Teaching symbolic play skills to children with autism using pivotal response training

Effects of mini-basketball training program on social communication impairments and regional homogeneity of brain functions in preschool children with autism spectrum disorder

BACKGROUND

Social communication impairments (SCI) is a core symptom of autism spectrum disorder (ASD) and is marked by challenges in social interaction. Although physical exercise has been shown to improve SCI, this finding has not been supported by comprehensive scientific evidence. Existing research has established a strong link between the SCI in children with ASD and abnormalities in regional homogeneity (ReHo). Therefore, investigating the effects of physical exercise on SCI and Reho in patients with ASD may help to elucidate the neurological mechanisms involved.

METHODS

The present study included 30 preschool children diagnosed with ASD, with 15 participants in each group (experimental and control). The experimental group underwent a 12-week mini-basketball training program (MBTP) based on routine behavioral rehabilitation, while the control group only received routine behavioral rehabilitation. The Social Responsiveness Scale-Second Edition (SRS-2) was employed to assess SCI in both groups. Resting-state functional magnetic resonance imaging technology was used to evaluate ReHo in both groups.

RESULTS

After 12-week of MBTP, significant group × time interactions were observed between the experimental and control groups in total SRS-2 scores (F = 14.514, p < 0.001, ηp2 = 0.341), as well as in the domains of social cognition (F = 15.620, p < 0.001, ηp2 = 0.358), social communication (F = 12.460, p < 0.01, ηp2 = 0.308), and autistic mannerisms (F = 9.970, p < 0.01, ηp2 = 0.263). No statistical difference was found in the scores for the social awareness subscale and social motivation subscale in the group × time interaction (all p > 0.05). The experimental group exhibited increased ReHo in the right Cerebellum_Crus1 and right parahippocampal gyrus, coupled with decreased ReHo in the left middle frontal gyrus (orbital part), left superior frontal gyrus (dorsolateral), left postcentral gyrus, and right superior parietal gyrus. Furthermore, a decrease in ReHo in the left postcentral gyrus positively correlated with changes in social communication scores in SCI behaviors (p < 0.05).

CONCLUSIONS

Our study underscores the effectiveness of a 12-week MBTP in ameliorating SCI and abnormalities in ReHo among preschool children with ASD.

TRIAL REGISTRATION

The trial is retrospectively registered on the Chinese Clinical Trial Registry (ChiCTR1900024973; August 5, 2019).

Using eCoaching to Support Mothers' Pretend Play Interactions at Home

A unique component of early childhood involves understanding how caregivers and educators promote children's developmental outcomes, with play opportunities being a key avenue for enhancing these skills. Targeted coaching is one type of support that can tap into active family engagement during playful learning. This collective case study examined how remote-based eCoaching could support family-centered practices related to the facilitation of pretend play in caregivers of preschool children in the home setting. Four mother-child dyads of preschool children, with and without a disability, participated in eCoaching focusing on pretend play behaviors. During the implementation of eCoaching, three primary findings emerged related to knowledge acquisition, mothers' facilitation of play with their children, and changes in children's pretend play behaviors. In general, both mothers and children benefited from the eCoaching experience. In addition, mothers' perceptions of eCoaching as a means of family-based support were positive, and all deemed eCoaching easy to engage in and beneficial.

Improvement of Autism Symptoms After Comprehensive Intensive Early Interventions in Community Settings

BACKGROUND

Preschool children with autism in southern Sweden participated in a comprehensive Naturalistic Developmental Behavioral Intervention (NDBI) program.

AIMS

To evaluate the ongoing NDBI program by comparing the pre- and postintervention outcomes in terms of improved autism symptom severity.

METHOD

The improvement of Autism Diagnostic Observation Schedule (ADOS-R) test results between baseline and evaluation among children participating in the NDBI program (n = 67) was compared with the results among children receiving community treatment as usual (n = 27) using analysis of covariance.

RESULTS

The study showed that children in the NDBI group improved their ADOS-R total scores between baseline and evaluation (-0.8 scores per year; 95% CI [-1.2, -0.4]), whereas no improvement was detected in the comparison group (+0.1 scores per year; 95% CI [-0.7, +0.9]). The change in the NDBI group versus the change in the comparison group was statistically significant after adjusting for possible confounders as well. Children in the NDBI group also significantly improved their ADOS severity scores, but the scores were not significantly different from those of the comparison group.

CONCLUSIONS

The results from the current naturalistic study must be interpreted cautiously, but they do support earlier studies reporting on improvement of autism symptoms after early intensive interventions. Results from observational studies are difficult to interpret, but it is nevertheless of uttermost importance to evaluate costly autism intervention programs. The results do indicate that children with autism benefit from participating in early comprehensive intensive programs.

