacy, 4
Centers for Disease Control and Prevention
(CDC), 99
in consequence strategy, 201–202
in self-regulation behavior, 317, 333, 336t,
382
Challenging behaviors
adaptive skills teaching and, 339–341
antecedent interventions, 311–315, 313b,
318, 341–343
Applied Behavior Analysis (ABA),
309–322, 313b, 316b, 319b
behavioral flexibility and, 327–331,
327t–330t
case example on, 341–343
conclusion on, 343
consequence interventions, 317, 343
data collection on, 374, 375f–376f
discrimination training and, 319–321,
319b, 323
extinction in, 318
functional approach to, 311–312
individualized antecedent interventions,
313–314, 313b, 342–343
measurement strategy in, 319–320
Naturalistic Developmental Behavioral
Interventions (NDBI) and, 310–311,
322–326
priming and, 313–314, 313b
prompt fading in, 324–325
reinforcement in, 318–324, 319b, 330–343
replacement behavior and, 314–318, 316b,
322, 326–327
selecting targets of, 332–333
self-management and, 318–319, 319b
self-regulation in, 327t–330t, 332–333
target behavior in, 318–323, 328t–330t,
334t–338t, 340
task analysis, 317, 333
teaching self-regulation in, 339–341
universal antecedent interventions,
312–313, 341
waiting and, 331, 332t
Child-initiated teaching, 11b, 16, 27, 62, 125
Child-parent dyadic play, 31, 33, 52, 141, 165,
279
425
Child-preferred activities, 16
motivation and, 124, 135–136, 141
in school settings, 349–352, 351b
social skills and, 296
Child’s attention, 13, 16, 89t, 135t
in antecedent strategies, 156, 164, 166
consequence strategies in, 205–206, 207t
joint attention behaviors and, 237–240,
240t, 249–252, 252t, 265
see also Joint Attention, Symbolic Play,
Engagement, and Regulation
Child’s lead, 16, 23–25, 29–34
antecedent-based strategies and, 167,
168t–170t
empowering parents and, 78, 81, 89t
motivation and, 124, 134–136, 137t–138t
in peer interactions, 299
social skills and, 289, 290t–291t, 299
Child-selected activities, 23
free play, 134b
motivation and, 133–134, 134b, 135t
self-regulation and, 323, 327, 333
see also Child-preferred activities
Choices, providing of, 136–139, 139t
in school settings, 349–352, 351b
Circle of Friends, 105
Classroom Pivotal Response Teaching
(CPRT), 31
checklist, 392, 395f
data collection and, 365
example activities, 357, 358t–359t
individual goals and, 357, 358t–359t
Cleaning, 137t, 155, 205
adaptive behavior and, 335t
case example of, 114, 116
symbolic play and, 287t
Clear cues, 180, 314, 322–323
Clear instruction
clear rules and, 164, 172
in group settings, 353–354
Clinic settings, 64–65
Clinician, 12, 16, 31, 36
delivered intervention, 78
staff training and, 399–402
see also Data collection
Cognitive subscale, of Bayley Scales of
Infant and Toddler Development
(BSID), 219–220
Common Core State Standards (CCSS), 104,
347–348
Communication and Symbolic Behavior
Scales (CSBS), 52, 219
Communication development
augmentative and alternative
communication in, 253–254
Autism spectrum disorder (ASD) profile
in, 237–338
426
Communication development—continued
Early Start Denver Model (ESDM) in,
240–241, 244, 250–251, 253
goal targeting in, 243–244, 245t–247t
joint attention behaviors in, 237–240, 240t,
249–252, 252t, 265
modeling in, 242–243
narrating in, 242–243
noncontingent reinforcement and,
243–244, 248b, 262, 262t
one-up rule in, 243
Picture Exchange Communication
System (PECS), 242, 245t, 253–254
recasting in, 243
receptive language and, 243, 251, 270t
reinforcing attempts, 244–248
shared control strategies, 243–244,
245t–247t
teaching and
typical children in, 238–240, 240t
visual cues and, 252, 271
Community programs, inclusion and,
106–109
Community settings, 60–62
Compound stimulus, 15
Comprehensive Assessment of Spoken
Language (CASL), 52
Comprehensive treatment model (CTM), 36
Consequence strategies, 317, 343
Applied Behavior Analysis (ABA) and,
193, 197, 208, 210
behavior change and, 199–200, 200t
child’s response in, 205–206, 207t
conclusion on, 210
effectiveness and, 196–199, 197b, 198t
extinction, 194t, 195, 199–201
free play and, 203, 208
natural consequences and, 202–205, 204f
negative punishment and, 194t, 195
negative reinforcement and, 194t, 195,
197–198
positive punishment and, 194t, 195
positive reinforcement and, 193–194, 194t,
203–204
Premack Principle and, 196, 196f
punishment and, 193–195, 194t, 197, 199
reinforcing attempts, 205
shaping and chaining, 201–202
strength of behavior and, 194–195, 194t
troubleshooting, 206–210, 207t
Contextual fit, see Goodness of fit
Contingency, 32
Contingent consequence, 196–199, 197b, 198t
Contingent reinforcement
in communication development, 243–244,
248b, 262, 262t
motivation and, 137t, 140
in school settings, 352
Index
Continuous data collection, 380
Continuous reinforcer schedule (CRS), 200,
