Journal of Positive Behavior Interventions

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Teaching Social Communication : A Comparison of Naturalistic Behavioral and Development, Social

Pragmatic Approaches for Children With Autism Spectrum Disorders
Brooke R. Ingersoll
Journal of Positive Behavior Interventions 2010 12: 33 originally published online 14 April 2009
DOI: 10.1177/1098300709334797

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 Journal of Positive Behavior
Interventions
Volume 12 Number 1

Teaching Social Communication January 2010 33-43

© 2010 Hammill Institute
on Disabilities
10.1177/1098300709334797

A Comparison of Naturalistic Behavioral and Development, http://jpbi.sagepub.com

hosted at
http://online.sagepub.com
Social Pragmatic Approaches for Children With Autism
Spectrum Disorders
Brooke R. Ingersoll
Michigan State University

There are a variety of effective treatments designed for increasing social communication in young children with autism
spectrum disorders (ASD). Two such treatments, naturalistic behavioral and developmental, social-pragmatic/relationship-
based interventions, differ in their underlying philosophy yet share many similarities in their implementation. They also
exhibit critical differences that may affect their effectiveness with children with ASD. This article provides a discussion of
the similarities and differences between these two approaches. Based on this comparison, it recommends new research
directions that should lead to the development of more effective social-communication interventions for young children
with ASD.

Keywords: autism; social communication; intervention; behavioral; developmental

I ndividuals with autism spectrum disorders (ASD)

demonstrate significant impairment in social interac-
tion and communication, and they exhibit a restricted
The main purpose of this article is to compare the natural-
istic behavioral (see Note 1) and developmental, social-
pragmatic (DSP; see Note 2) approaches as they are
range of interests and attention. These deficits interfere implemented with children with ASD. Although the
with learning and disrupt family life. There is consider- approaches differ significantly in underlying philosophy, a
able agreement in the field of ASD that intensive, early close examination of the intervention techniques used in
intervention leads to significant improvements in chil- the two approaches should reveal a great deal of similarity
dren’s functioning and long-term outcomes (National (Prizant & Wetherby, 1998). An appreciation of this simi-
Research Council, 2001). Beyond this, there is disagree- larity should foster better communication between disci-
ment regarding the best method of intervention. Clearly, plines. There are also critical differences in how the
interventions based on the principles of applied behavior interventions are implemented, which may impact their
analysis are the best studied and empirically validated effectiveness with children with ASD. An understanding
interventions for children with ASD to date (see of how these approaches differ should foster research that
Schreibman & Ingersoll, 2005, for review). Although analyzes the salient and effective features of each approach.
behaviorally based interventions are currently consid- Such research is likely to enhance the effectiveness of
ered the most effective treatment option for children with both approaches.
ASD (National Research Council, 2001), there are many
researchers and practitioners who advocate intervention
Historical and Theoretical Basis of
approaches drawn from the developmental and social-
pragmatic literatures. Naturalistic Behavioral Approaches
Both approaches are consistent with the field of posi-
tive behavior support in their use of positive teaching The use of behavioral interventions in the treatment of
strategies to promote communication and social interac- ASD began in the early 1960s (e.g., Ferster & DeMyer,
tions and to increase community participation. However,
there has traditionally been little interchange between the Author’s Note: This article was supported by a grant from Autism
behavioral and developmental treatment communities. Speaks.

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34   Journal of Positive Behavior Interventions

