Philadelphia College of Osteopathic Medicine

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PCOM Psychology Dissertations Student Dissertations, Theses and Papers

2010

A Case Study: Use of Applied Behavior Analysis

with an Austistic Adolescent
Evan Jaffe
Philadelphia College of Osteopathic Medicine, [email protected]

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Jaffe, Evan, "A Case Study: Use of Applied Behavior Analysis with an Austistic Adolescent" (2010). PCOM Psychology Dissertations.
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 Philadelphia College of Osteopathic Medicine

Department of Psychology

A CASE STUDY: USE OF APPLIED BEHAVIOR ANALYSIS WITH AN

AUTISTIC ADOLESCENT

By Evan Jaffe

Submitted in Partial Fulfillment of the Requirements of the Degree of

Doctor of Psychology

December 2010

 COLLEGE OF OSTEOPATHIC MEDICINE

DEPARTMENT OF PSYCHOLOGY

Dissertation Approval

This is to certify that the thesis presented to us by £V 0) t1 J;:ff~

on the I (::;+~ day of N()\)~J~r ,20/0, in partial fulfillment of the

requirements for the degree of Doctor of Psychology, has been examined and is

acceptable in both scholarship and literary quality.

Committee Members' Signatures:

George McCloskey, Ph.D. , Chairperson

Daniel H. Ingram, Psy.D.

Dr. Lisa Hain

Robert A. DiTomasso, Ph.D., ABPP, Chair, Department of Psychology

 iv

Acknowledgements

It is with great pleasure that I thank those who have guided me not only along my

educational path at the Philadelphia College of Osteopathic Medicine (PCOM) School

Psychology Doctoral Program but also with the dissertation process.

I have appreciated the professors who have afforded me the opportunity to expand my

knowledge of assessment, consultation, and counseling and who have made themselves

accessible for additional feedback and further discussions. I would like to acknowledge Dr.

George McCloskey, Dr. Dan Ingram, and Dr. Lisa Hain for their assistance and supervision with

the dissertation process. Dr. McCloskey’s patience, knowledge and insight significantly helped

my writing style, clarity, and organization. He offered a great deal of reassurance throughout

this arduous journey and it was truly an honor to work so closely with him. Dr. Ingram’s wide

array of expertise and passion in the area of Autism and Applied Behavior Analysis made him a

wonderful resource during this intense process. Dr. Hain provided valuable feedback, which was

essential to the revision process; her encouragement and support made this a pleasant experience.

I would also like to thank my family for their unconditional love and support. My

mother’s constant belief in me has been apparent since I was a child. I admire her unbelievable

strength and courage. My father has always been my role model and was a true inspiration

throughout the entire dissertation process. His work ethic, tenacity, and genuine demeanor have

guided me along this path. Throughout difficult times along the way, my brother’s sense of

humor was encouraging.

 v

I would like to thank my wife, Jaclyn, for standing by me and supporting me since I

began my doctoral program. I appreciate her unbelievable devotion, patience, understanding, and

love.

Last, I would like to dedicate this dissertation to my late grandparents, Violet and

Kenneth Glass, and Annette Jaffe. I know that they are always smiling down at me and their

endless love and affection will forever be remembered.

 vi

Abstract

Socialization between individuals is an important characteristic in human development. In

individuals with autism, there is a profound deficit with social skills and with social reciprocity.

Interventions and techniques are utilized to help enhance these skills. The purpose of this study

was to examine the effects that Applied Behavior Analysis using discrete trials can have on the

ability to elicit a spontaneous greeting in various settings by an adolescent male diagnosed with

autism. This study analyzed data collected during a ten week intervention program. Behavior

ratings reflected some uneven progress over the ten weeks, but significant improvements in the

targeted social behaviors were exhibited by the tenth week of training. The behavior checklist

appeared to be an effective tool for assessing the social behavior of an adolescent male

diagnosed with autism.

 Table of Contents

Chapter 1: Introduction

Statement of the Problem 1

Purpose of the Study 2

Research Questions 3

Chapter 2: Literature Review

Introduction 4

History of Autism 4

Classification of Autism and Pervasive Developmental disorders 6

Social, Cognitive and Adaptive Improvements in Children with Autism 9

Early Development (Ages 1 to 5 years old) 12

School Age (Ages 5 to 21 years old) 13

Theory of Mind 14

Assessment for the Identification of Autism 19

Early Identification 19

School Age Identification 20

Eligibility for Special Education Classification in the United States 21

Instruments Used in Assessment 22

Approaches to Intervention for Children Diagnosed with Autism 24

Applied Behavior Analysis 31

Effectiveness of Applied Behavior Analysis 33

 Discrete Trial Training and Verbal Behavior Approach 36

Discrete Trial Training 36

Verbal behavior Approach to Intervention with Children 38

Diagnosed with Autism

Multiculturalism and the Treatment of Autism 41

Summary 42

Chapter 3: Methods

Data Source 44

Procedures and Measures 45

Data Analysis 49

Chapter 4: Results

Figure 1: Making Eye Contact 52

Figure 2A: Acknowledging Others without Prompting 53

Figure 2B: Acknowledging Others with Prompting 54

Figure 2C: No Behaviors Observed 54

Figure 3A: Offering a Verbal Response without Prompting 57

Figure 3B: Offering a Verbal Response with Prompting 57

Figure 3C: No Behaviors Observed 58

Figure 4: Offering a Nonverbal Response 60

Figure 5: Maintaining Appropriate Distance During Interactions 61

Figure 6A: Avoidance of Engaging in Self-Stimulating Behaviors 63

Figure 6B: Discontinuation of Self-Stimulating Behaviors 63

Figure 6C: Continuation of Self-Stimulating Behaviors 64

Chapter 5: Discussion

Discussion 66

Limitations of the Study 72

Implications for the Field 74

Future Research 75

Conclusion 76

References 77

Appendixes 86

A. Behavior Checklist
Chapter 1: Introduction

Statement of the Problem

Research has demonstrated the need for social interaction from infancy to adulthood in

normal human development. Initiating conversation, making eye contact, and responding to

dialogue are important components of social competence. Individuals begin to develop these

social skills (i.e., how to greet and engage in conversation) at an early age through modeling by

others. As children mature, they refine these social skills as they enter adolescence and grow into

adulthood. However, children with autism develop and mature differently. Children with autism

exhibit many social difficulties. It appears that they do not comprehend nonverbal aspects of

communication and usually lack social reciprocity, such as understanding conversations or their

partners’ thoughts, feelings, ideas, and desires.

Impaired social development is one of the major criteria in the diagnosis of autism. Social

deficits are significant and appear throughout the child’s development. Rutter (1978) emphasized

the fact that the unusual social development observed in autism was one of the essential defining

features of autism; it was distinctive and not simply a function of co-morbid mental retardation.

Social development and cognitive ability define the functional levels of the individual, which

range from low functioning to high functioning.

Children with autism often lack the necessary skills to make initial greetings or gestures.

They are more responsive in situations in which their parents or other adults initiate

conversations and maintain proximity, but they do not tend to initiate the conversation the way

that other children do. Can children with autism learn how to initiate conversation with others in
 Case Study 2

an unfamiliar setting? Research has shown that children with autism are more likely to initiate an

interaction if prompted by another person (Gadia, Tuchman, & Rotta, 2004). Studies have also

shown that children with autism can learn to make initial greetings in structured settings such as

school. However, there are few studies that demonstrate success in getting individuals with

autism to initiate conversation in unstructured settings with little or no initial prompting.

The ability to establish a conversation with another person through an initial greeting or

gesture is an important ingredient to a successful social interaction. These skills must be

developed through continuous reinforcement and repetition. Research has shown that continuous

exposure to a skill, using applied behavior analysis and discrete trials, will have more successful

outcomes and be more likely to be generalized to other settings (Gadia, Tuchman, & Rotta,

2004). Observing and comparing the outcomes of children with autism when initiating

conversation in structured and familiar environments (home and school) and unfamiliar

environments (the community) is needed to measure the impact of interventions that are taught in

structured settings.

Purpose of the Study

The purpose of this study is to examine the effectiveness that a social skills intervention can have

on children with autism in making an initial greeting in an unfamiliar setting. A major purpose of

instruction for students with autism and other severe social handicaps is to develop functional

skills in natural home and community environments (Haring, & Kennedy et al., 1987). This

study will present data on a child with autism while he is observed in unfamiliar settings. The

study will assess whether or not interventions taught in a structured, academic setting will
 Case Study 3

improve the child’s ability to initiate a spontaneous greeting in an unfamiliar setting. Structured

observations will be conducted to examine if a single social skill, taught in school and at home,

can be generalized and applied in unfamiliar settings.

Research Questions

1. Is applied behavior analysis/discrete trials teaching effective in increasing six specific

behaviors involved in the occurrence of spontaneous social greetings in an adolescent child

diagnosed with autism during social encounters in public places?

2. Will all of the six social greeting behaviors that are being targeted with Applied Behavior

Analysis/Discrete Trials teaching show the same level of response in an adolescent diagnosed

with autism?

3. Can an adolescent diagnosed with autism who is taught to engage in six social greeting

behaviors make the transition from prompting to self-initiation of social greeting behaviors over

a ten week period?

 Case Study 4
Chapter 2: Literature Review

Introduction

Although autism is a well-known and widely researched disorder, the exact causes of

autism remain an enigma. Individuals with autism have significant difficulties in socializing with

others, in expressing their own feelings and in identifying and understanding the social cues of

others (Barbera, 2003, Linder, 1993). Center for Disease Control and Prevention (CDC, 2009)

has reported that autistic spectrum disorders are caused by a problem with the brain, but

scientists cannot identify specific causes. It has been suggested that a genetic predisposition

and/or environmental factors might contribute to the disorder (Barbera, 2003); Individuals can be

diagnosed as early as three years of age. The CDC has reported that early identification has

become more common because of growing public and professional awareness of autism.

History of autism

Children displaying behaviors characteristic of current conceptions of autism have been

recognized since the 1700’s. The term ‘autism’ was first used by the Swiss psychiatrist Eughen

Bleuler in 1911 to designate loss of contact with reality, which can cause difficulty with or

incapacity of communication (Gadia, Tuchman, & Rotta, 2004, p 8). Bleuler used the term

autism to describe schizophrenics who had difficulty relating to people and who appeared to be

turned inward or towards themselves (Pearson, 2008).

In 1943, Leo Kanner studied eleven children who demonstrated extreme aloneness and

labeled this condition as early infantile autism (Gadia, Tuchman & Rotta, 2004). The typical

difficulties that Kanner observed in these children were language abnormalities, social skill
 Case Study 5

deficits and unusual behavior patterns that showed a tendency to preserve the environment

(Matson & Minshawi, 2006). These behaviors were often compared with childhood

schizophrenia, but the age of onset, family history, and intelligence level were thought to

distinguish between the two disorders. Kanner believed that children with autism were born

without an innate ability to develop normal affective contact with other people. He suggested

that the parents of these children were very much career-oriented and intelligent but were

socially awkward, and displayed little affection toward their children (Matson & Minshawi,

2006; Gadia, Tuchman & Rotta, 2004). Kanner suggested that the parents’ child-rearing

practices directly correlated with their children’s developing autism. These beliefs became causal

explanations of autism in the 1960’s (Gadia, Tuchman, & Rotta, 2004, Linder, 1993). Further

etiological factors, including stimulus deprivation, parental personality disorder, and some

interaction between the biology and the experiences of the child were also considered (Linder,

1993, Matson and Minshawi, 2006)

In 1961, Ferster theorized how the role of parents as mediators of reinforcement could be

a potential cause of autistic behavior. These speculations by Ferster were not found to be valid,

but his beliefs did contribute to the initiation of behavioral analytic research leading to data-

based interventions for autism. Behavioral analytic principles attempted to address the learning

needs of children through the use of social reinforcers (i.e., tokens provided to elicit a behavior

response) (Gadia, Tuchman, & Rotta, 2004). This research was very much influential in the

development of therapeutic interventions, such as Ivar Lovaas’ work with applied behavior

analysis (Volkmar & Cohen, 1997). .

The 1970’s brought increased efforts to educate the public about autism. Parents became
 Case Study 6

more highly involved and formed the National Society for Autistic Children. By the 1980’s,

autism was recognized as a distinct disorder in the Diagnostic and Statistical Manual of Mental

Disorders (DSM) (Matson & Minshawi, 2006).

Classification of Autism and Pervasive Developmental Disorders

The two accepted classification systems used for diagnosing autism are the Diagnostic

and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR)

(American Psychiatric Association, 2000) and the International Classification of Diseases (ICD­

10) (World Health Organization (WHO), 2007).In addition, the Individuals with Disabilities

Education Improvement Act (IDEIA, U.S. Congress, 2005), also referred to as The Individual

with Disabilities Education Act (IDEA) is used for purposes of educational classification of

individuals with autism.

According to the DSM-IV-TR (APA, 2000), autism is manifested by delays or abnormal

functioning in at least one of the following areas prior to age 3 years: reciprocal social

interaction; language as used in social communication; and symbolic or imaginative play. It is

estimated that 650 to 1,000 of every 100,000 children are born with autism spectrum disorder

and that it affects boys four to five times as often as it affects. There is a higher risk of autism

among siblings of individuals with the disorder. Autism is more prevalent than Down’s

syndrome, pediatric AIDs and diabetes combined (Center for Disease Control, 2001). The DSM­

IV diagnostic criteria for autism include the following:

(1) qualitative impairment in social interaction, as manifested by at least two of the

following:
 Case Study 7

a. marked impairment in the use of multiple nonverbal behaviors such as eye to

eye gaze, facial expression, body postures, and gestures to regulate social interaction.

b. failure to develop peer relationships appropriate to developmental level.

c. a lack of spontaneous seeking to share enjoyment, interests, or achievements with other

people.

d. lack of social or emotional reciprocity

(2) qualitative impairments in communication as manifested by at least one of the

following:

a. delay in, or total lack of the development of spoken language

b. in individuals with adequate speech, marked impairment in the ability to initiate

or sustain a conversation with others

c. stereotyped and repetitive use of language or idiosyncratic language

d. lack of varied, spontaneous make-believe play or social imitative play appropriate to

developmental level

(3) restricted repetitive and stereotyped patterns of behavior , interests and activities, as

manifested by at least one of the following:

a. encompassing preoccupation with one or more stereotyped and restricted patterns of

interest that is abnormal either in intensity or focus

b. apparently inflexible adherence to specific, nonfunctional routines or rituals

c. stereotyped and repetitive motor mannerisms

d. persistent preoccupation with parts of objects

(4) Delays or abnormal functioning (with onset prior to age 3 years) in at least one of the
 Case Study 8

following areas; social interaction, language as used in social communication, or symbolic or

imaginative play.