200t
Cooking, 50, 111, 160
adaptive behavior and, 318, 325, 332–333,
336t
symbolic play and, 287t, 291t, 301
teaching moments and, 261t, 270t
Cooperative arrangement, 299–301, 302b
Corrective feedback, 88, 89t
Counting money, 326, 335t, 338t
Culture, 47–49
in goal selection, 224–225
Curriculum checklists, 220–221
Curriculum-based assessments, 13, 54
Daily living skills
prompting and, 190
routine in, 9
see also Routines
Data collection
acquisition tasks and, 371, 371b
Antecedent, behavior, and consequence
(A-B-C) data and, 374, 375f–376f
Applied Behavior Analysis (ABA) and,
361–363, 362b, 366–375, 389
Autism Focused Intervention Resources
and Modules (AFIRM) and, 399–400
baseline and, 370
on challenging behaviors, 374, 375f–376f
Classroom Pivotal Response Teaching
(CPRT) and, 365
conclusion on, 389
contexts for, 369–375, 371b, 372f–377f
embedded trials and, 177–179, 178b, 178t
general framework for, 362–363, 362b
on generalization, 373–374, 374f
initial assessment and, 370
Likert scale in, 367, 374–375, 380t
on maintenance of skills, 372, 372f–373f
measurement systems, 379–383, 380t,
382f, 384f–385f, 386b
models of
in natural environments, 383
permanent product, 380t, 381
probes in, 362, 368–373, 378t
prompt type and level, 371–372, 372f
reliability and, 262–263, 262b
across sessions, 371
task analysis in, 382–383, 384f–385f
time sampling, 380t, 381–382, 382f
treatment fidelity and, 374–375, 377f
trial-by-trial
types of data
validity and, 362, 362b, 386
see also Naturalistic Developmental
Behavioral Interventions
 Index
Data sheets, 363, 399, 412
for Antecedent, behavior, and
consequence (A-B-C) framework, 374,
375f–376f
in Classroom Pivotal Response Teaching
(CPRT), 365
in Developmentally Appropriate
Treatment for Autism in Toddlers
(Project DATA), 365–366
in Early Start Denver Model (ESDM), 364
on fidelity, 367, 377f
on generalization, 373–374, 374f
in Project Improving Parents as
Communication Teachers (ImPACT),
366–367
trial-by-trial, 371–372, 373f
Data Summary Sheet, 364
DeMyer, Marian, 5
Denver model, original, 22–23
see also Early Start Denver Model
Depression, 80, 326
Depth, of skills, 231
see also Goal development
Developmental cascades, 230–231
Developmental pragmatic communication
approach, 24
Developmentally Appropriate Treatment
for Autism (Project DATA), 21
data collection and, 362, 365–366
goal development and, 214, 222
inclusion and, 102
manual, 54
Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5), Autism
Spectrum Disorder (ASD) criteria for, 5
Differential Ability Scales (DAS), 219
Differential reinforcement, 10
Dining behavior, 64, 107, 115
Dinnertime meal, 9, 47, 68
adaptive skills and, 314, 318, 331, 339
consequence behavior and, 194, 196f
data collection and, 379, 388
motivational behavior and, 136, 138t, 141
shared control and, 247t
Direct reinforcement, 104, 210, 245t
in group settings, 348, 352
Directive coaching, 82
Discontinuous data collection, 380
Discrete trial training (DTT), 6–7, 16, 240
Discrimination training, 319–321, 319b, 323
Discriminative stimulus (SD), 14, 176
Dressing skills, 332–333, 334t, 338
DSM-5, see Diagnostic and Statistical Manual
of Mental Disorders, Fifth Edition
Duration data, 378t, 379
Dvortcsak, Anna, 32, 82, 250, 285b
Dyadic play, 31, 33, 52, 141, 165, 279
Dyadic synchrony, 279
427
Early cooperative play, 10
Early infantile autism, 4
Early intervention, 3, 7–8
Early learning, 9, 15
Early Social Communication Scales (ESCS),
53, 222
Early Start Denver Model (ESDM), 4, 10
antecedent strategies and, 154–155, 160,
165
case example and, 112
in communication development, 240–241,
244, 250–251, 253
core components of, 23
data collection an, 364
empirical support for, 22
4-day workshop in, 22
functional skills and, 51–52
introduction to, 21–22
relationship to other models, 23, 35t
in social skills, 283, 285–286, 289
Echolalia, 25, 130
Ecological validity, 9, 46, 47b
see also Natural environments
Effective feedback, in parent coaching,
87–88, 89t
Electroencephalogram (EEG), 22
Embedded trials, 177–179, 178b, 178t
Emory Autism Center, 114–115
Emotional attunement, 279
Emotional cues, 7, 130
Empirical validation
for Early Start Denver Model (ESDM), 22
for Enhanced Milieu Teaching (EMT), 24
future directions and, 409
of incidental teaching (IT), 26
of Joint Attention, Symbolic Play,
Engagement, and Regulation (JASPER),
27–28
of Naturalistic Developmental Behavioral
Interventions (NDBI), 10, 11b
of Pivotal Response Treatment (PRT),
31–32
of Project Improving Parents as
Communication Teachers (ImPACT),
33–34
Empowerment, of parents, 80–82, 81b
Engagement, 164–165
Joint Attention, Symbolic Play,
Engagement, and Regulation (JASPER)
and, 28–29
motivation and, 126–130, 127t–129t, 129b
