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Efficacy of a Teacher Training a Paraprofessional to Promote Communication

for a Student With Autism and Complex Communication Needs

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DOI: 10.1177/1088357617736052

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FOAXXX10.1177/1088357617736052Focus on Autism and Other Developmental DisabilitiesWermer et al.

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Focus on Autism and Other

Efficacy of a Teacher Training

Developmental Disabilities
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Communication for a Student DOI: 10.1177/1088357617736052

https://doi.org/10.1177/1088357617736052
focus.sagepub.com

With Autism and Complex

Communication Needs

Lauryn Wermer, MA1, Matthew E. Brock, PhD2,

and Rachel L. Seaman, PhD, BCBA-D1

Abstract
Students with complex communication needs require well-designed supports to communicate effectively in school settings.
Although paraprofessionals are often charged with supporting these students, they are rarely trained in how to promote
communication, and there is limited research on how they might be trained. In this study, we used a multiple baseline
across behaviors design to test the efficacy of a teacher-implemented training package to train a paraprofessional to provide
opportunities for an elementary student with autism to respond, set up opportunities for her to initiate, and implement
a systematic prompting hierarchy. We demonstrated a functional relation between the teacher-implemented training
and paraprofessional acquisition of the strategies, and paraprofessional implementation coincided with increased student
communication. This study replicates previous findings that paraprofessionals can be trained to implement evidence-based
practices to promote use of alternative/augmentative communication, and extends this literature by demonstrating that a
classroom teacher can deliver paraprofessional training effectively.

Keywords
staff training, augmentative/alternative communication, paraprofessionals, autism, performance feedback

