A Randomized Trial of Direct Instruction Language for Learning in Children With Autism Spectrum Disorder.

OBJECTIVE: To compare Direct Instruction Language for Learning (DI) plus treatment as usual (TAU) with TAU alone in children with autism spectrum disorder and moderate language delay. METHOD: In this study, 83 children (age range, 4 years to 7 years 11 months) were randomly assigned to DI+TAU (n = 42) or TAU (n = 41) for 6 months. Trained therapists delivered DI in twice-weekly, 90-minute sessions for 24 weeks. The primary outcome was the standard score on the age-appropriate version of the Clinical Evaluation of Language Fundamentals (CELF). The key secondary measure was the proportion of children rated by a clinician blinded to treatment as "much improved" or "very much improved" on the Clinical Global Impressions-Improvement (CGI-I) scale. RESULTS: Attrition was 12%. At end point, DI+TAU participants showed a 4.8-point (8.1%) increase on CELF vs 2.3 points (4.1%) in TAU participants (difference = 2.55, p = .14, effect size = 0.25), rendering this a negative trial on the prespecified primary outcome. In post hoc analysis that adjusted for IQ, mean difference was 3.5 (p = .04, effect size = 0.33). On CGI-I, 54.8% (23/42) of DI+TAU participants were rated much improved or very much improved compared with 21.9% (9/41) of TAU participants (χ2 = 9.4, p = .002). On the clinically meaningful threshold of >5 points on CELF, 55.5% of DI+TAU participants achieved this benchmark vs 29.3% of TAU participants (χ2 = 3.6, p = .06). Complete CELF data were available for 72 participants. In the combined sample, baseline CELF scores ≤50 were associated with no improvement. CONCLUSION: On CELF, DI+TAU did not meet the prespecified difference from TAU. When adjusted for IQ, DI+TAU was superior to TAU on CELF at end point. DI+TAU was superior to TAU on CGI-I. CLINICAL TRIAL REGISTRATION INFORMATION: Direct Instruction Language for Learning in Autism Spectrum Disorder; https://clinicaltrials.gov/; NCT02483910.

Adventures in Direct Instruction Implementation: The Devil Is in the Details.

This article tells the story of how a public charter school serving students with autism spectrum disorder (ASD) adopted Direct Instruction (DI) as their primary form of instruction. The journey from recognizing the need for evidence-based curriculum focused on academic skills to integrating DI on a daily basis was outlined using a common implementation framework. We measured results of the implementation process on student outcomes using reading scores obtained from the Kaufman Test of Educational Achievement (KTEA-II Brief). Results for 67 students who participated in a DI reading program for at least 2 years suggest that the implementation of DI led to significantly improved reading scores; with some students demonstrating greatly accelerated rates of learning for their age. Our study suggests that the road to adoption of DI may be long, but the results are powerful for the individuals served. We offer our steps to implementation as a guide and resource to educators and behavior analysts eager to utilize DI in their settings.

A Systematic Review and Quality Appraisal of Applications of Direct Instruction with Children with Autism Spectrum Disorder.

Developed by Siegfried ("Zig") Engelmann and colleagues, direct instruction (DI) has been recognized as an effective and replicable teaching model for decades. Although rooted in many principles of learning that behavior analysts utilize in daily practice, DI is not a common a component of behavior analytic services for learners with autism spectrum disorder (ASD). This may be attributed to behavior analysts' unfamiliarity with research evaluating the efficacy of DI with learners with ASD. This article synthesizes findings across studies evaluating DI with learners with ASD. The review addresses the contributions of the studies to date and identifies additional areas of research that may lead to more learners with ASD benefitting from DI.

Feasibility and Preliminary Efficacy of Direct Instruction for Individuals With Autism Utilizing Speech-Generating Devices.

Direct instruction (DI) is an evidence-based approach to education that has been shown to be effective across a wide variety of student populations. Growing evidence suggests that DI may be an efficacious strategy for individuals with autism spectrum disorder (ASD). The current study aimed to evaluate the feasibility of using DI with students with ASD who utilize speech-generating devices (SGDs); 3 students with ASD whose primary mode of communication was an SGD were exposed to the Language for Learning Curriculum, Lessons 1-10. Student performance on pre- and posttests was measured, as well as student performance on exercises within each lesson. The average time to complete an exercise, number of repetitions, number of terminated sessions, and student affect were also evaluated. Results indicated that all 3 students could participate and complete exercises with some modifications to support SGD use. The students demonstrated improved performance, positive affect, and overall timely completion of exercises. Taken together, these findings suggest that DI may be feasible for some students with ASD who utilize SGDs.