Engaging and enticing, see Antecedent-
based intervention
Enhanced Milieu Teaching (EMT), 10, 248
in antecedent-based treatment, 165
core components of, 24–25, 35t
data collection and, 367–368
empirical support for, 24
428
Enhanced Milieu Teaching (EMT)—
continued
goal selection and, 223
introduction to, 23–24
Naturalistic Developmental Behavioral
Interventions (NDBI) and, 25, 35t
social skills and, 282–283, 285
Enticing strategies, 164–166
Environmental arrangement, 13–14, 153–155
in social skills, 282–283
strategies of, 314–315
Establishing operations (EO), 125b
European-American culture, 48, 225
Evidence-based interventions, 357
Executive functioning behaviors, 335t, 337t
Expressive communication, 10, 26, 188, 220,
221t
prompting and, 188
see also Communication development
External variables, in behavioral
observation, 222–224, 223t
Extinction, 31, 194t, 195, 199–201
in challenging behavior, 318
Extinction burst, 195
Facilitated playdates, 299
Families
routines of, 47–48, 59–60, 78, 396
stress and, 309, 326–327, 343, 396
values in goal development, 224–225,
226b, 232
see also Social skills
Feasibility, of data collection, 386–387
Ferster, Charles, 5
Fidelity, see Treatment fidelity
First grade, 408
using Classroom Pivotal Response
Training (CPRT), 357, 358t–359t
First words, 55, 209, 227
communication skills and, 254–262,
256t–261t
goal development and, 227, 237, 239, 242
Fixed interval (FI) schedule of
reinforcement, 200, 200t
Fixed ratio (FR) schedule of reinforcement,
200, 200t
Flexibility, of behavior, 327–331, 327t–330t
Forward chaining, 201
Free operant preference assessment, 160
Free play
child-selected activity, 134b
consequence and, 203, 208
inclusion and, 110t, 113
natural environments and, 383
school and, 350t, 355
Frequency data, 375–378, 378t
Function, of behavior, 315
Index
Functional behavioral assessment (FBA),
310
Functional communication, 8
Functional magnetic resonance imaging
(fMRI), 56
Functional skills, 36
assessment for goal setting
in goal selection, 226
individualization and, 54–56
across intervention models, 51–52
see also Adaptive behavior
Functionally equivalent replacement
behaviors, 310
Game play, 293t–294t
Bingo and, 299–300, 319, 321
board games, 64, 227, 292, 292b, 296
free play, 110t, 113, 134b
Hide and Seek, 163, 269t
kinetic sand and, 135t, 261t
Lego blocks, 105–106, 142t
memory matching, 292, 295
video games, 114, 134, 167, 227
see also Social skills
Generalization, 24
data sheet on, 373–374, 374f
in group settings, 355
of skill, 57–58, 57b, 59b
Gestures, 9
imitation of, 131t, 132
prompting and, 188
Goal development
age appropriateness in, 231
assessment in, 218–224, 221t, 223t
behavioral observation in, 222–224, 223t
caregiver buy-in, 225–226, 226b
cascading effect and, 230–231
case examples and, 221, 221t, 226–227,
229–230
conclusion on, 231–232
considerations for, 224–227, 226b
developmental considerations in, 228–231
family values in, 224–225, 226b, 232
formulating goals, 214–216, 217t–218t,
218b
individualization and, 54–56
mastery criteria in, 214–215
Naturalistic Developmental Behavioral
Interventions (NDBI) and, 213–216
parent training goals, 216, 218b
published curricula in, 53–54
receptive language and, 219–220
standardized assessments, 219–220
standardized testing and, 52–53
Goodness of fit
data collection and, 386
of intervention approaches, 46–49, 47b
 Index
Graduate education, 114
Naturalistic Developmental Behavioral
Interventions (NDBI) training, 410–411
Grandma’s Rule, see Premack Principle
Grandparents, 48
Gross motor play, 64
Group parent education, 79
Group settings, 61
research design, 407
shared control in, 349–352, 351b
see also School settings
Handwriting, 351
Hart, Betty, 25
Heart disease, 80
Hide and Seek game, 163, 269t, 293t
Home settings, 59–60
Humor, 165–166
Hygiene, 334t
Imitation, 7, 9, 22, 46
of adult, 15
of body movements, 143
of child, 248, 249b
of child’s actions, 131, 131t
in consequence strategy, 206, 207t
of gestures, 131t, 132
with novel actions, 131t, 132
objects and, 131t, 132
parent coaching and, 78, 84, 84t, 91, 92t, 94
of vocalizations, 132–133
see also Social skills
Incidental teaching (IT), 10
core components of, 26–27, 35t
empirical support for, 26
introduction to, 25–26
Naturalistic Developmental Behavioral
Interventions (NDBI) and, 27, 35t
Inclusion
Alexa’s Playful Learning Academy for
Young Children (PLAYC), 102, 112–113
case example of, 112–116
challenges to, 110t–111t, 111
community programs and, 106–109
conclusion on, 116
free play and, 110t, 113, 134b
importance of, 99–100, 100b
Learning Experiences: An Alternative
Program for Preschoolers and Parents
(LEAP), 102–103
Naturalistic Developmental Behavioral
Interventions (NDBI) and, 102–106
in practice, 100–101, 101b
