Behavioral Treatment of Autistic Persons

Pergamon Research in Developmental Disabilities, Vol. 17, No. 6, pp. 433-465, 1996

Copyright 1996 Elsevier Science Ltd Printed in the USA. All rights reserved

0891-4222/96 $15.00 + .00

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Behavioral Treatment of Autistic Persons" A Review of Research From 1980 to

the Present

Johnny L. Matson

Louisiana State University

Debra A. Benavidez

Baylor College of Medicine

Lesley Stabinsky Compton

University of Denver

Theodosia Paclawskyj and Chris Baglio

Louisiana State University

Studies evaluating behavioral treatment of autism from 1980 to the present were reviewed. Studies included were published in journal articles and utilized behavioral methodology. A total of 251 studies were included in the review. Each study was analyzed for target behaviors and behavioral techniques implemented. Target behaviors were divided into categories, which included aberrant behaviors, social skills, language, daily living skills, and academic skills. Behavioral techniques were classified as positive, negative, extinction, or combined. Results were presented for each category. Recent trends in the treatment literature were alsoreviewed, andrecommendationsforfumreresearchwerepresented. Copyright 1996 Elsevier Science Ltd

Requests for reprints should be sent to Johnny L. Matson, Department of Psychology, Louisiana State University, Baton Rouge, LA 70803.

433

434 J. L Matson et al.

The syndrome of autism has been the object of much research interest since Kanner published a description of early infantile autism in 1943. Subsequent research on the etiology and treatment of autism were based primarily on psy- choanalytic theory, which was prevalent during the 1O40s and 1950s. According to psychodynamic theories of etiology, the autistic child's parents were respon- sible for the disorder. Parents were described as cold and emotionally reserved, and the autistic child was merely reacting to the parents' behavior by with- drawing into his/her own world. Bettelheim (1967) pioneered psychodynamic treatment techniques. Psychodynamic treatment focused on creating a non- threatening environment for the child and encouraging the child to express feelings and actions. In response to this approach, researchers conducting empirical studies evaluating the efficacy of psychodynamic treatment concluded that these techniques are not effective with autistic children (National Institute of Mental Health, 1975).

In the 1960s, as learning theory became more prominent, researchers began developing treatment techniques based on the principles of operant learning theory. Over 100 behavioral treatment studies had appeared in the literature by 1970 (DeMyer, Hingtgen, & Jackson, 1981). Ferster (1961) hypothesized that the behavioral excesses and deficits observed in autistic children were operant and therefore controlled by environmental consequences, including reinforcement, punishment, and extinction. In order to change the behavior of these children, it was necessary to modify these environmental consequences. Subsequent researchers published studies in which operant techniques were used to modify behaviors of autistic children. With regard to language, researchers began using behavioral techniques to increase speech. For example, Lovaas, Berberich, Perloff, and Schaeffer (1966) successfully shaped autistic children's vocalizations by reinforcing the children's responses when they approximated verbalizations by the therapist. Researchers also taught autistic subjects more complex language skills, including semantics and syntax (Risley & Wolf, 1967). The aberrant behaviors often displayed by autistic children were addressed during the 1960s. Lovaas and Simmons (1969) treated self-injurious behavior through the use of extinction, in which they ignored the behavior when it occurred, producing gradual decreases. These researchers also administered electric shock contingent on self-injurious behavior and produced a rapid decrease in the behavior. Researchers have also developed treatment strategies for stereotypy. Mulhern and Baumeister (1969) utilized differential reinforcement to treat targeted stereotyped behaviors, by reinforcing subjects when they were not engaging in target behaviors. Lovaas, Schaeffer, and Simmons (1965) and Risley (1968) implemented contingent electric shock, producing rapid decreases in stereotypy.

During the 1970s the amount of research on behavioral treatment of autism continued to increase as researchers addressed more target behaviors and developed increasingly sophisticated behavioral techniques. Over 200 studies were published from 1970 to 1980 (DeMyer, Hingtgen, & Jackson, 1981). In the area of language, reinforcement-based methods were utilized to teach abstract con-

Behavioral Treatment of Autism 435

cepts, such as prepositions, pronouns, time, yes/no, and same/different 0_.,ovaas, 1977). Researchers also decreased echolalia by teaching appropriate verbal responses (e.g., Carr, Schreibman & Lovaas, 1975; Freeman, Ritvo, & Miller, 1975; Schreibman & Carr, 1978). Researchers also addressed social skills diffi- culties in autistic children. Studies focused on increasing social initiations and responses (Ragland, Kerr, & Strain, 1978; Strain, Kerr, & Ragland, 1979). Academic interventions were also developed, as researchers sought to decrease stimulus overselectivity by teaching autistic children to respond to multiple stimulus cues (e.g., Koegel & Schreibman, 1977). With regard to aberrant behaviors, researchers continued to examine the use of extinction (Carr, Newsom, & Binkoff, 1976) and differential reinforcement (Favell, McGirnsey, & Jones, 1978) for decreasing self-injurious behavior. Researchers also evaluated aversive procedures for self-injurious behavior, focusing on those that were increasingly less intrusive. Tanner and Zeiler (1975) successfully used aromatic ammonia to decrease self-injurious behavior, and Azrin, Gottlieb, Hughart, Wesolowski, and Rahn (1975) implemented an overcorrection procedure. Treatment strategies were also developed for stereotypy. Researchers evaluated positive procedures, including differential reinforcement (Dietz & Repp, 1973; Herendeen, Jeffrey, & Graham, 1974) and sensory extinction, in which reinforcement through sensory feedback from the stereotyped behavior was pre- vented (Rincover, 1978). Aversive procedures for stereotypy have included restraint contingent on emission of the targeted stereotyped behavior (Koegel, Firestone, Kramme, & Dunlap, 1974) and positive practice overcorrection (Foxx & Azrin, 1973; Epstein, Doke, Sajwaj, Sorell, & Rimmer, 1974).

From 1980 to the present, the area of behavioral treatment research has continued to expand, addressing a multitude of target behaviors. Comprehensive reviews of treatment studies of autism during the 1960s (Hingtgen & Bryson, 1972) and 1970s (DeMyer et al., 1981) have been published. However, there is a need for review and evaluation of the behavioral treatment research since 1980. The purpose of the present study was to evaluate behavioral treatments of the excesses and deficits characterizing autism from 1980 to 1995. Behavioral treatment studies published in psychological, psychiatric, and educational jour- nals were evaluated. Target behaviors and behavioral techniques were evaluated in each study. Using this approach, it was intended to determine how the treatment of autistic individuals has progressed, in terms of type and complexity of target behaviors and behavioral techniques.

METHOD

Procedure

Studies included in this review were published in scientific journal articles and were implemented using single-case methodology. Articles were located through hand and computer searches using Psychological Abstracts and cross-checking

436 J. L. Matson et al.

references. A total of 251 studies were included in this review. The studies were reviewed by the second and third authors, Ph.D. students in clinical psychology, with master's degrees. Rules governing the collapsing of data across variables were adapted from Matson and Taras (1989): (a) if several experiments were described in a study, each experiment was classified separately; (b) when the effectiveness of two or more treatments were compared, the study was classified based on the most effective treatment; (c) if different treatments were used for different problem behaviors, the study would be classified more than once. The text of each study was examined for the following variables:

Category of Target Behaviors. Target behaviors were divided into five categories, including aberrant behaviors, social skills, language, daily living skills, and academic skills. Operational def'mitions of each category are presented in the Results and Discussion section.