The Effect of Teaching Initiations on the Communication of Children with Autism Spectrum Disorder: A Randomized Clinical Trial

This study examined the effect of Pivotal response treatment (PRT) to improve verbal initiations in children with Autism Spectrum Disorder, age 6-12 years old, using a Randomized Clinical Trial design. Intervention was conducted three times a week for 2 months, for a total of 24 one-hour sessions. The PRT intervention taught a variety of questions and attention/assistance-seeking initiations. The treatment as usual (TAU) group received standard language intervention. Results showed that the PRT group made significant improvements in their number of verbal initiations as well as collateral gains in general communicative skills and mean length of utterance (MLU) compared to the TAU group. Theoretical implications of including motivational approaches to develop social initiations are reviewed.

Improving pretend play for children with autism through experiencing the stimulus properties of real objects

Children with autism spectrum disorder (ASD) often lack symbolic play skills. Attribution of pretend properties (APP) is a type of symbolic play in which a child tacts pretend properties of an object (e.g., smelling a toy flower and saying, "It smells like a rose!"). Three Chinese boys (5-6 years of age) with ASD served as participants. A multiple-probe design across 5 objects was used to determine the effects of an intervention that involved having the child experience and tact sensory properties of real objects (e.g., rose). Corresponding test objects, including mock (e.g., a toy flower) and arbitrary objects (e.g., a stick), were used to evaluate whether tact responses for sensory properties were transferred. Results indicated that all 3 children emitted tacts of stimulus properties for test objects and maintained the skill for 7 to 10 weeks following the intervention. Two participants also tacted novel (nontarget) properties for test objects.

Pivotal Response Treatment for School-Aged Children and Adolescents with Autism Spectrum Disorder: A Randomized Controlled Trial

Pivotal Response Treatment (PRT) is promising for children with Autism Spectrum Disorder (ASD), but more methodologically robust designed studies are needed. In this randomized controlled trial, forty-four children with ASD, aged 9-15 years, were randomly allocated to PRT (n = 22) or treatment-as-usual (TAU; n = 22). Measurements were obtained after 12- and 20-weeks treatment, and 2-month follow-up. PRT resulted in significant greater improvements on parent-rated social-communicative skills after 12 weeks treatment (p = .004, partial η² = 0.22), compared to TAU. Furthermore, larger gains in PRT compared to TAU were observed on blindly rated global functioning, and parent-rated adaptive socialization skills and attention problems. Implications for clinical practice and suggestions for future research are discussed.

Enhancing Social Initiations Using Naturalistic Behavioral Intervention: Outcomes from a Randomized Controlled Trial for Children with Autism

Deficits in social skills are common in children with Autism Spectrum Disorder (ASD), and there is an urgent need for effective social skills interventions, especially for improving interactions with typically developing peers. This study examined the effects of a naturalistic behavioral social skills intervention in improving social initiations to peers through a randomized controlled trial. Analyses of multimethod, multi-informant measures indicated that children in the active group (SIMI) demonstrated greater improvement in the types of initiations which were systematically prompted and reinforced during treatment (i.e., behavior regulation). Generalization to joint attention and social interaction initiation types, as well as collateral gains in broader social functioning on clinician- and parent-rated standardized measures were also observed.

Examining Effectiveness and Predictors of Treatment Response of Pivotal Response Treatment in Autism: An Umbrella Review and a Meta-Analysis

The current study aimed to provide a comprehensive appraisal of the current evidence on the effectiveness of Pivotal Response Training (PRT) for individuals with autism spectrum disorder (ASD) and to explore predictors of treatment response. We conducted a systematic review of the following electronic databases and registers: PsycINFO, Medline, Embase, Cochrane Central Register of Controlled Trials, ERIC, Linguistics and Language Behavior Abstracts. Six systematic reviews were identified, two with meta-analytic component. Identified reviews varied widely in terms of their aims, outcomes, and designs which precluded a unified and consistent set of conclusions and recommendations. Ten RCTs were identified. Eight of identified RCTs reported at least one language and communication-related outcome. Statistically significant effects of PRT were identified across a majority of identified RCTs for a range of language and communication skills. However, evidence for positive treatment effects of PRT on outcome measures assessing other domains was less robust and/or specific. Overall, both previous systematic reviews and new meta-analysis of the RCTs suggest that PRT shows promise for improving language and communication. Only four RCTs examined the association between baseline child characteristics and treatment outcomes, however, no consistent pattern emerged. This review has identified several key methodological and design improvements that are needed to enable our field to fully capitalize on the potential of RCT designs and characterize detailed profiles of treatment responders. These findings are essential for informing the development of evidence-based guidelines for clinicians on what works for whom and why.

Social Skill Outcomes Following Physical Activity-Based Interventions for Individuals on the Autism Spectrum: A Scoping Review Spanning Young Childhood Through Young Adulthood

Researchers posit that physical activity (PA) settings may provide an increased opportunity for social interaction. However, little consensus exists regarding the construct of social skills. Moreover, little is known about what type or amount of PA is necessary for individuals on the autism spectrum to benefit from this increased interaction. Thus, this scoping review synthesized the components (e.g., design, participants, independent and dependent variables, etc.) and findings of PA-based interventions that included social skill components to identify how interventions have incorporated these skills in different settings. Based on a review of 25 articles, this review revealed a great deal of variability in the types of PA, social skills, and instruments studied, as well as the intensity of intervention delivery in the published findings. No longitudinal studies were identified as a part of the search. These results provide a foundation for the design of effective PA-based interventions that may have an increased impact on the social skills of individuals on the autism spectrum. Future research should employ longitudinal designs to capture the relationship between social skills and PA, as well as to increase the likelihood of capturing change.