1961, 1962). All behavioral interventions are based on occurs around the child’s expressed interest. Third, the
learning theory and thus share the same core assump- adult explicitly prompts the child to produce the target
tions. The first assumption is that operant behaviors, behavior. Fourth, the child’s production of the target
behaviors that are under voluntary control such as lan- behavior is reinforced with the item or activity of inter-
guage, play, and social interaction, are learned. The sec- est. Finally, the adult loosely shapes the child’s response
ond assumption is that these behaviors are developed and into a more complex response, providing reinforcement
maintained by antecedents and consequences (observ- for attempts to respond (Delprato, 2001; Kaiser, Yoder,
able environmental events that come before and after & Keetz, 1992).
them). Behavioral interventions share the same assump-
tion that new, appropriate skills can be taught through the
manipulation of antecedent variables (e.g., establishing Historical and Theoretical Basis of
operations, discriminative stimuli) and the systematic Developmental Approaches
application of reinforcement (Cooper, Heron, & Heward,
1987). In addition, they share the use of specific teaching The use of developmental interventions in the treat-
tools such as prompting (presenting a cue that increases ment of ASD began in the early 1980s. DSP interventions
the likelihood of specific response), chaining (linking are based on an integration of Piagetian developmental
two or more behaviors together), and fading (gradually psychology and psychoanalytic theory (Greenspan &
decreasing prompts over time to encourage spontaneous Lourie, 1981; National Research Council, 2001), as well
responding (Cooper et al., 1987). as the social-pragmatic model of language acquisition
Early behavioral interventions were highly structured (e.g., Bruner, 1983). DSP interventions that have been
and adult directed (e.g., Lovaas, 1977; Lovaas, Berberich, used with children with ASD include DIR/Floortime
Perloff, & Schaeffer, 1966; Lovaas, Freitag, Gold, & (Greenspan & Wieder, 1998), the Denver Model (Rogers
Kassorla, 1965; Lovaas, Koegel, Simmons, & Long, & DiLalla, 1991; Rogers & Lewis, 1989), Responsive
1973). As the field has progressed, behavioral interven- Teaching (Mahoney & Perales, 2003), Hanen (Manolson,
tions have undergone a number of modifications to 1992), and SCERTS (Prizant, Wetherby, Rubin, & Laurent,
improve instructional outcomes and generalization and 2003).
maintenance of skills. One such modification has been The first core assumption of the developmental phi-
the development of techniques that are more naturalistic losophy is that social-communication skills are learned in
and child centered. The first naturalistic behavioral treat- a similar developmental sequence by all children, regard-
ment was designed by Hart and Risley (1968) to teach less of their abilities (Gerber, 2003). Clearly children with
the use of descriptive adjectives to disadvantaged pre- ASD and other developmental disabilities do not develop
schoolers in a classroom setting. This study sought to at the same rate as typically developing children do; how-
increase generalization and spontaneous use of skills by ever, the DSP perspective considers the pattern in which
teaching them in the context of ongoing classroom they acquire skills to be the same. For this reason, typical
activities. Since its original conception, the naturalistic development is used to guide intervention targets for chil-
behavioral approach has undergone a variety of proce- dren with delays. For example, typically developing
dural elaborations, yielding a number of similar inter- infants begin using gestures and other nonverbal commu-
vention techniques, including incidental teaching (Hart nicative behaviors prior to using words. Thus, when work-
& Risley, 1968; McGee, Krantz, Mason, & McClannahan, ing with a nonverbal child with ASD, the therapist would
1983), mand model (Rogers-Warren & Warren, 1980), encourage gesture use prior to language. A second core
time delay (Halle, Marshall, & Spradlin, 1979), milieu assumption is that children learn through affect-laden
teaching (Alpert & Kaiser, 1992), interrupted behavior interactions with responsive caregivers. Responsiveness is
chains (Hunt & Goetz, 1988), and the natural language a complex behavior that involves a variety of interactive
paradigm/pivotal response training (Koegel, O’Dell, & components including reciprocity, contingency, affect,
Koegel, 1987; Koegel et al., 1989). and matching the child’s developmental level, interests,
These approaches all share the following basic com- and behavioral style (Mahoney, 1988; Mahoney, Finger,
ponents. First, teaching occurs in the natural environ- & Powell, 1985; Mahoney & Powell, 1988). This assump-
ment during ongoing interactions between the child and tion is drawn from research on typical development that
the adult, typically during play or daily routines. Second, indicates a relationship between caregivers’ responsive-
the child initiates the teaching episode by indicating ness and their children’s levels of social-communication
interest in an item or activity, at which point teaching development (Bornstein, Tamis-LeMonda, & Haynes,

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 Ingersoll / Comparison of Behavioral and Developmental Approaches   35  

Table 1
A Comparison of Intervention Techniques for Naturalistic Behavioral and Developmental,
Social-Pragmatic (DSP) Approaches
Naturalistic Behavioral DSP
Setting Natural Natural
Teaching episodes Child initiated Child initiated
Materials and activities Child selected Child selected
Target skills Specific social-communication skills (e.g., General social-communication skills (e.g., social
two-word phrases, pointing, pretend play engagement, nonverbal communication)
schemes)
Facilitative strategiesa Not a defined component Adult responsiveness (i.e., contingent imitation,
indirect language stimulation, affective attunement)
Elicitation strategies Environmental arrangement (i.e., in sight-out- Environmental arrangement (i.e., communicative
of-reach, controlling access, gaining temptations, playful obstruction, wait time)
attention)
Prompt strategiesa Varied according to child’s initiation (i.e., Not a defined component
physical guidance, modeling, explicit
instruction)
Reinforcement properties Natural Natural
Reinforcement contingencies Loose shaping, reinforce attempts toward target Reinforce all communicative behaviors
a. Techniques that are not a defined component of one of the approaches.