(5) The disturbance is not better accounted for by Rett’s disorder or Childhood

Disintegrative Disorder.

In IDEA regulations autism is defined as “a developmental disability significantly

affecting verbal and nonverbal communication and social interaction, generally evident before

age three that adversely affects a child’s educational performance. Other characteristics often

associated with autism are engagement in repetitive activities and stereotyped movements,

resistance to environmental change or change in daily routines, and unusual responses to

sensory experiences" (US Congress, 2005) This definition differs from the DSM-IV definition

and is used primarily for educational purposes to implement effective interventions in the school

setting (Pearson, 2008).

According to the Center for Disease Control and Prevention (2009), Autism is one of five

disorders in the category of Pervasive Developmental Disorders, the term, “Pervasive” referring

to a problem that cuts across multiple types of communication (Cowan, 2007). The other

disorders in this category include Asperger’s Syndrome, Pervasive Developmental Disorder-Non

Otherwise Specified (PDD-NOS), Rett’s Disorder, and Childhood Disintegrative Disorder. As

reported by Muller (2006), many states have adopted the term Autism Spectrum Disorders

(ASDs) to refer to these various conditions as a related group. Asperger’s Syndrome is exhibited

in individuals with relatively good verbal language but mild non-verbal language problems, a

limited range of interests and decreased ability to relate with others (Muller, 2006; APA, 2000.

PDD-NOS is displayed in individuals who show non-verbal language problems and do not meet
 Case Study 9

criteria for any other PDD disorder (Muller, 2006; APA, 2000). Rett’s Disorder is a rare

neurodegenerative disorder that affects only girls (Cowan, 2007; APA, 2000). Childhood

Disintegrative Disorder is used to characterize individuals who demonstrate normal development

during the first two year after birth, but soon thereafter exhibit a loss of acquired language,

social, motor and adaptive skills, poor bladder control, and a reduced ability to play (Cowan,

2007; APA, 2000).

Social, Cognitive and Adaptive Impairments in Children with Autism

Children with autism typically exhibit impairments in social functioning. The social

impairments are observed early in the development of children with Autism Spectrum Disorder

(Dryden-Edwards & Shiel, 2007; Lord, Storoschuk, Rutter, Pickles, 1993). Although the social

impairments associated with autism can affect the bonding between a mother and an infant,

Dryden-Edwards & Shiel (2007) suggest that, “contrary to popular belief, many, if not most,

autistic persons are capable of showing affection and do demonstrate affection and do bond with

their mothers or other caregivers” (p 2) As the infant develops, social interactions with others

becomes more obviously abnormal. Typical social skill deficits include difficulties with

“reciprocity, initiating interactions, maintaining eye contact, sharing enjoyment, displaying

empathy, and inferring the interests of others” (Bellini, 2003, p 3). These abnormalities in social

behavior displayed at an early age often enable diagnosticians to confirm the presence of autism

spectrum disorder in young children. Young, Brewer, and Pattison (2003) researched the ability

of parents to recognize the behavioral abnormalities in children who were diagnosed with autism

spectrum disorders. The deficit areas most noted by parents included gross motor difficulties,
 Case Study 10

social awareness and play deficits, language and communication difficulties, and unusual

preoccupations.

The CDC (2005) reported that the functional capabilities and the severity of autistic

symptoms can vary widely, ranging from low functioning individuals with severe impairments

who may be silent, mentally disabled, and who demonstrate stereotyped behaviors such as hand

flapping and rocking to high functioning individuals who may have active but distinctly odd

social behaviors, narrowly focused interests, and repetitive communication patterns. Volkmar &

Cohen (1997) have proposed a system of classification of autism whereby the disorder is divided

into low-, medium- and high-functioning autism (LFA, MFA, and HFA), based on IQ and/or

daily living skills. Although individuals diagnosed with Asperger’s Disorder tend to perform

better cognitively than those diagnosed with autism, the distinction between Asperger Syndrome

and high functioning autism remains unclear (Volkmar & Cohen, 1997).

Some researchers (Bellini, 2003, Dryden-Edwards & Shiel, 2007 ) suggest that individual

with autism spectrum disorder have auditory processing deficits that lessen the ability to attend

to important information in conversations, such as signals for transitions or at times when

statements are misunderstood and need to be clarified. Individuals with autism spectrum disorder

rely heavily on routines and do not adapt well to new surroundings, thereby restricting their

development of organizational skills and their understanding of the flexible nature of the social

world (Young, Brewer, and Pattison, 2003). Deficits in functional language and social

interaction have been identified as common characteristics of children with autism (Gadia,

Tuchman & Rotta, 2004). Social skills deficits can greatly impact the development of a child

with autism and may lead to social withdrawal and isolation. Children who have a tendency to
 Case Study 11

withdraw are rejected by peers, and often are perceived to be deviant in some way (Bellini,2003).

Normally-developing infants spend a great deal of time making eye contact with their

caregivers, but infants with autism spend little or no time engaged in eye contact with their

caregivers. If present from birth, a lack of attention to social stimuli may result in a failure to

initiate and integrate the basic interpersonal patterns that are believed to be the foundation for

later communication (Volkmar & Cohen, 1997, Webb & Jones, 2009). Younger children with

autism typically engage in solitary activities, forming few or no attachments with others and in

not responding to strangers, and older children with autism typically exhibit more attachments

with others but tend not to initiate social interactions. Some individuals with autism spectrum

disorder are very much interested in engaging others in social interactions but the odd and

eccentric behaviors they often exhibit can cause difficulties during social interactions. Social

deficits associated with autism spectrum disorders include failure to establish joint interaction

and failure to observe social norms or take a listener’s feelings into account (e.g., looking at an

adult and remarking “You are very fat”). They often rely on conventional formal social greetings

followed by elaboration of idiosyncratic interest or the echoing of a statement made to them.

When engaging in social interactions, individuals with autism are very poor at the appropriate

use of nonverbal social behaviors such as establishing eye contact, using proper voice tone, and

maintaining appropriate social distance from others. The functional communication skills of a

child with autism typically are impaired to some degree. Communication problems can include

poorly developed language, low rates of spontaneous speech, poor conversational skills, rigid or

overly scripted social language, unusual variations in volume and pitch, or limited understanding

of and use of, physical gestures when talking. Repeating verbatim what is said, commonly
 Case Study 12

referred to as echolalia, is often displayed by children diagnosed with autistic spectrum disorder.

Tantrums are employed as a way to escape from demands, to recruit social attention or to obtain

desired items (Prior, 2003, Webb & Jones, 2009).

Additional problems often exhibited by children with autistic spectrum disorder are

narrow interests, inflexible adherence to routines or rituals, repetitive motor movements,

preoccupation with parts of objects and unusual sensory preferences. Children diagnosed with

autism may experience difficulties in adjusting to novelty, in problems with sensory and motor

functioning, trouble developing adaptive daily living skills, problems with the use of executive

functions (e.g., sequencing, organization, sustaining, and shifting attention), and inconsistent

performance across settings (Prior, 2003). Stereotypical behaviors such as swinging, clapping

repeatedly, walking or repeating certain words, sentences or songs also are displayed frequently

by individuals with autism (Gadia, Tuchman, & Rotta, 2004, Schriver,, Allen, & Matthews,

1999).

Autistic Characteristics by Developmental Stage

Early Development (Ages 1-5 years old)

In the first year of life, infants who later go on to develop autism may exhibit subtle

disruptions in social interest and attention, communication, temperament, and head

circumference growth that occur prior to the onset of clinical symptoms (Webb & Jones, 2009).

Parents will typically report that they have had concerns with their child since birth or

immediately afterwards because of the child’s lack of social interaction. Volkmar & Cohen

(1997) determined that the eye gaze of the child is frequently reported to be abnormal by parents

of children with autism; 90% of parents reported that their children often, very often, or almost
 Case Study 13

always avoided eye contact. Social attachments do occur in these children but typically, they are

significantly delayed. Young children may react to environmental changes, but interactions with

other individuals hold less interest for them. They are unlikely to seek physical comfort from

their parents, unlikely to share interesting or pleasurable events, and unlikely to take pleasure in

interaction with their parents (Webb & Jones, 2009). They often fail to exhibit a shared gaze,

i.e., fail to show or point to objects or gaze alternately at an interactive partner and a desired or

interesting object/activity (Webb & Jones, 2009). They may ignore friendly greeters and show

little or no response to the speech of their parents, leading some parents to believe the child is

deaf. These deficits seem to be the most persistent problems exhibited by children with autism

between the ages of one and five.

School Age (Ages 5 to 21 years old)

During this age range, social functioning gradually improves over time in some children

with autism, but those who do improve rarely achieve levels social functioning levels consistent

with same-age peers , instead remaining passive or odd in their styles of interaction (Webb &

Jones, 2009). They continue to prefer to be left alone and often engage in self-stimulatory and

other unusual behaviors (Volkmar & Cohen, 1997). The mutual or cooperative play that is

typically seen in children of this age usually is absent. Adolescents have difficulties taking

another person’s point of view into account because theory of mind deficits are evident (Webb &

Jones, 2009). Social relationships mainly occur with adults and interest in interacting with other

children is rare (Volkmar & Cohen, 1997).

Del Valle, McEachern, & Chambers (2004) examined the way children with autism
 Case Study 14

respond to various situations and the way that they offer empathic responses. They found that

individuals with autism do not express concerns in response to another person’s anger or distress.

Children with autism exhibit impairments in prosocial behaviors, such as, giving, sharing,

helping, or offering affection to others. They have trouble learning, and then generalizing the

rules of social interchange. Wing (1991) found that inappropriate social interaction seen in

children with autism spectrum disorder were associated with impairments of two-way social

communication that affected non-verbal communication as much as or more than verbal

communication. The use of social stories, however, was found to help teach children with autism

how to behave appropriately in social situations and encouraged them to elicit certain responses.

Volkmar & Cohen (1997), Webb & Jones (2009), observed that social stories focus on the

development of social interaction by teaching autistic children not only how to identify problem

situations but also appropriate ways to cope with these problem situations.

In young adults with autism, a range of social outcomes have been observed. The higher

functioning individuals experience challenges in their attempts to develop friendships and relate

to others. Their desires to make social contact may be strong, but their abilities to do so are very

much limited. Feelings of inadequacy and isolation often are exhibited. (Volkmar, Cohen, 1997)

The significant difficulties with socialization that children with autism experience make it

difficult for them to interact appropriately with their caretakers, their siblings and other

individuals (Webb & Jones, 2009). Assessments can be very helpful in identifying the specific

difficulties that each individual encounters, and in selecting effective techniques and

interventions to address these weaknesses.

 Case Study 15

Theory of Mind

Individuals diagnosed with autism are thought to experience difficulty in understanding

the perspectives of other persons. The ability to grasp the perspective of another person is

referred to as Theory of Mind (Lind & Bowler, 2010). At five months of age, children typically

can recognize the different facial expressions of other persons and within a few more months are

able to understand the meaning of these facial expressions. As young children become able to

interpret the facial expressions of others, they begin to use this knowledge to alter or adapt their

behavior. This can be observed when a toddler looks at his mother’s face for cues about whether

or not it is safe to approach an unfamiliar person. This understanding that other people may think

and feel differently from one’ self is one example of a child’s use of “theory of mind” knowledge

(Baron-Cohen (1997). An absence of, or slowed acquisition and use of this type of theory of

mind knowledge is thought to underlie some of the social impairments and deficits in empathy

that is often seen in individuals with autism. The idea of joint attention is discussed next as it is

compared with theory of mind in individuals with autism.

Lind & Bowler (2010) researched the concept of joint attention and its relationship to

theory of mind with autistic children. Joint attention skills are behaviors produced by the child

that involve monitoring or directing the target of another person’s attention by coordinating his

or her attention with that of the other person. Joint attention deficits in autism impact the

individual’s ability to appreciate another person’s point of view. It has been suggested that joint

attention is a precursor to the development of theory of mind. A study was conducted with

children under the age of 5 diagnosed with autism to observe the use of pointing to determine the

meaning of the gesture and its relationship to joint attention. The study found that these children
 Case Study 16

were observed pointing to request something but were not pointing to get the attention or interest

of another person. This difference in the use of pointing behavior was found to be a significant

indicator of the theory of mind problems in autistic individuals, highlighting their distinct lack of

interest in interacting with or attending to others.

Baron-Cohen (1997) further elaborates about the theory of mind concept by suggesting

that theory of mind deficits reflect a lack of self-awareness of how one’s own thoughts and

feelings shape one’s behavior. As a result, individuals with autism have trouble understanding

thoughts and behaviors of others and with interpreting the verbal and nonverbal intents of others.

This deficit in theory of mind makes self-introspection difficult when attempting to identify their

own thoughts or ideas as their own behaviors. Therefore individuals with autism are believed to

live in a “black and white, here and now world” (p 63) and have a tendency to make responses in

a predictable and rigid manner (Lind &Bowler, 2010). This helps to explain the ritualistic,

concrete ways in which autistic individuals relate to others. Additionally, typically developing

children demonstrate an age-appropriate capacity for understanding irony, sarcasm, “white lies”,

the distinction between literal and non-literal speech and metaphors. This capacity reflects an

ability to understand the social intentions of others that are conveyed through the use of these

language mechanisms (Baron-Cohen, 1997). Autistic individuals often struggle with these

intention-driven forms of language comprehension. Because of deficits in theory of mind,

individuals with autism experience difficulty in understanding many social conventions that are

not explicitly stated and that often change with the social context.