All children with autism spectrum disorder (ASD) have
some level of social-communication impairment (American
Psychiatric Association, 2013), but a subset of these children
has particularly limited verbal repertoires (Tager-Flusberg &
Kasari, 2013). Augmentative and/or alternative communica-
tion (AAC) strategies can empower these children to com-
municate effectively and appropriately. AAC encompasses
any form of nonspeech communication, including sign lan-
guage, picture symbols, gestures, and speech-generating
devices (Beukelman, Mirenda, & Beukelman, 2013).
Researchers have demonstrated that children with ASD with
limited verbal skills can utilize AAC to communicate for a
variety of purposes including requesting basic wants and
needs (Ganz & Simpson, 2004), socializing with peers
(Chung & Carter, 2013), and sharing experiences with fam-
ily members (Thunberg, Sandberg, & Ahlsén, 2009).
Although AAC has the potential to dramatically improve
functional communication outcomes, its efficacy is tied to
how well it is supported and promoted. This is particularly
evident in school settings, where researchers have docu-
mented that AAC-users rarely communicate with adults or
peers without strategic intervention (Chung, Carter, &
Sisco, 2012). There is evidence that school staff can utilize
a number of simple strategies to effectively teach communi-
cation to students who use AAC. Examples include provid-
ing frequent opportunities for students to respond (OTR;
Bingham, Spooner, & Browder, 2007), manipulating envi-
ronments or routines to set up opportunities to initiate (OTI;
Douglas, Light, & McNaughton, 2013), and using a least-
to-most (LTM) prompting hierarchy to provide and then
subsequently fade support (Bingham et al., 2007). The first
strategy, OTR, involves inviting a student response to a
question or a statement. Providing OTR not only increases
student communication, but can also increase student
engagement, improve achievement, and decrease problem
1
The Ohio State University, Columbus, USA
2
Crane Center for Early Childhood Research and Policy, The Ohio State
University, Columbus, USA
Corresponding Author:
Matthew E. Brock, Department of Educational Studies, Crane Center
for Early Childhood Research and Policy, The Ohio State University, 334
PAES Building, 305 West 17th Avenue, Columbus, OH 43210, USA.
Email: brock.184@osu.edu
2 Focus on Autism and Other Developmental Disabilities 00(0)
behaviors (Cavanaugh, 2013). Without training, adults
often provide relatively few OTR to AAC-users compared
with other students (Baxter, Enderby, Judge, & Evans,
2012). The second strategy, OTI, involves manipulating the
environment, violating the child’s expectations, or other
approaches that encourage a student to initiate communica-
tion. Students who use AAC may rarely initiate communi-
cation without these focused efforts (Douglas, Light, &
McNaughton, 2013). The third strategy, LTM prompting,
involves providing increasing levels of assistance to enable
students to communicate successfully. Communication
partners can use this strategy when a student does not ini-
tially communicate given an OTR or OTI (Bingham et al.,
2007). Furthermore, LTM prompting is designed to fade
adult assistance over time and build independence.
Despite the efficacy of these strategies, many school
staff have not been trained to use them (Baxter et al., 2012).
In particular, paraprofessionals typically have little or no
formal training in any instructional or support strategies
(Carter, O’Rourke, Sisco, & Pelsue, 2009). This is of great
concern, especially when one considers that special educa-
tion paraprofessionals outnumber all other special educa-
tion personnel (U.S. Department of Education, 2013) and
often deliver instruction to students with complex com-
munication challenges (Carter et al., 2009).
Very few studies have focused on training paraprofes-
sionals to teach communication. We only identified three
studies that involve training paraprofessionals to increase
use of AAC. Douglas, Light, and McNaughton (2013)
taught paraprofessionals two strategies to promote commu-
nication during play. The first strategy involved identifying
activities and providing means for communication, locating
and providing vocabulary, and environmental arrangement.
The second strategy involved modeling AAC use, offering
opportunities for communication, responding to communi-
cation, and extending interactions. The training consisted of
four 2-hr sessions spread across 2 weeks and was conducted
by the author who delivered one-to-one training to each
paraprofessional. Paraprofessionals intervened with three
preschoolers with developmental disabilities. Introduction
of training coincided with an increase in the frequency of
paraprofessional-provided opportunities to communicate
across all three paraprofessionals. However, a clear and
substantial increase in frequency of student communication
was observed for only one of the three students.
Douglas, McNaughton, and Light (2013) conducted a
similar study to train three paraprofessionals to teach pre-
school children with complex communication needs. One
student was diagnosed with ASD, and the other two with
developmental disabilities and hearing impairments.
Training consisted of five online training modules that
taught paraprofessionals to provide opportunities for
­communication, wait for the child’s communication, and
then respond. Introduction of training coincided with
increases in the frequency of paraprofessional-provided
communication opportunities and responses across all three
paraprofessionals. However, student effects were detected
for only one of the three students.
In a third study conducted by a different research group,
Bingham et al. (2007) trained three paraprofessionals to pro-
mote use of AAC with three students ages 8 to 16 with severe/
profound intellectual disability or multiple disabilities who
exhibited challenging behavior. In an initial 2-hr one-to-one
training session, researchers trained each paraprofessional to
provide opportunities for students to communicate, prompt
communication using LTM prompting, and respond to stu-
dent communication. In addition, they trained paraprofes-
sionals to track and self-evaluate their own behavior.