1999; Hoff-Ginsburg & Shatz, 1982; Mahoney & Perales, social-communication skills such as symbolic play (e.g.,
2003; Prizant, Wetherby, & Rydell, 2000; Siller & Sigman, Stahmer, 1995), joint attention (e.g., Whalen &
2002). Thus, DSP interventions typically use facilitative Schreibman, 2003), and object (Ingersoll & Schreibman,
strategies to increase the adult’s responsiveness to the 2006) and gesture (Ingersoll, Lewis, & Kroman, 2007)
child’s behavior. imitation. Whereas the DSP approach also addresses
DSP interventions share several common characteris- communication, it has been more focused on increasing
tics. First, teaching follows theh child’s lead or interest. social interactions and general communication ability
Second, all communicative attempts including uncon- (i.e., both verbal and nonverbal behaviors) rather than
ventional (e.g., jargon, echolalia, hand leading, nonver- specific language forms (Fey, 1986).
bal protests) and preintentional communication (e.g., Second, in both approaches, the intervention is con-
reaching and grabbing, eye gaze, crying, facial expres- ducted within meaningful activities in the natural envi-
sions, body postures) are responded to as if they were ronment to the greatest extent possible. For young
purposeful (although, at times, the intervention provider children with ASD, meaningful activities typically
may wait for a more complex response). Third, emo- involve play and daily routines. Both approaches also
tional expressions and affect sharing are emphasized by teach parents to be the primary intervention providers
the adult. Fourth, language and social input are adjusted (e.g., Laski, Charlop, & Schreibman, 1988; Mahoney &
to facilitate communicative growth (Prizant et al., Perales, 2003), although DSP interventions are more
2000). likely to be exclusively parent-implemented than are
naturalistic behavioral interventions. Despite the fact
Similarities Between Approaches that both approaches advocate teaching parents to pro-
vide some or all of the treatment, they differ in their
Despite differences in underlying philosophies, there philosophical reasons for doing so. DSP approaches con-
are a number of similarities between naturalistic behav- sider the parent–child relationship to be the primary
ioral and DSP approaches in terms of their implementa- environment in which social communication develops
tion. First, both approaches are focused primarily on (Mahoney et al., 1985), whereas the naturalistic behav-
increasing social-communication skills. The naturalistic ioral approach has moved toward including parents in
behavioral approach has traditionally been used to teach the intervention process as a method for increasing gen-
specific verbal language targets, such as vocabulary and eralization (Stokes & Baer, 1977).
language structures (Kaiser et al., 1992), although more A third similarity between the two approaches is that
recently studies have focused on teaching nonverbal the teaching episodes are initiated by the child based on

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36   Journal of Positive Behavior Interventions

