Autism: Teaching Parents how to Prompt Communication & Socialization

Introduction
Social dysfunction is the single most defining feature of autism (Kanner, 1943) and arguably its most handicapping as well. From the beginning, improved social functioning has been considered one of the most important intervention outcomes. A variety of social  interventions have been designed, empirically examined, and published in the autism literature. These interventions differ in a variety of ways: the age group of the people with autism involved, the target behavior of the intervention (initiation, response, maintenance), the kind of social partner involved: peer or adult, the intervention strategy used, and the characteristics of the intervener: adult or peer. Almost all of the published interventions represent a behavioral methodology, involving careful definition of the target behaviors to be acquired, increased, or diminished, definition of the antecedents and consequences of the behavior, the use of task analysis, and measurement of the acquisition of the behavior, maintenance of the behavior under more natural reinforcement conditions, and generalization to other settings, persons, and behaviors.

Interventions for Facilitating Social Interactions in Preschoolers
Interventions That Enhance Parent–Preschooler Interactions
Two published papers have focused on increasing interactions of very young children with their parents. Both of these studies involve noncontrolled group designs without reversals or other methods that unequivocally demonstrate a causal relationship. Dawson and Galpert (1990) described a pre–post study of 14 children, ages 20 to 66 months, and their mothers. The intervention involved teaching the parent to imitate the child in play with toys for 20 minutes each day for 2 weeks. Follow-up after 2 weeks demonstrated significant increases over baseline in increased gaze to mother’s face, increased number of toys played with, and increased number of play schemas used, as well as generalization to novel toys. Rogers, Herbison, Lewis, Pantone, and Reis (1986) used a similar pre–post design to assess changes in child behavior of 13 preschoolers following 6 or more months of intensive intervention in a daily preschool program that heavily emphasized positive adult–child interactions, play, and communication. Several markers of significantly improved social functioning were found, including improvements in the social-communicative play levels with a familiar adult and increases in child positive affect and social initiations and decreased negative responses to mother’s initiations during mother–child play. Maternal behavior was stable across the two samples; thus changes in child behavior did not appear due to changes in maternal behaviors, but rather represented generalization of effects from the day program. Improvement in social interactions was demonstrated across three separate measures and with various partners, adding convergent validity to the impact of this model on social development of young children with autism.

Interventions That Enhance Preschoolers’ Interactions with Other Adults
Two approaches for increasing interactions with teachers or other therapists have been demonstrated using multiple baseline approaches. One approach, coming from the work of Schreibman using pivotal response training (PRT), was described in several publications by Stahmer, Schreibman, and colleagues. In pivotal response training, certain behaviors are seen as central to wide areas of functioning. Changing pivotal behaviors is thought to affect change in other associated behaviors without specifically targeting them.

Stahmer (1995) compared two interventions—symbolic play training and language training—using pivotal response techniques, including child choice and reinforcing attempts, among others, with seven preschoolaged children with autism who had some verbal skills. In addition to demonstrating increases in the targeted symbolic play skills, the children demonstrated increased positive responses to adult initiations and smaller increases in initiations to adults in the play training, but not the language training, intervention. These results were maintained for 3 months after the end of treatment and generalized over settings and other adults, but not peers.

Krantz and McClannahan (1998) used a visual cuing system involving a script-fading procedure to increase social initiations to a teacher. The technique, previously found to be effective with older children, involved using a one-word stimulus embedded in a child’s independent play schedule. The stimulus prompted the child to approach an adult and initiate a joint attention request (look, watch me, etc.), to which the adult responded with various comments about the child’s behavior, but without any other reinforcing consequence.

Over time the script was faded. Three preschoolers with some language learned the procedure, maintained and increased initiations even after the stimuli were faded, and demonstrated generalization by using unscripted and elaborated initiations and by generalizing across new adults and new activities. One important aspect of this technique for eliciting social initiations deserves highlighting. By using a visual cue, potential difficulties seen in adult prompting paradigms (disruptions in ongoing social interactions, constant presence of cuing adult, difficulties with fading adult prompts; Oke & Schreibman, 1990) were avoided.

Interventions That Increase Preschoolers’ Peer Interactions
The largest body of published work focuses on preschoolers’ peer interactions, probably because the current emphasis on inclusive preschools for children with disabilities has made peer interaction such a focal issue. Several successful methods have been published, replicated, and moved from short-term experiments to long-term experimental preschool models. Main methods involve peer-mediated intervention, peer tutoring, and adult instruction in various games and scripts. Peer Mediated Techniques for Increasing Interaction and Responses to Peers

Progress in this area has been profoundly influenced by the work of Strain, Odom, Goldstein, and their associates, who have worked to develop successful peer-mediated strategies for the past 20years, some of which are discussed below. Their work represents the strongest empirical support for a single type of social intervention for autism. In their peer-mediated approach, typical peers are taught to initiate "play organizers" with perseverance: sharing, helping, giving affection, and praise. Peers role-play with adults until they have learned the strategies successfully and then are cued by adults to begin to interact with the target children around typical play materials and activities. The peers are reinforced by adults for their efforts, and the reinforcements are systematically and carefully reduced.