Mini-Basketball Training Program Improves Social Communication and White Matter Integrity in Children with Autism

Impairments in social communication (SC) represent one of the core symptoms of autism spectrum disorder (ASD). While previous studies have demonstrated that exercise intervention improves SC in children with ASD, there is currently no neuroscientific evidence supporting its benefits. Therefore, we evaluated the outcomes of a long-term exercise intervention on SC and white matter integrity (WMI) in children with ASD, and further explored the neural mechanism of exercise intervention on SC in these children. Twenty-nine children aged 3–6 years with ASD were assigned to either exercise group (n = 15) or control group (n = 14). The exercise group received a scheduled mini-basketball training program (5 sessions per week, forty minutes per session) for 12 consecutive weeks, while the control group was instructed to maintain their daily activities. Groups were assessed before and after intervention on SC and WMI. SC scores were lower in the exercise group post-intervention. Compared with the control group, WMI of the exercise group showed higher fractional anisotropy in the body of corpus callosum, fornix, right cerebral peduncle, left posterior limb of internal capsule, right retrolenticular part of internal capsule, left anterior corona radiate and left superior fronto-occipital fasciculus; lower mean diffusivity in the left anterior corona radiate and the bilateral corticospinal tract. Furthermore, increased WMI was associated with lower scores on a measure of social cognition in the overall sample. This study is the first to provide evidence that exercise intervention improves SC and white matter integrity in children with autism.

The effectiveness of using colors in L1 and L2 vocabulary development of autistic children

Purpose

The purpose of this paper is to examine the effectiveness of using colors and learner’s intelligence quotient (IQ) in teaching new vocabulary in Arabic (L1) and English (L2) to children with autism spectrum disorder (henceforth, ASD).

Design/methodology/approach

To this end, 12 autistic children whose ages ranged between 7 and 12 were observed while they were being taught ten new words. The children were divided into two groups based on their IQ: Low (70–74) and High (76–79). The children were also divided into two groups: Group 1 studied the words written in a black font, whereas Group 2 studied the same words, but written in colors (each letter in the word in a different color), and an illustrative picture was provided with each word for both groups. The pictures were also different in color in the former group, while the picture was in black and white in the latter. The children involved in the study have a relatively slight ability to read letters based on an annual language assessment conducted by the center, and they learn a new word by learning its shape and by repetition. The experiment took place over a two-week period that involved teaching, revising and testing.

Findings

The results of the study showed that the children’s IQ played a crucial role in learning L1 and L2 vocabulary. The results also demonstrated that using colors had no significant impact on the children’s performance in the test. Finally, the results showed that teaching new words to children with ASD through repetition and drilling could be regarded as a useful technique. The study concludes with some recommendations for further studies.

Originality/value

The study shows that using pictures is a very useful tool in teaching L1 and L2 vocabulary to children with ASD.

Effects of Video Modeling on the Acquisition, Maintenance, and Generalization of Playing with Imaginary Objects in Children with Autism Spectrum Disorder

Many children with autism spectrum disorder (ASD) do not have symbolic play skills. One type of symbolic play involves playing with imaginary objects, in which a child displays play actions without actual objects. The purpose of this study was to evaluate the effects of video modeling on the acquisition, maintenance, and generalization of playing with imaginary objects in young children with ASD. Three male Chinese children (aged 4-5 years) with ASD participated in this study. A multiple-probe across three behaviors design was used. The results indicated that video modeling was effective in establishing and maintaining target symbolic play behaviors for the three children. Generalization to untaught imaginary play activities occurred in all three children.

Believing in Make-Believe: Efficacy of a Pretend Play Intervention for School-Aged Children with High-Functioning Autism Spectrum Disorder

Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder marked by socio-emotional deficits, and difficulties with pretend play skills. Play skills are related to processes of adaptive functioning and emotion understanding. The present pilot study implemented an in-person pretend play intervention to school-aged children (ages 6 to 9 years, intervention group = 18, control group = 7) diagnosed with high-functioning ASD (HF-ASD), to increase children's cognitive and affective play skills, and emotional understanding abilities. The intervention consisted of 5 weekly sessions, 15-20 minutes each. The intervention group significantly increased in imagination and cognitive play skills, which generalized to increased skills in emotional understanding. Findings demonstrate the positive impact of a short, easily facilitated, accessible play intervention for school-aged children with HF-ASD.

Arranging play activities with missing items to increase object-substitution symbolic play in children with autism spectrum disorder

PURPOSE

Many children with autism spectrum disorder do not have symbolic play skills. The purpose of this study was to evaluate the effects of a training procedure on the acquisition, maintenance, and generalization of object-substitution symbolic play in children with autism spectrum disorder.