Introduction of training coincided with increases in parapro-
fessional-provided prompts and responses across all three
paraprofessionals. Paraprofessional implementation coin-
cided with clear and substantial increases in AAC use for two
of the three students, and decreases in challenging behavior
across all three students.
Collectively, these three studies provide important initial
evidence about how to train paraprofessionals to increase
use of AAC. However, these studies also have a number of
limitations that leave important questions unanswered.
First, paraprofessional implementation did not consistently
lead to improvement of child communication. Across the
three studies, clear effects on communication outcomes
were only demonstrated for four of the nine students. Given
these mixed outcomes, it is difficult to make clear recom-
mendations for practice. Second, all three studies involved
training paraprofessionals to simultaneously implement
multiple strategies, so it is not possible to disaggregate the
relative effects of each individual strategy. Therefore, it is
unclear if one particular strategy or combination of strate-
gies should be prioritized to improve student outcomes.
Third, across all three studies, only one student diagnosed
with ASD experienced an improved communication out-
come. Further replication is needed to verify that parapro-
fessional training can result in improved outcomes for this
population. Fourth, and perhaps most importantly, all three
of the aforementioned studies involved training provided by
external research teams. Therefore, it is unclear if special
education teachers can effectively train paraprofessionals to
teach communication.
We designed a study to address these limitations in the
research literature. First, we sought to maximize the effi-
cacy of the training by carefully selecting adult training
strategies and facilitative communication strategies with a
strong evidence base. Specifically, we designed a training
that emphasized modeling, role-play, and performance
feedback—three strategies supported by evidence in both
the paraprofessional (Brock & Carter, 2013) and broader
training literature (Snyder et al., 2012). We focused our
training on paraprofessional-implemented OTR, OTI, and
LTM—each validated in prior studies (i.e., Bingham et al.,
2007; Douglas, Light, & McNaughton, 2013; Douglas,
Wermer et al.
McNaughton, & Light, 2013; see review above). Second,
we designed staggered training on three different strategies
so that we could isolate the relative impact of each strategy.
Third, we measured the impact of paraprofessional imple-
mentation on the communication of a student with ASD to
further expand the research base for this specific popula-
tion. Fourth, the first author—a classroom special education
teacher—trained a paraprofessional in her own classroom
to test the efficacy of teacher-delivered training.
Our study addressed two research questions:
Research Question 1: What is the efficacy of a training
package (featuring modeling, role-play, and perfor-
mance feedback) on the degree to which a paraprofes-
sional implements OTR, OTI, and LTM prompting to
promote communication for an elementary student
with ASD?
Research Question 2: How does the frequency of stu-
dent communication change when the paraprofes-
sional implements each of these strategies?
Method
Participants
We recruited a paraprofessional from the first author’s
classroom who worked with a student diagnosed with ASD
who used AAC as a primary means of communication. The
paraprofessional provided consent, the parent of the stu-
dent provided permission, and the student provided assent
to collect data for research purposes. The first author, a
classroom teacher, implemented all paraprofessional train-
ing procedures.
Teacher. The teacher was a White 25-year-old female who
had been a special education teacher for 2 years. She held a
bachelor’s degree in speech pathology and audiology and
was in her second year of master’s program in special edu-
cation. The teacher had taken a number of undergraduate
and graduate courses focused on AAC.
Paraprofessional. Lindsey was a White 26-year-old female
who had been a paraprofessional for 2.5 years. She held a
bachelor’s degree and did not have a teaching license or cer-
tificate. She had been working with the target student for 4.5
months. In the past year, Lindsey received a total of 4 hr of
formal training. None of this training focused on promoting
AAC use, and Lindsey reported that she had not received any
training focused on promoting AAC use prior to this study.
Student. Angela was a 7-year-old girl diagnosed with ASD
and intellectual disability who qualified for her state’s alter-
nate assessment. Her primary means of communication was
a high-tech AAC device, although she occasionally used one
3
to two word utterances to request highly preferred items
(e.g., chips, cookie). Her AAC system involved a specialized
application (i.e., Language Acquisition Through Motor
Planning [LAMP] Words for Life) that was programmed on
an iPad. LAMP is a high-tech dynamic symbol-based com-
munication system that is paired with text and audio speech
output. Angela directly selected icons by touching them with
her index finger. Angela’s Individualized Education Pro-
gram (IEP) goals for expressive communication included
requesting help, obtaining teacher attention, initiating with a
peer, and producing novel two to five word utterances.
Angela rarely communicated at school. Most communica-
tion on her AAC device was limited to one to two word mes-
sages that were often off-topic and did not appear to serve
any clear function. For example, during a literacy lesson
about digraphs and blends, Angela would push “credit card”
or her mother’s name. On rare occasions, she would request
highly preferred items (e.g., favorite songs, lemonade).
However, even these rare requests might be difficult for a
novel communication partner to interpret. For example, a
novel communication partner might not understand that
when Angela pushes the icon for “juice,” she is actually
requesting assistance with inserting the straw into her juice
box. The Vineland Adaptive Behavior II Checklist was com-
pleted and specific weaknesses were noted for communica-