Evaluation of a Treatment Package to Increase Mean Length of Utterances for Children with Autism.

Skinner's (1957) classification of mand responses has spawned decades of research related to teaching individuals with developmental disabilities. However, few studies have evaluated how to teach individuals with autism to progress from simple to more complex mands for desired items and activities. The present study used a treatment package consisting of errorless teaching, differential reinforcement, and systematic decision rules to increase the number of words per mand utterance used by 6 children with autism. Daily probes were conducted in the absence of prompting and differential reinforcement throughout every stage of the treatment. Results showed that all children showed significant developmental gains in the mean length of utterances. Increased rates of manding, increased emission of mand frames, and decreased instances of indicating responses (i.e., pointing, reaching) in the absence of mands were also observed. Implications regarding the feasibility of intensive mand training in practice are discussed.

Teaching children with autism to mand for social information.

We replicated Shillingsburg et al. (2018) by teaching children with autism to mand for social information while analyzing the variables influencing the emission of mands. We presented questions about a social partner that were known and observable (e.g., "What is Robin doing?"), known but unobservable (i.e., questions for which an intraverbal response had previously been taught, such as, "Where does Robin work?"), or unknown (e.g., "What is Robin's favorite food?"). Correct answers were reinforced across all conditions. During treatment, we prompted children to mand for information from the social partner following only unknown questions. All children acquired mands for social information and answered previously unknown questions correctly after manding for social information and 3 of 4 participants emitted mands to novel social partners, including a peer with autism.

Promoting the development of verbal responses using instructive feedback.

Shillingsburg, Frampton, Cleveland, and Cariveau (2018) taught listener and tact by feature, name-feature intraverbal, and feature-name intraverbal responses across sets and reported emergence of responses that were not directly trained for 6 individuals diagnosed with autism spectrum disorder (ASD). The current study was a systematic replication with the addition of instructive feedback (IF) with 2 children diagnosed with ASD. During trials for previously mastered listener by name responses (e.g., "Point to Tennessee" and child selects a picture of Tennessee), the experimenters provided related IF (e.g., "The capital of this state is Nashville"). After 3 sessions, we evaluated the effects of IF on related verbal responses (e.g., listener by feature, tact by feature, name-feature intraverbal, and feature-name intraverbal) across sets probes. We observed increased correct responses for related verbal responses; replicating Shillingsburg et al. Results suggest that the inclusion of IF may increase the efficiency of verbal behavior programming.

Teaching mands for information using speech generating devices: A replication and extension.

Approximately 30% of individuals diagnosed with autism spectrum disorder (ASD) fail to develop vocal communication and, therefore, use some form of augmentative or alternative communication system. The current study replicates and extends previous research on teaching "Who?" and "Which?" mands for information to 3 young children diagnosed with ASD using a speech generating device. Procedures were evaluated using a multiple baseline across participants design. All participants learned to mand for information and, subsequently, used the information to access preferred items.

Brief Report: Feasibility and Preliminary Efficacy of a Behavioral Intervention for Minimally Verbal Girls with Autism Spectrum Disorder.

We report the feasibility and preliminary efficacy of a structured behavioral intervention with a sample of minimally verbal girls with autism spectrum disorder between the ages of 2 and 6 years old. Ten participants with no functional vocal behavior were randomized to a 4-week behavioral intervention or waitlist control group. Caregivers reported child communicative repertoires at pre- and post-randomization assessments. Social communication was also assessed at these time points using the Early Social Communication Scales. All feasibility benchmarks were met and findings of preliminary efficacy showed large effect sizes within groups. The current findings suggest the feasibility of recruiting and retaining samples of young, minimally verbal girls with autism spectrum disorder in randomized clinical trials.

Rapport Building and Instructional Fading Prior to Discrete Trial Instruction: Moving From Child-Led Play to Intensive Teaching.