METHODS

A single-case experimental design (multiple-probe across four behaviors) was used. One girl (5 years) and two boys (4-5 years) participated in this study. The training procedure involved withdrawing necessary items in play activities, supplying multiple substitutes, and providing hierarchical assistive prompts. Each child's symbolic play responses across baseline, intervention, and follow-up conditions were recorded and graphed. Data analysis involved visual inspection of graphs.

RESULTS

The results indicated that the procedure effectively increased and maintained object-substitution symbolic play. Generalization to untaught play activities occurred in all children, and symbolic play increased in the free play setting for one child.

CONCLUSIONS

Arranging play activities with missing items increased opportunities for children to engage in symbolic play. The training procedure can be used in clinical and educational settings as an initial step to establish and improve complex play behavior in children with autism spectrum disorder who lack such skills.IMPLICATIONS FOR REHABILITATIONMany children with autism spectrum disorder have inappropriate play behaviors and do not demonstrate symbolic play.Arranging play activities with missing items and systematic assistive prompts effectively increased object-substitution symbolic play.Generalization of symbolic play to untrained play activities occurred after the intervention.

Teaching Object Play to Young Children With Disabilities: A Systematic Review of Methods and Rigor

In this systematic review, we examined the rigor and outcomes across 27 object play intervention studies using single-case research methodology. We focused on studies including children age 5 years or younger and examined several descriptive characteristics including materials, instructional packages, and settings. We also analyzed the facilitation and measurement of generalized play and several methodological features including quality, rigor, and visual analysis procedures. Overall, the identified studies demonstrated positive outcomes, although quality and rigor limited interpretations of the outcomes. Previous reviews also have noted strong outcomes and weak to moderate quality for single-case studies. Our results should be interpreted with caution given previous reviews of play intervention studies identified strong outcomes and quality from group-design studies. Additional replications testing robust interventions using single-case research with strong methodological rigor are warranted.

A Systematic Review of Linguistic and Verbal Behavior Outcomes of Pivotal Response Treatment

Pivotal Response Treatment (PRT) is a popular intervention for improving targeted and untargeted communication skills for learners with autism. We systematically reviewed communication outcomes reported in experimental research to determine linguistic forms and verbal behavior functions associated with PRT. We found most researchers aggregated results or did not report sufficient detail to determine linguistic forms and/or verbal behavior functions. Generalization of communication skills to untargeted people, settings, materials, and/or activities was evident. However, only one study clearly indicated untargeted linguistic forms emerged following PRT, and no researchers described results that indicated improved generalized and collateral verbal behavior functions. We suggest PRT researchers more clearly define and report primary, generalized, and collateral communication-specific outcomes in order to advance research and practice.

A Systematic Review of Interventions to Improve the Occupation of Play in Children With Autism

Play in children with autism spectrum disorder (ASD) is often atypical, yet consensus regarding effective occupational therapy strategies for improving play is not established. To examine the efficacy of strategies used in occupational therapy to improve play in ASD, authors completed a systematic review of papers from January 1980 through January 2019. Search terms included autism, Asperger's, ASD, autistic in combination with play, playfulness, pretend, imagination, praxis, creativity, and generativity. Twenty papers met inclusion criteria and were reviewed. Reviewed interventions included parent education, modified play materials or environments, imitation of the child, and modeling by an adult, a peer, or video. Moderate to strong support exists for the specific strategies of imitation of the child and modeling for the child, with lesser or mixed support for other strategies. Certain strategies commonly used in occupational therapy may be effective in improving the occupation of play in ASD.

Teaching "Imaginary Objects" Symbolic Play to Young Children with Autism

Symbolic play skills are important in language acquisition and child development. Children with autism spectrum disorder (ASD) often have difficulties demonstrating such play behaviors. Imaginary objects symbolic play refers to play behavior in which children perform play actions without actual objects. Three boys with ASD (3-7 years) participated in this study. A multiple-probe across three participants and two settings design was employed to evaluate the effects of intraverbal training on the acquisition and generalization of imaginary objects symbolic play. Results indicated that all children acquired and maintained target imaginary objects play activities. Generalization to untaught activities occurred in one child. All three children' symbolic play emerged or increased in free play after the instruction.

Parental experiences using the Therapy Outcomes by You (TOBY) application to deliver early intervention to their child with autism

PURPOSE

As computer-based interventions become commonplace for parents of children with neurodevelopmental disorders, this study sought to understand the experience of using a parent-delivered supplementary early intervention therapy for children with autism spectrum disorder grounded in a variety of behavioral, sensory, developmental, and relationship-based approaches and delivered via a tablet device.

METHODS

Parental experiences using the 'Therapy Outcomes by You' (TOBY) application were collected through semi-structured interviews with 17 parents.

RESULTS

Parents reported TOBY facilitated parent-child engagement, provided ideas for therapeutic activities, created feelings of empowerment, and positively impacted their child's development. Barriers to use included preparation time, execution of the intervention, and individual strengths and weaknesses of their child.