Target Behaviors. Target behaviors explicitly described by the authors were included and classified under one of the five behavior categories. For studies addressing target behaviors in more than one category, it was possible to classify the study more than once (e.g., a study targeting an aberrant behavior and a language-related behavior may be classified under both categories).

Behavioral Techniques. Techniques explicitly described by the authors were included. For this analysis, they were categorized as positive, aversive, combined, or extinction. Positive procedures consist of those in which nonaversive methods were used. Aversive procedures refer to those in which punishment was administered to subjects contingent upon emission of the target behavior. Extinction refers to procedures in which reinforcement for the emission of the target behavior was withdrawn. Combined procedures involve the application of a combination of two or more of the previously described methods.

Raters and Reliability

Reliability for number of studies obtained was established by having a Ph.D. student in clinical psychology with a master's degree conduct a search of studies for 2 years. Using the standard percent agreement formula, agreement on number of studies per year averaged 81%, using the standard percent agreement formula. Individual reliablities were 83% and 89%.

Reliability for article ratings was established by having a third reviewer, a Ph.D. student in clinical psychology with a bachelor's degree, review 13% of the same studies. Agreement on study variables averaged 84%, using the standard percent agreement formula. Individual reliabilities ranged from 80% to 90%.

RESULTS AND DISCUSSION

Results for each category are presented below, along with a review of relevant studies and prevalent trends constituting each category. A review of


recent trends in behavioral research with autistic persons is also presented. This paper will conclude with a summary of the results and suggestions for future research.

Aberrant Behaviors

Aberrant behaviors, including stereotypy and self-injurious behavior, are frequently seen in autistic individuals (Schreibman, 1988). Target behaviors in this category were grouped together because they all have the following com- monalities: they are behavioral excesses, they interfere with opportunities for interaction within the environment, and they deter the individual from learning functional behaviors. The most frequently addressed aberrant behaviors included stereotypy (22%), aggression (17%), and self-injurious behavior (14%). Target behaviors and procedures implemented are shown in Table 1.

As shown in Table 1, the categories of behavioral techniques addressing aberrant behaviors included positive (53%), aversive (20%), extinction (1%),

TABLE 1 Target Behaviors and Procedures for Aberrant Behaviors

Target Behavior

Procedure

Positive Aversive Combined Extinction

Aggression Stereotypy Self-injurious behavior Repetitive/Inappropriate vocalizations

Destroying property Tantrums Noncompliance Pica Grabbing Physical withdrawal Diurnal bruxism Spitting Inappropriate touching Out-of-seat Anorexia nervosa Phobias Grimacing Visual overselectivity Off-task Falling Stealing Tensing body Body rocking Mouthing objects

13 5 7 12 14 4 9 2 9

1 3 1 2 2 2


and combined (26%). It is apparent from the inclusion of positive and negative procedures that treatment goals focused on decreasing maladaptive behaviors and increasing functionally appropriate behaviors.

Using methodologies derived from the principles of operant conditioning, researchers have developed the functional analysis model of assessment and treatment. This technique typically addresses aberrant behaviors and provides a means by which antecedents and consequences for a particular behavior are arranged in highly controlled assessment conditions. High rates of behavior occurring during a particular assessment condition are indicative of a specific functional property of the behavior. Interventions matching the contingencies governing the behavior are then designed (Neef & Iwata, 1994). In one of the earliest applications of functional analysis, Iwata, Dorsey, Slifer, Bauman, and Richman (1982) hypothesized that self-injurious behavior served multiple functions for certain individuals with severe developmental disabilities. These researchers presented a methodology for assessment of self-injurious behavior. They utilized assessment conditions based on empirically-derived functions of self-injurious behavior, including contingent attention, self-stimulation, and demands. Based on the results of their assessments, the researchers prescribed successful interventions. Hating and Kennedy (1990) analyzed the problem behaviors (spitting, loud vocalizations, stereotypy) of two autistic subjects across differing contexts, including instructional task sessions and leisure activity sessions. Differential reinforcement of other behavior (DRO) and time-out were implemented in these settings. The researchers found that these interventions produced different outcomes, depending on environmental context. The researchers concluded that although the problem behaviors appeared to be topographically similar, their functional control was not. Consequently, functional analysis within only one environmental context may provide insuf- ficient data for an effective behavior management program. In addition, Sasso et al. (1992) compared experimental analyses of aberrant behavior with descriptive analyses by teachers to determine the utility of functional analysis implemented in the school setting. The researchers found that these assessment methods yielded comparable findings, which supports the validity of functional analysis across settings and therapists. Interventions based on assessment results were also successful in reducing aberrant behaviors. Functional analysis is a technique that holds much promise for the development of effective assessment and treatment techniques for aberrant behaviors.

Functional communication training is a treatment technique based on the principles of functional analysis. This is an intervention designed to reduce aberrant behaviors by teaching subjects communicative responses that are functionally equivalent to the aberrant behavior. Carr and Durand (1985) systematically assessed the functions of aberrant behavior and successfully implemented functional communication training with subjects with mental retardation. Bird, Dores, Moniz, and Robinson, (1989) compared functional communication training to DRO with people with autism and mental retarda-


tion who demonstrated aggression and self-injury. They postulated that functional communication training would be a more effective treatment because subjects would be taught responses that are functionally equivalent to the aberrant behaviors, as reinforcers obtained by functional communication would be the same as those obtained by the aberrant behavior. For example, the authors determined through functional analysis that the function of one subject's self- injurious behavior was escape from task demands. They subsequently trained the subject to request a break from task demands and dramatically reduced the incidence of self-injurious behavior. Durand and Cart (1992) found that functional communication training evoked desired consequences from others in the environment who were unfamiliar with the student and the procedure. When compared with time-out from positive reinforcement, functional communication training produced more appropriate behavior when the subject was around persons unfamiliar with existing contingencies. Functional communication training is therefore a technique that can provide an efficient, nonaversive means of reducing aberrant behaviors, even among others who are unaware of the procedure.

In recent years, there has been much debate over the appropriateness of aversive procedures for individuals with handicaps. Critics of aversive procedures have stated that nonaversive procedures are effective treatments for the majority of aberrant behaviors (LaVigna & Donnellan, 1986). However, some aberrant behaviors, such as aggression and self-injurious behavior, in their most severe form can be extremely destructive and harmful. These behaviors often require immediate treatment to prevent serious injury to the individual and others. Researchers have demonstrated that rapid decreases in aberrant behaviors may be achieved by using aversive procedures (Matson & Taras, 1989). When severe, harmful aberrant behaviors are treated, the use of a less intrusive procedure with more gradual effects may be considered unethical (Repp & Deitz, 1978). Nevertheless, there is potential for abuse of aversive interventions; it is essential that appropriate procedures for regulating the use of aversives are in place (Matson & Kazdin, 1981). These procedures may specify patient consent, qualified professionals, and peer reviews. When aversives are incorporated in a treatment plan, it is generally recommended that the least intrusive procedure possible be utilized for a target behavior (Repp & Deitz, 1978). The question of whether less intrusive procedures may be implemented in a program that is as effective as a single, more intrusive procedure has been addressed by researchers. Charlop, Burgio, Iwata, and Ivancic (1988) conducted a study to evaluate the possibility of utilizing a variety of less intrusive aversive procedures to reduce aberrant behaviors rather than a single, more intrusive aversive procedure. The varied presentation enhanced the effectiveness of the less intrusive procedures.