Independence, 153
encouragement of, 86, 104, 107–108,
112–113
429
functional skills and, 45, 49–50, 63
quality indicators and, 397–398
Individual parent education, 79
Individual preference, see Child-selected
activities
Individualized antecedent interventions,
313–314, 313b, 342–343
Individualized education program (IEP),
63, 99–100
case example on, 341–343
goals and, 348, 357
quality indicators of, 386–397
standards in data collection, 365
team, 171
Individuals with Disabilities Education
Improvement Act of 2004 (PL 108-446),
62, 99
Ingersoll, Brooke, 32, 82, 250, 285b
In-home child care providers, 31
In-home intervention, 26
Initial assessment, 66, 221, 370, 370b
Initiation behaviors, 30
Instructional cues, 30
antecedents and, 176
bubbles and, 181, 184t
definitions and, 175–176
learning opportunities and, 177–182,
178b, 178t, 180f, 182t
natural and varied, 181, 182t
receptive language and, 182t, 189–190
in school settings, 353–354
see also Communication development;
Prompting
Instructional strategies, 9–10
Intensity data, 378t, 379
Internet use, 50
Internet-based training, 79
Interspersing maintenance tasks, 144
Interval recording, see Time sampling
Interval schedules of reinforcement, 200
Intervention outcomes, measurement
of, 408
IPad, 208, 253, 324, 354
IQ score, 6, 22, 284, 408
Joint activity routines, 23
Joint Attention, Symbolic Play, Engagement,
and Regulation (JASPER), 10, 24
in antecedent strategies, 154–155, 165
in challenging behavior, 311, 325
in communication development, 241–242,
251–252
core components of, 28–29, 35t
data collection and, 369
empirical support for, 27–28
functional skills and, 51–52
introduction to, 27
430
Joint Attention, Symbolic Play, Engagement,
and Regulation (JASPER)—continued
motivation and, 128, 130–131, 133, 145
Naturalistic Developmental Behavioral
Interventions (NDBI) and, 29–30, 35t
teaching play and, 289
Joint attention behaviors, 8–10, 46
in communication development, 237–240,
240t, 249–252, 252t, 265
initiation of, 27, 229
Joint engagement, 29, 56, 178, 281t
Kanner, Leo, 4
Key stakeholders, 58, 77
parents as, 36
Kindergarten, 105, 112, 114, 358t–359t
Kinetic sand, 135t, 261t
Kitchen, 8–9, 59, 64, 179, 318, 320
antecedent behavior and, 151, 168t
cleaning of, 116
natural environments and, 383
Language
Assessment of Basic Language and
Learning Skills (ABLLS), 54, 222
Comprehensive Assessment of Spoken
Language (CASL), 52
natural language paradigm, 23–24
receptive language, 10, 52, 112, 138, 399
speech-language pathologist (SLP),
253–255
Systematic Analysis of Language
Transcripts (SALT), 223, 367
see also Communication development;
Social skills; Verbal skills
Latency data, 378t, 379
Learned helplessness, 124
Learning Experiences: An Alternative
Program for Preschoolers and Parents
(LEAP), 21, 63
inclusion and, 102–103
Learning opportunities, 9, 13
case examples of, 190–191
conclusions on, 191
definitions of, 175–176
embedded trials and, 177–179, 178b, 178t
instruction pace and, 179–180, 180f
Naturalistic Developmental Behavioral
Interventions (NDBI) and, 177–182,
178b, 178t, 180f, 182t
prompting and, 182–186, 184t–185t
Lego blocks, 105–106, 142t
natural consequences and, 203–204, 204f
question asking and, 270t
in reinforcement activities, 349, 352
teaching first words and, 259t
Index
Likert scale, 367, 374–375, 380t
Lovaas, Ivar, 6, 240, 408
Maintenance of skills, 57–58, 57b
data collection on, 372, 372f–373f
in group settings, 355
Maintenance tasks, 14, 181–182
acquisition tasks in, 282t, 297
task variation and, 248
Maladaptive behaviors, 10, 339
Manualization, 12, 392
Manualized content, 35t, 36, 85, 103, 298, 400
Martial arts, 61
Mastery criteria, 13, 214–215
Math centers, 156
Math skills, 17
in school setting, 348–349, 351–353, 355,
356t, 359t
McGee, Gail, 25–27
Mealtime, 47, 78
adaptive behavior and, 327, 334t, 336t
data collection and, 383
joint engagement and, 281t
pizza and, 55, 68, 257t, 291t, 300, 302b
quality indicators and, 396
routines and, 156, 168t
see also Dinnertime meal
Mean length of utterance (MLU), 367–368
Measurement systems
in challenging behavior, 319–320
continuous data collection, 380
discontinuous data collection, 380
methods of, 379, 380t
see also Data collection
Memory matching game, 292, 295
Menstrual cycle, 334t
Milieu teaching, see Enhanced Milieu
Teaching
Modeling, 10, 15
in communication development, 242–243
in consequence strategy, 205–206
in imitation, 285
inclusion and, 109
Morphology, 239
Motivating operations (MO), 125b
in consequence strategy, 197, 197b
Motivation
behavioral momentum and, 137t, 144
child’s lead in, 124, 134–136, 137t–138t
child-selected activities and, 133–134,
134b, 135t
choices and, 136–139, 139t
engagement and, 126–130, 127t–129t, 129b