the child’s interest. This is referred to as following the a defined component of all naturalistic behavioral inter-
child’s lead in both approaches. Given the focus on ventions. The use of direct elicitation of specific child
child-initiated teaching episodes, teaching materials and behaviors stems from the belief that novel behavior is
activities are selected by the child. Both approaches also learned via reinforcement and, thus, must occur in order to
use environmental arrangement to elicit initiations from contact the reinforcer. The goal of the use of prompt strat-
the child. In the naturalistic behavioral approach, these egies is to elicit specific target behaviors that can then be
strategies are referred to as environmental arrangement reinforced to promote social communication develop-
(Kaiser, Ostrosky, & Alpert, 1992), controlling access, or ment. The naturalistic behavioral approach uses a variety
motivating operations (Koenig & Gerenser, 2006) and of prompt strategies to elicit desired behaviors including
are used to ensure that the child is motivated by the physical guidance, model, mand model, interrupted behav-
material prior to presenting a prompt for a specific ior chains, and time delay (Mirenda & Iacono, 1988).
response. In the DSP approach, these strategies are The use of direct prompting is not a defined compo-
referred to as communicative temptations (Paul, 2001)— nent of DSP interventions and, in some ways, is consid-
although this term is sometimes used by some naturalis- ered antithetical to DSP philosophy. Some proponents of
tic behavioral approaches as well—or playful obstruction a DSP perspective consider prompting a hindrance to the
(Greenspan & Wieder, 1998) and are used to encourage development of balanced social interactions by placing
the child to initiate or respond to the adult in some way. the child in a learning role and the partner in a teaching
Unlike the naturalistic behavioral approach, the DSP role (Trent, Kaiser, & Wolery, 2005). In addition,
approach does not typically prompt a more complex prompting is considered a more directive approach and,
response after the child’s initiation, as is discussed thus, is incompatible with adult responsiveness (Mahoney
below. & MacDonald, 2007). However, several DSP approaches
A final similarity between approaches is the use of advocate the use of scaffolding, which involves teaching
natural reinforcement. Both naturalistic behavioral and the child a new skill by providing hints or clues for prob-
DSP approaches teach within the natural environment lem solving that help the child achieve an outcome that
and, thus, the reinforcement for the child’s communica- is beyond his or her current ability (Wood, Bruner, &
tion is natural to the interaction. For example, if the child Ross, 1976), and wait time, which involves waiting with
and adult are playing with bubbles, the adult might blow an expectant look for the child to increase the complexity
bubbles and wait for the child to respond. If the child of his response before responding (e.g., Manolson,
looks at the adult and says “buh,” the adult would rein- 1992). Both of these concepts can be viewed as prompts
force the child’s behavior by blowing more bubbles for a response from a behavioral perspective. Thus,
(natural reinforcement). Both approaches also employ many individuals using a DSP approach may, in fact, be
loose reinforcement contingencies. The naturalistic using direct prompting. However, the rate of prompts is
behavioral approach uses loose shaping (Delprato, 2001) significantly lower in DSP approaches.
and reinforces goal-directed attempts to respond cor- The second significant difference between the two
rectly (Koegel et al., 1987) to reinforce trying and to approaches is the use of facilitative strategies in DSP
keep the child’s motivation high while teaching novel interventions. These strategies are drawn from the typi-
behaviors (Koegel, O’Dell, & Dunlap, 1988). The DSP cal developmental literature and are associated with a
approach responds to all communicative attempts, includ- responsive interaction style of care giving. As mentioned
ing unconventional and preintentional communication, previously, caregiver responsiveness is associated with
as if they were purposeful, and it may reinforce any com- accelerated language and social development in typical
municative act within an interaction (Prizant et al., children. The goal of the facilitative strategies is to
2000). Thus, the DSP approach shapes skills even more increase the adult’s responsiveness to the child’s behav-
loosely and is more inclined to reinforce unconventional ior, which should, in turn, promote social communica-
communication behaviors than the naturalistic behav- tion development. There are a variety of facilitative
ioral approach. strategies used to encourage adult responsiveness includ-
ing contingent imitation of the child’s verbal and nonver-
bal behavior, indirect language stimulation (modeling
Differences Between Approaches simplified language around the child’s focus of attention
and expanding on the child’s language behaviors), bal-
In practice, naturalistic behavioral and DSP approaches anced turns, a focus on emotional exchanges, and height-
differ in two significant ways. First, direct prompting is ened animation (e.g., Prizant et al., 2000).

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 Ingersoll / Comparison of Behavioral and Developmental Approaches   37  