Researchers have developed effective strategies for treating aberrant behaviors, in spite of the lingering controversy surrounding strategies involving the use of aversives. The goal of treatment strategies has become twofold, incorporating


decreases in aberrant behavior and increases in positive behavior. This is accom- plished through the use of reinforcement-based strategies in conjunction with aversive procedures or extinction. Recent investigators have devised more sophisticated assessment methodologies, such as functional analysis, to ensure implementation of appropriate treatments. Researchers have also focused on less intrusive aversive procedures, evaluating ways to generate more powerful effects. These are areas for continuing research, as investigators develop more efficient and socially acceptable methods for treating aberrant behaviors.

Social Skills

The inability to develop normal social relationships is described as one of the most pervasive deficits of autism (Newsom, Hovanitz, & Rincover, 1988; Schreibman, 1988). All studies which addressed behaviors comprising appropriate interactions with others were included in this category. The most frequent target behaviors included initiations (32%), responses (23%), and reciprocal interactions (15%). Target behaviors and behavioral techniques are presented in Table 2.

As shown in Table 2, these behaviors were increased using positive (98%) and combined (2%) procedures. It is evident that nearly all studies focused on increasing appropriate behaviors, rather than decreasing inappropriate behaviors.

Target behaviors ranged from simple to complex, with simple behaviors functioning as precursors to more complex social behaviors. Holding a conversation, for example, requires the prerequisite skills of attending, eye contact, appropriate voice tone, and asking and responding to questions. Often the social skills deficits of autistic persons are so pervasive that instruction in simple behaviors is necessary before behaviors encompassing more complex interactions can be introduced (Newsom & Rincover, 1989). For the majority of studies, treatment consisted of direct training of socially appropriate behaviors using positive reinforcement techniques.

In many of the studies addressing social skills, peers served as confederates during training, as they were taught to initiate social interactions with autistic children. Researchers using peer confederates reported that the number of responses and duration of interactions significantly increased for both peers and target children (Goldstein & Wickstrom, 1986; Shafer, Egel, & Neef, 1984). However, Odom and Strain (1986) compared a treatment program training normal peers to initiate interactions with autistic children with another program training teachers to prompt autistic children to initiate to peers. The researchers found that normal peer initiations increased the autistic children's social responses, but teacher prompting increased the autistic children's social responses and initiations. One problem facing researchers was the issue of generalization: how to train autistic subjects to generalize learned social behaviors to persons other than peer confederates. Strain (1983) and Haring and Lovinger (1989) discussed the importance of considering the reciprocal


TABLE 2 Target Behaviors and Procedures for Social Skills

Target Behavior

Procedure

Positive Avers ive Combined Extinction

Social Interactions: Initiations + Responses + Reciprocal interactions 7

Initiations + Responses 2 Initiations + Reciprocal

interactions 2 Initiations 9 Responses 5

Eye contact 5 Play skills 3 Offering/Requesting/Providing assistance 3

Sharing 3 Conversational skills 2 Greeting 2 Terminating social exchanges 2 Expressing affection 2 Decreasing avoidance 2 Physical approach 2 Appropriate affect Appropriate sitting Recruiting praise Requests Appropriate speech content Appropriate voice tone Appropriate gestures Imitation

nature of social interactions. These researchers emphasized the importance of ensuring peer responses to the initiations of autistic subjects, otherwise the subjects initiations will extinguish. They advocated training autistic children to initiate interactions with peers taught to respond appropriately.

Several studies evaluated the technique of "loose training," or reducing instructional control over a subject by training the subject with more than one peer confederate. In these studies, it was postulated that if autistic subjects were exposed to more than one peer during training, they would be more likely to generalize their newly learned skills to peers not involved in training (Campbell & Stremel-Campbell, 1982). Accordingly, researchers utilizing loose training taught autistic youths to initiate and sustain social interactions with various nonhandicapped peers. These researchers found that autistic subjects learned and generalized these skills to other peers in the same setting (Brady, McEvoy, Wehby, & Ellis, 1987; Brady, Shores, McEvoy, Ellis, & Fox, 1987; Gaylord- Ross, Haring, Breen, & Pitts-Conway, 1984; McEvoy, et al., 1988).

442 Z LMa~on etaL

Recent researchers addressing treatment of social skills in autistic persons have evaluated the effects of treating pivotal social behaviors. According to Koegel, Koegel, and Schreibman (1991), pivotal behaviors refer to behaviors that, when modified, result in collateral changes in other behaviors constituting the same response class as the pivotal behaviors. Consequently the treatment of pivotal behaviors has the potential to produce changes in multiple areas of functioning in autistic persons. Findings by Koegel, Koegel, Hurley, and Frea (1992) provide support for this hypothesis. These researchers used a self-management strategy to teach autistic children social communication skills and found collateral increases in social behaviors not targeted for treatment and decreases in disruptive behavior. The authors concluded that in these subjects, the social behaviors and disruptive behaviors were part of a larger class of behaviors serving similar functions. Koegel and Frea (1993) extended these findings by using self-management strategies to change one or two social communicative behaviors (e.g., eye gaze, gestures). They hypothesized that these behavior changes would result in improvements in social communicative behaviors not targeted for treatment (e.g., voice volume, facial expression, and affect). These researchers reported collateral behavior changes and concluded that all behaviors modified by the treatment program comstituted the same response class. Results of these studies provide support for the identification and treatment of pivotal social behaviors, as changes in a social behaviors targeted for treatment may result in modification of a broader range of social and disruptive behaviors.

Researchers have developed techniques to improve the social behavior of autistic children. There is a growing emphasis on the dynamic nature of social interactions, as treatments focus on teaching autistic subjects to engage in reciprocal interactions. Autistic subjects are thereby taught to extend social interactions beyond initiations and single responses. Investigators have also devised methods to facilitate generalization of social skills. Studies have included peer confederates, so that autistic subjects can learn appropriate behaviors with individuals who part of the subjects' natural environment. The technique of loose training was also developed to facilitate generalization of social behaviors to peers not involved in training. Investigators have recently begun treating social skills as pivotal behaviors, constituting a single response class. They found that by changing a single behavior during treatment, it is possible to produce collateral changes in other behaviors in the same response class. This technique has important implications for treatment, as it is clearly more efficient than teaching multiple behaviors. Future research is needed to continue evaluating the relationships among social behaviors, in order to determine how changes in one behavior affect others.

Language

Speech deficits and unusual speech and language patterns are identifying characteristics of autistic persons; approximately 50% of these individuals lack


expressive and receptive language (Schreibman, 1988). Researchers have conducted studies evaluating methods to remediate language deficits. Target behaviors comprising both expressive (87%) and receptive (11%) language, as well as both combined (2%), were addressed in this category. Target behaviors and behavioral techniques are presented in Table 3.