Discrete trial instruction (DTI) is effective for teaching skills to children with autism spectrum disorder (ASD). Although effective, instructional settings can become aversive resulting in avoidant and escape-related behaviors. Given the significant social impairments associated with ASD, interventions that promote social approach and reduce avoidance are warranted. Rapport building or "pairing" the therapist and teaching setting with highly preferred activities prior to instruction can reduce problematic behaviors during subsequent instruction. However, the path from child-led play to DTI is not well established. Instructional fading may assist in bridging this gap. Four participants with ASD who were beginning an intensive behavioral intervention program were included in the current study. Participants progressed through nine stages of pairing and instructional fading with minimal problem behavior and high percentages of in-seat and close proximity to the therapist. Guidelines for incorporating rapport building strategies prior to intensive teaching with children with ASD are proposed.

The Effects of the Interspersal of Related Responses on the Emergence of Intraverbals for Children With Autism Spectrum Disorder.

The present study evaluated the emergence of intraverbals for 2 children diagnosed with autism spectrum disorder. Prior to baseline, both children demonstrated tact, tact function, listener, and listener by function responses with 12 pictorial stimuli, yet they failed to demonstrate intraverbals related to the function of the items (e.g., "What do you do with [item]?" and "What do you use to [function]?"). Following baseline, previously mastered related tact, tact function, listener, and listener by function tasks were presented prior to probe trials for the target item-function and function-item intraverbals. Results showed that interspersal of the related tasks for a subset of the intraverbals led to the emergence of untrained item-function and function-item intraverbals for both participants. In Experiment 2, the long-term effects of this remedial training on the emergence of untrained intraverbals was evaluated as new tact and listener responses were trained. Results of Experiment 2 showed that tact function and listener by function training was sufficient to establish the emergence of item-function and function-item intraverbals in the absence of related-task interspersal. These results are discussed in relation to current explanations for emergent responding.

A Preliminary Procedure for Teaching Children with Autism to Mand for Social Information.

We used procedures established within the mands for information literature to teach two children with autism to mand for social information. Establishing operation trials were alternated with abolishing operation trials to verify the function of the responses as mands. Use of the acquired information was evaluated by examining responding to questions about their social partner. Both participants acquired mands for social information and showed generalization to novel social partners.

Increasing Functional Leisure Engagement for Children With Autism Using Backward Chaining.

Research with individuals with disabilities has demonstrated the utility of intervention approaches to address toy play, also referred to as functional leisure engagement (FLE). Examples include prompting FLE, blocking stereotypy, and differentially reinforcing appropriate FLE with social or automatic (i.e., access to stereotypy) reinforcers. Backward chaining has yet to be evaluated, but may be useful for establishing more complex FLE. The current study employed a treatment package consisting of these components with three school-aged children with autism in a therapeutic classroom. Effects were evaluated during pretest and posttest sessions, which consisted of free access to toys in a novel setting. The percentage of session with FLE was evaluated using a multiple probe design across participants. Results showed all participants demonstrated an increase in FLE and two participants showed decreased stereotypy. Feasibility for classroom implementation is discussed.

Teaching Problem Explanations Using Instructive Feedback.

Instructive feedback (IF) is a procedure in which extra information is presented to a participant during the consequence portion of instruction for other skills. Previous research has demonstrated that participants with intellectual disabilities may acquire a portion of non-targeted skills (secondary targets) without explicit instruction when extra information is presented. Previous research has demonstrated that IF has resulted in more efficient instruction for participants with disabilities as a whole. However, few studies have focused on participants with autism spectrum disorders (ASDs). Additionally, the measures of secondary target acquisition in past research have focused solely on discrete responses (e.g., one-word utterances). The current investigation extended the IF literature related to participants with ASD by including longer verbal responses as secondary targets and assessing maintenance for both primary and secondary targets. Across three participants, IF resulted in the acquisition of at least a portion of secondary targets without explicit teaching. For two participants, additional instruction was required before IF resulted in acquisition of secondary targets. Across all three participants, gains observed for both primary and secondary targets in intervention were maintained.

Using Textual Prompts to Teach Mands for Information Using "Who?".