Although the use of facilitative strategies is not a (Mahoney & Perales, 2003). There is also empirical evi-
defined component of the naturalistic behavioral dence that a commonly used developmental strategy,
approach, one or more of these strategies may be used a contingent imitation, is effective for increasing eye con-
way of building rapport with the child (McLaughlin & tact (Tiegerman & Primavera, 1984), positive affect
Carr, 2005). Thus, whereas the naturalistic behavioral (Harris, Handleman, & Fong, 1987), coordinated joint
approach does not consider facilitative strategies to be an attention (Ingersoll & Schreibman, 2006; Lewy &
active treatment component, many individuals using a Dawson, 1992), and number of play schemes (Dawson &
naturalistic behavioral approach employ these strategies Galpert, 1990; Tiegerman & Primavera, 1981). However,
within their intervention sessions to keep the child’s the evidence base for the DSP approach is clearly less
motivation high, although at a significantly lower rate developed than for the naturalistic behavioral approach.
than do individuals using a DSP approach. In summary, the main differences between the natural-
One final difference between the two approaches is istic behavioral and DSP approaches are their underlying
the use of different research methodologies to assess the philosophies and their research base and tradition, rather
effectiveness of their interventions. Given its foundation than the specific intervention techniques employed. The
in applied behavior analysis, the naturalistic behavioral most significant differences in the defined techniques
approach places a strong emphasis on data collection and employed in each approach, the use of prompting and
has been evaluated primarily with single-subject design facilitative strategies, are a direct result of their differing
methodology. Treatment effects are usually based on underlying philosophies; however, in practice, therapists
changes in rates of specific behavioral targets (e.g., sin- from both perspectives often incorporate strategies from
gle words, object imitation, pretend play acts) during the other approach to improve child response.
short-term intervention periods (e.g., several months). A
growing number of single-subject design studies have
consistently found naturalistic behavioral interventions Barriers to Cross-Fertilization
to be successful for teaching language (e.g., Gillett &
LeBlanc, 2007; Laski et al., 1988) and other social- Given their similarities in implementation, there are a
communication skills, including play (Stahmer, 1995; number of potential areas for cross-fertilization that
Thorp, Stahmer, & Schreibman, 1995), peer interaction could improve the ability of both naturalistic behavioral
(McGee, Almeida, Sulzer-Azaroff, & Feldman, 1992; and DSP interventions to promote social-communication
Pierce & Schreibman, 1995), imitation (Ingersoll & development in children with ASD. However, a lack of
Schreibman, 2006; Ingersoll et al., 2007), and joint familiarity with each other’s literature seems to have
attention (Rocha, Schreibman, & Stahmer, 2007; Whalen limited the necessary dialogue. For example, advocates
& Schreibman, 2003) in children with ASD. of the DSP approach criticize applied behavior analysis
In contrast, the efficacy of DSP interventions for chil- for a failure to address specific deficits associated with
dren with ASD has been examined primarily using nonex- autism and a focus on isolated behaviors, which could
perimental designs (e.g., Greenspan & Wieder, 1997; lead to difficulty with generalization and maintenance
Mahoney & Perales, 2003, 2005; Rogers & Lewis, 1989; (Rogers & Lewis, 1989; Tsakiris, 2000). These criticisms
Solomon, Necheles, Ferch, & Bruckman, 2007; Wetherby may be valid in relation to very early behavioral inter-
& Woods, 2006), although several controlled studies of ventions used with children with autism. However, since
DSP intervention have recently been published (Aldred, that time the field has developed technology to enhance
Green, & Adams, 2004; Hwang & Hughes, 2000; Ingersoll, generalization and maintenance (Stokes & Baer, 1977)
Dvortcsak, Whalen, & Sikora, 2005; McConachie, Randle, and has begun to focus on improving autism-specific
Hammal, & Le Couteur, 2005). Most DSP intervention deficits, such as joint attention (Schreibman & Ingersoll,
studies have measured gains in broad areas of social- 2005). Thus, these criticisms reflect a lack of familiarity
communicative functioning using structured observations with contemporary behavioral interventions, including
or standardized assessments during intervention periods naturalistic behavioral approaches. Advocates of the
of up to a year or more. These studies have found improve- behavioral approach have discounted the DSP approach
ments in developmental skills in excess of what would for its lack of empirical support (e.g., Metz, Mulick, &
be predicted by the children’s pretreatment functioning Butter, 2005; Simpson, 2005; T. Smith, 1996). Similarly,
level (e.g., Mahoney & Perales, 2005; Rogers & Lewis, although there has historically been limited empirical
1989) and an association between improvements in child study of developmentally oriented interventions, there
functioning and increases in parent responsiveness is a growing body of literature that indicates DSP