imitation and, 131–133, 131t
Joint Attention, Symbolic Play,
Engagement, and Regulation (JASPER)
and, 128, 130–131, 133, 145
 Index
maintenance tasks and, 144
measurement of, 125–126
natural reinforcement and, 145
Naturalistic Developmental Behavioral
Interventions (NDBI) and, 124–125,
125b
noncontingent reinforcement, 137t, 140
operational definitions of, 125–126,
127t–128t
Pivotal Response Treatment (PRT) and,
125, 133, 135, 141, 144–146
Project Improving Parents as
Communication Teachers (ImPACT)
and, 125, 130–133, 135, 143, 146
reinforcing attempts, 125, 145–146
in school settings, 349, 350t
shaping procedures, 125, 145–146
shared control and, 139–141, 142t–143t
taking turns and, 141–144, 143t
task variation and, 144
Motivational behavior, dinnertime meal
and, 136, 138t, 141
Motivation-based interaction, 9
Movies, 47, 116, 171, 353
Mullen Scales of Early Learning (MSEL),
52, 219
Music, 64, 199
instruments of, 132, 135t, 259t, 267
lessons, 61, 171, 230
social games and, 293t
time delay and, 283
toys, 91, 155
MyLIFE program, 114–116
Narration, 165, 242–243
National Professional Development Center
on Autism Spectrum Disorder, 347, 357,
393–394, 399
National Research Council, 45, 77
National Standards Project, 318, 347
inclusion and, 101
Natural environments, 9
conclusion on, 69
data collection in, 383–389, 386b, 389b
examples of, 66–68, 66t
free play and, 383
goodness of treatment fit and, 46–49, 47b
selecting meaningful skills for, 45–46
self-regulating behavior and, 340
skill maintenance and, 57–58, 57b
social validity and, 47–49, 47b, 49b, 60, 65
types of
Natural language paradigm, 23–24
Natural reinforcement, 14, 202–205, 204f
inclusion and, 108
Naturalistic Developmental Behavioral
Interventions (NDBI)
431
in academic settings, 347– 350t, 351b, 354t
adaptive skills and, 333–339, 334t–338t
antecedent strategies and, 151–152, 152b
challenging behavior and, 310–311
common procedural elements and, 12–13
communication goals
communication targeting, 240–248,
245t–247t, 248b–249b
in community programs, 106–109
consequence strategy troubleshooting,
206–210, 207t
core components of, 8, 11–12, 35t
data collection and, 13
Developmentally Appropriate Treatment
for Autism (Project DATA) and, 362,
365–366
empirical validation of, 10–16, 11b, 22–34
future directions in, 407–412
goal development, 213–216
goodness of fit of, 46–49, 47b
incidental teaching (IT), 26–27, 35t
inclusive setting and, 102–106
instructional strategies and, 9–10, 13–16
introduction to, 3–4, 8–10
learning opportunities and, 177–182,
178b, 178t, 180f, 182t
models of
motivation and, 124–125, 125b
parent-mediated intervention and, 77–79
quality indicators of
in school settings
self-regulation skills and, 327, 328t–330t
teaching play and, 288–289
teaching targets and, 8–9
treatment delivery contexts, 9
see also Social skills
Negative cascading effects, 230
Negative punishment, 194t, 195
Negative reinforcement, 194t, 195, 197–198
No Child Left Behind Act of 2001 (PL 107-
110), 99
Noncontingent reinforcement, 161, 161b
in communication development, 243–244,
248b, 262, 262t, 290b, 297
motivation and, 137t, 140
Nonverbal individuals, 237–238
Augmentative and alternative
communication (AAC), 253–254
Nonverbal mirroring, 143
Nonverbal Reasoning Ability, of
Differential Ability Scales (DAS), 219
Nonverbal self-stimulatory behavior, 56
Nonverbal skills, prompts for, 183, 184t–185t
Novel actions, 131t, 132
Obesity, 80
Object play routines, 280–282, 281t–282t
432 Index
One-on-one activity, 316, 350t
playdates, 278
setting, 163
teaching, 26, 383
One-up rule, 243, 265, 297
Operant conditioning, 175
see also Instructional cues; Prompting
Operant methodology, 6
Operational definitions, 367, 375, 379
of motivation, 125–126, 127t–128t
Overdependence on prompts, 6
Overselectivity, to stimulus, 15–16
Paired choice preference assessment, 160
Parallel play, 26, 298
Paraprofessionals, 31
Parent and Caregiver Active Participation
Toolkit (PACT), 82–83, 83t, 85
Parent coaching
effective feedback in, 87–88, 89t
imitation and, 78, 84, 84t, 91, 92t, 94
Project Improving Parents as
Communication Teachers (ImPACT)
and, 82–83, 83t, 85
reflective discussion in, 90, 90b
in self-regulation behaviors, 340–341
written content of, 85
Parent education program, 33
Parent psychological functioning, 79–82, 81b
Parent stress, 31, 35, 56, 78–82, 81b, 225
Parent training goals, 216, 218b
Parent-child interactions, 81–82, 91, 341–342
dyadic play and, 31, 33, 52, 141, 165, 279
see also Families
Parent-mediated intervention
brainstorming and, 84–86, 84t
coaching practices, 82–83, 83t
group parent education and, 79
individual parent education and, 79
Naturalistic Developmental Behavioral
Interventions (NDBI) and, 77–79