tion and socialization domains. Her cognitive score on the
Developmental Profile III was the age equivalent of 7
months. On the Receptive-Expressive Emergent Language
Test–Third Edition (REEL-3; she had an age-equivalent
score of 3 months for receptive language and 7 months for
expressive language; <1st percentile). Angela received
occupational, physical, music, and speech therapy. Each
week, 90 min of speech therapy were delivered in a one-on-
one setting outside of the classroom.
Setting and Materials
All training and intervention sessions took place in a private
school and therapy center for students 3 to 16 years old with
ASD, other developmental disabilities, and typically devel-
oping peers. There were approximately 150 students at the
school, with just over 90% diagnosed with a developmental
disability. Approximately half of the students at the school
were White/non-Hispanic and about 75% were male.
Throughout the center, adult-to-student ratios ranged from
1:1 to 1:3. In this particular classroom, there was one spe-
cial education teacher, three paraprofessionals, seven stu-
dents with ASD, and no typically developing peers. All
students were 6 to 7 years old.
All data were collected during snack time. Snack time
occurred midafternoon each day with all students and teach-
ers sitting at one large table together. Duration of snack time
ranged from 10 to 25 min. Angela had a lemonade drink
specifically for snack and then items such as apples,
4 Focus on Autism and Other Developmental Disabilities 00(0)
pretzels, nuts, popcorn, and raisins leftover that she did not
eat at lunch. Angela’s AAC device was available and within
close proximity to her across all observation sessions.
Dependent Variables
We measured four dependent variables, which included
paraprofessional implementation fidelity of three different
evidence-based practices designed to increase the frequency
of student communication. We video-recorded all sessions
and coded all dependent variables from the video after each
session. Data were collected using a frequency count for all
three paraprofessional behaviors and the student behavior,
and then converted into rate per minute by dividing the
number of occurrences by the duration of the observation
(in minutes).
Paraprofessional implementation fidelity. We measured imple-
mentation of three different evidence-based practices: creat-
ing OTR, OTI, and a LTM-prompting hierarchy. OTR were
defined as asking a question, giving a direction, or otherwise
communicating with the student in a way that necessitates a
communicative response. Examples of OTR included,
“What would you like for snack?” “What is your favorite
food?” “Do you want goldfish or cookies?” Nonexamples
included “I see you have goldfish today” and “push in your
chair.” OTI were defined as violating the child’s expecta-
tions to provoke the need for communication. This included
any behavior that clearly deviated from what would be antic-
ipated in an activity or routine, such as withholding materi-
als (e.g., withholding a desired snack item), providing
incorrect or partial materials (e.g., giving her a drink without
the straw), denying access to materials, failing to initiate an
expected routine, or deviating from an established schedule
(e.g., skipping a scheduled snack time).
The third dependent variable was LTM prompting.
Implementation steps included (a) providing a 3 to 5 s delay
with no prompting to give the student a chance to commu-
nicate independently without assistance, (b) reinforcing any
communicative attempts with specific praise, (c) providing
the next more intensive prompt (i.e., verbal, gestural, then
physical) if needed, and (d) providing a 3 to 5 s response
interval after each prompt. We counted a chain as correctly
implemented only if implementation was consistent with
the four criteria listed above.
Student communication. We also measured Angela’s com-
municative attempts. Communicative attempts were defined
as any verbal (i.e., speech), gestural, or AAC device-sup-
ported utterance directed toward a person. We categorized
the topography of each communicative attempt as (a) verbal
speech, (b) use of high-tech AAC device, or (c) other (i.e.,
any communication that was neither verbal speech nor
involved the high-tech AAC device).
Observer Training and Agreement
A secondary observer coded 30% of all sessions, balanced
across experimental conditions. The first author trained the
secondary observer, a graduate student, by reviewing a
detailed coding manual, directing her to code practice vid-
eos, and providing feedback until the secondary observer
achieved 100% agreement with the first author on two dif-
ferent practice videos. An agreement was defined as the
secondary coder recording the same code within 5 s of the
primary coder’s time stamp (i.e., either 5 s before or 5 s
after). Point-by-point agreement was calculated by dividing
total agreements by the total number of behaviors that the
first author recorded. Overall, agreement was 94% (range =
86%–96%) across all variables and sessions. Agreement
was 96% (range = 86%–100%) for OTR, 86% (range =
75%–100%) for OTI, 94% (range = 88%–100%) for LTM
prompting, and 95% (range = 50%–100%) for the student’s
communicative attempts.
Procedural integrity. The same secondary observer viewed
30% of all training and feedback sessions to measure and
ensure procedural integrity of the training methods. The
observer utilized 12 to 17 item implementation checklists
for each specific training and feedback session. Overall,
procedural fidelity was 94% (range = 89%–100%). Proce-
dural integrity was calculated by dividing the number cor-
rect by the total number of opportunities.
Experimental Design
A multiple-baseline-across-behaviors design (Gast, Lloyd,
& Ledford, 2014) involved staggered introduction of the
independent variable (i.e., the training package) across the
three paraprofessional-implemented strategies. Therefore,
this design allowed opportunities to demonstrate and repli-
cate effects for paraprofessional behavior. We measured
student behavior as a secondary descriptive measure, but
we did not test the efficacy of paraprofessional-imple-
mented strategies on student behavior in the context of an
experimental design. We introduced paraprofessional train-