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38   Journal of Positive Behavior Interventions

techniques are effective for teaching social communication such as heightened affect, which are defined components
in young children with developmental disabilities includ- of DSP interventions. Similarly, DSP providers are often
ing ASD (e.g., Aldred et al., 2004; Ingersoll et al., 2005; very contingent about when they reward behaviors,
Mahoney & Perales, 2003; McConachie et al., 2005; working toward increasing the child’s complexity. But
Rogers & Lewis, 1989; Wetherby & Woods, 2006). DSP interventions do define that aspect of the interven-
Therefore, the first step in developing a dialogue is for tion. Thus, additional similarities in the implementation
both disciplines to familiarize themselves with each of the two approaches are likely masked by a failure of
other’s literature. To this end, graduate and professional both approaches to define some often-used strategies as
programs that prepare professionals to work with indi- part of their interventions. If these aspects of the inter-
viduals with autism (e.g., special education, psychology, ventions were defined, it would be easier for researchers
speech pathology) should consider offering interdisci- to look more closely at similarities and differences.
plinary courses that cover both the behavioral and devel-
opmental literatures as they relate to autism interventions.
Another possibility would be to accept (or recommend) Future Research Directions
instruction on child development as continuing educa-
tion for the board-certified behavior or associate behav- There are several research directions that have the
ior analyst credential. Similarly, instruction in behavioral potential to improve the knowledge base of both
principles could be included in the recommended con- approaches as well as the effectiveness of their interven-
tinuing education requirements of professional organiza- tion strategies. First, research should examine the bene-
tions whose members are likely to have a strong fits of teaching skills within a developmental framework.
background in the developmental but not necessarily Research on early social communication development in
behavioral literature, such as the American Speech- autism suggests that in most areas children with autism
Language-Hearing Association. Furthermore, members exhibit delayed rather than deviant skills, and their
of each discipline should make efforts to present their developmental trajectories follow similar yet signifi-
research in outlets that are interdisciplinary in nature. cantly slower patterns (Morgan, Cutrer, Coplin, &
Another barrier to collaboration between disciplines Rodrigue, 1989; Snow, Hertzig, & Shapiro, 1987). In
is the use of highly specialized terminology in each dis- addition, research examining the effectiveness of teach-
cipline, which may mask underlying similarities between ing play skills found that children with autism were able
interventions (Koenig & Gerenser, 2006). For example, to learn play acts that were appropriate for their develop-
behavior analysts refer to prompting and developmental- mental age significantly faster than play acts that were
ists refer to scaffolding, when, in fact, the two terms can appropriate for their chronological age (Lifter, Sulzer-
refer to the same behavior on the part of the therapist. To Azaroff, Anderson, & Cowdery, 1993). These findings
decrease confusion and promote collaboration, both dis- suggest that using typical development to guide the
ciplines should examine the degree to which their own selection of teaching targets may be more important that
terminology captures concepts present in the other’s lit- behavior analysts have previously acknowledged
erature. To the extent that they overlap, each discipline (Anderson & Romanczyk, 1999).
should make a concerted effort to describe their interven- Furthermore, in the past two decades, the develop-
tion techniques in language that is accessible to the other mental literature has highlighted a number of early
discipline and to develop a common language where social-communication behaviors that are linked to the
appropriate. In light of this recommendation, further development of more advanced social and cognitive
discussions will refer to naturalistic behavioral and DSP skills in typical children, including joint attention (e.g.,
approaches in terms of their unique intervention strate- Bates, Benigni, Bretherton, Camaioni, & Volterra, 1979),
gies, prompting and facilitation, rather than as separate gesture use (e.g., Özçalişkan & Goldin-Meadow, 2005),
interventions. symbolic play (e.g., Shore, O’Connell, & Bates, 1984),
A related issue is that intervention providers in each and imitation (e.g., Uzgiris, 1981). These behaviors are
discipline often use strategies that are not defined com- found to be deficient in children with ASD (e.g.,
ponents of the intervention they are using to enhance Charman & Stone, 2006). Several recent findings indi-
child response. For example, behavior analysts often talk cate that teaching early social-communication skills can
about being fun as “good teaching,” but they do not lead to increased development of later emerging behav-
define “being fun” as an active intervention component. iors in ASD. For example, Whalen, Schreibman, and
It is likely that being fun involves facilitative strategies, Ingersoll (2006) found that teaching young children with

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 Ingersoll / Comparison of Behavioral and Developmental Approaches   39  