Behavioral techniques consisted of positive (89%) and combined (11%) procedures. Most studies evaluated direct instruction of language using reinforcement

TABLE 3 Target Behaviors and Procedures for Language

Preccdure

Target Behavior Positive Avers ive Combined Extinction

Expressive Verbal Answering questions Labeling Spontaneous verbalizations Prompted verbalizations Pronoun use

Answers to "Wh-" questions Sentence use "Yes" and "No" as mands Multiple descriptors Verbalizing past events "I/You" responses Verbal tacts "Give me-" as mands Naming pictures Preposition use Adjective use

Nonverbal Prompted sign use Spontaneous sign use Pointing Requesting Answering questions Alternative communication

Mixed Labeling Pronoun use

"Yes/No" Responses Preposition use Articulation

Receptive Labeling Noun/Verb/Adjective use Preposition use

Receptive + Expressive Sign language


techniques. As shown in Table 3, the majority of studies addressed expressive language, which is typically trained after the individual demonstrates a receptive vocabulary of at least l0 words (Lovaas, 1981). Two modalities of expressive language were addressed, including oral and sign.

Researchers have evaluated procedures for increasing expressive language. In the 1960s and 1970s, researchers developed effective programs for training verbal imitation, expressive labeling, answering questions, and requests (Lovaas, 1977, 1981). However, researchers found that autistic children frequently fail to generalize their speech to unfamiliar persons and settings, possibly because of their overly selective attention (Lovaas, Koegel, & Schreibman, 1979). More recent research has address methods to facilitate generalization of expressive language by autistic subjects. These methods include incidental teaching, the natural language paradigm, and time delay.

Schepis et al. (1982) introduced incidental teaching, a procedure used successfully with preschoolers (Hart & Risley, 1975). Incidental teaching is a technique of increasing language by using naturally occurring interactions between the client and the caregiver. Schepis et al. (1982) evaluated an incidental teaching program to increase expressive sign language in nonverbal adults with autism. In this study, incidental teaching was implemented by arranging the physical environment in a manner encouraging the subject to use signs. This was done by placing preferred items on a shelf and allowing subjects to request these items using signs. Caregivers reinforced subjects for sign use by giving them the requested item. Staff members also prompted and reinforced sign use when appropriate during naturally occurring interactions (e.g., when a subject wanted to drink from a water fountain, the caregiver prompted the subject to sign the word drink and provided access to the water fountain as a reinforcer for sign use). In addition, caregivers conducted brief training sessions, in which they presented objects and prompted subjects to sign the names of the objects. The researchers reported a significant increase in sign use by subjects. Carr and Kologinsky (1983) trained autistic children to sign words spontaneously for reinforcer items. During the training component, subjects were presented with an item, prompted to sign the appropriate label, then given the item as a reinforcer. During the maintenance component, experi- menters did not prompt subjects to use signs. However, they were reinforced for spontaneously signing an object label by being allowed access to the object. The researchers reported a significant increase in spontaneous sign use. McGee, Krantz, and McClannahan (1985) compared discrete-trial teaching to incidental teaching procedures for increasing appropriate preposition use in autistic children. In the discrete-trial format, teachers presented two stimulus items to subjects, then prompted correct preposition use. Subjects were reinforced with praise and access to one of the stimuli. In the incidental teaching format, stimulus materials were displayed in the training area and teachers prompted and praised appropriate preposition use after subjects named or requested one of the items. The researchers found that the incidental teaching


procedure promoted more appropriate preposition use and greater generalization across settings, teachers, and positions of training stimuli.

The natural language teaching paradigm for increasing verbal language in nonverbal autistic children was introduced by Koegel, O'Dell, and Koegel (1987). This paradigm incorporates a discrete-trial language training program with incidental teaching techniques, thereby promoting more natural speaking situations during training. Koegel et al. (1987) compared a natural language program with an analogue discrete-trial program. In the natural language program, these researchers began sessions by allowing the child to select a stimulus object, then modeled the name of the object. The child was reinforced for any verbal response with praise and an opportunity to play with the object. Koegel et al. (1987) found that the children exhibited more verbalizations and displayed more generalization to spontaneous verbalizations with the natural language teaching program. Elliott, Hall, and Soper (1991) compared discrete- trial language teaching to natural language teaching by implementing both procedures with two groups in a multiple baseline, crossover design. These researchers found that both techniques produced significant increases in spontaneous verbalizations in both groups. They also found that neither method was superior. However, the researchers hypothesized that natural language teaching is a better choice because the technique is implemented in a less arti- ficial teaching environment and effectively facilitates generalization.

The time delay procedure for increasing expressive language was introduced by Halle, Marshall, and Spradlin (1979), who implemented this procedure with institutionalized mentally retarded persons. Time delay is a technique in which the teacher presents a target stimulus (e.g., soda) to the subject and prompts the appropriate response (e.g., "I want soda.") The onset of the prompt is subsequently delayed for increasing amounts of time until the subject spontaneously requests the item. Charlop, Schreibman, and Thibodeau (1985) used the time delay procedure to increase expressive language in autistic children. Using this procedure, the subjects were taught to request desired objects in the absence of verbal cues. The researchers reported generalization of spontaneous requesting from the training environment to unfamiliar persons, settings, and stimuli. Ingenmey and VanHouten (1991) successfully implemented a time delay procedure with an autistic child to increase spontaneous speech during play activities, including playing with cars and drawing. These researchers also reported generalization across stimulus items constituting the same behavioral class (e.g., cars that were not used as stimuli for training car play) and across different settings.

Studies evaluating techniques for increasing expressive language have focused on verbal language (62%), nonverbal language (25%), and total communication (both forms combined) (13%). One question that has been addressed by researchers is which language modality is most appropriate for autistic individuals. Barrera, Lobato-Barrera, and Sulzer-Azaroff (1980) compared the uses of oral language, sign language, and total communication in teaching expressive language to a mute autistic child. These researchers found


that total communication training was superior to oral or sign language training. Cohen (1981) used total communication training to teach an autistic child to sign a word and simultaneously say the corresponding spoken word. Increases in unprompted vocal labeling, simultaneous vocal and signed phras- es, and a reduction in echolalia were reported. Barrera and Sulzer-Azaroff (1983) used an alternating treatment design to compare the effectiveness of oral and total communication training for increasing expressive labeling in echolalic autistic children. These researchers found that total communication was more effective in teaching expressive labeling. Newsom and Rincover (1989) recommend teaching language using the total communication approach when it is unclear as to which modality is most appropriate. These authors also recommend conducting regular, objective assessments to determine the effectiveness of the approach being implemented.

Few studies were found using evaluation techniques for increasing receptive language. For the studies that did so, positive (71%) and combined (29%) behavioral techniques were used. For example, Egel, Shafer, and Neef (1984) used positive techniques (modeling and positive reinforcement) to teach receptive preposition use to autistic children. Specifically, they taught the children two responses to prompts containing prepositions: placing themselves in relationship to objects on a table (e.g., standing behind/beside/in front of a chair), and placing objects in positional relationship to others on a table (e.g., putting a sock behind/beside/in front of a shoe). These researchers found that teaching the children to respond by positioning objects increased receptive preposition use more quickly than teaching them to respond by positioning themselves.

