Best Practices in Screening,
Assessment and Intervention
for Children with
Autism Spectrum Disorders
Susan L. Hepburn, Ph.D.
University of Colorado at Denver and Health Sciences
Juneau, Fairbanks, and Anchorage, Alaska
March 2008
The Autism Spectrum
Pervasive Developmental Disorders
Autism
PDD-NOS
Asperger Syndrome
Similarities = Difficulties in 3 areas:
Social functioning
Communication/language
Restricted activities and interests
Possible Differences Amongst Kids with an ASD







Level of cognitive functioning
Presence/absence of spoken language
Severity of symptoms
Specific behavioral expression of symptoms
Chronological age
Temperament or behavioral style
Vulnerability to other conditions, such as attentional,
anxiety or mood issues
Social Style

Aloof

Passive

Active-But-Odd
Social Style and Goals
Aloof
 Responding
Passive
 Initiating
Active-But-Odd  Reciprocity
Children with different styles require different educational
approaches
Developmental Aspects of Autism

Symptoms are
qualitatively different at
different stages of
development
Developmental Model of Autism
Moderating
Features
Social/Communicative
Functioning
Associated Features
Outcomes
To elaborate....

Core features: (1) Social-communicative
functioning and (2) ability to adapt
(or modify behavior in response to changes in context in a
fluid manner)

Moderating features: (1) cognitive ability, (2)
language ability, (3) behavioral style

Associated features: (1) attention, (2) anxiety, (3)
mood, & (4) problem behaviors
Best practice = developmentallyinformed practice
Screening
Assessment
Intervention
Always considering an individual child’s core symptoms of autism,
moderating factors, and associated features
Focus of Today’s Talk

What do we know about autism across
development in childhood and adolescence?

And what does our developmental knowledge tell
us about what we should be doing?



Screening
Assessment
Intervention
Studying Autism in Infancy

Retrospective videotape analysis


Record review


See reviews by Charman (2000) and Rogers (2001); Werner et
al (2000)
e.g., Johnson, Siddons, Frith, & Morton (1992)
Prospective sibling studies

e.g., Zweigenbaum et al (2005); Landa et al. (2005); Rogers et
al.(2005)
Possible Symptoms in Infancy

Deficits in dyadic – “person-to-person” -social
interaction




Baby is out of sync with caregivers
Lack of social smile
Delayed response to name
Unusual affect

Lack of appropriate facial expressions
Adrien et al, (1993); Baranek (1999); Rogers (2005)
Possible Symptoms in Infancy (cont.)

Signs of central nervous system dysfunction
 Hypotonia
 Lack of appropriate facial expressions
 Abnormalities in orientation to visual stimuli
 Aversion to touch

Signs of poor frontal lobe development


Poor integration of verbal and nonverbal behaviors
Poor attention
Adrien et al, (1993); Baranek (1999); Ozonoff et al (2007)
In summary, the results of infant studies suggest
that abnormalities are:

Subtle

More likely to involve the absence of rich social behaviors and
not the presence of unusual behaviors

Qualitative

A matter of reduced frequency, not complete absence
(Charman et al, 1997)

Inconsistent: Presence of intact behavior sometimes does not
mean everything is okay (Charman et al, 1998)
Absolute Indicators for a Developmental
Evaluation from Birth to 3 Years

No babbling by 12 months

No gesturing by 12 months

No single words by 16 months

No 2-word spontaneous phrases by 24 months

Any loss of any language or social skills at any time
American Academy of Pediatrics, 2005; Centers for Disease Control, 2006;
Firstsigns.org)
Characteristics of Autism
at Young Ages
Toddlerhood: (18 – 36 months)
Best Discriminators of Autism between
18 months and 3 years of age

Social and communicative impairments





Less likely look at others
Less likely to show objects
Less likely to point to an object
Less likely to orient to name
Less likely to follow attention
**Overall: lack of social orienting
(Charman & Baird, 2002; Cox et al, 1999; Osterling & Dawson,
1994; Mundy et al, 1994; Stone, Hoffman, Lewis, & Ousley, 1994;
Stone, Ousley & Coonrod, 2005)
Sometimes….

Parents of young children report general
behavior problems, with few reports of
social difficulties (Charman & Baird, 2002)

Parents of young children notice unusual
responses to sensation (Baranek, Foster, &
Berkson, 1997)

Regression of communication skills occurs
in approximately 15-30% of cases
(Filipek et al, 1989)
By 30 months, many children with autism can…

Follow an adult’s attention (i.e., “respond to joint attention”;

Indicate a simple request – without coordinated eye contact
Mundy et al, 1994)
– usually requesting improves in complexity by age 3 (DiLavore
& Lord, 1995)

Communicate to get access to objects, but not to get
an adult’s attention; Stone et al, 1997)


However, requesting behavior in autism rarely includes
coordinated eye gaze, gesture, and/or vocalizations (Stone et al, 1997)
Manipulate another person’s hand like a tool to send a
message (Stone et al, 1997)
Characteristics of Autism
at Young Ages
Preschool Years: (3 – 5 years)
Discriminating Items on Screening Tools for
Preschool-aged Children (3 – 5 years)

Rarely performs simple actions with a doll

Rarely engages in pretend play

Rarely integrates gestures and/or eye gaze with attempts to
communicate

May respond better to an adult’s bid for attention, but still has
trouble with initiating joint attention


Fewer shows and points to share attention
Imitation is not spontaneous, and/or is often of poor quality
Robins et al, 2002; Stone et al, 2005; Wetherby & Woods, 2004
Compared to Typical Development…