According to theory of mind, individuals with autism have difficulty interacting with

others and listening and making appropriate interpretations of another person’s intent. Without a
 Case Study 17

theory of mind, “the idea that there is a way of knowing what makes people tick would be totally

alien. There would be no inquisitiveness about other people’s beliefs…Without a theory of mind,

one would merely be an attached observer of behavior” (Frith, 1989, p.131). According to Frith,

individuals with autism exhibit abnormalities in the ways in which they interact with others

because they do not take into account the other person’s state of mind. This causes these

individuals to repeat what others say or to make embarrassing remarks, or to make remarks that

appear to be overly formal and inappropriate, given a close affective relationship to the listener.

Frith (1989) commented that nonverbal communication problems are commonly exhibited in

individuals with autism. They typically use “instrumental” gestures such as “come here” hand

motions but they experience difficulties in understanding expressive gestures such as a raised eye

brow. This is important to note, because these types of gestures, which require realization of

one’s own state of mind and others’ states of mind, are imperative for social interaction.

Autism has been called a condition of mindblindness (Lind & Bowler, 2010), meaning

that children with autism are unable to understand mental states. This concept can be explained

by a deficit in metarepresentation. Metarepresenation is the inability to develop mental

representation for the contents of other people’s minds (Volkmar & Cohen, 1997, Baron-Cohen,

1997). Younger autistic children are unable to engage in pretend play because they are believed

to be lacking the metapresentational ability to coin one’s own thoughts as imaginary (Lind &

Bowler, 2010). Autistic children experience challenges relating in social situations because they

are unable to predict the actions of others and they cannot perceive others’ beliefs, desires and

intentions. Therefore they are able to interpret only the actions that are immediately in front of

them. They experience difficulties with cognition and emotions and have significant deficiencies
 Case Study 18

with social interaction and communication. This deficit inhibits their basic cognitive ability to

understand and recognize others’ thoughts and perceptions.

Kanner believed that individuals with autism are unable to relate to others and that this

was observable from birth. He felt that they were born with an innate inability to form

appropriate contact with others, and that they had difficulties forming bonds and interactions.

Proponents of the theory of mind hypothesis differ about when metarepresentational

capacities would be initially observed. Some believe that theory of mind is first observed in a

young child’s ability to exhibit pretend play, yet others believe that it is first observed with the

development of joint attention behaviors when the child is 8 to 12 months old (Volkmar &

Cohen, 1997). According to this belief of theory of mind, abnormalities in an autistic child’s

social functioning should not be apparent before the age of 8 to 12 months (Lind & Bowler,

2010, Volkmar & Cohen, 1997). There is debate about the exact time at which these behaviors

emerge; Kanner’s belief, however, supports the idea that impairments in social functioning are

found before the age predicted by the theory of mind.

Members of the neo-Kanner school do not doubt that children with autism are lacking the

necessary social cognitions described within the context of theory of mind. The failure to acquire

theory of mind is the result of their weakness in social relatedness and desire to socialize with

others, and in their ability to share their experiences with others. These beliefs are felt to be

“motivational deficits” and if they emerge as early as birth, then infants are likely to have

deficiencies across development, including impairments in social behavior, language and

cognition.

The theory of mind deficit attempted to explain the social, communicative, and
 Case Study 19

imaginative abnormalities that are commonly found in autistic individuals. These deficits

impact the individual’s ability to reflect on one’s own mental states and those of others.

Assessment for the Identification of Autism

Early Identification:

It is debatable whether or not autism can be identified in the early months of life.

According to a study by Gillberg, Ehlers, & Shaumann (1990), it is possible to identify autism

during early infancy. These researchers found that early age symptoms include peculiarities in

eye gaze, hearing and play. Avoidance of establishing eye contact is a common characteristic of

individuals diagnosed with autism. Infants with autism display eye gazes that tend to be brief and

only out of the corner of their eyes. Peculiarities in hearing also are present in most cases.

Children with autism often are believed to be deaf at an early age. However, they rarely are

found to be suffering from a hearing loss even though they may not respond to their names, and

appear to be sensitive to odd auditory changes in the environment. Babies with autism show a

lack of interest in the types of games that typical babies enjoy, and they are not engaged in any

play activities with their parents or others. Babies with autism do not point out things of interest,

do not take an active part in playing baby games and do not want to share activities. Assessment

for autism at this early age is conducted by a multidisciplinary team of experts in the field,

typically in a child development unit. This unit would include a pediatrician, clinical

psychologist, child psychiatrist, speech therapist, play therapist, nurse specialist and social

worker. During multidisciplinary team assessments, the parent is asked to provide a family

history, history of the pregnancy, and the child’s behavior and developmental progress. A
 Case Study 20

physical examination is required to determine any underlying medical conditions that may be

contributing to deviations and/or delays in expected developmental progress. These

developmental assessments include assessment of fine and gross motor skills, language, sensory

perception, social and emotional development and play. The quality of development is a critical

focus of the assessment process. When the results of the assessment indicate a diagnosis of

autism, recommendations are made for early intervention opportunities that can provide social

experiences and learning opportunities.

School Age Identification:

Assessment of a child with autism spectrum disorder during the school-age years needs to

be conducted by an expert in the field who is knowledgeable about the characteristics of the

disorder. Because of the complexity of behaviors commonly found in individuals with autism, a

thorough assessment across multiple settings should be completed. In school, the assessment

should include input from teachers, speech-language pathologists, and occupational therapists.

The evaluations for autism should target the specific domains known to reflect the problems

encountered by autistic children including social competence, communication (verbal, nonverbal

and pragmatics), behavior variability, and environmental influences (Ingram, 2005).

Eligibility for Special Education Classification in the United States

A child who is diagnosed with any autistic spectrum disorder is eligible for special

education programming (National Research Council, 2001). Special education programs in the

United States report the number of children receiving services for autistic children to the CDC.

According to the CDC (2009), from 1998 to 2007, the number of 6 to 21 year old children
 Case Study 21

diagnosed as autistic and receiving services as in public special education programs increased

five-fold from 54,064 to 258,305. In accordance with federal and state law, schools must provide

a free, appropriate public education (FAPE) for children diagnosed with autism (National

Research Council, 2001). However, children with a disability cannot be given any service or

support that a parent feels is unwarranted. The child is typically provided with an educational

program chosen as a result of what is available and affordable in the given district. Because of

the litigation related to implementation of the Individuals with Disability Act, the complexity of

autistic spectrum disorder has become a prominent issue between parents and school districts.

Mandell & Palmer (2005) reported that states varied in the number of children diagnosed

with Autistic Spectrum Disorder. Education-related spending, the number of pediatricians in the

state, and the number of school-based health centers in the state were positively associated with

the prevalence of identification of Autistic Spectrum Disorder. Increased access to pediatricians

and school-based health centers may lead to improved recognition of Autistic Spectrum

Disorder. Indeed, the increased prevalence of autistic spectrum disorders impacts education-

related spending, necessitating the hiring of better-trained educational staff who can recognize

the problem, and also highly qualified in-school specialists who can provide the necessary

screening and comprehensive assessment required for diagnosis. In 1990, Autistic Spectrum

Disorder was categorized as a separate condition that qualifies children for special education

services. However, appropriate screening and assessment are expensive. In addition, there is a

shortage of professionals in the United States who are adequately trained in the diagnosis and

treatment of ASD. Specialized classrooms, 1-on-1 instruction, and intensive behavioral

interventions are costly and not available in many communities (Mandell & Palmer, 2005).
 Case Study 22

Instruments Used in Assessment:

The assessment for diagnosing a child with autism spectrum disorder requires the

examiner to be aware of the characteristics of the disorder and the response patterns typically

demonstrated (Ingram, 2005). Assessment procedures used in the diagnosis of autism rely

heavily on observation, consultation with teachers, interviews with parents, and behavior rating

scales. Observations should be completed across multiple settings when assessing for autism.

Observation recording should reflect how long the behavior is exhibited, and the frequency with

which it occurs. The observer must be aware that an individual’s ability to engage and play with

others stems from the individual’s social and cognitive abilities. Children with autism exhibit

less sophisticated individual play and minimal amount of engagement in group play (Guralnick

& Groom, 1985).

Prior (2003) discussed multiple ways to conduct assessments of children with autism.

Social skill interviews with primary caregivers provide a great deal of information regarding the

child’s typical characteristics and behaviors at home. Behavior rating scales such as the Autism

Behavior Checklist (ASIEP) (Krug, Arick, & Almond, 1993), Childhood Autism Rating Scale

(CARS) (Schopler, Reichler, & Renner, 1988), Vineland Adaptive Behavior Scales (VABS)

(Sparrow, Cicchetti & Balla, 1984), Autism Diagnostic Interview-Revised (ADI-R) (Lord,

Rutter, & LeCoteur, 1994),), and the Gilliam Autism Rating Scale (GARS) (Gilliam, 1995)

are thought to useful instruments in the diagnostic process (Prior, 2003).

The ABC is a direct observation instrument that surveys five categories including sensory

integration, relating to others, body and object use, language, and social and self-help (Faherty,

2000). Teachers and/or parents can complete the scales. The child is assessed according to how
 Case Study 23

his/her behaviors deviate from those of a sample of normal functioning children of the same age.

The CARS is a fifteen-item rating scale that helps differentiate children with autism from those

with other developmental delays (Faherty, 2000).

The VABS is divided into various sections, assessing the child’s functional abilities in various

settings (home, school, community etc.) The abilities assessed include social skills,

communication skills, daily living skills, and motor skills development. Social skill assessments

are practical and useful with school-age children in educational settings. Assessments in the

educational setting are usually conducted by school psychologists and case managers who

collaborate with teachers and other related service providers (i.e., occupational therapists, speech

therapists). All of the assessments are valuable resources, and the results can be helpful in

determining appropriate interventions to remediate social skill deficits.

Additional assessments used in the diagnosis of autistic spectrum disorders include the

following:

Autism Screening Instrument for Educational Planning (ASIEP) (Krug, Arich, & Almond,

1993)-observational protocol with 5 standardized subtests including observations and clinical

interviews.

Autism Diagnostic Observation Schedule-WPS (ADOS-WPS) (Lord, Rutter & LeCoteur, 1994)­

an interactive observation format where the examiners socialize with the child using a

standardized algorithm scoring format.

Autism Diagnostic Rating Schedule (ADOS) (Lord, Rutter, & LeCoteur, 1994) - a direct

interaction assessment instrument that provides opportunities to observe and assess

communication patterns, social-reciprocal interactions and stereotypical play patterns.

 Case Study 24

Psychoeducational Profile-Revised (PEP-R) (Schople, Reichler, Bashford, Lansing, & Marcus,

1990) is a diagnostic instrument requiring the examiner to interact directly with the child. The

instrument assesses a wide array of developmental functioning in areas including imitation, fine

motor, gross motor, eye-hand integration, cognitive performance and cognitive-verbal capacities.

Approaches to Intervention for Children Diagnosed with Autism

The prevalence of autistic spectrum disorders has been increasing and the need for

intense intervention in schools has become a necessity. The National Research Council (2001)

has noted that the courts have significant involvement in the determination of how autistic

children are being educated in schools. As previously discussed, the types and ways in which

interventions are implemented differ across the country (National Research Council, 2001).

Barbera (2003) stated that a “one size fits all” methodology for treating these individuals is

neither practical nor realistic. Each child requires an individualized education plan (IEP) that is

unique to his/her specific needs and addresses the specific goals, services, and accommodations

necessary to treat him/her effectively.

According to the CDC Autism Fact Sheet (2010), the main research-based treatment for

autistic spectrum disorders is intensive, structured teaching of skills, commonly known as

behavioral interventions. There are several components that must be addressed when providing

an educational program well-suited to the needs of an individual child diagnosed with autism,

including individualized supports and services, systematic instruction, comprehensive and

structured learning environments, specialized curriculum focus, a functional approach to problem

behavior, and family involvement (Iovannone, Dunlap, Huber & Kincaid, 2003). Furthermore, it
 Case Study 25

was stated that IDEA supports the theory of Positive Behavioral Interventions and Supports

(PBS). Positive Behavioral Interventions and Supports reward desirable behaviors and take

rewards away when undesirable behaviors are exhibited (Rutherford, Wilcox, & Stowe, 2002).

The social skills interventions used with children diagnosed with autism are considered a form of

positive behavior intervention and support.

Social skill interventions have expanded over the years. Some of the basic skills taught

include the ability to gain a listener’s attention, and initiating a topic and staying on topic for an

appropriate period of time while expressing his/her personal views and opinions. Social groups,

peer partnerships, formal social skills training programs and narrative and/ or pictorial

approaches-including social stories and comic strips-are some of the non-technological social

skill interventions available for teaching these skills (Faherty, 2000). For individuals with

autism, the development of social interactions and relationships can depend on many variables

including the number, type, setting and distribution of peer social interactions. Interventions used

should provide interactions at a rate similar to those found in the child’s environment, and should

utilize age-appropriate activities. Attention should be paid to the social validity of the

interactions taught in the interventions. In implementing social interventions with autistic

individuals one should use direct instruction of relevant social behaviors, which relies on the

overt manipulation of task-analyzed skills to promote higher frequencies of social behavior.

Another method is to provide a prompt in order to elicit a response, followed by reinforcement

(attention or praise) to commend him/her on the positive interaction with another person.

Social groups allow children to recognize the importance of being a good listener and

foster the ability to take turns in speaking and listening in a variety of settings. It is
 Case Study 26

recommended that social groups be appropriately structured with the following guidelines:

meeting on a consistent basis; keeping the group small; displaying a schedule of events;

providing visual cues; using social stories to explain problematic situations; and beginning and

concluding the session with a familiar routine. Social groups have had positive outcomes in

promoting social interaction among children with autism, allowing them to play and interact

appropriately and facilitate communication (Faherty, 2000).