ing for the first tier after 5 or more days of stable parapro-
fessional performance in the baseline conditions. We
introduced the intervention in each subsequent tier after (a)
baseline data were table for that tier, and (b) we detected an
effect in the previous tier through visual analysis.
Procedures
Baseline. Before the introduction of intervention, Lindsey’s
and Angela’s behaviors were observed during snack time.
We did not provide any training or feedback during this con-
dition. A typical snack time began with the students being
instructed to get their lunch boxes out of the classroom lunch
Wermer et al.
bin and to find a seat at the table. Students were allowed to
have any food that was left in their lunchbox that they had not
finished at lunchtime. Teachers helped the students open
their items when asked, or sometimes before the students
asked. Teachers sometimes sat at the table and had their own
snack and they primarily talked among themselves. There
were low levels of conversation between the teachers and the
students, and even less between students.
Intervention. All training was delivered by the first author, a
classroom teacher. Training consisted of an initial 10 to 20
min training for each target (i.e., 10 min for OTR, 10 min
for OTI, and 20 min for LTM prompting), and then ongoing
performance feedback after each intervention session. Dur-
ing the initial training session, the first author provided a
rationale for why the given strategy was selected and how
we anticipated it would affect student outcomes. For exam-
ple, the first author explained that OTR are important for
increasing engagement and opportunities for the student to
communicate. Second, she defined the strategy and
reviewed the associated implementation steps. For exam-
ple, the author defined OTR as asking a question, giving a
direction, or otherwise communicating with the student in a
way that necessitates a communicative response. Third, she
modeled examples of how to use the strategy, and then had
Lindsey practice using the strategy through role-play. For
example, they practiced greeting the student and asking the
student questions. Fourth, she worked with Lindsey to
brainstorm specific ways the strategy could be applied dur-
ing classroom routines, and recorded these ideas on a plan-
ning sheet. Finally, she encouraged Lindsey to implement
the strategy during the next observation, and invited Lind-
sey to ask any questions. One initial training session was
implemented for each strategy, with the exception of LTM
prompting—due to marked decrease in correct implementa-
tion, a second 20-min training session was conducted that
matched the format of the initial training session. The first
author instructed Lindsey to continue using each strategy
even after training focused on a subsequent strategy (e.g.,
continue using OTR and OTI during LTM training).
Performance feedback sessions lasted approximately 5
min, and took place after each observation session. The
first author took notes during observation sessions and
watched the videos after the school day ended. Performance
feedback was either delivered at the end of the school day
or the next morning before school. The first author pro-
vided specific examples of positive implementation,
explained any missed opportunities with corrective model-
ing, and answered any questions the paraprofessional had
at that time.
Maintenance. After effects had been demonstrated across
all three behaviors, training and feedback were terminated.
Maintenance probes were collected 1, 2, 3, and 4 weeks
5
after training was terminated to gauge the degree to which
Lindsey continued to maintain implementation fidelity
and Angela continued to demonstrate increased rates of
communication.
Social validity. Following completion of data collection,
Lindsey was given a questionnaire to determine if she
believed the training and intervention were effective. Using
a 5-point scale (1 = not effective at all; 2 = not very effec-
tive; 3 = somewhat effective; 4 = quite effective; 5 = very
effective), she indicated her perceptions of (a) the effective-
ness of the training and role-play for implementing each
new strategy, (b) effectiveness of the feedback (after the
sessions) on helping to implement each new strategy, and
(c) the effect each strategy had on increasing the student’s
use of AAC device. Her perceptions of the effectiveness of
each of the three intervention strategies was assessed
through separate questions using the same 5-point scale.
She was asked if she would be likely to participate in a simi-
lar professional development opportunity in the future and
if she would recommend this kind of opportunity to a col-
league (1 = not at all likely; 2 = not very likely; 3 = some-
what likely; 4 = quite likely; 5 = very likely). Finally, she
was asked open-ended questions about what she liked about
the intervention strategies, what she disliked about the
intervention strategies, what she liked about the training
process, and what she did not like about the training
process.
Results
Paraprofessional training coincided with clear and substan-
tial changes in Lindsey’s implementation of all three strate-
gies. Together, these three effects establish a functional
relation. Furthermore, paraprofessional implementation of
strategies coincided with substantial increases in student
communication. Although informative, student communi-
cation was a secondary variable that was not manipulated
experimentally; therefore, no functional relation for student
behavior can be established. Both paraprofessional and stu-
dent data are displayed in Figure 1.
OTR. Lindsey’s rate of OTR during baseline was flat, with
only one OTR across five sessions. With the introduction of
the intervention, OTR immediately increased. After the first
session, data were somewhat variable (range = 0.58–1.48)
but maintained at a flat level through the training condition.
Lindsey’s rate of creating OTR decreased somewhat during
the maintenance condition (range = 0.4–1.3); however,
these lower rates during maintenance probes still markedly
exceeded baseline levels.
OTI. Across the 11 days of baseline, Lindsey rate of OTI
was flat (i.e., all points were zero). After introduction of the
6 Focus on Autism and Other Developmental Disabilities 00(0)