ASD to make joint attention initiations using a naturalis- ends, single-subject designs, often used in the naturalistic
tic behavioral intervention led to increases in language, behavioral literature, may provide a particularly useful
play, and imitation despite the fact that these behaviors research strategy.
were not directly targeted. Similarly, Ingersoll and Third, the majority of the studies of DSP approaches
Schreibman (2006) found increases in language, play, have focused on the effect of teaching parents facilitative
and joint attention after targeting reciprocal object imita- strategies to increase their responsiveness to their child.
tion using a naturalistic behavioral intervention. These studies have shown that increases in parents’ use
Furthermore, Kasari and colleagues (Kasari, Paparella, of facilitative strategies are associated with improvement
Freeman, & Jahromi, 2008) found that children with in children’s social-communication skills. Research is
autism who received focused training in either joint beginning to emerge that indicates the use of facilitative
attention or symbolic play had greater gains in expres- strategies by professionals can also be effective for pro-
sive language 12 months postintervention than did chil- moting social-communication skills in young children
dren in a control group. These findings may suggest that with ASD (Ingersoll et al., 2005) and other developmen-
teaching skills within a developmental framework, tal disorders (Yoder & Warren, 2001). However, addi-
regardless of the teaching technique (behavioral or tional research is needed to determine whether the use of
developmental), may lead to wider ranging improvement a purely facilitative approach is effective as a therapist-
in social communication. implemented procedure. One might argue that the use of
Second, while the DSP approach is promising, it is facilitative strategies, particularly indirect language
necessary to examine the degree to which a purely stimulation, might be most effective when used through-
facilitative approach is effective for increasing social- out a child’s day by the child’s caregivers rather than
communication skills in children with ASD using exper- during focused periods of time, such as therapy sessions.
imental designs. To date, most of the research using However, additional research is needed before conclud-
these intervention strategies has been conducted with ing that facilitative strategies should be used primarily as
children with language and/or general developmental a parent-implemented intervention.
delay (e.g., Girolametto, Pearce, & Weitzman, 1996; Fourth, research should determine whether some
Kaiser et al., 1996). Although there is an increasing num- social-communication skills are best taught using direct
ber of studies examining the use of DSP approaches with prompting and others are better taught using facilitative
children with autism, the majority of these studies are strategies. It might be expected that direct-prompting
nonexperimental (e.g., Greenspan & Wieder, 1997; strategies are more effective at increasing specific social-
Mahoney & Perales, 2003, 2005; Rogers & Lewis, 1989; communication skills, whereas facilitative techniques
Solomon et al., 2007; Wetherby & Woods, 2006) and are more effective at improving general social respon-
cannot rule out the possibility that child gains are due to siveness. Also, some researchers have proposed that
maturation or some other confound. Given that children certain facilitative strategies (indirect language stimula-
with ASD tend to have specific difficulties with social tion) primarily teach initiation and commenting skills,
engagement, it is possible that they might particularly whereas prompting strategies primarily teach responding
benefit from facilitative techniques. Conversely, it is and requesting skills (Salmon, Rowan, & Mitchell,
possible that, because they also tend to have difficulty 1998). For example, Salmon et al. (1998) used an alter-
with initiations, they may be less likely to respond to a nating-treatments design to compare the effectiveness of
purely responsive approach than are children with other direct prompting to facilitative techniques in three pre-
disabilities (Fey, 1986). A number of randomized control verbal children with developmental delays. The results
trials aimed at examining the effectiveness of the DSP indicated that the children used a greater proportion of
approach with children with ASD are currently under- responses than initiations and requests than comments in
way (e.g., Autism Speaks, n.d.) that should be able to the direct-prompting condition, whereas their proportion
answer this question. of responses to initiations and requests to comments was
In addition, as is the case with many comprehensive more balanced in the facilitative condition. In a partial
interventions, it is unknown which specific facilitative replication of this study with two preschoolers with
strategies are necessary to produce changes. Research ASD, Ingersoll (2008) found that although direct prompt-
that can conduct direct comparisons between individual ing led to higher rates of total and prompted language,
treatment techniques (e.g., indirect language stimulation facilitation led to higher rates of comments.
vs. contingent imitation) would help determine whether Fifth, research should examine whether direct prompt-
certain facilitative strategies are more effective than oth- ing or facilitative strategies are more effective depending
ers are for promoting social communication. To these on the child’s pretreatment characteristics. There is some