Researchers addressing behavioral treatment of language deficits in autistic children have primarily investigated methods for increasing expressive language. Studies have documented techniques that not only increase language production but also facilitate generalization of language. Several methods of producing generalization were developed. Incidental teaching is a technique in which autistic children are taught expressive language in the context of naturally occurring interactions with the teacher. The natural language paradigm also promotes language teaching in a natural context, as it combines discrete trials with incidental teaching. In time delay, subjects learn to use expressive language in the absence of verbal cues, as prompts are delayed for increasing amounts of time. Researchers have addressed the question of whether to teach speech or sign language, and con- chided that the total communication method (teaching both language forms simultaneously) should be used when it is not clear as to which technique is best. Few studies addressed receptive language with autistic children. Because these children often have deficits in receptive language, this is an area for future research.

Daily Living Skills

Individuals with autism are often challenged by deficits in dally living skills (Harris, 1988). These skills consist of behaviors that are necessary for success-


ful day-to-day functioning. Target behaviors and behavioral techniques are shown in Table 4.

Behavioral techniques used to increase daily living skills consisted of positive (83%) and combined (17%) techniques. The majority of studies appeared to focus on using positive reinforcement techniques to teach specific behaviors constituting the aforementioned areas. A few studies employed aversives in conjunction with positive reinforcement to decrease the frequency of problem behaviors interfering with learning. Target behaviors were divided into four areas containing distinct groups of skills including self-help, community, leisure, and vocational.

Self-help skills (53%) are defined as behaviors enabling individuals to care independently for their own bodily needs (Taras & Matese, 1990). This is a widespread area of deficit for persons with developmental disabilities (Lovaas, 1981). The benefits of teaching self-help skills to autistic persons are twofold. First, learning self-help skills will enable the autistic individual to become more independent. In addition, if the individual is able to provide basic care on

TABLE 4 Target Behaviors and Procedures For Daily Living Skills

Target Behavior

Procedure

Positive Aversive Combined Extinction

Self-help skills Dressing Tying shoes Brushing teeth Food preparation Eating Washing face Combing hair Drinking Setting table Cleaning sink Doing laundry Making bed Deodorant application Toileting

Community skills Crossing street Purchases Checking out books

Leisure skills Toy play Ball play Choosing recreational activities

Vocational skills Cleaning restroom Increasing production rate


his or her own, there will be additional time for caregivers to focus on teaching other necessary skills (Reid, Wilson, & Faw, 1991). Researchers have evaluated methods for teaching autistic persons self-help skills. For example, Pierce and Schreibman (1994) used picture prompts, positive reinforcement, modeling, and fading to successfully teach autistic children dressing, food preparation, setting the table, doing laundry, and making beds.

Another area of daily living skills is community skills (14%), which allow persons to function successfully in community settings (Danforth & Drabman, 1990). Over the last 20 years, there has been an increasing trend towards community placement of persons with developmental disabilities. This trend has resulted from court cases, such as Wyatt v. Stickney, which prompted the transfer of individuals from state institutions to community settings. However, persons with developmental disabilities often do not have the necessary skills to function independently in the community. Researchers have investigated techniques for teaching community skills to autistic individuals. Steinborn and Knapp (1982) taught an autistic child pedestrian skills using prompts, modeling and positive reinforcement. Haring, Kennedy, Adams, and Pitts-Conway (1987) taught autistic adults to purchase items using prompts and positive reinforcement.

A third area of dally living skills included studies evaluating methods of increasing leisure skills (28%), defined as behaviors allowing individuals to engage in recreational activities (Hawkins, 1982). Autistic individuals typically engage in fewer leisure activities when compared to their nonhandicapped counterparts (Schreibman, 1988). These individuals often fail to learn the necessary skills to engage in a leisure activity, and they frequently engage in behaviors that interfere with these activities, including stereotypy and self- injurious behavior. Researchers have attempted to increase leisure skills by directly teaching persons with autism specific activities such as playing with toys. For example, using modeling and positive reinforcement, Tryon and Keane (1986) taught autistic children to play with toys. Researchers have also implemented both positive and negative behavioral procedures to produce a decrease in negative behaviors while increasing leisure skills. Coe, Matson, Fee, Manikam, and Linarello (1990) used prompts, feedback, and positive reinforcement to teach autistic children to play ball. These researchers also implemented time-out to decrease disruptive behaviors occurring during training sessions.

A fourth area of daily living skills consists of vocational skills (5%), which include behaviors necessary for successful adjustment to job settings (Smith & Coleman, 1986). Because of the behavioral excesses and deficits that often characterize persons with autism, it is important that they be taught the skills necessary to function successfully in a vocational setting. A few researchers have investigated the efficacy of behavioral interventions. For example, Smith and Coleman (1986) successfully utilized positive reinforcement procedures to teach job skills (e.g., increasing production rate) to autistic persons. These researchers also utilized combined procedures to decrease inappropriate behaviors in the job setting.


It is apparent that relatively few researchers have evaluated techniques for teaching daily living skills to autistic persons. Teaching daily living skills to autistic persons is particularly difficult because of the language problems, stimulus overselectivity, and aberrant behaviors that characterize a significant part of this population (Schreibman, 1988). Accordingly, the majority of treatment studies with autistic children focus on remediating these more salient behavioral excesses and deficits, rather than on activities of daily living. The database on techniques for teaching daily living skills to mentally retarded persons, however, is quite extensive (e.g., Danforth & Drabman, 1990; Taras & Matese, 1990). As a result, research is necessary to determine whether techniques proven successful with mentally retarded persons are appropriate for autistic persons. A few studies have done this using single-case methodology.

One technique that has proven effective with mentally retarded persons is task analysis (Homer & Keilitz, 1975). Task analysis is a procedure in which a complex behavior is broken down into simpler component behaviors (Sulzer-Azaroff & Mayer, 1977). The process of task analysis begins with observation of the target behavior, listing specific components in order of occurrence, and listing sub- skills required for successful performance (Huguenin, Weidenman, & Mulick, 1991). For example the behavior of cleaning the sink can be broken down into the following steps: (a) turn on water, (b) dampen sponge, (c) turn off water, (d) apply small amount of cleaning agent to sink, (e) scrub inside of sink with damp sponge, (f) turn on water, (g) rinse sponge, (h) rinse sink thoroughly so no cleaner is left, (i) squeeze sponge, (j) put sponge away (Smith & Belcher, 1985). A subskill necessary for successful completion of these tasks may include fine motor dexterity sufficient for turning the water faucet on and off. Task analysis has several advantages, particularly when used with autistic persons. Training programs developed by this method may be tailored for individual students and modified according to intellectual level. This may be done by skipping steps or breaking steps down further. Task analysis may also be used for behaviors constituting many different skills areas. Skills may be subsequently taught by using chaining. In chaining, each component behavior is considered part of a behavioral chain. These component behaviors are taught to subjects one at a time, either in forward order (forward chaining) or in backward order (backward chaining). Studies on self-help and community skills incorporated task analysis and chaining with autistic persons. Matson, Taras, Sevin, Love, and Fridley (1990) taught autistic children self-help skills including shoe tying, hair combing, dressing, eating, and drinking. Task analysis was utilized to break down target behaviors. These researchers subsequently used a forward chaining procedure incorporating modeling, instructions, and positive reinforcement to teach these behaviors. Blew, Schwartz, and Luce (1985) used peer models to teach autistic children community skills including crossing the street, making purchases, and checking out books from the library. Each behavior was task analyzed into component behaviors, then a forward chaining procedure including modeling and positive reinforcement was used to teach subjects these behaviors.