Figure 1. Rate per minute of paraprofessional implementation behaviors (top three tiers) and student communication (bottom tier).
Note. Student communication data are shown for all communication (stacked bar), unprompted independent communication (white bar), and prompted
communication (darkened bar). Data were collected every school day in the first three phases, and once a week for 4 weeks during the maintenance
phase.

intervention, the rate of OTI immediately increased.
Although there was some variability (range = 0.26–1.29),
data remained relatively stable through the end of the inter-
vention condition and maintained at this level during the
maintenance condition with similar variability (range =
0.43–1.29).
Systematic prompting. Lindsey’s rate of correct LTM-
prompting implementation was flat in the baseline condi-
tion (i.e., at or near zero). With the introduction of the
intervention, there was an immediate increase in level for
the first two sessions. There was a sharp decrease in level
on Day 3 after a weekend (.08). Because of this sharp drop
in performance, the first author delivered a second didactic
training session (labeled “second training session” in Figure
1). Specific implementation errors that were corrected
during the second training session included providing two
different prompts simultaneously, or not providing specific
praise following a communicative attempt. The retraining
session was formatted similarly to the initial training,
although the first author placed greater emphasis on the spe-
cific implementation steps with the highest rates of errors.
Following the second training session, the rate of correct
implementation increased and then maintained for the
remainder of the intervention condition, with some variabil-
ity (range = 0.47–1.42). Lindsey maintained the systematic
prompting hierarchy at the highest rate of the three behav-
iors during maintenance probes (range = 0.57–1.2).
Communicative attempts. Across baseline sessions, the tar-
get student had a total of two communicative attempts
(range = 0–0.27). After Lindsey began to provide OTR,
Wermer et al.
Angela’s rate of communication showed some variability
and a very small change in level. After Lindsey began to
provide OTI, Angela’s rate of independent communication
increased in level but was still somewhat variable. After
Lindsey began implementation of LTM prompting, Ange-
la’s overall rate of communication increased. Most of this
increase can be attributed to prompted communication. The
student’s communicative attempts exceeded baseline levels
for the remainder of the study.
The majority of communicative attempts (81%) were
independent, and the remaining 19% were prompted. In
baseline, both communicative attempts were independent.
During the OTR condition, eight communicative attempts
were independent, two followed a verbal prompt, three fol-
lowed a gestural prompt, and one communicative attempt
was physically prompted. During the OTI condition, 34
communicative attempts were independent and two were
physically prompted. During LTM, 57 communicative
attempts were independent, 20 followed a verbal prompt,
18 followed a gestural prompt, and 32 were physically
prompted. Across all conditions, 96% of all communicative
attempts involved the high-tech AAC device, 1% were ver-
bal, and the remaining 3% were categorized as involving
other methods of AAC (e.g., pointing to an object in a field
of choices). The student’s verbal repertoire included “wa-
wa” (water), “no,” “bye,” or “done.” AAC communication
consisted of a range of words from requesting specific
snack items (e.g., lemonade, apples, popcorn), answering
yes or no to a question, to talking about the months in a
year. Other communication most commonly involved point-
ing to make a selection in response to an OTR.
Social Validity
Lindsey’s written responses on a questionnaire indicated
that she perceived the initial training and role-play for each
strategy to be very effective in helping her implement new
strategies (i.e., 5 on a 5-point scale). Similarly, she indi-
cated that the feedback following all sessions was very
effective. When asked about the intervention strategies, she
indicated that OTR were somewhat effective (i.e., 3 on a
5-point scale), OTI were somewhat effective, and that LTM
prompting was very effective (i.e., 5 on a 5-point scale).
Lindsey stated that she was very likely (i.e., 5 on a 5-point
scale) to use these same strategies with the same student or
a different student in the future. Her overall feedback about
the training was positive, and she indicated that she would
be very likely to both participate in a similar training oppor-
tunity in the future and recommend this kind of training
opportunity to a colleague (i.e., 5 on a 5-point scale).
In addition to this survey data, the first author recorded
observational notes about Lindsey’s intervention behavior
with other students in the classroom with complex commu-
nication challenges. According to these observational notes,
7
Lindsey created more OTR across a number of students
after receiving training. She tended to provide these oppor-
tunities during natural opportunities for social conversation
(e.g., arrival, dismissal, snack, lunch). She asked questions
such as “What are you all doing after school tonight?”
“What are you being for Halloween?” “What do you guys
have for snack today” or “Who else likes popcorn?”
Discussion
In this study, we tested the efficacy of a training package
that featured promising training methods (i.e., modeling,
role-play, and performance feedback) on a paraprofession-
al’s implementation of three evidence-based practices for
promoting increased communication with a student with
ASD and complex communication needs. The paraprofes-
sional implemented all three practices accurately, and the
rate of student communication improved substantially.
These findings extend the research literature in a number of
key ways.
First, this study demonstrated that a special education
teacher can train a paraprofessional to implement strategies
designed to increase communication for a student with ASD
and complex communication needs. Although the law
requires that paraprofessionals be appropriately trained and
supervised (Individuals With Disabilities Education
Improvement Act, 2004), there is a lack of evidence-based
models for accomplishing this goal. Practically, the individ-
uals best positioned to provide training to paraprofessionals
are likely the special education teachers who are already
responsible for their supervision (Brock & Carter, 2013).
Although many teachers report that they are not well pre-