CONCLUSION

The overall parental experience of TOBY was positive when use of the application aligned with parental proficiency, opportunities for use, and importantly, the needs of the child.

Meta-analysis of naturalistic developmental behavioral interventions for young children with autism spectrum disorder

Naturalistic developmental behavioral intervention is an emerging class of interventions for young children with autism spectrum disorder. The present article is a meta-analysis of outcomes of group-design studies ( n = 27) testing interventions using naturalistic developmental behavioral intervention strategies. Small, significant positive effects of naturalistic developmental behavioral intervention were found for expressive language ( g = 0.32), reduction in symptoms of autism spectrum disorder ( g = −0.38), and play skills ( g = 0.23). Larger effects were found for social engagement ( g = 0.65) and overall cognitive development ( g = 0.48). A marginal effect was found for joint attention ( g = 0.14) and receptive language ( g = 0.28). For joint attention, improvement was moderated by hours of professional involvement. Evidence of publication and reporting bias was present for language outcomes. This meta-analysis grows the evidence base for naturalistic developmental behavioral interventions, particularly in the key areas of social engagement and cognition.

Effectiveness of a multi-level implementation strategy for ASD interventions: study protocol for two linked cluster randomized trials

BACKGROUND

The Centers for Disease Control (2018) estimates that 1 in 59 children has autism spectrum disorder, and the annual cost of ASD in the U.S. is estimated to be $236 billion. Evidence-based interventions have been developed and demonstrate effectiveness in improving child outcomes. However, research on generalizable methods to scale up these practices in the multiple service systems caring for these children has been limited and is critical to meet this growing public health need. This project includes two, coordinated studies testing the effectiveness of the Translating Evidence-based Interventions (EBI) for ASD: Multi-Level Implementation Strategy (TEAMS) model. TEAMS focuses on improving implementation leadership, organizational climate, and provider attitudes and motivation in order to improve two key implementation outcomes-provider training completion and intervention fidelity and subsequent child outcomes. The TEAMS Leadership Institute applies implementation leadership strategies and TEAMS Individualized Provider Strategies for training applies motivational interviewing strategies to facilitate provider and organizational behavior change.

METHODS

A cluster randomized implementation/effectiveness Hybrid, type 3, trial with a dismantling design will be used to understand the effectiveness of TEAMS and the mechanisms of change across settings and participants. Study #1 will test the TEAMS model with AIM HI (An Individualized Mental Health Intervention for ASD) in publicly funded mental health services. Study #2 will test TEAMS with CPRT (Classroom Pivotal Response Teaching) in education settings. Thirty-seven mental health programs and 37 school districts will be randomized, stratified by county and study, to one of four groups (Standard Provider Training Only, Standard Provider Training + Leader Training, Enhanced Provider Training, Enhanced Provider Training + Leader Training) to test the effectiveness of combining standard, EBI-specific training with the two TEAMS modules individually and together on multiple implementation outcomes. Implementation outcomes including provider training completion, fidelity (coded by observers blind to group assignment) and child behavior change will be examined for 295 mental health providers, 295 teachers, and 590 children.

DISCUSSION

This implementation intervention has the potential to increase quality of care for ASD in publicly funded settings by improving effectiveness of intervention implementation. The process and modules will be generalizable to multiple service systems, providers, and interventions, providing broad impact in community services.

TRIAL REGISTRATION

This study is registered with Clinicaltrials.gov ( NCT03380078 ). Registered 20 December 2017, retrospectively registered.

Increasing "Object-Substitution" Symbolic Play in Young Children With Autism Spectrum Disorders

Children with autism spectrum disorders (ASD) may not develop symbolic play skills, so such skills need to be taught specifically. We report an experiment regarding a procedure targeting "object-substitution" symbolic play skills. The "object-substitution" symbolic play behavior occurred when the child labeled a common object with the name of a substitute and used the object to perform a play action (e.g., As she put a bowl on her head, she called it a hat). A multiple probe across behaviors design was employed with five children (four boys and one girl, aged 3 to 6 years) with ASD. All children had verbal communication and demonstrated functional play and generalized imitation, but no symbolic play skills prior to the study. The instruction consisted of intraverbal training, picture prompts, and modeling of play actions. All children demonstrated object-substitution symbolic play skills after the instruction. The occurrences of response generalization were also discussed.