parent empowerment and, 80–82, 81b
parent stress and, 80
Project Improving Parents as
Communication Teachers (ImPACT)
and, 82–83, 83t, 85
psychological functioning in, 79–82, 81b
treatment fidelity and, 77, 79, 82, 94
see also Project Improving Parents as
Communication Teachers
Parent-professional collaboration, 48–49
Patience, 323, 339
see also Waiting
Peekaboo, 251, 271
Peer imitation, 26
Peer-mediated interventions (PMI), 31, 272,
347, 357
child’s lead in, 298–299
inclusion and, 104–105
see also Inclusion
Permanent product, 380t, 381
Person-centered planning, 55
Person-engaged play, 29
Phonology, 239
Photographic activity schedules, 162
Phrase speech, 263–265, 264t–266t
Physical education (PE), 162
Physical prompting, see Gestures
Picture Exchange Communication System
(PECS), 56, 230
book, 188–189
in communication development, 242,
245t, 253–254
Pivotal areas, 30, 125
Pivotal Response Treatment (PRT), 4, 10, 22,
125, 133, 135, 141, 144–146
in antecedent strategies, 155, 160
in challenging behavior, 310–311
core components of, 32, 35t
data collection and, 368–369
empirical support for, 31–32
functional skills and, 50–51
goal development and, 216, 223, 229
introduction to, 30–31
learning opportunities and, 179, 183, 186
Naturalistic Developmental Behavioral
Interventions (NDBI) and, 32, 35t
teaching play and, 286, 289, 298
Pizza, 55, 68, 257t, 291t, 300, 302b
PL 101-336, see Americans with Disabilities
Act (ADA) of 1990 (PL 101-336)
PL 107-110, see No Child Left Behind Act of
2001 (PL 107-110)
PL 108-446, see Individuals with Disabilities
Education Improvement Act of 2004
(PL 108-446)
Planning, of routines, 156–160, 157b,
158t–159t
Play routines, see Routines
Play skills, 46
cooking and, 287t, 291t, 301
development of, 286–288, 287t–288t
object play routines, 280–282, 281t–282t
Pivotal Response Treatment (PRT) and,
286, 289, 298
prompting and, 189
routines in, 280–282, 281t–282t
teaching of, 288–289, 290b
see also Free play; Social skills
Playpartner, as reinforcer, 297–298
Positive behavior, 309, 313, 319, 343
Positive behavior support (PBS), 310–311
Positive punishment, 194t, 195
Positive reinforcement, 5–6, 193–194, 194t,
203–204
 Index
Pragmatics, 52
Prelinguistic behaviors, 51
see also Imitation; Joint attention
Premack Principle, 196, 196f, 339
Preschool programs
case example, 112–114
Enhanced Milieu Teaching (EMT) in, 24
inclusion and, 102–103
Joint Attention, Symbolic Play,
Engagement, and Regulation (JASPER)
in, 28
Project Improving Parents as
Communication Teachers (ImPACT)
in, 33
Presymbolic play, 287t
Preverbal communication, targets and
strategies, 249–252, 252t
Priming
antecedent strategies and, 163–164,
313–314, 313b
case example of, 172
inclusive settings and, 105
Probes, in data collection, 362, 368–373, 378t
Progress tracking, 398–399
Project DATA, see Developmentally
Appropriate Treatment for Autism
Project Improving Parents as Communication
Teachers (ImPACT), 4, 10
antecedent strategies and, 154, 165
challenging behavior and, 310
in communication development, 241, 244,
250
core components of, 34, 35t
data collection and, 366–367
empirical support for, 33–34
functional skills and, 51–52
goal development and, 216, 221
introduction to, 32–33
Joint Attention, Symbolic Play,
Engagement, and Regulation (JASPER)
and, 30
learning opportunities and, 179, 186–187
motivation and, 125, 130–133, 135, 143,
146
Naturalistic Developmental Behavioral
Interventions (NDBI) and, 34, 35t
parent coaching and, 82–83, 83t, 85
quality indicators and, 392, 397–398
social skills and, 282–283
Prompt fading, 11b, 187, 187b
community programs and, 108–109
in self-regulating behavior, 324–325
Prompting, 10, 14
daily living skills and, 190
data collection and level, 371–372, 372f
hierarchy and, 183–186
imitation and, 285
least-to-most supportive, 186
433
most-to-least supportive, 186
play skills and, 189
receptive language and, 182t, 189–190
social skills and, 190
for specific skills, 187–190
types of, 183, 184t–185t
Prompting strategies
definitions in, 175–176
for self-regulation, 322–323
in social skills, 294–295
Published documentation
in goal development, 53–54
increasing access to, 412
Punishment, 193–195, 194t, 197, 199
Quality indicators, of treatment programs,
391–403, 392b, 395f, 402f
Question-asking, 267–271, 267t–270t
Rady Children’s Hospital, 112
Randomized controlled trial (RCT), 27–28,
289
in communication development, 240–241
future directions and, 408
Rapport, 160–161, 161b
Rate data, 378, 378t
Ratio schedules of reinforcement, 200, 200t
Recasting, 243
Receptive labeling, 26, 189
Receptive language, 10, 52, 112, 138, 399
Bayley Scales of Infant and Toddler
Development (BSID) and, 219–220
communication development and, 243,
251, 270t