In the area of daily living skills, target behaviors comprised four skill categories, including self-help, community, leisure, and vocational skills. Most of the studies addressed self-help skills. However, with the continued emphasis on community placement of individuals with developmental disabilities, the remaining skill categories are important areas for future research. The number of studies addressing daily living skills in mentally retarded subjects is significantly greater than in autistic subjects. Consequently there is a need to determine whether treatment strategies effective with mentally retarded persons are equally effective with autistic persons. Investigators have found that one strategy, task analysis, is appropriate for both populations. Future research is needed to increase the number of effective techniques for teaching daily living skills to autistic persons.

Academic Skills

Research in this category included studies that addressed behaviors typically taught in academic and physical education settings. Behavioral techniques consisted of positive (88%) and combined (12%) procedures. A wide range of behaviors were addressed in this category, as shown in Table 5.

Behaviors addressed included discrimination (58%) and task acquisition and performance (9%). Researchers have evaluated methods for facilitating autistic children's learning in academic settings. One technique is task variation. Dunlap and Koegel (1980) compared two methods of teaching autistic children specific tasks (e.g., color/object identification, counting objects). In the constant task method, they utilized a single task throughout a training session. In the varied task method, they utilized a target task interspersed with a variety of different tasks. The researchers found that the varied task method was more effective, and they hypothesized that the stimulus variation may have increased the children's responsivity. Weber and Thorpe (I 989) also compared constant task presentation with task variation, finding that task variation was more effective in teaching gross motor skills.

Researchers have also evaluated the effects of reinforcer variation and reinforcer type on learning. Egel (1981) compared the effects of constant and varied reinforcer presentation on discrimination tasks and on-task behavior. This researcher found that varied reinforcer presentation produced greater increases in target behaviors than constant reinforcer presentation. Egel (1981) hypothesized that repeatedly presenting the same reinforcer may cause satiation. With regard to reinforcer type, Ferrari and Harris (1981) hypothesized that sensory reinforcers (e.g., vibration, music, light) may function as appropriate reinforcers for some autistic children. They compared the use of sensory reinforcers (vibration, music, strobe light) with edible and social reinforcers when teaching object discrimination to autistic children. These authors found that sensory reinforcers were as effective as edible and social reinforcers. Rincover and Newsom (1985) compared a sensory reinforcer with an edible reinforcer.


TABLE 5 Target Behaviors and Procedures for Academic Interventions

Procedure

Target Behavior Positive Avers ive Combined Extinction

Discrimination Object 9 2 Picture 7 Color 7 Shape 7 Letter/Word 3 1 Number 2 1 Body part 1

Task acquisition/Performance 6 Gross motor skills 3 1 On-task behavior 3 1 Object manipulation 2 Reading 2 Matching 1 Categorization 1 Visual orientation 1 Number identification 1 Mathematics 1 Handwriting 1 Recall 1 Transitions between activities 1 On-schedule behavior 1 Spelling 1 Memory 1

They found that the sensory reinforcer produced a higher percentage of correct responding. These researchers hypothesized that sensory reinforcers were more resistant to satiation. Wolery, Kirk, and Gast (1985) assessed the effectiveness of using stereotypic behavior as a reinforcer. Subjects were cued by a model to engage in stereotypic behaviors after responding correctly on matching and labeling tasks. The researchers reported a significant increase in percentage of correct responses and no significant increase in the rate of stereotypic behavior in other settings.

Many studies evaluated methods to remediate stimulus overselectivity, a problem commonly found in autistic children. Stimulus overselectivity inter- feres with learning because autistic persons with this characteristic often respond to a restricted number of cues available during learning situations (Schreibman, 1988). Researchers frequently used discrimination tasks when evaluating treatment strategies. According to Lovaas, Koegel, and Schreibman (1979), when presented with multiple cues (i.e., a stimulus with visual, auditory, and motor components), autistic children tend to respond to only one cue. They have difficulty discriminating between complex stimuli, even when multiple cues are presented in the same modality (e.g., multiple visual, auditory, or


motor cues). In the 1970s, researchers began teaching autistic children with stimulus overselectivity to respond to simultaneous multiple cues presented in discrimination tasks. Schreibman, Koegel, and Craig (1977) taught autistic children to respond correctly during discrimination tasks involving stimuli with two available cues. These researchers then engaged the children in pro- longed testing by interspersing unreinforced trials with reinforced trials. Eventually most of the children were able to respond appropriately to both stimulus cues. Koegel and Schreibman (1977) also successfully taught autistic children a discrimination task requiring a response to multiple cues. More recently researchers have utilized discrimination tasks to teach autistic children learning strategies that are similar to those used by nonhandicapped children. Schreibman, Charlop, and Koegel (1982) taught autistic children with a history of overselectivity to respond to multiple cues and utilize an extra-stimulus prompt. Children were presented with stimuli, each with distinct multiple cues (e.g., color, shape, size). They were instructed to use these multiple cues when selecting stimuli. Subjects were subsequently taught to use an extra-stimulus prompt, consisting of the teacher pointing to a model of the correct stimulus. Burke and Cerniglia (1990) instructed autistic children in responding to multiple stimulus components. They taught the children to follow one-, two-, three-, and four-component instructions and discriminate among objects of different types, sizes, and colors. These researchers then assessed generalization of the newly taught skills by presenting subjects with multicomponent stimuli in nat- uralistic settings. The researchers found that after discrimination training, subjects responded more often to multicomponent stimuli in other settings. Burke and Cerniglia (1990) viewed stimulus overselectivity as a pivotal behavior, hypothesizing that teaching autistic children to respond to multiple cues will facilitate their acquisition of other advanced learning strategies such as observational learning.

Researchers have developed behavioral methods to enhance learning in autistic persons. These methods include task variation, reinforcer type, and reinforcer variation. Investigators have found that the learning of autistic children is enhanced when they vary tasks during learning sessions. Reinforcer type differentially affects learning, as sensory reinforcers produce a higher percentage of correct responding than other types of reinforcers. Reinforcer variation, presenting a variety of reinforcers during a treatment session, also enhances learning. It was hypothesized that these three techniques improve learning because they are resistant to satiation. The literature on academic skills training with mentally retarded persons is more extensive than literature on academic skills training with autistic persons (Weisberg, 1990). However, autistic children often have unique behaviors that interfere with learning. Stimulus overselectivity is one such behavior; researchers have successfully reduced its effects by teaching autistic children to respond to multiple cues. Recent researchers (Burke & Cerniglia, 1990) hypothesized that stimulus overselectivity is a pivotal behavior. Future studies are needed to evaluate this


hypothesis, and thereby develop more efficient learning strategies to enhance the training of autistic persons.

Other Recent Trends in Behavioral Treatment With Autistic Persons

In addition to the aforementioned treatment studies, several trends in behavioral treatment with autistic children have recently emerged. These trends include specific behavioral strategies that have successfully altered target behaviors. For each trend, target behaviors are not limited to single subject areas, as each technique was found effective with behaviors across different categories. Several trends are described below, in conjunction with relevant research.