Facilitating Social Play for Children with PDDs: Effects of Paired Robotic Devices

Interacting with toys and other people is fundamental for developing social communication skills. However, children with autism spectrum disorder (ASD) are characterized by having a significant impairment in social interaction, which often leads to deficits in play skills. For this reason, methods of teaching play skills to young children with ASD have been well documented. Although previous studies have examined a variety of instructional strategies for teaching skills, few studies have evaluated the potential of using robotic devices. The purpose of the present study is to examine whether automatic feedback provided by colored lights and vibration via paired robotic devices, COLOLO, facilitates social play behaviors in children with ASD. We also explore how social play relates to social interaction. COLOLO is a system of paired spherical devices covered with soft fabric. All participants in this study were recruited as volunteers through the Department of Psychology at Keio University. The pilot study included three participants diagnosed with Pervasive Developmental Disorders (PDDs; 5- to 6-year-old boys), and compared experimental conditions with and without automatic feedback from the devices (colored lights and vibration). The results indicated that the participants in the condition that included feedback from the devices exhibited increased rates of ball contact and looking at the therapist’s ball, but did not exhibit increased rates of eye contact or positive affect. In the experimental study, a systematic replication of the pilot study was performed with three other participants diagnosed with PDDs (3- to 6-year-old boys), using an A-B-A-B design. Again, the results demonstrated that, in the condition with colored lights and vibration, the children increased ball contact as well as looking at the therapist’s ball. However, the results did not show the effect of automatic feedback consistently for three children. These findings are discussed in terms of the potential of paired robotic devices as a method to facilitate social play for children with ASD.

Pivotal response treatment for autism spectrum disorder: current perspectives

Pivotal response treatment (PRT) is an evidence-based behavioral intervention based on applied behavior analysis principles aimed to improve social communication skills in individuals with autism spectrum disorder (ASD). PRT adopts a more naturalistic approach and focuses on using a number of strategies to help increase children's motivation during intervention. Since its conceptualization, PRT has received much empirical support for eliciting therapeutic gains in greater use of functional social communication skills in individuals with ASD. Building upon the empirical evidence supporting PRT, recent advancements have increasingly turned to using interdisciplinary research integrating neuroimaging techniques and behavioral measures to help identify objective biomarkers of treatment, which have two primary purposes. First, neuroimaging results can help characterize how PRT may elicit change, and facilitate partitioning of the heterogeneous profiles of neural mechanisms underlying similar profile of behavioral changes observed over PRT. Second, neuroimaging provides an objective means to both map and track how biomarkers may serve as reliable and sensitive predictors of responder profiles to PRT, assisting clinicians to identify who will most likely benefit from PRT. Together, a better understanding of both mechanisms of change and predictors of responder profile will help PRT to serve as a more precise and targeted intervention for individuals with ASD, thus moving towards the goal of precision medicine and improving quality of care. This review focuses on the recent emerging neuroimaging evidences supporting PRT, offering current perspectives on the importance of interdisciplinary research to help clinicians better understand how PRT works and predict who will respond to PRT.

Pivotal Response Treatment: Case Reports

The current paper provides an overview of an evidence-based treatment, Pivotal Response Treatment (PRT), for autism spectrum disorder (ASD). The paper describes PRT principles and then illustrates the approach using two case reports. The children are preschool-aged children with high-functioning ASD. They were participating in a four-month clinical trial of PRT. At the start of treatment, they presented with significant social communication impairments, including a minimal understanding of reciprocity, limited play skills, and repetitive behaviors and speech. The paper outlines how behavioral treatment goals were identified and then how activities were designed, using principles of PRT, to target skill acquisition. Following the treatment course, both children made substantial and meaningful gains in social communication skill development.

Do behavioural approaches teach children with autism to play or are they pretending?

Play is, by definition, internally motivated, flexible, spontaneous and voluntary. Yet some researchers claim to have taught children with autism to play using behavioural interventions that are heavily structured, repetitive and make use of external reinforcements. In the current systematic review, we examine the extent to which these claims are supported by the evidence presented by the researchers themselves. We conclude that the most effective behavioural interventions have been those which have built on children's existing abilities or have relied on the motivating nature of activities themselves rather than on external rewards. We discuss the problems inherent in distinguishing between behavioural and cognitive change in children's play and highlight generalization as a poorly understood but focal process. Finally, we discuss the value of teaching children with autism play behaviours when these are not characterized by the defining qualities of play as a disposition.

Dysregulation of pretend play and communication development in children with autism

We hypothesized that the difficulties of the child with autism originate from disorders of organization and regulation of actions according to environmental changes. Autism impoverishes general mental representation skills, which are the basis of symbolic play and the development of communication. Twenty-one children with autism were compared with 14 children with global intellectual impairment and 15 matched typically developing children, on both regulation of play activities and communication development. Regulation of play was very disordered in children with autism, with breaking off, dissociation and instability of actions. However, in directed play their actions were more structured and corresponded to a better developmental level. In addition, dysregulation was associated with delayed, heterogeneous development of communication skills. The results of this study are in line with our hypotheses and emphasize the role of symbolic play in differential diagnosis and the value of therapies based on regulation processes and symbolic play.

Social Play and Autistic Spectrum Disorders

The article considers the nature of the presumed social play deficit in autistic spectrum disorders (ASDs). The nature of play and its typical development is outlined and discussed in relation to play development in ASDs. It is suggested that social play is a confluence of two strands of development that are affected in autism: social and emotional development, and the cognitive development of play. It is shown that social play develops in a transactional way and in ASDs initial social difficulties prevent the development of social interaction, with its role in eliciting and enriching spontaneous play. At the same time, cognitive and affective difficulties prevent the play of children with autism developing to the extent of attracting other children and being of a complexity from which social play might develop. This cycle of impoverished play opportunities for children with ASDs may be broken through direct teaching and there are encouraging models of teaching social play with some success.