goal development and, 219–220
prompting and, 182t, 189–190
Reciprocal conversation, 271–272
Reciprocal imitation training (RIT), 132,
284–285, 285b
Reciprocity, 127t
Reflective discussion, in parent coaching,
90, 90b
Reinforcement, 13
in challenging behavior, 318–324, 319b,
330–343
natural reinforcers, 202–205, 204f
playpartner in, 297–298
in school settings, 348–349, 352, 355–356,
357t
see also Consequence strategies
Reinforcer value, 180, 180f
Reinforcing attempts, 14, 125, 145–146
communication goals and, 244–248
in consequence strategy, 205
Relationship building, 160–161, 161b
see also Social skills
434
Reliability, in data collection, 262–263, 262b
see also Empirical validation
Replacement behaviors, 23, 314–318, 316b,
322, 326–327
Response latency, 126, 127t
Response-reinforcer contingency, 124
Responsive interaction, 23
Responsivity, 15, 127t, 206, 271
Restrictive environments, 36, 62, 99–100, 309
Risley, Todd, 25
Routines, 9
family, 47–48, 59–60, 78, 396
mealtime and, 156, 168t
object play and, 280–282, 281t–282t
opportunity set up, 165–166
optimizing of, 164–167, 168t–170t
planning and, 156–160, 157b, 158t–159t
quality indicators and, 396–398, 402f
self-regulation and, 325–326, 330t,
332–333, 339
sensory social, 279–280, 281t, 285–286
violation of, 13
Sameness, 166, 327
Schedules, 161–162
School settings, 62–64
activities and, 355–357, 356b, 356t–359t
behavior in, 335t, 337t
child-preferred activities, 349–352, 351b
Classroom Pivotal Response Teaching
(CPRT) in, 357, 358t–359t
clear instruction in, 353–354
Common Core State Standards (CCSS)
and, 347–348
contingent reinforcement and, 352
first grade and, 357, 358t–359t, 408
free play and, 350t, 355
generalization in, 355
individual goals and, 357, 358t–359t
kindergarten, 105, 112, 114, 358t–359t
maintenance of skills in, 355
math skills in, 348–349, 351–353, 355,
356t, 359t
Naturalistic Developmental Behavioral
Interventions (NDBI) in, 348–349
peer-mediated interventions (PMI) and,
347, 357
reinforcement in, 348–349, 352, 355–356,
357t
shared control in, 349–352, 351b
Self-advocacy behaviors, 325–326, 329t
Self-management skills, 30, 105, 272
challenging behavior and, 318–319, 319b
generalized, 322
transition to training and, 321–322
Self-monitoring, 102–103, 105, 272, 322, 392
Index
Self-regulation behavior
aggression and, 309–310, 324–326
behavioral flexibility and, 327–331,
327t–330t
chaining in, 317, 333, 336t, 382
child-selected activities and, 323, 327,
333
commonly taught behaviors in, 327t–330t,
332–333
daily routine in, 325–326, 330t, 332–333,
339
natural environments and, 340
Naturalistic Developmental Behavioral
Interventions (NDBI) skills and,
322–326, 327, 328t–330t
parent coaching in, 340–341
promoting of, 326
prompt fading in, 324–325
selecting targets in, 326–327
teaching of, 339–341
Self-stimulatory behavior, 288
Semantics, 239
Sensory social routines, 22, 279–280, 281t,
285–286
Service-delivery models, 411
Setting events, 151–152, 152b, 156
Shaping procedures, 10
chaining and, 23, 201–202
motivation and, 125, 145–146
Shared control
antecedent-based strategies, 167,
168t–170t
communication goals and, 243–244,
245t–247t
in community programs, 107–108
in cooperative arrangements, 300–301,
302b
in group settings, 349–352, 351b
motivation and, 139–141, 142t–143t
in social skills, 296
Shared engagement, 9, 10
Siblings, 48, 271–272, 273t
Single subject design studies, 407
Skill acquisition, 371, 371b
see also Acquisition tasks
Skill generalization, 57–58, 57b, 59b
Skinner, B.F., 11
Sleep disturbances, 80
Smartphones, 325
Social Communication, Emotional
Regulation, and Transactional Support
(SCERTS) Model, 21
Social emotion, 8
Social initiations, 31
Social motivation hypothesis, 22
Social orienting, 7
Social reciprocity, 15
 Index
Social skills
acquisition tasks and, 248, 266t, 279, 282t
balanced turns, 285, 295–296
child’s lead in, 289, 290t–291t, 299
conclusion on, 301
cooperative arrangement, 299–301, 302b
Early Start Denver Model (ESDM) in, 283,
285–286, 289
environmental arrangement in, 282–283
facilitated playdates, 299
imitation and, 131t, 132–133, 285
music and, 293t
peer-mediated interventions, 298–299
play and
playdates and, 278, 297, 299–301, 302b
playpartner in, 297–298
prompting and, 190
Reciprocal Imitation Training (RIT),
284–285, 285b
sensory social routines, 279–280, 281t,
285–286
teaching strategies for, 284–286, 285b
turn taking in, 285, 295–296
vocal imitation, 132–133, 285–286
Social Skills Improvement System (SSIS),
106
Social Story, 314
Social validity, 47–49, 47b, 49b, 60, 65
Special education programs, 29, 54, 101, 114
future directions and, 411
teacher of, 193
Speech-generating devices, 28, 56, 253
Speech-language pathologist (SLP), 253–255