pared to train and supervise paraprofessionals (French,
2001), this study shows for the first time that if teachers were
prepared to use effective training strategies, they could train
paraprofessionals to implement evidence-based practices
that increase communication for students who use AAC.
Furthermore, findings from this study, combined with those
from previous studies (i.e., Bingham et al., 2007; Douglas,
Light, & McNaughton, 2013; Douglas, McNaughton, &
Light, 2013) provide initial evidence across research groups
that paraprofessional-implemented strategies can improve
communication outcomes for students with ASD.
Second, results from this study provide insight into the
relative impact of different paraprofessional-implemented
practices on student communication. When the paraprofes-
sional created more OTR, the student’s rate of communica-
tive attempts remained unchanged. When the
paraprofessional set up OTI, the student’s independent
communication increased markedly. We suspect that the
difference in effects between the two strategies relates to
the student’s motivation to communicate. When the para-
professional provided OTRs (e.g., “How are you doing?”),
the student did not have an opportunity to access a highly
8 Focus on Autism and Other Developmental Disabilities 00(0)
desired object or interactions; the only natural reinforcer
was further social interaction. In contrast, when the para-
professional provided OTI (e.g., provided a juice box with
no straw), the student could only access a highly desired
object (e.g., the juice box) through communication. Finally,
when the paraprofessional began to use LTM prompting,
the student’s prompted communication increased mark-
edly, but her independent communication remained rela-
tively unchanged. This change suggests that prior to LTM
prompting, student communication was mostly limited to
utterances that were within her repertoire and allowed her
to access highly desired objects or interactions. With LTM
prompting, the student began to use vocabulary not yet in
her independent repertoire.
Related to this point, based on her responses to the social
validity questionnaire and her maintenance of strategies,
the paraprofessional also perceived that OTIs and LTM
prompting (and not OTRs) had the greatest impact on stu-
dent communication. In the social validity survey, she indi-
cated that she perceived OTRs to be just somewhat effective.
Furthermore, she maintained implementation of OTIs and
LTM prompting and much higher rates than OTRs after
training was terminated, suggesting she prioritized the strat-
egies she perceived to be most effective.
Third, baseline data from this study suggest that parapro-
fessionals may not naturally perceive nonacademic times as
rich opportunities to promote student communication.
Lindsey rarely provided any opportunities for communica-
tion opportunities, nor did she prompt communication
behaviors prior to training. When considered alongside the
results from previous studies, results from this study
strengthen existing evidence that many paraprofessionals
are quite willing and capable of promoting student commu-
nication. However, they need training and guidance to both
identify missed opportunities and implement effective
strategies.
Implications for Practice
Findings from this study have important implications for
practice. First, special educators can and should provide
focused training to paraprofessionals that enables them to
increase the communication of students who use AAC. To
provide training, special educators themselves must be
skilled in promoting communication. We recommend utiliz-
ing a combination of modeling and ongoing performance
feedback. Although we recommend focused training for
paraprofessionals, we also advise teachers to thoughtfully
consider how they allocate responsibilities to paraprofes-
sionals. Licensed teachers should be responsible for teach-
ing new communication acts to students with complex
communication, although it may be appropriate for parapro-
fessionals to target the improvement of these skills. It is
important for teachers to think carefully when allocating
classroom responsibilities, and to prioritize teacher-imple-
mented focused interventions with students with the most
complex support needs (Giangreco, Doyle, & Suter, 2012).
One barrier that teachers frequently cite to providing higher
quality training and supervision is time (e.g., Breton, 2010);
administrators could help mitigate this barrier by providing
designated time for training and planning when possible.
Second, teachers should consider individual student
characteristics and communication profiles when designing
trainings for paraprofessionals. Implementation of the strat-
egies discussed in this study would differ based on student
characteristics. For example, we trained a paraprofessional
to use a physical prompt as the most intrusive prompt in the
prompting hierarchy because the student was using direct
selection on a high-tech AAC device; a model prompt might
be more appropriate for a student who uses sign language.
Similarly, the impact of OTI is linked to student’s motiva-
tion, so teachers should consider what items or activities are
highly motivating. It may be helpful to implement a prefer-
ence assessment.
Third, given how rapidly the parparofessional acquired
OTI and the immediate impact on student outcomes, teach-
ers might consider prioritizing OTI. In contrast, OTR had
less of an impact on student communication and LTM
prompting was more difficult for the paraprofessional to
acquire. We also note that we staggered training on prac-
tices in a particular order for the purpose of maintaining
experimental control and gauging the impact of individual
strategies on student communication; in everyday practice,
it might be more efficient for teachers to provide training on
more effective strategies first (e.g., OTI) or focus on more
than one strategy at the same time.
Limitations and Future Research
There are several limitations to this study. First, this parapro-
fessional was selected from the first author’s classroom, and
is likely not representative of all paraprofessionals.
Researchers might implement similar studies with other
paraprofessionals with different characteristics (e.g., differ-
ent levels of experience, age) to determine if our effects rep-
licate. Second, we did not collect generalization data, so it is
unclear if the paraprofessional would be able to generalize
these strategies to new students and situations, or if the stu-
dent’s rate of communication increased in other situations.
In future studies, researchers could collect these data and
program for generalization as needed. They should focus on