Recent research on teaching mands for information to children with language deficits has focused on manipulating establishing operations (EOs). However, only a few of those studies have programmed both EO conditions (in which information is needed) and abolishing operation (AO) conditions (in which information has already been provided) to ensure functional use of the mand for information. Shillingsburg, Bowen, Valentino, and Pierce (Journal of Applied Behavior Analysis, 47, 136-150, 2014) provided a successful demonstration of differential responding between EO and AO conditions demonstrating control of the response by the relevant EO. Echoic prompts resulted in successful mands for information "Who?" One limitation of this study was that the participants did not re-issue the initial mand upon approaching the named adult to retrieve the item. This may be problematic in the natural environment as it is unlikely that the named adult would know what the child was looking for. The current study sought to replicate and expand previous research by using textual prompts to teach the mand "Who?" in four children diagnosed with autism (Phase 1) and by requiring the mand for the item be re-issued upon approaching the named adult (Phase 2). Textual prompts resulted in differential use of the mand for information during EO and AO conditions for all of the participants. Additionally, three of the four participants who did not re-issue the mand to the named adult during the Phase 2 baseline did so following the intervention. Overall, results support the use of textual prompts to teach mands for information to children with autism.

The use of matrix training to promote generative language with children with autism.

Matrix training consists of planning instruction by arranging components of desired skills across 2 axes. After training with diagonal targets that each combine 2 unique skill components, responses to nondiagonal targets, consisting of novel combinations of the components, may emerge. A multiple-probe design across participants was used to evaluate matrix training with known nouns (e.g., cat) and verbs (e.g., jumping) with 5 children with autism spectrum disorders (ASD). Following baseline of Matrix 1 and a generalization matrix, diagonal targets within Matrix 1 were trained as noun-verb combinations (e.g., cat jumping). Posttests showed recombinative generalization within Matrix 1 and the generalization matrix for 4 participants. For 1 participant, diagonal training across multiple matrices was provided until correct responding was observed in the generalization matrix. Results support the use of matrix training to promote untrained responses for learners with ASD and offer a systematic way to evaluate the extent of generalization within and across matrices.

Stability of daily preference across multiple individuals.

Preference stability provides clues about the extent to which a clinician might be able to deliver a particular stimulus contingent on behavior as a reinforcer. Previous research has been somewhat mixed in terms of evidence for preference stability. Results of the current study are consistent with studies that have reported correlations between preference assessments, suggesting that preferences are relatively stable across time.

Stimulus-Stimulus Pairing to Increase Vocalizations in Children with Language Delays: a Review.

Stimulus-stimulus pairing (SSP) is a procedure used to increase vocalizations in children with significant language delays. However, results from studies that have examined the effectiveness of SSP have been discrepant. The following review of the literature summarizes the results from 13 experiments published between 1996 and 2014 that used this procedure with children with language delays. Studies were analyzed across various participant and procedural variables, and an effect size estimate (nonoverlap of all pairs) was calculated for a portion of the participants in the studies reviewed. Results indicated an overall moderate intervention effect for SSP of speech sounds. Recommendations are provided for future researchers about information to report and potential avenues for future studies.

Evaluation of the efficiency of listener and tact instruction for children with autism.

Recent literature reviews have highlighted the need to better understand the relation between speaker and listener behavior when teaching learners with autism spectrum disorders (ASD). The current study used a modified parallel-treatments design to compare directly the degree to which tact and listener behavior emerged during instruction in the opposite relation for 4 children with ASD. Results showed tact training to be either equally or more efficient than listener training for all participants. However, varied patterns of emergent responding across participants indicate a need for further research. Data on collateral responding during instruction did not suggest that the presence or absence of overt collateral behaviors were predictive of emergence. The results highlight the importance for clinicians and educators to assess emergent tact and listener repertoires periodically.

Mands for information using "who?" and "which?" in the presence of establishing and abolishing operations.

Treatments designed to teach mands for information have included prompting and differential reinforcement, as well as procedures to manipulate the relevant establishing operation (EO). However, previous studies have not included relevant abolishing operation (AO) conditions to ensure that the mand is under relevant antecedent control. Data on listener responses (i.e., use of the information) are also absent in the literature. The current study shows differential responding under EO and AO conditions and reports listener responses that demonstrate use of the provided information. Three participants, diagnosed with an autism spectrum disorder, learned to mand for information using "who?" and "which?" questions exclusively under EO conditions. In addition, each participant responded to the information provided to access a preferred item. Generalization of the "which?" mand for information was also demonstrated across novel stimuli.