Behavioral Approaches to Promoting Play

A variety of techniques grounded in behavioral psychology, and more specifically in applied behavior analysis, have been established to increase and improve play skills in children with autistic spectrum disorders. This article introduces a set of efficacious methods, which range from highly structured techniques to more naturalistic strategies. It focuses on object play as other authors in the issue discuss social play in greater depth. Behavioral techniques that are reviewed include: discrete trial training, use of stereotyped behaviors to increase play skills, pivotal response training, reciprocal imitation training, differential reinforcement of appropriate behavior, in vivo modeling and play scripts, and video modeling. A discussion of expanding behavior techniques to teach more complex play as well as training in varied environments is also presented. References are provided to allow the reader to obtain more in-depth information about each technique.

Remembering parents in parent-mediated early intervention: An approach to examining impact on parents and families

The goal of this review is to advance the discussion regarding meaningful outcomes of early intervention for children with autism spectrum disorder. The rapid growth in the development and evaluation of early intervention approaches for autism spectrum disorder includes both therapist-driven and parent-mediated interventions. The majority of research on both approaches to early intervention focuses on promoting child outcomes (e.g. language acquisition) with less emphasis on family and parent outcomes (e.g. quality of life, self-efficacy). Given that parent buy-in is essential for parent-mediated interventions to be effective over time, increased attention to family outcomes that are of value to families and have the potential to be impacted positively by these interventions is needed to develop, disseminate, and sustain high-quality interventions in community settings. In this review, we draw from work on parent and family outcomes targeted in related fields (e.g. Part C early intervention, pediatric chronic illness, behavior management parent training) that we propose are particularly relevant for evaluating the impact of parent-mediated interventions in early intervention for autism spectrum disorder.

Naturalistic Developmental Behavioral Interventions: Empirically Validated Treatments for Autism Spectrum Disorder

Earlier autism diagnosis, the importance of early intervention, and development of specific interventions for young children have contributed to the emergence of similar, empirically supported, autism interventions that represent the merging of applied behavioral and developmental sciences. “Naturalistic Developmental Behavioral Interventions (NDBI)” are implemented in natural settings, involve shared control between child and therapist, utilize natural contingencies, and use a variety of behavioral strategies to teach developmentally appropriate and prerequisite skills. We describe the development of NDBIs, their theoretical bases, empirical support, requisite characteristics, common features, and suggest future research needs. We wish to bring parsimony to a field that includes interventions with different names but common features thus improving understanding and choice-making among families, service providers and referring agencies.

Heterogeneity of neural mechanisms of response to pivotal response treatment

We investigated the mechanisms by which Pivotal Response Treatment (PRT) improves social communication in a case series of 10 preschool-aged children with Autism Spectrum Disorder (ASD). Functional magnetic resonance imaging (fMRI) identified brain responses during a biological motion perception task conducted prior to and following 16 weeks of PRT treatment. Overall, the neural systems supporting social perception in these 10 children were malleable through implementation of PRT; following treatment, neural responses were more similar to those of typically developing children (TD). However, at baseline, half of the children exhibited hypoactivation, relative to a group of TD children, in the right posterior superior temporal sulcus (pSTS), and half exhibited hyperactivation in this region. Strikingly, the groups exhibited differential neural responses to treatment: The five children who exhibited hypoactivation at baseline evidenced increased activation in components of the reward system including the ventral striatum and putamen. The five children who exhibited hyperactivation at baseline evidenced decreased activation in subcortical regions critical for regulating the flow of stimulation and conveying signals of salience to the cortex-the thalamus, amygdala, and hippocampus. Our results support further investigation into the differential effects of particular treatment strategies relative to specific neural targets. Identification of treatment strategies that address the patterns of neural vulnerability unique to each patient is consistent with the priority of creating individually tailored interventions customized to the behavioral and neural characteristics of a given person.

Improvements in social and adaptive functioning following short-duration PRT program: a clinical replication

Pivotal Response Treatment (PRT) is an empirically validated behavioral treatment for individuals with autism spectrum disorders (ASD). The purpose of the current study was to assess the efficacy of PRT for ten cognitively-able preschool-aged children with ASD in the context of a short-duration (4-month) treatment model. Most research on PRT used individual behavioral goals as outcome measures, but the current study utilized standardized assessments of broader-based social communication and adaptive skills. The children made substantial gains; however, magnitude and consistency of response across measures were variable. The results provide additional support for the efficacy of PRT as well as evidence for improvements in higher-order social communication and adaptive skill development within the context of a short-duration PRT model.