a range of contexts other than food-based activities, and they
might also focus on training peers to implement these strate-
gies to promote communication. Third, two of the three
paraprofessional-implemented strategies focused on chang-
ing opportunities for communication. Although beneficial,
these strategies did not actually teach or increase communi-
cation skills not already within the student’s repertoire. In
Wermer et al.
future studies, researchers might focus more heavily on
strategies that teach new communication acts.
Conclusion
During the school day, there are often many missed natural
opportunities to promote and expand communication for
students with ASD and complex communication needs.
Given their lack of formal training, it is unsurprising that
paraprofessionals often struggle to identify and capitalize
on these opportunities. This study demonstrates that teacher-
delivered training can enable a paraprofessional to increase
student communication. Although this study focused only
on one student during one part of the school day, this simple
training package could likely be used to target any student
who has complex communication challenges during any
part of the school day. If all special education staff were
trained to provide and capitalize on communication oppor-
tunities across the school day, they could have a profoundly
positive impact on the lives of students with complex com-
munication challenges.
Acknowledgments
We would like to thank Dr. Diane Sainato for her advice and sup-
port. We would also like to thank Alana Oif for her assistance with
data collection.
Rachel Seaman is now a Postdoctoral Fellow at Emory
University.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
References
American Psychiatric Association. (2013). Diagnostic and sta-
tistical manual of mental disorders (5th ed.). Arlington, VA:
American Psychiatric Publishing.
Baxter, S., Enderby, P., Judge, S., & Evans, P. (2012). Barriers
and facilitators to use of high technology augmentative and
alternative communication devices: A systematic review and
qualitative synthesis. International Journal of Language &
Communication Disorders, 47, 115–129. doi:10.1111/j.1460-
6984.2011.00090.x
Beukelman, D. R., Mirenda, P., & Beukelman, D. R. (2013).
Augmentative and alternative communication: Supporting
children and adults with complex communication needs (4th
ed.). Baltimore, MD: Paul H. Brookes.
Bingham, M. A., Spooner, F., & Browder, D. (2007). Training
­paraeducators to promote the use of augmentative and ­alternative
communication by students with significant disabilities. Education
& Training in Developmental Disabilities, 42, 339–352.
9
Breton, W. (2010). Special education paraprofessionals:
Perceptions of preservice preparation, supervision, and ongo-
ing developmental training. International Journal of Special
Education, 25, 34–45.
Brock, M. E., & Carter, E. W. (2013). A systematic review of
paraprofessional-delivered instruction to improve outcomes
for students with intellectual and developmental disabilities.
Research & Practice for Persons With Severe Disabilities, 38,
211–221. doi:10.1177/154079691303800401
Carter, E. W., O’Rourke, L., Sisco, L. G., & Pelsue, D.
(2009). Knowledge, responsibilities, and training needs of
paraprofessionals in elementary and secondary schools.
Remedial and Special Education, 30, 344–359. doi:10.1177/
0741932508324399
Carter, E. W., Sisco, L. G., Brown, L., Brickham, D., &
Al-Khabbaz, Z. A. (2008). Peer interactions and academic
engagement of youth with developmental disabilities in inclu-
sive middle and high school classrooms. American Journal on
Mental Retardation, 113, 479–494.
Cavanaugh, B. (2013). Performance feedback and teachers’ use of
praise and opportunities to respond: A review of the literature.
Education & Treatment of Children, 36, 111–137.
Chung, Y. C., & Carter, E. W. (2013). Promoting peer
interactions in inclusive classrooms for students who
use speech-generating devices. Research & Practice
for Persons With Severe Disabilities, 38, 94–109.
doi:10.2511/027494813807714492
Chung, Y. C., Carter, E. W., & Sisco, L. G. (2012). A systematic
review of interventions to increase peer interactions for stu-
dents with complex communication challenges. Research &
Practice for Persons With Severe Disabilities, 37, 271–287.
doi:10.2511/027494813805327304
Douglas, S. N., Light, J. C., & McNaughton, D. B. (2013).
Teaching paraeducators to support the communication
of young children with complex communication needs.
Topics in Early Childhood Special Education, 33, 91–101.
doi:10.1177/0271121412467074
Douglas, S. N., McNaughton, D., & Light, J. (2013). Online
training for paraeducators to support the communication of
young children. Journal of Early Intervention, 35, 223–242.
doi:10.1177/1053815114526782
French, N. K. (2001). Supervising paraprofessionals: A survey
of teacher practices. The Journal of Special Education, 35,
41–53. doi:10.1177/002246690103500105
Ganz, J. B., & Simpson, R. L. (2004). Effects on communicative
requesting and speech development of the Picture exchange
communication system in children with characteristics of
autism. Journal of Autism and Developmental Disorders,
34, 395–409. doi:10.1023/b:jadd.0000037416.59095.d7
Gast, D. L., Lloyd, B. L., & Ledford, J. R. (2014). Multiple base-
line and multiple probe designs. In D. L. Gast & J. R. Ledford
(Eds.), Single subject research methodology in behavioral
sciences (pp. 251–296). New York, NY: Routledge.
Giangreco, M. F., Doyle, M. B., & Suter, J. C. (2012). Constructively
responding to requests for ­paraprofessionals: We keep asking
the wrong ­questions. Remedial and Special Education, 33,
362–373. doi:10.1177/0741932511413472
Individuals With Disabilities Education Improvement Act, 20
U.S.C. § 1400 (2004).
10
Snyder, P., Hemmeter, M. L., Meeker, K. A., Kinder, K., Pasia,
C., & McLaughlin, T. (2012). Characterizing key features
of the early childhood professional development literature.
Infants & Young Children, 25, 188–212.
Tager-Flusberg, H., & Kasari, C. (2013). Minimally verbal school-
aged children with autism spectrum disorder: The neglected
end of the spectrum. Autism Research, 6, 468–478.
View publication stats
Focus on Autism and Other Developmental Disabilities 00(0)
Thunberg, G., Sandberg, A. D., & Ahlsén, E. (2009). Speech-
generating devices used at home by children with autism
spectrum disorders: A preliminary assessment. Focus on
Autism and Other Developmental Disabilities, 24, 104–114.
U.S Department of Education (2013). IDEA Section 618 data
products. Retrieved from https://www2.ed.gov/programs/
osepidea/618-data/index.html