Peer partnerships are a practical method to utilize when trying to promote friendships and

interaction skills in children with autism. The child is encouraged to partner with another whom

he/she has met through class, as a peer tutor, or through extracurricular activities or class

assignments. These relationships can be very successful when the partner is sensitive and aware

of the child with autism (McGinnis & Goldstein, 1984, 1990).

Social skills training has elicited significant outcomes with increased prompting and

reinforcement. A study was conducted in teaching children social interaction, with teacher

prompting in order to demonstrate appropriate responses and ways to initiate conversations

(Volkmar & Cohen, 1997). The prompting eventually faded when the children were able to

exhibit the responses independently. In this study, the children were encouraged to interact with

their peers with autism, but the continuation of the social skill improvements were contingent on

the teacher’s prompting of peers to direct social initiations to the children with special needs.

Peers were taught strategies such as getting their friends’ attention, getting their friends to play,

sharing with their friends, and talking to their friends. The children with autism were prompted

by their teachers but after the various strategies were taught, the children with autism practiced

using them without prompting. The social skills that were taught were considered as having been
 Case Study 27

mastered when the child demonstrated the social interaction routine in three consecutive

instances without teacher prompting. These children were also taught to self-evaluate their

reactions by checking a “yes” box or “no” box with the assistance of their teacher. Results from

this study suggested that responsiveness from the children with autism increased. However, there

were no improvements in their ability to initiate conversation. The carry-over to different settings

also was proven successful with the children in this study. The children who learned how to

monitor their social responses began to decrease inappropriate behaviors and to improve their

social skills (Volkmar & Cohen, 1997).

Social skills training programs such as the SCORE Skills (Vernon, Schumaker &

Deshler, 1996) and Skillstreaming (McGinnis & Goldstein, 1984, 1990) can teach appropriate

social skills. Five skills are explored in the SCORE Skills Training Program: “share ideas”;

“compliment others”; “offer help or encouragement”; “recommend changes nicely”; and

“exercise self-control” (Vernon, Schumaker & Deshler, 1996). The skills are reinforced through

the use of role-playing and modeling after the concepts are clearly understood by the individual.

This program can be extremely successful in high functioning children with autism. It is initially

difficult for the individual to grasp the idea of role-playing, but children with autism who are

higher-functioning and more sociable are able to participate in simple role-playing exercises.

They eventually increase their self-awareness and demonstrate greater self-control in social

interactions after learning and practicing the skills (Vernon, Schumaker & Deshler, 1996).

Skillstreaming, another structured social skills intervention, uses role-playing, modeling,

performance feedback, and transfer of training to teach children positive social

behaviors. Skillstreaming programs group individuals, based on their social skills. They are
 Case Study 28

grouped by target social skills: beginning social skills such as “listening” and “asking for help”;

school-related skills such as “asking a question” or “following directions”; friendship-making

skills such as “joining in” and “sharing”; dealing with feelings such as “asking to talk” or

“showing affection”; alternatives to aggression such as “dealing with teasing” and “being mad”;

and dealing with stress such as “being honest” and “saying no” (McGinnis & Goldstein,

1984,1990). Skillstreaming has been used with autistic children, but little research has been

reported on the effectiveness of the program.

Carol Gray (1994) developed “social stories” as a technique that defines the relevant cues

in a social situation and describes appropriate responses. Social stories can use a specific activity,

such as homework time. The components of a social story should provide social modeling, task

analysis, visual aids, practice with corrective feedback and priming. Research and previous

studies have concluded that social stories can be extremely effective, and the concepts can carry

over into other settings and even into other scenarios (Gray, 1984 and Thieman & Goldstein,

2001).

Comic Strip Conversations depict interactions between people to help children with

autism understand conversations (Gray, 1994). This technique uses symbols to demonstrate basic

conversational skills, including “listening”, “interrupting”, “loud”, and “quiet words”, “talk”, and

“thoughts”. This technique can reinforce learning and facilitate appropriate conversations. Social

skills “picture stories” (Baker, 2001) use digital pictures of actual children exhibiting the various

social skills. The pictures usually include small captions showing what the child may be saying

or thinking. The picture stories demonstrate the various social skills, sorting them by topics,

including asking for help, and initiating or joining conversations. These pictures illustrate the
 Case Study 29

various steps in carrying out a conversation, showing what is appropriate to say or do in an

interaction. This technique has demonstrated good success, and children emulate many of the

target social behaviors. They become more highly focused in conversations, and higher

functioning students often can engage in conversations for a short period of time.

There have also been significant technological advances in interventions addressing

autism spectrum disorder. Some of these interventions have included animated cartoon

characters (Bosseler & Massaro 2003) and robots (Dautehhahn & Weery 2004). Research has

shown that animated cartoons that teach vocabulary have been effective in helping children learn

new vocabulary words, retain knowledge, and apply the newly learned words to new images

outside the realm of the computer program.

The Aurora Project has created robots that reinforce behaviors involved in social

interaction such as eye-gaze, turn-taking, and imitation games. The robots are described as

“highly personable, conforming to the needs, interests and abilities the child who socializes with

it” and it is effective in providing a “scaffold for learning that can be gradually faded as the

child’s skills and competencies in the area increase” (Dautehhahn & Weery 2004). This project

has been used with autistic children and results have indicated that the children generally showed

more interest in the robot (in terms of gaze, touch, etc.) and were more engaged in interactions

with the robot than with another non-robotic toy (Dautenhahn & Billard, 2002). The main

limitation of the robot currently used in the Aurora project lies in the fact that it can offer only a

small number of interactions (limited to spatial approach/avoidance turn-taking games)

(Dautenhahn & Billard, 2002).

Pivotal Response Training (PRT) emphasizes responses to multiple cues and improved
 Case Study 30

motivation. This technique instills the proper means to elicit appropriate responses to questions

asked of individuals with autism. This method was used on two adolescents with autism, and

produced positive outcomes in social behavior and communication (i.e., reductions in social

perseverations and inappropriate facial expressions) that generalized beyond the immediate

treatment setting (Cohen & Volkmar, 1997).

It is important to teach to individuals with autism to establish multiple means of

communication so that they learn ways to make requests and interact appropriately. As with

gestures, one must provide clearly visible models by being at an individual’s physical level,

encouraging face-to-face gaze, and producing words slowly, clearly, and repetitively. Specific

speech repetition enhances the training and usage of the words. There are several methods that

can be used to reinforce positive social interaction, including using imitation of an individual’s

vocalizations and modifying them in playful turn taking; using short relevant phrases and

intonation patterns; using stereotypic and ritualized utterances in routines; modeling short

utterances; and singing songs or reciting rhymes that have slots for filling in words or sounds.

Using appropriate modeling and opportunities to vocalize and imitate sounds and gestures can be

beneficial for autistic individuals who are verbal.

Teaching children with autism ways to initiate conversations is an important part in

socialization. A study was conducted to teach children with autism how to initiate conversations

with peers. The role of self- initiation was presented. For example, Oke and Schreibman (1990)

taught non-handicapped peers to initiate interactions with children with autism. The children

were videotaped while initiating conversations to teach them appropriate ways to interact. There

was an increase in the level of social interaction by the autistic children; through the use of this
 Case Study 31

strategy the children did demonstrate a greater capacity for initiating conversation.

A study by Belchic and Harris (1994) studied how preschool children interacted socially

with children with autism. The children were initially taught to initiate interaction with adults

and then were expected to generalize this with other children. The children with autism modeled

the behavior and were able to generalize this behavior with their siblings and with other children.

Situational and communicative scripts are important ways to increase the social skills of children

with autism. These strategies are taught through real life experiences and situations. The children

also are encouraged to communicate in these real life settings because it is felt that there is

greater likelihood for carryover and generalization to everyday experiences when the

interventions are focused on true events. Individuals with autism have significant difficulties

with understanding the meaning and relevance of acquiring social skills in social events.

Exposing these children to these situations allows them to learn proper exchanges in situations

such as using the telephone, ordering food in a restaurant, or engaging in the discourse of

classroom instruction and response.

Applied Behavior Analysis

Applied Behavior Analysis (ABA) is a systemic application of behavioral principles to

address deficits in socially significant behavior, verbal skills and reasoning skills. The key

aspects of ABA include observing the frequency of occurrence of behaviors as well as the

antecedents to the behaviors and the consequences that follow the behaviors; breaking down

desired skills into steps; teaching the steps through repeated presentation of discrete trials and

collecting performance data to evaluate if there should be any changes over time (Prior, 2003). .

Baer, Wolf, and Risely (1967) outlined seven essential elements of an ABA-based
 Case Study 32

program:

A) The program must be applied. The behaviors that one chooses to focus upon should have

some social significance.

B) The program must be behavioral. The environment and physical events should be

recorded with precision.

C) The program must be analytic. There should be clear and convincing evidence, through

carefully collected data, that the intervention is responsible for a change in a behavior.

D) The program must be conceptually systematic. There should be relevance to established

and accepted principles.

E) The program must be effective. The program should seek to change the targeted behavior

to a meaningful degree.

F) The program should display some generality. A change in behavior should be seen in a

wide variety of environments, or should spread to a wide variety of related or similar

behaviors.

All of these elements are imperative when implementing ABA with autistic individuals to

obtain the desired outcomes. The following terms and definitions are commonly used in

Applied Behavior Analysis (Alberto & Troutman, 2003):

Repeated Opportunities for Learning-Teaching new skills with repeated trials so

that the new skill becomes ingrained and the child has more opportunities to

recognize when the skill is to be used.

Generalization of skills-This refers to the ability to demonstrate a skill, taught

under specific conditions, in novel situations such as new locations, with different
 Case Study 33

people, with different materials or when asked in a different way.

Prompting-An added stimulus that increases the probability of the desired

response.

Fading- The gradual removal of prompts allowing the discriminative stimulus to

occasion a response independently.

Pairing-The simultaneous presentation of primary and secondary reinforcers to

condition the secondary reinforcer. After the association has been established, the

secondary reinforcer takes over the reinforcing function, and the primary

reinforcer is no longer necessary.

Modeling-The demonstration of a desired behavior in order to prompt an imitative

response.

Shaping-Teaching new behaviors through differential reinforcement of successive

approximations to a specified target behavior.

Chaining- An instructional procedure that reinforces individual response in

sequence, forming a complex behavior.

Effectiveness of Applied Behavior Analysis

When discussing any treatment modality it is important to examine the efficacy of the

technique. There has been some debate regarding the benefits and drawbacks of this program.

This section is a critique of the use of Applied Behavior Analysis with autistic individuals.
 Case Study 34

Lovaas’ (1987) study of children diagnosed with autism at the Young Autistic Project led

him to conclude that these children can learn most effectively using the ABA technique,

particularly with a Discrete Trials methodology. He found that children that were receiving

approximately forty hours per week of ABA demonstrated the greatest improvements in

behavior. Francis (2005) noted that the intensity of the behavioral intervention was the most

significant factor in predicting treatment outcome. The length of treatment also was critical in

achieving successful outcomes; it was found that long-term treatment achieved better results than

shorter-term treatment. The children with autism who received intensive ABA treatment made

larger improvements in most skill areas than children who participated in the other interventions.

Parents whose children received intensive ABA reported less stress than parents whose children

received other treatments. In addition, the social behaviors of approximately one-half of the

group became indistinguishable from the social behaviors of neuro-typical peers in a first grade

class.

Lovaas’ seminal study has drawn criticism as well as praise. One criticism is that

Lovaas’ study was not empirically sound (Francis, 2005; Gresham et al., 1999; Wheeler et al.,

2006). In addition, Lovaas’ technique was felt to be obsolete and too narrow in its approach to

language acquisition (Francis, 2005). His work was also believed to give false hope to parents,

who had very little knowledge of the disorder. Lovaas’ study, however, did encourage these

parents to seek the necessary services from their child’s public school. This increased school

districts’ awareness of autism as well as their ability to start identifying the disorder and

providing and implementing effective programs to address the needs of autistic children.
 Case Study 35

Dillenburger, Keenan, Gallagher, & McElhinney (2004) examined parents’ responses to

the use of applied behavior analysis with their children. Their findings confirmed a high level of

perceived effectiveness of applied behavior analysis. The parents felt that applied behavior

analysis was effective in terms of attaining behavioral goals, creating strong intervention

strategies, and improving the overall quality of life for their children. The quality of the training

provided to educational staff using the applied behavior analysis techniques was critical; the

study found that college educated therapists were more successful with applied behavior analysis

when compared with parent-employed therapists who had received short-term training. Last, this

study showed that the age of the child and the onset of treatment is an important factor in the

success rate.

Applied Behavior Analysis is an accepted approach to help improve social skills in

autistic individuals (Dillenburger, Keenan, Gallagher, & McElhinney, 2004). However, some are

concerned that the practice of Applied Behavior Analysis creates ‘robots’ because the consistent

repetition of skills makes it less likely that the individual with autism will learn to think

independently (Prior, 2003; Wheeler et al., 2006). The fact that most children with autism have a

monotonous voice quality also makes them sound robotic (Barbera, 2003). The strategies taught

require the individuals to repeat words, phrases and sentences because the continuous practice

provides more comfort and ease with verbal communication. ABA is similar to learning a new

language. One must practice the skills taught in ABA repeatedly just as one would practice to

become fluent in a new language. A second criticism pertains to the frequency with which the

program is applied. Discrete trial teaching is typically recommended for 40 hours per week

(Barbera, 2003; Hernandez, 2008). This can be very stressful for parents and can create potential
 Case Study 36

difficulties in the household. ABA is not an “all or nothing” approach; as long as the program is

being applied, results should be observed. However, they may not be observed as quickly when

training is reduced in frequency and duration. A third challenge with ABA is finding qualified

professionals who can effectively conduct the program (Barbera, 2003; Wheeler et al., 2006).