These strategies are powerful in increasing the social interactions of young children with autism, and both generalization and maintenance have been demonstrated in inclusive preschool classes, as reported in many published multiple baseline studies (Goldstein, Kaczmarek, Pennington, & Shafer, 1992; Hoyson, Jamieson, & Strain, 1984; Odom et al., 1999; Odom & Strain, 1986; Strain, Kerr, & Ragland, 1979; Strain, Shores, & Timm, 1977). Over the years, these researchers have carefully explored variables involved in achieving maximum effects, including generalization and maintenance. Such variables have included characteristics of the peers, methods of prompting and reinforcing peers, fading reinforcers, ages of children, and characteristics of the setting. Various replications of these techniques have demonstrated the importance of using multiple peer trainers in achieving generalization across untrained peers (Brady, Shores, McEvoy, Ellis, & Fox, 1987) and in maintaining skills in the peer-trainers (Sainato, Goldstein, & Strain, 1992). Self-monitoring systems have been successfully used to maintain the interactions without adult reinforcement (Strain, Kohler, Storey, & Danko, 1994). Delivering these interventions in inclusive preschools rather than in lab settings results in the more stable, generalized, and well-maintained increases in social interactions. Finally, Strain and Danko (1995) and Strain et al. (1994) demonstrated that parents could be taught to teach peer-mediated approaches to siblings at home, with resulting improvements in child–sibling interactions.

The use of play organizers was replicated and extended by Oke and Schreibman (1990) in a case study. After using the peer-mediated approach with one high functioning 5-year-old with autism, they added two procedures. First, they trained the typical peer to discriminate between parallel play and interactive play, which increased and stabilized responding of the target child. Second, they trained the target child in the peer-initiating procedures. This third intervention had four important effects: maintenance of high rates of social engagement during the reversal phase, decrease in inappropriate behaviors, normalization of child affect, and maintenance and generalization across peers but not across settings.

The peer-mediated procedures appear to gain their effectiveness by using typical peers as the interventionists, thus eliminating the need to develop procedures to transfer learning from adult partners to peer partners. This is an important feature because studies have demonstrated that use of adult partners to increase interactions of children with autism does not easily generalize to peer partners. These highly effective peer-mediation approaches are complex to deliver, requiring socially skilled typical peers and precise adult control at training peers, managing and fading reinforcement, and monitoring ongoing child interaction data. However, the approach is manualized (Danko, Lawry, & Strain, 1998) and well described in many publications.

Adult Instruction in Social Games
Goldstein, Wickstrom, Hoyson, Jamieson, and Odom (1988) taught sociodramatic scripts to two trios of preschool children consisting of two typical peers and a child with social, communicative, and behavioral problems. Although other references to this paper by the authors describe this as an intervention for children with autism, the diagnosis of autism was not mentioned in this paper. Each script contained three social roles and each child was trained in each role, with teacher instruction gradually reduced, until each child could carry out 80% of each role’s script. Following training, increases in child interaction and generalization across settings and other behaviors improved during free play periods at preschool. However, the effects depended on continued teacher prompts in role-playing activities and did not result in general increases in social exchanges across the preschool day.

Comparative Studies of Various Approaches
There is little comparative information on these approaches for children with autism. In a recent paper, Odom et al. (1999) compared three different social intervention approaches for preschoolers with disabilities, but children with autism were not listed as part of the subject group. In comparing preschoolers in special education classes in four conditions—structured play, adult instruction in social skills, peer-mediated techniques, and a fourth condition combining all three approaches, along with a control condition, the peermediated strategies resulted in the greatest long-term effects that generalized across people and settings.
- Rogers, SJ, Interventions that facilitate socialization in children with autism, Journal of Autism and Developmental Disorders, Oct. 2000 Vol. 30.

Personal Reflection Exercise #2
The preceding section contained information about interventions that facilitate socialization in preschool children with autism.  Write three case study examples regarding how you might use the content of this section in your practice.

Update
Joint Attention Performance in Preschool-Aged
Boys with Autism or Fragile X Syndrome

- Thurman, A. J., & Dimachkie Nunnally, A. (2022). Joint attention performance in preschool-aged boys with autism or fragile X syndrome. Frontiers in psychology, 13, 918181.

Peer-Reviewed Journal Article References:
Hiles Howard, A. R., Lindaman, S., Copeland, R., & Cross, D. R. (2018). Theraplay impact on parents and children with autism spectrum disorder: Improvements in affect, joint attention, and social cooperation. International Journal of Play Therapy, 27(1), 56–68. 

Hillman, H. (2018). Child-centered play therapy as an intervention for children with autism: A literature review. International Journal of Play Therapy, 27(4), 198–204.

MacCormack, J. (2019). Part 1: Why child-centered play therapists should care about play-based social interventions for youth with ASD. International Journal of Play Therapy, 28(3), 157–167. 

Online Continuing Education QUESTION 16
In what socialization approach are peers utilized to role play sharing, helping, giving affection and praise for preschool children with autism? Record the letter of the correct answer the CEU Test.