Empirically derived consequences. Researchers have recently begun evaluating methodologies for developing empirically derived consequences for target behaviors. These methodologies are based on the principles of functional analysis. They include techniques for assessing reinforcers for use in teaching sessions. Pace, Ivancic, Edwards, Iwata, and Page (1985) developed a two-step process for assessing reinforcers. Subjects were exposed to 16 stimuli while observers recorded which stimuli the subjects approached. The potency of the stimuli as reinforcers was then determined by recording how frequently each stimulus was approached. Mason, McGee, Farmer-Dougan, and Risley (1989) developed a reinforcer assessment package with autistic children in which they implemented the Pace et al. (1985) two-step procedure and conducted daily mini-assessments by presenting items that had been designated as preferred reinforcers during the initial comprehensive assessment. The child was prompted to choose from two items, and the selected items were used as reinforcers for subsequent teaching sessions. Using children with severe handicaps, Fisher et al. (1992) compared the Pace et al. (1985) two-step procedure with another procedure employing a forced-choice format in which all stimuli were presented in pairs and the student was prompted to select one of the pair of stimuli. These researchers found that the forced-choice assessment better predicted which stimuli would function as more potent reinforcers in a subsequent treatment program. Researchers have recently begun to use empirical approaches to assess punishers systematically. Fisher et al. (1994) described a strategy for assessing punishers when they treated children with pervasive developmental disorders and severe pica. These researchers identified reinforcers using the procedure described by Fisher et al. (1992). To identify punishers, these researchers described a two-step process consisting of a stimulus avoidance assessment and a punisher assessment. In the stimulus avoidance assessment, nine potential punishers were presented noncontingently to each subject in individual sessions. To determine the amount of nonpreference for each procedure, researchers measured negative vocalizations and avoidance movements. During the punisher assessment, subjects were presented with each of three selected punishers (those with the lowest, median, and highest


amount of nonpreference) contingent on target behaviors. The punisher that produced the greatest reduction in target behaviors was selected as the punisher for subsequent treatment sessions.

Behaviora l momentum. Nevin, Mandell, and Atak (1983) postulated that learned behavior has momentum: behavior maintained by a schedule of reinforcement may persist over time after reinforcement conditions are changed. This momentum may be created by increasing the response and reinforcement rate of a behavior in a particular response class. Mace et al. (1988) applied this principle when designing an intervention for noncompliance, finding that presenting a series of instructions with a high probability of compliance immedi- ately before an instruction with a low probability of compliance increased the rate of compliance with the low probability instruction. These researchers concluded that this increase in compliance resulted from the behavioral momentum created by the series of high probability instructions. Davis, Brady, Williams, and Hamilton (1992) used a similar methodology, presenting low probability requests after a series of high probability requests, and successfully used multiple trainers to produce generalized responding. Houlihan, Jacobson, and Brandon (1994) treated noncompliance in an autistic child by presenting a series of high probability requests followed by a low probability request, com- paring the effectiveness of presenting the low probability request 5 s and 20 s after the high probability sequence. These researchers found that the shorter (5 s) interval between high probability and low probability requests produced significant improvement over baseline, whereas the longer (20 s) interval produced no improvement over baseline. Therefore the length between prompts is crucial, possibly because the shorter interval increases the rate of reinforcement for compliance. Davis, Brady, Hamilton, McEvoy, and Williams (1994) gave autistic children requests with a low probability of response (e.g., share toy) grouped with high probability requests (e.g., point to toy). Subjects' respon- siveness to low probability requests increased, unprompted initiations and extended interactions to the training peers increased, and levels of initiations or interactions with peers were maintained even when prompts were removed.

Peer/Sibling interventions. As mentioned previously, treatment studies using social skills as target behaviors with autistic children have successfully incorporated peers as confederates. Studies addressing other types of target behaviors have successfully used peers as models or as trainers for autistic children.

Researchers began in the 1970s by developing treatment programs based on the principles of observational learning that incorporated adults as models of desired behavior (Barry & Overmann, 1977; Varni, Lovaas, Koegel, & Everett, 1979). However studies employing normal peers as models reported more successful results. For example, Coleman and Stedman (1974) reported that an autistic child appeared to use more appropriate voice tone when exposed to a normal peer model. In the 1980s, researchers continued to evaluate treatments


based on observational learning with peer models. Specifically, autistic subjects observed peer models being reinforced for performing target behaviors (Charlop, Schreibman, & Tryon, 1983; Egel, Richman, & Koegel, 1981). However, researchers found that treatment strategies that directly taught target behaviors to autistic subjects were superior to those that merely exposed subjects to peer models (Blew, Schwartz, & Luce, 1985; Charlop & Walsh, 1986).

Researchers have also used peers and siblings as trainers for autistic subjects by teaching the peer or sibling to implement various behavioral procedures. For example, Schreibman, O'Neill, and Koegel (1983) taught siblings of autistic children to implement behavior modification procedures, including reinforcement and extinction, to teach behaviors such as discrimination and expressive labeling. The siblings were able to elicit significant increases in target behaviors. Mangus, Henderson, and French (1986) successfully taught peer tutors to implement a token economy with autistic children to increase on-task behavior. Coe, Matson, Craigie, and Gossen (199 l) taught siblings of autistic children to prompt and reinforce play skills, producing significant increases in these skills. Kamps, Barbetta, Leonard, and Delquadri (1994) trained nonhandicapped peers to serve as tutors to autistic students and found significant increases in reading fluency, correct responses to comprehension questions, and duration of social interactions. Researchers have also taught peers to implement incidental teaching procedures with autistic subjects. McGee, Almeida, Sulzer-Azaroff, and Feldman (1992) successfully instructed nonhandicapped peers to use incidental teaching to increase labeling of preferred toys. Handicapped peers have also been successfully taught to use incidental teaching procedures. Farmer-Dougan (1994) taught group home residents to use incidental teaching procedures to increase the number of appropriate requests and verbalizations by fellow residents with mental retardation and autism.

Parent-mediated interventions. Since the 1970s, a number of studies have evaluated the effectiveness of teaching parents behavioral principles and techniques in working with their autistic children. These have included studies reporting outcome of parent training groups. Koegel, Schreibman, Britten, Burke, and O'Neill (1982) provided a group of parents of autistic children with 25 to 50 hr of training in behavior modification. The researchers then compared these children with a group of autistic children receiving 4 to 5 hr of out- patient treatment. They found that only the children whose parents received training generalized improvements in appropriate behavior to the home setting. Harris, Wolchik, and Milch (1982) also trained groups of parents of autistic children in behavior modification, finding significant improvements in the children's language and in the parents' behavior modification skills. Lovaas (1987) reported the results of a comprehensive early intervention program for children with autism, in which parents were trained to be the primary therapists in an intensive home-based training program for young autistic children. Treatment was conducted for approximately 40 hr a week for at least 2 years.