Parents must inquire about the professionals’ abilities and qualifications and examine

information related to the clinician’s formal training, experience and competency.

Children with autism exhibit social skill deficits that impact their ability to make eye

contact, respond appropriately to others, and follow social cues. Social skills programs are

frequently implemented in schools to reinforce these skills. Applied Behavior Analysis is a

technique used to reinforce social skills by breaking the various skills into manageable parts for

the autistic child to learn. Although Applied Behavior Analysis has shown success with children

with autism for more than thirty years (Dillenburger, Keenan, Gallagher, & McElhinney, 2004),

many questions about the technique continue to be raised, such as, “Can children with autism

apply what they have learned across various settings?” Research has shown that skills taught

through school-based instruction are typically not generalized to natural environments or settings

(Haring & Kennedy, et al., 1987). One way to promote generalization however, has been to

teach the skills in additional settings until the skills emerge in yet-to-be trained settings- a

strategy known as “training sufficient exemplars”(Haring & Kennedy, et al. 1987).

Discrete Trial Training and Verbal Behavior Approach

The two main types of ABA are the discrete trial approach and verbal behavior approach.
 Case Study 37

The following are brief descriptions of each technique and their impacts on individuals with

autism.

Discrete Trial Training (DTT)

Discrete Trial Training (DTT), an educational approach for teaching children with

autism, has received strong empirical support (Downs et al., 2007). It has been reported that 47%

of children with autism taught through an organized early intensive curriculum employing

DTT instruction achieved normal levels of intellectual and academic functioning after two or

three years of treatment, and that their gains were maintained over several years (Lovaas, 1987;

McEachin, Smith, & Lovaas, 1993).

Discrete trials are defined as a discrete opportunity for occurrence of a behavior. A trial is

operationally defined by its three behavioral components: an antecedent stimulus, a response,

and a stimulus (Reed, Osborne, & Corness, 2006). The delivery of the antecedent stimulus marks

the beginning of the trial, and the delivery of the stimulus signifies the termination of the trial.

Applied Behavior Analysis yields positive outcomes with children diagnosed with autistic

spectrum disorders by enhancing their life skills (Reed, Osborne, & Corness, 2006). The

Discrete Trial Training allows for continuous opportunities for trial/error learning. It is teacher-

controlled (the teacher determines the sequence of instruction and material taught); minimal

thinking is required by the student; it is easy to collect and evaluate data related to program

implementation (Simpson, 2005; Hernandez, 2008).

The DTT instructional method has several advantages. The most important is the five

step instructional procedure that is used to teach young children a wide range of skills. It has

been particularly effective in teaching children with autism new behaviors and skills (Downs et
 Case Study 38

al., 2007). The five instructional steps include: the discriminative stimulus, which is the

instructional or environmental cue to which the teacher would like to respond; the prompting

stimulus, a prompt or cue from the teacher; the response, the skill or behavior that is the target of

instruction; the reinforcing stimulus, which is the reward designed to motivate the child to

respond correctly; and the inter-trial interval, which is a brief pause between consecutive trials

(Downs et al., 2007). Downs (2007) also reports that DTT is an effective instructional method

that can be used to teach autistic children how to generalize trained skills through the use of

imitation, receptive language, expressive language and conversational skills. Furthermore, DTT

procedures are readily adaptable to individualized, developmentally appropriate curricula and

facilitate ongoing data collection that allows for a continuous formative assessment of student

progress. Downs (2007) & Cowan (2007) indicated that although it is often thought of as

occurring outside of students’ typical routines, DTT instruction can be embedded throughout the

school’s ongoing daily activities.

In their study in 2007, Downs, Downs, Johansen and Fossum investigated the

effectiveness of providing DTT instruction to children with autism within a public school setting.

The effects of providing DTT on the participants’ cognitive, language, behavioral and social-

functioning were evaluated. Results showed positive changes in adaptive behavior development

and social emotional functioning for students who received DTT. Furthermore, Wolf (1964)

found that DTT is an effective method of teaching children with autism. These children rarely

exhibit personally and socially desirable behaviors to which reinforcements can be applied while

they are engaged in behaviors that interfere with teaching and learning. To eliminate these

behaviors and teaching appropriate and desirable behaviors, it is imperative to create highly
 Case Study 39

controlled and carefully monitored teaching environments. The DTT method can be used with

young children in the early stages of development to improve such behaviors as attending,

imitating, following instructions, and answering questions (Anderson, Taras, & Cannon, 1996).

Some concerns with the use of DTT have been expressed. One of these concerns is that

students are not interacting with peers during intervention, a fact that may interfere with their

social-emotional development (Downs., et al., 2007). Greenspan (1992) has argued that behavior

analytic approaches to intervention such as DTT hinder the social-emotional and behavioral

development of young children with developmental disabilities. However, Downs et al. (2007),

found the opposite to be true because these children can exhibit improvements in social

functioning. Last, teaching in a highly controlled situation results in responding that is under the

control of a few highly specific stimuli. The treatment gains observed in a controlled setting

rarely carry over to new situations, people, or tasks (Cowan, 2005).

The Verbal Behavior (VB) Approach to Intervention with Children Diagnosed with Autism

The Verbal Behavior Approach (VB) to teaching children with autism is based on

Skinner’s behavior theory (1957). The verbal behavior approach is a treatment of autism that

focuses primarily on the development of verbal responses. This technique recognizes language as

a specific behavior and teaches the child how to use language to request an item that he/she

desires. The basic teaching procedures of VB consist of the standard methodology of ABA

(Cooper, Heron, & Heward, 1987; Hernandez, 2008). The VB approach suggests that in order to

learn a skill, a child must have an imitation repertoire (Burk, 2007).

Sundberg (2006) stated:

 Case Study 40

The verbal behavior approach is simply normative, applied behavior analysis with a few

refinements. That is, it incorporates all of the standard methodology of applied behavior

analysis, but it explicitly adopts Skinner’s interpretive framework for analyzing verbal

contingencies. In other words, it is a minor variation on a methodology that has an

enormous empirical foundation. The worst-case scenario is that the added framework

does not help. But even in a case in which it does not work, the child is still getting a full-

fledged program of applied behavior analysis procedures. It is simply hard to believe that

a set of procedures guided only by a distinction between receptive and expressive

language can be as sharp as one that respects all of the various types of contingencies

analyzed by Skinner.

In the Verbal Behavior approach, expressive language is seen as a behavior that can be

taught, and different functions of words are taught explicitly (Barbera & Rasmussen, 2007). An

example of this technique is the use of teaching the word “ball”. Using the verbal behavior

approach, the word “ball” could be taught using either verbalization or sign language. A child

with autism is expected to ask for the ball or make a request using sign language. In addition, the

child with autism would be able to identify a picture of a ball and answer questions about its

function. Sign language is encouraged if the child is nonverbal. This is important because the

main focus of the verbal behavior approach is being able to interact with another person to make

a request (Barbera & Rasmussen, 2007).

Barbera (2007) found that the VB approach reduces tantrums and other problem

behaviors because it begins by assessing the child’s likes and interests, and then uses those likes
 Case Study 41

and interests (reinforcers) to motivate the child so that he or she can start to learn. After the

reinforcers have been identified, the child will immediately start receiving objects of

reinforcement, and then will ask for objects either verbally or through sign language. After the

child responds to the reinforcers and asks for several items or activities, the skill is considered

learned (Barbera, 2007; Hernandez, 2008). In a study conducted by Murphy, Holmes and

Holmes (2005), three children with autism were examined as they made requests for a given

reinforcer. The task required these three children to make a request for a token on three

successive occasions. The results indicated that for children with autism, a request will be given

when reinforcers are immediately given, following appropriate conditional discrimination

training.

To summarize, ABA describes human behavior in observable measures and

reinforcement is an important part of this approach. ABA must be conducted in a highly

structured environment in which opportunity for data collection is permissible. Both Discrete

Trial Training and Verbal Behavior are variations of ABA that can have positive effects when

implemented appropriately. There has been debate over the effectiveness of ABA and its various

approaches. Some speculate that there is not enough research to support these approaches and

that generalization of the trained skills is weak. Despite the criticism, ABA has become a widely

known technique, improving the ability of school districts to identify and better serve the needs

of children diagnosed with autism.

Multiculturalism and the treatment of autism

Individuals with autism spectrum disorder are found in all cultures, ethnicities, and within
 Case Study 42

all socioeconomic levels. The diagnostic criteria in the United States are consistent with the

criteria identified in other cultures. Dyches, Wilder, Sudweeks, Obiakor & Algozzine (2004),

have reported that individuals with autism who are Black or Asian/Pacific Islander have been

diagnosed with autism at about twice the rate of Caucasian students. Autistic children face

additional challenges when placed in culturally different environments in which multiple

languages are in use. Schools must have trained personnel who are able to meet the needs of

diagnosed children from culturally diverse backgrounds.

It is important to note that school personnel need to take the cultural backgrounds into

consideration when educating individuals with autism because most likely the children will

continue to reside and work in the dominant culture. Therefore, teachers of multicultural students

with autism need to develop ways to teach appropriate social skills that are relevant to their

cultural backgrounds (Wilder, et al., 2004). Parents must also take an active role in the

treatment and education of their child in order for positive results to show greater likelihood of

generalization in culturally diverse situations (Hernandez, 2008).

Summary

In the sixty-seven years since Leo Kanner initially described childhood autism, a

tremendous amount of research has gone into the diagnosis of the disorder, into theories about its

causes, and into its treatment. Autism has been described as a developmental disorder of

neurobiologic origin (Barbera, 2003). Refinements in diagnosis have led to an understanding of

the wide array of disorders that fall within the autistic spectrum. This, along with a greater

awareness on the part of the general public, has led to a dramatic increase in the prevalence of
 Case Study 43

identified cases of autism. Assessing autistic children at an early age can lead to more effective

treatment for these individuals.

Although an understanding of the causes of autism remains unclear, significant progress

has been made in treating affected individuals. State education agencies have recognized that

individuals diagnosed with autism are underserved as well as inappropriately served (Hernandez,

2008). Comprehensive programs that address the deficits identified in these individuals must be

designed and implemented in the public school structure. The goal of determining a successful

behavioral approach is based on the quality of evidence that supports its use. Behavioral

approaches such as Applied Behavior Analysis have been shown repeatedly to have a significant

impact on autistic individuals’ social functioning. However, there has been little research on the

effects of generalizability using Applied Behavior Analysis. Furthermore, autistic individuals are

believed to have deficits with theory of mind (Baron-Cohen, 1997), which is reflected in

difficulties interpreting the perceptions of others and is believed to impact their overall behavior.

Several studies have shown that Applied Behavior Analysis can provide an in-depth structured

approach that, if administered by qualified personnel, can lead to positive effects on social

behavior (Cowan, 2007).

The study reported here examined the data collected during a ten week ABA training

program. This case study focused on the use of Applied Behavior Analysis using discrete trials

to train an autistic child to provide a spontaneous response in various settings. The training was

completed to demonstrate that the use of Applied Behavior Analysis with Discrete Trials both at

home and at school can generalize what was taught into other settings. The student taught in this

case study was taken to various settings and observed producing spontaneous social greetings. It
 Case Study 44

was hypothesized that the training completed both in school and at home would increase the

student’s ability to make a socially appropriate greeting and demonstrate appropriate social

behaviors in a variety of settings.

 Case Study 45

Chapter 3: Method

Data Source

The data used in this study were obtained from the treatment records collected on a

twelve year old adolescent male student with autism. At the time of implementation of the

treatment program during which the data were collected, the student resided with his parents and

younger brother. The family is of Hispanic background. Both parents were working long hours,

and the paternal grandparents were caring for the student and his siblings after school.

Records reviewed for this study included the results from a psychological evaluation

given in June, 2007 that yielded the following scores on the Comprehensive Test of Nonverbal

Intelligence: Nonverbal IQ Standard Score = 67 (Very Poor range); Pictorial Nonverbal IQ

Standard Score = 70 (Borderline range); Geometric Nonverbal IQ Standard Score = 68 (Very

Poor range). Academic skills assessment indicated that the student could identify numerals and

number words to nineteen, sing parts of the alphabet song, randomly identify letters of the

alphabet, identify colors and shapes, name planets, point to body parts, match words/phrases to

pictures, read words and passages on level 1 sequential reading program, tell biographical

information, place four cards in sequence, and complete open ended sentences by matching a

picture with a verbal response. The student’s parents also completed the Vineland Adaptive

Behavior Scales (VABS) as part of the assessment. The VABS results were as follows:

Communication Skills age equivalent 2.6; Daily Living Skills age equivalent 3.5; Socialization

Skills age equivalent 3.2; and Motor Skills age equivalent 4.11.
 Case Study 46

At the time of the original data collection, the student was attending school in a self-

contained special education classroom in a suburban middle school. His class consisted of five

students with one head teacher and five aides; one was assigned to each student. The class

utilized applied behavior analysis (ABA) and discrete trials to teach social and academic skills.

In addition to applied behavior analysis being implemented in the classroom, the student was

receiving applied behavior analysis training five nights a week for a total of ten hours per week,

per recommendation in his individualized education plan (IEP). The school- and home-based

ABA programs were run concurrently. The skills taught in school were reinforced daily at home.

Procedures and Measure

This study assessed the effectiveness of Applied Behavior Analysis on improving

socialization skills in a student with autism. Previously collected data were accessed for

analysis using a single case study design. The literature review explained applied behavior

analysis as a structured methodology used to increase a child’s capacities (i.e., social skills,

academics) through discrete trials learning. In this study, the student’s ability to make an

appropriate greeting to others was observed and evaluated. The student was taught to exchange a

greeting (i.e., say “hello”), when initially prompted. It was expected that he would gradually

begin to greet others spontaneously without prompting and the prompting could be gradually

faded. The educational program was conducted so that skills were continuously reinforced. The

educational program was conducted for a ten-week period. During the program, the student was

taught the skill of making an initial greeting in school and at home with a familiar person. An

initial greeting was defined either as a “hello” when first making eye contact with the other
 Case Study 47

person. A familiar person was defined as a parent, grandparent, teacher, or ABA therapist. The

student was then exposed to various settings in which he was expected spontaneously to greet

those unfamiliar to him. Unfamiliar people were defined as anyone not included as familiar

people (e.g., a store clerks).