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40   Journal of Positive Behavior Interventions

research to suggest that in children with developmental possibility that prompting and facilitation teach different
delays the effectiveness of prompting and facilitation skills, a combined approach may be able to address a
varies depending on the pretreatment language age of the wider range of child behavior. Furthermore, it is possible
child. For example, Yoder, Kaiser, and Goldstein (1995) that facilitative strategies increase the child’s general
found that children at lower language levels (expressive responsiveness to intervention, making him or her more
language age <2 years) responded better to an interven- receptive to prompting techniques. Several interventions
tion that used direct prompting (milieu teaching), and have combined approaches based on this premise, par-
children with higher language levels (expressive lan- ticularly Enhanced Milieu Teaching (Kaiser & Hester,
guage age >2.5 years) responded better to an interven- 1994), Responsivity Training and Prelinguistic Milieu
tion that used facilitation (responsive interaction). Teaching (Yoder & Warren, 2002), the parent-mediated
Research that can further compare the effectiveness of approach described by Ingersoll and Dvortcsak (2006),
prompting and facilitative techniques for children with and Roger and Dawson’s Early Start Denver Model
varying behavioral profiles will likely provide a better (M. Smith, Rogers, & Dawson, in press). Whereas studies
understanding of which techniques produce the best out- have demonstrated that these combined interventions are
comes for which children. effective for teaching social-communication skills to chil-
Sixth, research should evaluate whether the use of dren with ASD (Hancock & Kaiser, 2002; Kaiser,
prompting or facilitation is more effective based on fam- Hancock, & Nietfeld, 2000) and other developmental
ily characteristics. Previous research with children with delays (Kaiser & Hester, 1994), the combined approach
developmental delays suggests that the parent character- has not been directly compared to either naturalistic
istics can have a moderating effect on the child’s behavioral or DSP approaches implemented in isolation.
response to specific intervention strategies. For example,
Yoder and Warren (2001) found that children whose
mothers were initially more responsive and had more Conclusion
formal education made more progress in a therapist-
implemented intervention that used direct prompting In summary, despite the fact that their theoretical
(prelinguistic milieu teaching), whereas children whose foundations differ considerably, both naturalistic behav-
mothers were less responsive and had less education ioral and DSP approaches share many commonalities
made more gains in a therapist-implemented interven- that make their interventions quite similar in practice.
tion that used adult facilitative techniques (responsive There are several areas in which the two interventions
interaction). The authors hypothesized that mothers who differ, including the most common focus of intervention
were initially more responsive responded more effec- targets, the degree of acceptance of communicative
tively to the emerging communication behaviors that behaviors, and most substantially the use of prompting
their children learned to use via prelinguistic milieu and facilitative strategies. Despite these differences,
teaching. This led the authors to propose adding respon- intervention providers often use techniques that are not
siveness training to parent-implemented prelinguistic defined as part of the approach they are using.
milieu teaching to teach parents to respond to their There are a number of potential areas for cross-
child’s communication, thus facilitating additional com- fertilization between the two approaches. Increasing
munication growth. familiarity with each other’s literature and developing a
A related question is whether one strategy is more common language between approaches, where appropri-
likely to be adopted by parents than the other. Preference ate, would facilitate collaboration between disciplines
for naturalistic behavioral or DSP approaches may be and promote research on individual treatment techniques
due to a preference for the underlying treatment philoso- rather than the comprehensive treatment models. This
phy, it may be related to the techniques themselves, or should lead to more fine-grained examination of effec-
both. It would also be important to determine whether, tive intervention strategies, including which intervention
regardless of preference, parents are able to learn to techniques are most effective for teaching specific
implement prompting or facilitative strategies with a social-communication skills, which children are most
higher degree of fidelity. It is likely that preference for likely to respond to a more directive versus a more
and ability to use an intervention would be related to facilitative approach, and how well parents learn the dif-
specific characteristics on the part of the parent. ferent intervention strategies and how likely they are to
Finally, research should examine whether combining use them. Furthermore, research could examine whether
prompting and facilitative strategies leads to more power- combining important elements of both approaches leads
ful interventions. It might be expected that, given the to better outcomes than either approach can provide on

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 Ingersoll / Comparison of Behavioral and Developmental Approaches   41  

its own. These steps will likely lead to the development Gillett, J. N., & LeBlanc, L. A. (2007). Parent-implemented natural
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