Spontaneous speech, 26
Staff training, quality of, 399–402
Standardized assessments
functional testing and, 52–53
in goal development, 219–220
Stimulus discrimination, 176
Stimulus generalization, 176, 181
Stimulus overselectivity, 15–16
Stokes, T.F., 11–12, 58
Strategies for Teaching Based on Autism
Research, 63
Strength of behavior, 194–195, 194t
Stress
family, 309, 326–327, 343, 396
of parents, 31, 35, 56, 78–82, 81b, 225
Structured Laboratory Observations (SLO),
53
Structured playgroups, 102–103, 105–106
Superman, 291b, 359t
Swimming, 61, 302
Symbolic play, 28–29, 202, 228
autosymbolic play and, 287t
cooking and, 287t, 291t, 301
across models, 51–52
435
presymbolic play and, 287t
in social skills, 287t, 289–290, 291b
see also Joint Attention, Symbolic Play,
Engagement, and Regulation
Synchronization, 25
Synchronizing, adult behavior, 136
Syntax, 52
Systematic Analysis of Language
Transcripts (SALT), 223, 367
Target behavior, 318–323, 328t–330t,
334t–338t, 340
see also Challenging behaviors
Task analysis, 106
in challenging behavior, 317, 333
in data collection, 382–383, 384f–385f
Task variation, 32, 144, 166–167, 248
reinforcer value and, 180, 180f
Teaching
adaptive behavior, 333–341, 334t–338t
antecedent-based intervention and,
153–164, 158t–159t, 161b, 175b
Augmentative and alternative
communication (AAC) and, 253–254
child-initiated, 11b, 16, 27, 62, 125
Classroom Pivotal Response Teaching
(CPRT) and, 357, 358t–359t, 365, 392,
395f
incidental teaching (IT) and, 10, 25–27, 35t
one-on-one activity, 26, 383
Pivotal Response Treatment (PRT) and,
286, 289, 298
of play skills, 288–289, 290b
question-asking, 267, 267t–270t, 271
routines, 11b, 15, 156
self-regulation, 339–341
Strategies for Teaching Based on Autism
Research and, 63
targets of, 8–9, 187–188, 222
see also Communication development;
Enhanced Milieu Teaching (EMT)
Teaching environment, 12, 51, 62
antecedent-based strategies and, 151–152,
155, 164
playdates and, 297–301, 302b
see also Natural environments
Team activities, 61
“Technical eclectic” approach, 36
Technology-based parent-mediated
intervention, 79
Telehealth, 33
Telemedicine, 79
Three-term contingency, 6, 151–152, 210, 241
see also Antecedent, behavior, and
consequence
Time delays, 24, 187, 283
436
Time sampling, 380t, 381–382, 382f
Toilet training, 302, 323, 334t, 378
Topography, 310
Toys, 91, 155
see also Play skills
Treatment fidelity, 11b, 12–13
data collection and, 374–375, 377f
data sheets, 367, 377f
future directions of, 409
inclusive settings and, 106–107
parent-mediated intervention, 77, 79, 82,
94
quality indicators of, 393–398, 395f
Triadic attention, 251
Trial-by-trial recording, 13, 364–368,
379–380, 387
data sheet of, 371–372, 373f
Turn taking, 248
balanced turns and, 78, 91, 92t, 109
motivation and, 141–144, 143t
in social skills, 285, 295–296
Two-word utterances, 263, 265t
Undergraduate education, 114
Naturalistic Developmental Behavioral
Interventions (NDBI) training, 410–411
Uni-directional model, 410
United Nations, 99
Universal antecedent interventions,
312–313, 341
Validity
data collection and, 362, 362b, 386
ecological validity, 46, 47b
social validity, 47–49, 47b, 49b, 60, 65
Variable interval (VI) schedule of
reinforcement, 200, 200t
Variable ratio (VR) schedule of
reinforcement, 200, 200t
Varied turns, 248
see also Balanced turns
Verbal Behavior Milestones Assessment
and Placement Program (VB-MAPP),
54, 222
Verbal cues, 180, 183, 185t
Index
Verbal requesting, 84, 84t
Verbal skills
imitation and, 132–133, 285–286
prompting and, 188
prompts for, 183, 184t–185t
Video, 53, 325
games, 114, 134, 167, 227
in priming, 163
Video modeling (VM), 272, 289, 320, 323
strategies of, 104
Vineland Adaptive Behavior Scales, 52
Violation, of routine, 13
Visual cues, 109, 138–139, 282
communication development and, 252,
271
prompting and, 184t–185t
self-regulation and, 313b, 314, 324, 328t
Visual schedules, 314, 332, 339
Visual Spatial scale, of Wechsler Intelligence
Scale for Children (WISC), 219
Vocal imitation, 132–133, 285–286
Vocalization, see Verbal skills
Vygotsky’s theory, 228
“Wait-ask-say-show-do,” 27
Waiting, 331, 332t
Walden Early Childhood Program, 102
Walden Toddler Model, 27, 62
Walden Toddler Program, 25–27
Water balloons, 159t, 259t–260t, 282t, 293t
Wechsler Intelligence Scale for Children
(WISC), 219
Wechsler Preschool and Primary Scale of
Intelligence (WPPSI), 219
Whole-group reinforcement, 356, 357t
Words, 55, 209, 227
first words, 254–262, 256t–263t
goal development and, 227, 237, 239, 242
imitation of, 132–133, 285–286
two-word utterances, 263, 265t
vocalization of, 131t, 145–146, 202
See also Communication development
Written content, of parent coaching, 85
Zone of proximal development, 228, 297