The data collected during program implementation evaluated the student’s spontaneous

and prompted social greeting behaviors with unfamiliar persons in social settings in public places

(e.g., McDonald’s restaurant; CVS drug store), based on criteria that reflected the social greeting

skills taught to the student at home and school. The student’s encounters with unfamiliar person

were observed and evaluated for the frequency of occurrence of the socially appropriate greeting

behaviors that were emphasized in the social greeting discrete trial teaching sessions.

Evaluations of the student’s social greetings were recorded using a checklist, indicating the

frequency of occurrence of specific greeting behaviors (see Appendix A). Four different

observers used the behavior checklist to record their evaluations of the adequacy of the student’s

performance of six behaviors that are part of social greetings.

The observers included two Applied Behavior Analysis therapists that worked with the

student in the school and home settings, the head teacher in the student’s classroom, and the one-

to-one aide assigned to the student in the classroom. The observers were qualified persons who

had been trained prior to the start of the program to observe and evaluate the student’s social

greetings. The observers were provided with the behavior checklists along with brief operational

definitions of the social greeting behaviors to assist the observers with the scoring of each

checklist item.
 Case Study 48

Behaviors on the checklist were assigned a score of “0” or “2” based on whether or not

they were performed spontaneously. Three of the six items also allowed for intermediate scores

of “1” if prompting was needed to produce the socially appropriate greeting behavior. A prompt

was defined as providing the student with reminders and/or commands to offer the desired

behavior; for example, telling the student to say “hello” to a service worker but the student did

not respond within 5-10 seconds.

The specific behaviors that were rated during social greeting interactions included: 1)

making eye contact; 2) acknowledging the other person without prompting; 3) offering an

adequate verbal response to the other person’s greeting; 4) responding reciprocally with a wave

or a smile; 5) maintaining appropriate distance between him and the other person; 6) not

engaging in self-stimulating behaviors. Each behavior was evaluated using specifically defined

ratings.

The first behavior pertained to the student making eye contact with an unknown person.

As noted in the checklist, this item could only be scored “0” or “2”. If the student made eye

contact, a “2” would be assigned. If the student did not make eye contact a “0” would be

assigned. Making eye contact was defined as looking directly at the other person’s eyes and

sustaining a mutual gaze for at least 2 seconds.

The second behavior was rated as a “2” if the student spontaneously acknowledged an

unfamiliar person, whereas acknowledging the unfamiliar person with prompting was assigned a

‘1”, not acknowledging the unfamiliar person with or without prompting was rated as “0”.

Acknowledging the unfamiliar person was defined as looking in the direction of the other person

at least once and demonstrating body position cues (i.e., face and body are positioned in the
 Case Study 49

direction of the unfamiliar person, shoulders still and perpendicular to the floor demonstrating

appropriate posture) that could be interpreted as a readiness to engage the other person in some

form of social interaction.

The third behavior pertained to offering a verbal greeting. If the student offered an

adequate verbal response such as, “Hello”, a score of “2” was assigned., If the student offered an

inadequate verbal response, such as repeating what the other person said, a score of “1’ was

assigned. If the student offered no verbal response, a score of “0” was assigned. A verbal

greeting was defined as saying “Hello” or offering some other verbal response consistent with

the other person’s greeting, such as saying “I’m fine thanks” if asked, and ,“How are you?”

The fourth behavior pertained to offering a reciprocal nonverbal greeting when offered a

nonverbal greeting by an unfamiliar person, such as a wave or a smile. If the student responded

reciprocally with a wave or a smile, a “2” was assigned, but if the student did not respond, a “0”

was assigned. A nonverbal response was defined as a reciprocated head nodding and smiling

when the other person nodded and smiled at the student.

The fifth behavior pertained to maintaining appropriate proximity between the student

and the unfamiliar person. Maintaining an appropriate distance was scored as a “2” and not

maintaining an appropriate distance between him and the person was scored as a “0”.

Maintaining a socially appropriate distance was operationally defined as maintaining

approximately 2-3 feet between him and the other person while engaging in a social greeting,

ordering a product, or asking a question.

The sixth behavior pertained to the occurrence of self-stimulation during the interaction.

If the student did not engage in self-stimulating behaviors, a score of “2” was assigned. If the
 Case Study 50

student engaged in self-stimulating behaviors but discontinued when prompted to do so, a score

of “1” was assigned. If the student engaged in self-stimulating behavior and did not discontinue

when prompted to do so, a score of “0” was assigned. Avoiding engagement in socially

inappropriate, self-stimulating behaviors was operationally defined as not doing any of the

following; waving his hands in the air, staring at various objects, or staring closely at his fingers

for the duration of the social interaction.

Ratings of social greetings with unfamiliar persons during the first two weeks of the

education program were used to establish a baseline. The student was observed in various public

settings that afforded opportunities to offer spontaneous social greetings. During the first two

weeks, the student was provided with prompting. A prompt was operationally defined as a

reminder provided by the rater, (e.g., a whispered verbal command to say “hello”). During the

second two weeks, the prompting by the rater was faded gradually but the student was given

positive reinforcement immediately after a spontaneous greeting was offered (i.e., being told

“good job”, being given a piece of candy, or being given a drink). The student was expected to

provide a spontaneous greeting without the assistance of a prompt or reinforcement during the

remaining six weeks of the education program. Prompting and/or positive reinforcement were

still provided, however, if the student did not engage in a social greeting when the opportunity to

do so was present. In these instances, a prompt was provided and the appropriate rating of “1”

was assigned to behaviors that were completed when prompted. .

 Case Study 51

Data Analysis

The behavior checklists were completed daily (Monday through Friday) by four separate

raters for ten consecutive weeks. The four raters observed the student in public places daily, at

various times of the day. After ratings were assigned for ten weeks, the scores were transferred

to an excel spreadsheet. The scores were divided into separate columns according to the

individual raters. The scores were initially recorded by day over the ten week period in order to

allow for examination of progress within the individual weeks for each of the six behaviors that

were rated. Weekly scores were generated for each behavior by summing the daily scores for

each week. The weekly scores ranged from 0 to 10 for each behavior.

For the purpose of this study’s data analysis, the weekly scores were converted into

percentages from 0% to 100% to represent the frequency of occurrence of the target behaviors

for any specific week. Weekly frequencies of occurrence of behaviors were plotted on bar graphs

for the ten week training program period. Each bar graph included four bars for each week with

each bar representing the weekly ratings of one of the four raters. In the case of behaviors 1, 4,

and 5, one graph was completed for each behavior, with each graph representing the frequency

of occurrence of behaviors that occurred spontaneously. For behaviors 2, 3, and 6, three separate

bar graphs were used to represent the frequency of spontaneously occurring behaviors, behaviors

that occurred only after prompting, and lack of spontaneous or prompted behaviors. The bars

were also color coded to highlight differences found among the raters.
 Case Study 52

Chapter 4: Results

The data representing the results of a ten week educational program designed to teach an

adolescent male diagnosed with autism to offer spontaneous social greetings were analyzed.

During the program, the student was observed in public places where there was potential for

interacting with people unfamiliar to the student. These unfamiliar people included various

cashiers or clerks working in public establishments where the student was observed. A behavior

checklist was created and used by raters to examine six behaviors likely to be part of an

appropriate spontaneous social greeting. There were four raters assigned to rate the student’s

behavior and provide prompts and reinforcement as needed. Ratings occurred on a daily basis,

Monday through Friday, for a ten week period while the educational program was being

conducted. The weekly scores from each of the four raters for each of the six behaviors are

depicted in the following graphs.

Figure 1 shows the frequency of occurrence of the behavior Making Eye Contact, based

on the weekly ratings of the four raters. Behaviors scored as a ‘0’ appear as blank spots on the

bar graph and indicate that the student did not exhibit the behavior during the designated week.

Scores for the ten week period ranged from 0% to 100% showing significant improvements after

week 5.
 Case Study 53

Figure 1. Making Eye Contact

100
90
80
70
Percentage

60 Home ABA
Sch ool ABA
50
Aide
40 T each er
30
20
10
0
10
1

9
k

k
ee

ee

ee

ee

ee

ee

ee

ee

ee

ee
W

Figure 1: Making Eye Contact

The student was observed in various public places (i.e., McDonalds, CVS) where he had

the opportunity to make appropriate eye contact with unfamiliar persons (i.e., clerks or cashiers).

Eye contact was observed and rated, based on whether or not the student was able to look

directly at the other person’s eyes and sustain a mutual gaze for at least 2 seconds. Ratings

reflected inconsistent performance of this behavior during the first five weeks of the program,

with results ranging from 0% to 80%. The school ABA therapist did not observe the student

make eye contact during weeks 2, 4, and 5. The teacher did not see the student make eye contact

during weeks 1, 2, and 5. The home ABA therapist did not observe the student make eye contact

during week 5. The aide saw the student make eye contact at least once every week. The scores

became more consistent across the four raters after week five, with the student being observed

performing
 Case Study 54

the behavior with greater frequency. During weeks 6 to 10, all four raters observed the student

making eye contact with an unfamiliar person in at least 80% of all social encounters.

Figures 2A, 2B and 2C show the frequency of occurrence of the behavior Acknowledging

Others without prompting (2A) or with prompting (2B), and frequency of the absence of the

behavior even after prompting (2C), based on the weekly ratings of the four raters. The blank

spaces on the bar graph in Figure 2A indicate that the behavior did not occur after prompting

during that week. The blank spaces on the bar graph in Figure 2B indicate that the behavior did

not occur without prompting during that week. The blank spaces in Figure 2C indicate that the

behavior occurred either with prompting or spontaneously without prompting during that week.

Figure 2A: Acknowledging Others without Prompting

100
90
80
70
Percentage

Home ABA
60 School ABA
50 Teacher

40 Aide

30
20
10
0
Week Week Week Week Week Week Week Week Week Week
1 2 3 4 5 6 7 8 9 10
 Case Study 55

Figure 2B: Acknowledging Others with Prompting

100
90
80
Percentage

Home ABA
70
60 School ABA
50
Teacher
40
30 Aide

20
10
0
Week Week Week Week Week Week Week Week Week Week

1 2 3 4 5 6 7 8 9 10

Figure 2C: No Behaviors Observed

100

90

80

Percentage

Home ABA
70

60
School ABA

50

Teacher
40

30
Aide

20

10

10
1

9
k

k
ee

ee

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W

W
 Case Study 56

The student was observed in situations that afforded opportunities to acknowledging the presence

of an unfamiliar person by looking in the direction of the person at least once and demonstrating

body position cues (i.e., the student’s face and body are positioned in the direction of the

unknown person, shoulders still and perpendicular to the floor demonstrating appropriate

posture) that would be interpreted as a readiness to engage the other person in some form of

social interaction. Figures 2A, 2B and 2C indicate that the target behavior was observed either

after a prompt was provided or without a prompt during weeks two to nine. The home ABA

therapist was the only rater who did not observe the behavior consistently during the first week

(without prompting 60%, see Figure 2A, no behavior exhibited 40%, see Figure 2C). The school

ABA therapist, the teacher and the teacher aide observed the behavior predominately with

prompting provided during the first week (Figures 2A and 2B); the school ABA therapist and

aide observed the behavior with prompting given 100% of the time; the teacher observed the

behavior with prompting given, 60% of the time and without prompting given, 40% of the time.

During weeks two, six, and eight, the behavior was observed 100% of the time with prompting

by all four raters (Figure 2B). There were inconsistencies in the student’s performance during

weeks 3, 4, 5, 7, and 9. During week 3, the student was observed acknowledging others 100% of

the time with prompting by the teacher and aide (Figure 2B). The home ABA therapist observed

the behavior 60% of the time with prompting (Figure 2B) and 40% of the time without

prompting (Figure 2A). The school ABA therapist observed the behavior with prompting 80% of

the time (Figure 2B) and without prompting 20% of the time (Figure 2A). During week four, the

teacher and aide observed the student acknowledging others without prompting 100% of the time

(Figure 2A). However, the home ABA therapist observed the behavior 100% of the time with
 Case Study 57

prompting (Figure 2B) and the school ABA therapist observed the behavior 80% of the time

without prompting (Figure 2A) and 20% of the time with prompting (Figure 2B). On week five,

the two ABA therapists observed the behavior 100% of the time with prompting (Figure 2B).

Conversely, the teacher observed the behavior 100% of the time without prompting (Figure 2A).

During week seven, the teacher and aide observed the behavior 100% of the time without

prompting (Figure 2A) and the ABA therapists observed the behavior 100% of the time with

prompting (Figure 2B). During week nine, the two ABA therapists observed the behavior 100%

of the time with prompting (Figure 2B), whereas the aide observed the behavior 100% of the

time without prompting (Figure 2A). The teacher observed the behavior 40% of the time with

prompting (Figure 2B) and 60% of the time without prompting (Figure 2A). Finally, on week

ten, the four raters observed the student exhibiting the behavior 100% of the time without

prompting (Figure 2A).

Figures 3A, 3B and 3C show the weekly ratings of the four raters of the frequency of

occurrence of the behavior Offering a Verbal Response without prompting (3A), with prompting

(3B), and absence of the behavior even after prompting (3C). The blank spaces on the bar graph

in Figure 3A indicate that the behavior did not occur after prompting during that week. The

blank spaces on the bar graph in Figure 3B indicate that the behavior did not occur without

prompting during that week. The blank spaces in Figure 3C indicate that the behavior occurred

either with prompting or spontaneously without prompting during that week.