Intellectual level and educational placements of these children were compared to children who received approximately 10 hr of individual treatment or no treatment. According to outcome data, 47% of the children receiving intensive treatment were educationally and intellectually normal, whereas in the control groups, only one child was placed in a regular class. Despite the success of these group outcome studies, Koegel, Glahn, and Nieminen (1978) found that parents of autistic children successfully learned skills to teach specific behaviors to their children, but were unable to generalize these skills to teach other behaviors not originally targeted for training. A number of studies utilizing single-case methodology, in which parents were instructed in treating specific skills, have been published. Laski, Charlop, and Schreibman (1988) trained parents to use the natural language paradigm to increase speech in their autistic children. These researchers found that the training program produced significant increases in parent's requests for verbalizations and in the autistic children's appropriate speech. Love, Matson, and West (1990) trained mothers of autistic children with phobias to implement a treatment program utilizing par- ticipant modeling procedures. These researchers reported a significant increase in approach behaviors and decreases in verbalizations and vocalizations of fear. Charlop and Trasowech (1991) trained parents of autistic children to use a time delay procedure to increase spontaneous speech in naturally occurring settings. This approach yielded rapid increases in spontaneous speech, and the researchers reported maintenance of up to 30 months. Finally, Krantz, MacDuff, and McClannahan (1993) taught parents of autistic children to help their children follow photographic schedules depicting various activities, including leisure, social interaction, self-care, and housekeeping tasks. The researchers found significant increases in social engagement and decreases in disruptive behavior. The results of studies thus far are promising and show that parents of autistic children are capable of learning behavioral techniques to increase and decrease their children's target behaviors.

Self-management. Self-management is a treatment technique that has been found effective with persons with and without disabilities (O'Leary & Dubey, 1979). This technique consists of teaching subjects to monitor occurrences of appropriate behavior and nonoccurrences of inappropriate behavior and of reinforcing subjects who do so accurately. The schedule of reinforcement is gradually thinned. In children without disabilities, researchers have successfully used this technique to increase speech sounds (Koegel, Koegel, & Ingham, 1986) and academic skills (Harris, 1986). According to Koegel and Koegel (1990), self-management is beneficial because this procedure may be used for extended time periods without the presence of a treatment provider, and self-management techniques may be employed in a variety of settings. Koegel and Koegel (1990) evaluated the use of self-management in treating the stereotypic behavior of autistic children. These researchers taught subjects at school and other community settings to record nonoccurrences of stereotypic behavior and reinforced sub-


jects for accuracy. Prompts were eventually faded and the schedule of reinforcement was thinned. The researchers found that the subjects were able to record nonoccurrences of stereotypic behavior accurately and decreased the number of occurrences of this behavior. Koegel, Koegel, Hurley, and Frea (1992) used self- management to increase social skills in autistic children and found that the procedure simultaneously decreased disruptive behavior. The authors hypothesized that as the children leamed to interact more effectively with others, conversational interactions became less aversive and less likely to result in disruptive behavior motivated by escape or avoidance. Stahmer and Schreibman (1992) used self-management to increase appropriate play in children with autism and found that as play skills increased, self-stimulatory behaviors decreased. Subjects also generalized play behavior to multiple settings. Koegel and Frea (1993) utilized self-management to increase social behavior in children with autism and found that technique resulted in improvements in social behavior, as well as generalized changes in social behaviors not targeted for treatment. Finally, Pierce and Schreibman (1994) successfully implemented pictorial self-management, a technique in which children with autism were trained to use picture prompts to per- form daily living skills and to self-reinforce upon completion of tasks. The authors concluded that this procedure was effective in the absence of supervi- sion, and was useful for young, low-functioning children with autism.

SUMMARY AND FUTURE DIRECTIONS

Since 1980 the database on behavioral treatment of autism has increased dramatically. Categories of target behaviors addressed include aberrant behaviors, social skills, language, daily living skills, and academic skills. In the area of aberrant behaviors, researchers have developed functional analysis, a sophisticated method for determining the most effective treatment. Researchers are also developing ways to enhance the effectiveness of reinforcement-based and less intrusive aversive treatment procedures. In the area of social skills, investigators are focusing on methods to facilitate generalization of social behaviors. These methods include use of peer confederates, loose training, and changing pivotal behaviors. With regard to language interventions, the primary focus has been on generalization. Techniques for enhancing generalization include incidental teaching, the natural language paradigm, and time delay. The majority of language interventions have targeted expressive language. In the area of dally living skills, four skill categories were identified, including self-help, community, leisure, and vocational skills. Using autistic subjects, researchers have evaluated techniques for increasing daily living skills proven effective with mentally retarded persons. One technique is task analysis. With regard to academic skills, investigators have evaluated techniques for facilitating learning in autistic children. Techniques include task variation, reinforcer type, and reinforcer variation. Methods to remediate stimulus overselectivity have also been developed.


Several trends in behavioral treatment research have become prominent since 1980. Researchers began using consequences derived using the principles of functional analysis for target behaviors. They found that empirically derived consequences produced more potent treatment effects. Researchers also documented the concept of behavioral momentum, reporting that behavior may persist for a period of time after the schedule of reinforcement has been changed. This led to new treatments for noncompliance and social skills deficits. There is also a growing trend for investigators to use peers, siblings, and parents as models or trainers of appropriate behavior. Researchers have reported that involving these significant others enhanced treatment effects and promoted generalization. Finally, investigators have evaluated the use of self-management, a treatment technique proven effective with children without disabilities. Recent studies have proven that this technique can produce significant changes in the behavior of autistic children.

Since 1980, research on behavioral treatment of autistic children has become increasingly sophisticated. Researchers have addressed a multitude of target behaviors and developed more efficient methods to modify these behaviors. Yet there is a need for continued research in this area. Researchers have found that many techniques that are effective with mentally retarded persons are equally appropriate for autistic persons. However, many areas of behavioral treatment addressed extensively with mentally retarded persons have yet to be thoroughly evaluated with autistic persons. This is particularly true in the areas of daily living skills and academic interventions.

Investigators have recognized the need for effective assessment techniques to ensure implementation of the most appropriate treatment. Functional analysis is one assessment technique; researchers have found that it is a powerful tool for efficient treatment selection. This technique has proven successful with autistic persons and should be investigated further. Researchers have already documented well the success of this technique with aberrant behaviors. However, future studies should determine whether functional analysis may be applied to other categories of behavior.

Generalization is one of the most difficult challenges facing teachers of autistic persons. Numerous studies have evaluated techniques for increasing generalization of newly learned behaviors. Studies have shown that generalization is enhanced when autistic subjects are trained in their natural environ- ments, as demonstrated by the successes of incidental teaching and the natural language paradigm. The use of peers, siblings, or parents in treatment also facilitates generalization, as the autistic child learns to emit target behavior around others who are part of the child's environment.

In addition, there is also a growing trend towards streamlining treatment methods to conserve time and effort. Researchers developed treatments based on the concept of pivotal behaviors, which postulates that changes in one behavior may produce changes in collateral behaviors. This procedure holds great potential for autistic children, as this may significantly decrease the num-


ber of behaviors requiring direct treatment. Self-management is another procedure that may significantly increase treatment efficiency. Since the subject is taught to monitor his or her own behavior, implementation of this technique may decrease the amount of time the therapist is required to be present. Future studies should continue to evaluate these techniques, particularly by further classifying groups of collateral behaviors and determining which behaviors are best targeted for these methods.

The amount of research on behavioral treatment with autistic persons has significantly increased since 1980 and will continue to do so. Treatment techniques have become increasingly sophisticated and efficient. Consequently there are many areas in this field which will benefit from continued research.

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