Team collaboration: the use of behavior principles for serving students with ASD

PURPOSE

Speech-language pathologists (SLPs) and behavior analysts are key members of school-based teams that serve children with autism spectrum disorders (ASD). Behavior analysts approach assessment and intervention through the lens of applied behavior analysis (ABA). ABA-based interventions have been found effective for targeting skills across multiple domains for children with ASD. However, some SLPs may be unfamiliar with the breadth of ABA-based interventions. The intent of this tutorial is to briefly introduce key ABA principles, provide examples of ABA-based interventions used within schools, and identify strategies for successful collaboration between behavior analysts and SLPs.

METHOD

This tutorial draws from empirical studies of ABA-based interventions for children with ASD within school settings, as well as discussions in the extant literature about the use of behavior principles by SLPs and strategies for interdisciplinary collaboration.

CONCLUSION

Given the prevalence of ASD at 1 in 68 children (Centers for Disease Control and Prevention, 2014) and the high cost of serving these children within schools (an average cost of 286% over regular education; Chambers, Shkolnik, & Perez, 2003), the need for effective, comprehensive service provision and efficiency within interdisciplinary teams is paramount. Communication, mutual understanding, and recognition of common ground between SLPs and behavior analysts can lead to successful collaboration.

Pivotal response treatment for children with autism spectrum disorder: a systematic review of research quality

OBJECTIVE

Research has indicated support for pivotal response treatment (PRT) as an effective, efficacious and naturalistic intervention for communication and social functioning of children with autism spectrum disorder (ASD). Previously not undertaken, this article describes a systematic evaluation of the adherence of PRT research studies to standards of ASD research quality.

METHOD

A systematic search was conducted on two databases. Seventeen PRT studies were evaluated on their use of seven specified research standards.

RESULTS

Strong adherence to research quality standards was demonstrated in the use of standardized protocols, systematic application of intervention procedures, inter-rater reliability and objective evaluators. Variation was found in adherence to treatment fidelity standards and in the use of longitudinal designs. Only two studies implemented comparison designs.

CONCLUSION

It is recommended that researchers compare interventions, use longitudinal designs, better describe their methodology and implement greater adherence to treatment fidelity to enhance research quality and strengthen conclusions.

Comparing the teaching interaction procedure to social stories: a replication study

This study compared the teaching interaction procedure to social stories implemented in a group setting to teach social skills to three children diagnosed with autism spectrum disorder. The researchers taught each participant one social skill with the teaching interaction procedure, one social skill with the social story procedure, and one social skill was assigned to a no intervention condition. The teaching interaction procedure consisted of didactic questions, teacher demonstration, and role-play; the social story procedure consisted of reading a book and answering comprehension questions. The researchers measured participants' performances during probes, responses to comprehension questions, and responding during role-plays. The results indicated that the teaching interaction procedure was more efficacious than the social story procedure across all three participants.

Effective Behavioural Strategies for the Defining Characteristics of Autism

The following review paper describes the outcomes of data-based behavioural intervention strategies for the defining characteristics of autistic disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994). The results of relevant evaluations of behaviour analytic procedures are reviewed for each of the four potential areas of difficulty under each of the main criteria for autistic disorder, which are: (a) impairment in social interaction, (b) impairment in communication, and (c) restrictive, repetitive, and stereotyped patterns of behaviour, interests, and activities (DSM-IV). The current areas of research activity as well as those domains that have received comparatively little attention by behavioural researchers are identified, and suggestions for future research are discussed.

A quarter century of progress on the early detection and treatment of autism spectrum disorder

The last 25 years have witnessed tremendous changes in our ability to detect autism very early in life and provide interventions that can significantly influence children's outcomes. It was once questioned whether autism could be recognized before children had developed language and symbolic play skills; now changes in early behaviors, as well as structural brain changes, have been documented in infants 6-12 months of age who later develop autism. Advances in brain imaging and genetics offer the possibility of detecting autism before the syndrome is fully manifest, thereby reducing or preventing symptoms from developing. Whereas the primary mode of behavioral intervention a few decades ago relied on operant conditioning, recent approaches integrate the methods of applied behavioral analysis within a developmental, relationship-focused intervention model that are implemented by both parents and clinicians. These interventions have been found to have positive effects on children's developmental trajectory, as measured by both behavioral and neurophysiological assessments. Future approaches will likely combine both behavioral and pharmacological treatments for children who have less robust responses to behavioral interventions. There has been a paradigm shift in the way that autism is viewed, evolving from a lifelong condition with a very poor prognosis to one in which significant gains and neuroplasticity is expected, especially when the condition is detected early and appropriate interventions are provided. The grand challenge for the future is to bridge the tremendous gap between research and the implementation of evidence-based practices in the broader community, both in the United States and worldwide. Significant disparities in access to appropriate health care for children with autism exist that urgently require advocacy and more resources.

Using communication to reduce challenging behaviors in individuals with autism spectrum disorders and intellectual disability

This article describes the relationship between expressive communication impairments and common challenging behaviors in individuals with Autism Spectrum Disorder and Intellectual Disability. The communication challenges of individuals with Autism Spectrum Disorder/Intellectual Disability are described and several evidence-based intervention strategies are proposed to support communication so as to decrease challenging behaviors. Recommendations for practice are offered.