 Case Study 58

Figure 3A: Offering a Verbal Response Without Prompting

100
90
80
Percentage

70 Home ABA
60
School ABA
50
Teacher
40
30 Aide

20
10
0
10
1

9
k

k
ee

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W

Figure 3B: Offering a Verbal Response with Prompting

100
90
80
Percentage

70
60 Home ABA
School ABA
50
Teacher
40 Aide
30
20
10
0
Week Week Week Week Week Week Week Week Week Week
1 2 3 4 5 6 7 8 9 10
 Case Study 59

Figure 3C: No Behaviors Observed

100
90
80
70
Percentage

Home ABA
60
School ABA
50
40 Teacher

30 Aide

20
10
0
Week Week Week Week Week Week Week Week Week Week
1 2 3 4 5 6 7 8 9 10

The student was observed in situations that afforded the opportunity to offer a socially

appropriate verbal greeting. A verbal greeting was defined as saying, “Hello”, or a verbal

response consistent with another person’s greeting, such as saying, “I’m fine thanks”, if asked

“How are you?” Ratings reflected behaviors observed with/without a prompt provided, and

behaviors not exhibited at all during the week. The ratings demonstrated inconsistent

performance of this behavior over the ten week period. During week one, the home ABA

therapist and the teacher observed the behavior 100% of the time, without prompting (Figure

3A). The school ABA therapist observed the behavior without prompting 60% of the time and

observed no behaviors 40% of the time (Figure 3C). The aide observed the behavior with

prompting 60% of the time (Figure 3B) and without prompting 40% of the time (Figure 3A). All

four raters observed the behavior 100% of the time with prompting during weeks two, six, and
 Case Study 60

seven (Figure 3B). On week three, the teacher and aide observed the behavior 100% of the time

with prompting (Figure 3B). The home ABA therapist observed the behavior with prompting

80% of the time (Figure 3B) and 20% of the time the behavior was not exhibited (Figure 3C).

The school ABA therapist observed the behavior 60% of the time with prompting (Figure 3B)

and 40% of the time the behavior was not exhibited (Figure 3C). During week four, the home

ABA therapist observed the behavior, with prompting 100% of the time (Figure 3B). The school

ABA therapist observed the behavior with prompting 20% of the time (Figure 3B) and 80% of

the time without prompting (Figure 3A). The teacher observed no behavior 100% of the time

(Figure 3C) but the aide observed the behavior 100% of the time without prompting (Figure 3A).

During week five, both ABA therapists and the teacher observed the behavior 100% of the time

without prompting (Figure 3A) but the aide observed the behavior 100% of the time with

prompting (Figure 3B). During week eight, all four raters observed the behavior 100% of the

time without prompting (Figure 3A). During week nine, the ABA therapists observed the

behavior 80% of the time with prompting (Figure 3B) and 20% of the time without prompting

(Figure 3A). The teacher observed the behavior 100% of the time with prompting (Figure 3B).

The aide observed the behavior 80% of the time with prompting (Figure 3B) but did not observe

the behavior 20% of the time (Figure 3C). During week ten, all four raters observed the behavior

100% of the time without prompting (Figure 3A).

 Case Study 61

Figure 4 shows the frequency of occurrence of the behavior Offering a Nonverbal

Response based on the weekly ratings of the four raters.

Case Study 59

Figure 4. Offering a Nonverbal Response

100
90
80
70
60 Home ABA
Percentage

School ABA
50
Aide
40 T eacher
30
20
10
0
10
1

9
k

k
ee

ee

ee

ee

ee

ee

ee

ee

ee

ee
W

The student was observed making a nonverbal response consistent with the nonverbal

greeting by another person, such as head nodding and smiling when the other person nodded or

smiled at him. The student’s behavior was inconsistent during the first four weeks. During week

1, the home ABA therapist observed the student offering a nonverbal response 60% of the time;

the aide and the teacher observed the behavior 40% of the time and the school ABA therapist

observed the behavior 20% of the time. During the second week, the home ABA therapist

observed the behavior 20% of the time but the school ABA therapist observed the behavior

100% of the time. However, the aide and the teacher did not observe the behavior occurring

during that week. During week three, none of the raters observed any occurrences of the target
 Case Study 62

behavior. During week four, the home ABA therapist observed the behavior 100% of the time

and the school teacher observed the behavior 20% of the time. The school ABA therapist and

aide did not observe the behavior occur. During weeks five through ten, the target behavior was

observed 100% of the time by all four raters.

Figure 5 shows the frequency of occurrence of the behavior Maintaining Appropriate

Distance During Interaction based on the weekly ratings of the four raters.

Figure 5. Maintaining Appropriate Distance During Interaction

100
90
80
70
60 Home ABA
Percentage

School ABA
50
Aide
40 T eacher
30
20
10
0
10
1

9
k

k
ee

ee

ee

ee

ee

ee

ee

ee

ee

ee
W

The student was observed in public places where he had the opportunity to maintain a

socially appropriate distance of approximately 2-3 feet between himself and an unfamiliar person

while engaging in a social greeting, ordering a product, or asking a question. The home ABA

therapist and teacher observed the student exhibiting the behavior 100% of the time during the

first week. The school ABA therapist observed this behavior 60% of the time during the first
 Case Study 63

week. The aide observed the behavior 80% of the time. Frequency of occurrence of the target

behavior declined during the second and third weeks of the program. During the second week,

the student was observed maintaining an appropriate distance 60% of the time by the home

ABA therapist and 0% of the time by the other three raters. The student was not observed

exhibiting the behavior during the third week by any of the four raters. During week 4, the ABA

therapists and the teacher observed the behavior 100% of the time but the aide observed the

behavior only 40% of the time. During week 5, the home ABA therapist, the teacher and the

aide observed the behavior 100% of the time. However, the school ABA therapist did not

observe the behavior during week 5. During weeks six to ten, all four raters observed the student

maintaining a socially appropriate distance during interactions 100% of the time.

Figures 6A, 6B and 6C show the weekly ratings of the four raters for the frequency of

occurrence of the avoidance of engagement in self-stimulating behaviors (6A), the

discontinuation of self-stimulating behaviors when prompted (6B), and continuation of self-

stimulating behaviors even after prompts to discontinue (6C). The blank spaces on the bar graph

in Figure 6A indicate that the student was observed engaging in self-stimulating behavior by a

rater during that week. The blank spaces on the bar graph in Figure 6B indicate that self-

stimulating behavior that was not discontinued after a prompt was observed by the rater during

that week. The blank spaces in Figure 6C indicate that the behavior either did not occur or was

discontinued after prompting during that week.

 Case Study 64

Figure 6A: Avoidance of Engaging in Self-Stimulating Behaviors

100
90
80
70
Percentage

60 Home ABA

50 School ABA

40 Teacher

30 Aide

20
10
0
Week Week Week Week Week Week Week Week Week Week
1 2 3 4 5 6 7 8 9 10

Figure 6B: Discontinuation of Self-Stimulating Behaviors

100
90
80
Percentage

70 Home ABA

60 School ABA
50
Teacher
40
Aide
30
20
10
0
10
W 1

W 2

W 3

W 4

W 5

W 6

W 7

W 8

9
k

k
ee

ee

ee

ee

ee

ee

ee

ee

ee

ee
W

W
 Case Study 65

Figure 6C: Continuation of Self-Stimulating Behaviors

100
90
80
Percentage

70 Home ABA
60
School ABA
50
40 T eacher
30
Aide
20
10
0 10
1

9
k

k
ee

ee

ee

ee

ee

ee

ee

ee

ee

ee
W

The student was observed for socially inappropriate self-stimulating behaviors, such as

waving his hands in the air, staring at various objects, or staring closely at his fingers for the

duration of social interactions with unfamiliar persons in public places. During weeks two, four,

five, seven, and eight, all four raters observed the student resist engaging in self-stimulating

behaviors 100% of the week without prompting (Figure 6A). However, there were

inconsistencies during the other five weeks. On week three, the teacher and aide observed the

student engage in self-stimulating behaviors in all social interactions with unfamiliar persons

(Figure 6C). The ABA therapists observed this behavior 80% of the time (Figure 6C). However,

both observed the student resist this behavior 20% of the time with prompting (Figure 6B). On

week six, the teacher and aide observed the appropriate behavior without prompting 100% of the

time (Figure 6A). On the contrary, the ABA therapists observed the behavior without
 Case Study 66

prompting 100% of the time (Figure 6A). On the ninth week, the home ABA therapist observed

the appropriate behavior 40% of the time with prompting (Figure 6B) and 60% of the time

without prompting (Figure 6A). The school ABA therapist observed the appropriate behavior

100% of the time without prompting (Figure 6A). The teacher observed the appropriate behavior

80% of the time without prompting (Figure 6A) and 20% of the time with prompting (Figure

6B). The aide observed the appropriate behavior 60% of the time without prompting and 40% of

the time with prompting. By the tenth week, the home ABA therapist observed the appropriate

behavior 100% of the time without prompting (Figure 6A). The school ABA therapist and

teacher observed the appropriate behavior 40% of the time without prompting (Figure 6A) and

40% of the time with prompting (Figure 6B). The aide observed the appropriate behavior without

prompting 80% of the time (Figure 6A) and with prompting 20% of the time (Figure 6B).
 Case Study 67

Chapter 5: Discussion

This study analyzed the data collected from raters who observed a student diagnosed with

autism in situations that provided the student with the opportunity to demonstrate socially

appropriate greetings while undergoing a ten week ABA training program designed to improve

the student's ability to engage in such socially appropriate behaviors.

Given the study results, interpretation of the findings has noted specific factors that may

have had an impact on this student’s ability to engage in socially appropriate behaviors. These

include possible idiosyncrasies in the behaviors of this autistic student; possible subjectivity or

bias among raters; the various times of the day and the specific days of the week that the student

was observed; variations in environmental settings where behavior observations were conducted;

and variations in how prompting was interpreted or provided. Overall results are viewed in light

of the factors noted above. Similar to findings by Simpson (2001), ABA was effective in

increasing spontaneous greetings in this student with autism and has improved his socialization

by targeting specific behaviors that impacted upon his ability to interact with others. During the

ten week program, the student demonstrated improvement in his ability to make a spontaneous

social greeting and exhibited appropriate behaviors while interacting with others (i.e., making

eye contact, demonstrating appropriate proximity between him and another person). Of greatest

importance, the student learned and implemented the skills needed to interact successfully with

others across various settings (home and school) which denote generalization of skills (Prior,

2003)
 Case Study 68

Children with autism typically exhibit impairments in social functioning which are

evidenced by failing to form typical social relatedness (Dryden-Edwards & Shiel, 2007). There

are significant inconsistencies expected in how individuals with autism learn, and regression can

typically occur if the program implemented is not structured and conducted consistently. Autistic

individuals are believed to have difficulty understanding the perspectives of other persons and

are lacking what is commonly known as having a “theory of mind” (Baron-Cohen, 1997).

Because of deficits in theory of mind, individuals with autism experience difficulty in

understanding many social conventions that are not explicitly stated and that often change with

the social context (Frith, 1989). In this study, the student was taught appropriate ways to provide

a spontaneous social greeting and behave appropriately in the context of the interaction.

However, due to deficits in theory of mind, this student initially experienced difficulties in

exhibiting appropriate behavior (i.e., engaging in self-stimulating behaviors). This student’s

performance appeared to fluctuate in the beginning weeks as acquisition of learning was taking

place, but his performance became more stable as the study progressed, and he became more

familiar and comfortable with the expectations.

Given that ABA as an intervention is responsible for analysis of behaviors in order to

achieve behavioral change (Faherty, 2000), one may question the consistency of implementation

and the extent of time needed to produce beneficial social behavioral change. In this regard, there

was a positive relationship between the consistency of the ABA program, its daily

implementation for ten weeks, and the desired outcomes. This is in line with ABA programs that

need to be taught and applied daily and structured consistently in order to achieve positive results

(Simpson, 2001). Of note is the degree of behavioral change over the course of the study;
 Case Study 69

whereas, this student was inconsistent in his efforts to interact appropriately with others during

the first few weeks of the study, his behavior improved during the second half of the study,

revealing significant improvements by the last week. Part of this inconsistency can be attributed

to the learning curve, but it could also be attributed to inconsistency in the ways in which his

behaviors were being rated. The individual ratings appeared to be inconsistent during the first

few weeks of the study as well, but they gradually became more consistent during the second

half of the study. The ratings demonstrated differences in the offering of prompts for the

occurrence of desired behavior between raters, with results revealing that prompting was faded

completely by the tenth week of the educational program. In terms of self-stimulating behaviors,

the findings were inconsistent, but there was an improvement for the demonstration of

appropriate behaviors daily by the tenth week, with continued prompting.

According to Frith (1989), children interpret the facial expressions of others and use this

knowledge to alter or adapt their behavior. This understanding that other people may think and

feel differently from oneself is one example of a child’s use of “theory of mind” knowledge

(Baron-Cohen (1997). In this case study, understanding the facial expressions and social cues of

others was imperative. If the unknown person appeared not to be interested, then the student

would be less inclined to socialize. However, if the unknown person appeared to be interested

(i.e., smiling or waving) then the student would be more inclined to approach the person and

interact. An absence of, or slowed acquisition and use of this type of theory of mind knowledge

is thought to underlie some of the social impairments and deficits in empathy often seen in

individuals with autism. However, these individuals become more adaptable to surroundings as

they become more familiar with them. This student’s theory of mind deficit was observed in his
 Case Study 70

difficulty with interpreting the facial expressions of others. The student’s comfort level and

inclination to provide a response was impacted by his understanding of the person’s social

behavior. The student was initially more reserved and had difficulty interpreting the facial

expressions of others. The student would initially engage in self-stimulating behaviors (i.e.,

flapping hands) and he did not seem prepared or inclined to provide any greeting or nonverbal

gesture. However, as the educational program progressed, the student gradually became

comfortable with and more consistent in greeting various clerks and he was seemingly more

confident with what was expected of him. Relative to targeting specific behavior domains with

ABA, the same level of response may not always occur in different social contexts. In this study,

the student had initial difficulty with reading other people’s nonverbal behaviors, which can

complicate two-way social communication (Wing, 1991). Because nonverbal communication

problems are commonly exhibited in individuals with autism, it is not surprising that this student

had difficulty with understanding expressive gestures such as a raised eyebrow (Frith, 2989). As

the study progressed, this student improved his ability to engage in and read nonverbal

communication, and this area appears to be the most clearly defined area of behavior change

utilizing ABA.

It is well known that engaging in self-stimulating behaviors is prominent in autistic

children (Barbara, 2007; Wing, 1991). Despite the growth in reading of nonverbal behaviors, this

student found the least amount of success in eliminating self-stimulatory behaviors and

continued to rely on prompting to disengage these self-stimulating behaviors.

Continuous prompting is beneficial when initially learning a new behavior and the

reduction of prompts is often associated with increased independent performance of skills and
 Case Study 71

the generalization of newly learned skills to different environments (Lewis, 2010). Children

with autism frequently cannot apply what they have learned in one situation and utilize it in a

similar, though not identical, setting. This has important implications in a therapeutic context.

Parent-professional involvement and community-based instruction can increase the

generalization of social learning in students with autism. The generalization of the ability to self-

initiate can be improved by providing treatment in the classroom and home, such as providing

intervention within everyday classroom routines with typical peers, or within everyday routines

at home whereby parents are taught to incorporate therapeutic techniques. This was certainly

apparent with the student in this study. This student typically kept to himself and was seemingly

introverted. However, he did not exhibit this behavior while this study was conducted. He was

able to exhibit the behavior taught across multiple settings more frequently as the study

progressed. Lewis (2010) believes that generalization in various environments is the “acid test”

for mastered social skills. The results of this study showed that intense programming completed

at home and in school for this student increased the generalization and self-initiation of social

skills across the multiple settings in which the student was observed. The student visited various

settings and was consistently expected to approach others and make a spontaneous greeting. He

became increasingly more confident, smiling and showing interest in approaching unfamiliar

persons rather than engaging in avoidance behaviors or withdrawing into himself.

Furthermore, research has shown that children with autism are involved more often in

solitary activities, forming few or no attachments with others and not responding to others;

however, very often children with autism are interested in engaging others in social interactions

but their odd and eccentric behaviors often negatively impact these social interactions (Baron­
 Case Study 72

Cohen, 1997). When engaging in social interactions, individuals with autism have difficulties

with engaging in nonverbal social behaviors such as establishing eye contact, using proper voice

tone, and maintaining appropriate social distance from others. In addition, autistic individuals

display abnormalities in how they interact with others because they do not take into account the

other person’s state of mind. These individuals have a tendency to repeat what others say, make

embarrassing remarks, or make remarks that appear to be extremely formal and inappropriate

given a close affective relationship to the listener (Frith, 1989).. These behaviors by the student

were observed when the educational program began. This student had a tendency to repeat what

others said and did not make appropriate eye contact or effectively use social gestures. By the

tenth week, use of the ABA program increased this student’s ability to make an appropriate

social greeting and demonstrate the necessary nonverbal behaviors involved when interacting

(i.e., making eye contact, using gestures and being in proximity to the others).

The student was able to transition from prompting to self-initiation of these behaviors

over the ten week period. The most significant improvements were exhibited in socially

appropriate nonverbal behaviors such as head nodding and making eye contact, and with his

ability to offer a verbal response. According to theory of mind, individuals with autism have

difficulty interacting with others and listening and making appropriate interpretations of the other

person’s intent (Lind & Bowler, 2010). It appeared that the student no longer relied on the

prompting from others to make appropriate eye contact, offer a head nod, maintain appropriate

distance, and offer a greeting. This became a ‘learned behavior’ that the student could now

initiate. The educational program was successful in increasing the student’s ability to make

social greetings through ABA and the skills were reinforced and applied in social situations
 Case Study 73

daily.

A factor that may have caused some of the inconsistencies in performance reflected in the

results is the subjectivity among the raters’ judgments about the frequency of occurrence of

specific target behaviors (i.e., low inter-rater reliability). The raters scored the student’s behavior

based on their observations of the student in various settings. There were inconsistencies in

ratings among all four raters for all six target behaviors. Each day the student was being

observed in various settings at two different times. The two ABA therapists typically recorded

data around the same time in the afternoon and the teacher and teacher aide typically recorded

data around the same time in the morning. However, there were instances in which one rater was

observing the student exhibit behavior but the other rater was not observing him because he/she

was tending to something else. This may explain the reasons why the teacher and teacher aide’s

ratings were different in many instances and why the ABA therapist’s ratings were different in

some instances. In addition, the raters had their own interpretations of various aspects of the

student’s behavior that also could have led to differences in ratings. For example, one rater may

have observed the student and interpreted his behaviors as representative of making a head nod

(nonverbal greeting), but the other rater observed the same behavior but did not interpret it as a

head nod. In future studies, more specific training should be provided to raters in attempts to

increase the consistency of interpretation of observed behaviors among raters.

 Case Study 74

Limitations of the Study

This study examined the effects of Applied Behavior Analysis, using discrete trials to

improve the social interaction of one adolescent male with autism. Results showed various

degrees of improvements in specific targeted behavior components of social interaction being

observed by various raters. Some of the targeted behaviors were exhibited consistently by the

end of the training period, whereas other targeted behaviors were exhibited inconsistently.

Observation of the outcomes was limited to a ten week period during which the training was

being conducted, making it difficult to conclude with certainty that the behaviors would continue

to be exhibited without prompting after conclusion of the training program..

Another limitation was that this was a single case study design exploring the

effectiveness of a social skills program on an adolescent with autism. Although this student

showed clear improvements in his social interactions, a study of a larger number of autistic

children would be necessary to demonstrate generalizability of the results. A study involving a

larger number of students would allow for examination variation in training effectiveness based

on factors such as gender, IQ, age, and race.

Another limitation was the length of the program. The program was conducted over the

course of only ten weeks. Some targeted behaviors were observed as having emerging sooner

and having been performed with greater consistency sooner than others over the course of the ten

weeks of training. Therefore, the study would need to be extended to determine if the less

frequently exhibited behaviors eventually occurred with consistency.

A fifth limitation in this study was that it occurred only on Mondays through Fridays

during the ten week period. On the weekends, the student was not observed eliciting a social
 Case Study 75

greeting and he was not encouraged to practice these behaviors. The student typically would

regress over the weekend, and he would need to relearn the behavior at the beginning of the

following week in order to return to the level of frequency that he exhibited in the desired and

observed behavior by the end of the previous week. Therefore, if his parents or an educator

required the student to exhibit the behavior on Saturday and Sunday, there may have been a

lesser decline in results over time.

A sixth limitation that influenced the student’s behavior was the change in settings over

time. The student visited different settings over the ten week period so that he would be

continuously introduced to unfamiliar people. There were some settings that he found very

interesting and others that were of little or no interest to him. Although it was not studied

systematically, it was observed by the raters that the student required more prompting in the

settings that were not interesting to him. For example, it was observed that the student was more

enthusiastic when he went to Wendy’s and McDonalds and much less enthusiastic in settings

such as CVS.

Last, the various times of the day during which the student was observed as well as the

days on which he was observed may have influenced the results. The student was observed daily

for ten weeks during two separate time periods. The first time period was between 11:00 a.m.

and 1:00 p.m. during the school day. The teacher and teacher aide observed the student during

this time period. The two ABA therapists observed the student after 4:00 p.m. each day. The

results of observations during the school day did contrast at various times with observations

made by the ABA therapists after school, because the student’s performance usually was judged

as being more effective later in the day. This pattern again may reflect variation in the student’s
 Case Study 76

enthusiasm and/or alertness at different times of the day, or it may have reflected a stronger

desire to perform consistently with expectations when working with the therapists after school

rather than when working with the teacher and aide during the school day.

Implications for the Field

This study examined the use of a behavior technique to promote a spontaneous social

greeting in an adolescent with autism. This was a ten week program and six criteria were

explored in determining the effectiveness of Applied Behavior Analysis using Discrete Trials.

This program demonstrated Applied Behavior Analysis using Discrete Trials to be an

effective program in teaching an autistic child to provide spontaneous social greetings, reflecting

generally consistent performance of the target behaviors by the tenth week of training. The

length of the study is important because it permitted the observation of positive behaviors near

the end of the program despite variations and periods of regression during the course of training.

Self-stimulatory behaviors are commonly observed in autistic children. The data

collected for this particular autistic adolescent indicated that this adolescent demonstrated a great

deal of difficulty suppressing self-stimulatory behavior, but with additional prompting he was

able to reduce the frequency of these behaviors by the tenth week. Although it was unclear

whether the improvement was a result of learned behavior or was an increase in the development

of some aspect of theory of mind, it is recommended that targeting the self-stimulation be

prioritized in future discrete trials applications with students who demonstrate these behaviors.
 Case Study 77

Future Research

This study was designed to evaluate the effectiveness of a social skills training program

provided to an adolescent with autism. This study observed the adolescent’s ability to

demonstrate behaviors associated with spontaneous social greetings. Future research could

examine the effectiveness of this program with a larger number of adolescents diagnosed with

Autism, and could examine the effectiveness of this type of social training program with

individuals diagnosed with autism of various ages and functional levels. Results of such studies

could provide new insights on how to refine curriculum and current social skills programs being

used with children with autism. Second, future studies could examine the long-term effects of

similar training programs by monitoring students’ spontaneous greeting behaviors for weeks or

for months after the initial training program time period.

Conclusion

This study examined the effectiveness of an educational program designed to help a

student engage in spontaneous social greetings in various social settings. The student was taught

the necessary skills in school and at home using Applied Behavior Analysis using Discrete

Trials. He was taught how to apply the skills across multiple settings with unfamiliar people. The

study documented the degree to which the skills being taught were applied in multiple settings

over a ten week period while training was ongoing. Results suggest that Applied Behavior

Analysis using Discrete Trials can be useful for increasing an autistic adolescent’s spontaneous

social greetings when taught by individuals with proper training.

 Case Study 78

The data examined in this study indicated that the student was able to demonstrated

spontaneous social greetings consistently with others unfamiliar to him. He learned the skills and

was able to show significant improvements by the tenth week of the study. The student

demonstrated the ability to make appropriate social greetings after ten weeks of training. The

student was initially provided with prompting in order to encourage him to engage successfully

with others. However, he later exhibited this behavior without needing specific cues or prompts

from any of the raters. The behavior checklist developed for this study was found to be an

effective tool for monitoring adequacy of spontaneous social greeting behaviors and may be

useful in future studies assessing the effectiveness of discrete trials training of spontaneous social

greetings.
 Case Study 79

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Appendix 1.
Behavior Checklist
Name:
Setting:
Time of Day:
Date:

Circle the description that most accurately characterizes

Behavior Julian’s behavior during his social encounters today
2 0
When approached by an unknown person made eye contact. did not made eye
(store clerk, salesman, worker), Julian contact.

2 1 0
When approached by an unknown person, acknowledged the acknowledged did not occur
Julian person without the person with with or without
prompting. prompting. prompting

2 1 0
When approached by an unknown person, offered an offered an offered no verbal
with or without prompting Julian adequate verbal inadequate verbal response.
response such as response such as
“Hello.” repeating what
the other person
said.

2 0
When offered a nonverbal greeting by an responded did not respond.
unknown person, such as a wave or a reciprocally with a
smile, Julian wave or a smile.

2 0
When approached by an unknown person, maintained an did not maintain
Julian appropriate an appropriate
distance between distance between
him and the him and the
person. person.

2 1 0
During his interaction, Julian did not engage in engaged in self- engaged in self-
self-stimulating stimulating stimulating
behaviors. behaviors but behaviors but did
discontinued not discontinue
when prompted when prompted
to do so. to do so.
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*Julian will be taking daily trips to various settings (McDonalds, CVS, etc.) and expected to
make an appropriate greeting with an un known person.

**Please note how the following terms should be interpreted:

Unknown person- defined as a salesman, clerk or worker.

Julian will be taking daily trips to various settings (McDonalds, CVS, etc.) and will be expected
to offer a socially appropriate greeting when approaching or when approached by a service
worker in one of these locations.

Socially appropriate greetings are broken down into the following distinct stages:

1. Acknowledging the presence of the other person by looking in the direction of the other
person at least once and demonstrating body position cues (i.e., Julian’s face and body
are positioned in the direction of the unknown person, shoulders still and perpendicular to
the floor demonstrating appropriate posture) that would be interpreted as a readiness to
engage the other person in some form of social interaction.
2. Making eye contact by looking directly at the other person’s eyes and sustaining a mutual
gaze for at least 2 seconds.
3. Offering a socially appropriate greeting such as:
a. A verbal greeting such as saying “Hello” or a verbal response consistent with the
other person’s greeting, such as saying “I’m fine thanks” if asked “How are you?”
b. A nonverbal response consistent with the nonverbal greeting of another person,
such as head nodding and smiling when the other person nods and smiles at
Julian.
4. Maintaining a socially appropriate distance of approximately 2-3 feet between himself
and the other person while engaging in a social greeting, ordering a product, or asking a
question.
5. Avoiding engaging in socially inappropriate self-stimulating behaviors, such as waving
his hands in the air, staring at various objects, or staring closely at his fingers for the
duration of the social interaction.

When an adequate amount of time has elapsed (5-10 seconds) during which Julian could have
engaged in the socially appropriate behaviors listed above but did not do so, a prompt should be
offered to cue Julian to initiate the socially appropriate series of behavior listed above.

A prompt is defined as one of the four raters (teacher, teacher’s aide, two Applied Behavior
Analysis therapists) providing Julian reminders and/or commands to elicit the desired socially
appropriate behavior, for example, telling Julian to say “hello” to a service worker after the
service worker said hello and Julian did not respond within 5-10 seconds.