Remarkably, typically-developing children do many of the
behaviors lacking in 4-year olds with autism by the end of
their first or second years of life
(Carpenter, Nagell, & Tomasello, 1998; Fenson et al, 1994)

These behaviors are associated with word learning
(Tomasello, 2001)

And social understanding (Charman et al, 2000)
Autism
Lack of social interest
 Limited use of pointing
 Poor nonverbal
communication
 Poor imitation skills
 Limited pretend play

RELATIVE to overall
developmental level
Vs.
Developmental
Delay
Any impairment in
social or
communicative
behavior seems
consistent with the
child’s mental age
Development is evenly
delayed; few splinter
skills
(Lord & Pickles, 1996)
Characteristics of Autism
at School Age
Elementary Years: (6 – 11 years)
Middle School Years (11 – 14 years)
High School Years (14 – 18 years)
Transition/Young Adulthood (19 – 22)
Developmental Challenges
During Elementary Years







Play gets more cooperative
Social groups form (in and out)
Planning and other executive function skills become
more important
Social demands for conformity increase
Social relationships are more complex
Increased reliance on nonverbal cues and subtlety of
social signals
May be more self-awareness of differences, particularly
around the 3rd grade
Around Puberty….





Some children become more anxious
Some become a bit overwhelmed by the
organizational demands of middle school
Some show some problem behaviors that
haven’t shown for a long time
Some have questions about social rules and
boundaries and need some psychoeducation
Important time to monitor for overall well-being
Quality of Life for Teenagers




Does he/she have a favorite activity or passion
and are there opportunities to enjoy this often?
Are there chances to spend time with other kids
of similar ages and interests?
Is there a chance to get exercise and have time
outside?
Are there expectations for taking personal
responsibility at home and at school?
Critical Issues of Late Adolescence
(Ozonoff et al., 2002)







Finding support people other than parents
Disclosure
Sexual development
Romantic relationships
Identity Development
Depression and anxiety
Seizures or other neurological symptoms (e.g., tics)
Implications for Screening
Across childhood and adolescence
Essential Elements of Screening

Developmental history (e.g., milestones, first concerns)

Medical history

Family history

Cognitive/developmental assessment

Needs to include interview and observation
Best Practice in Screening

If you hear concerns about nonverbal social-communication
behavior linked with concerns about rigidity – refer for
screening

Gather both parent report and direct observation data

Integrate observations from a multidisciplinary team

Directly assess social reciprocity
(Charman & Baird, 2002; Filipek et al, 1999; Lord & Risi, 1999; Rogers,
2001; Sandler et al, 2001)
Best Practice (cont.)

Obtain information from unstructured situations

Consider the child’s access to social experience

Clinicians should seek training on semi-structured
interviews to expand their knowledge of autism at
different levels of development– even if they don’t use
them all the time
(Charman & Baird, 2002; Filipek et al, 1999; Lord & Risi, 1999; Rogers,
2001; Sandler et al, 2001)
Best Practice (cont.)

Include a medical and developmental history

Provide various types of social presses in
interaction with child
(Charman & Baird, 2002; Filipek et al, 1999; Lord & Risi, 1999; Rogers,
2001; Sandler et al, 2001)
Consider the known genetic risks

5% of families with a child on the autism spectrum will
have another

This translates to 5 in 100, or 50 in 1000
 Typical rate is 1 in 1000
 Risk increases from 1 to 50 per 1000
Or….

If you have a child with autism, you have a 19-out-of-20 chance
that a future child will not be autistic
Keep in mind... The risk of having a second child with
some features (but not the whole picture) is thought to be
higher
(LeCouteur et al., 1996; Rutter et al, 1996; Szatmari, Jones, Zwaigenbaum, & MacLean, 1998)
Challenges of Screening for Autism in
Young Children




Autism can occur with other conditions
Hard to know how good the standardized tools
are for early identification
Reliability of early diagnosis is still being
assessed
It is still difficult to predict prognosis
(Charman & Baird, 2002)
Remember how different the picture can look in
young children (Dixon et al., 2005)

Majority of toddlers with autism do NOT
display the following DSM-IV symptoms:





Impaired conversation
Adherence to routine
Stereotyped language
Restricted interests
Preoccupations with parts of objects
Screening Instruments for Young Children

Within the general population:

Checklist for Autism in Toddlers (CHAT; Baird et al,
2000; Baron-Cohen et al, 2000)

Within a clinically-referred population:


Modified CHAT (M-CHAT; Robin et al, 2001)
Screening for Autism in Toddlers (STAT; Stone,
Coonrod, & Ousley, 2000

Pervasive Developmental Disorders Screening Test
(PDDST; Siegel, 1999)
New Screening Tools for Young Children

STAT – scoring system for children between 12-24
months (Stone et al., 2005)

First year Inventory (FYI) (Watson et al. 2005)—screening
12 month olds in general population for risk of ASD

Language impairments in ASD (Zwaigenbaum et al. 2005);
less vocalization overall and more atypical vocalizations

AOSI (Bryson et al, 2007): development of instrument to
measure autistic behaviors in very young children
(beginning at 6 months)
Why screen after age 5?

Some bright children, particularly those who are not high in activity
level, may not be identified in the preschool years

The impact of having high-functioning autism can hit harder after
preschool – and more kids need help
 Due to increase in organizational demands
 Due to increase in abstract (not rote) material in 2nd-3rd grade
 Due to decreased opportunities to learn

Some severely-impaired, developmentally delayed children are
misdiagnosed with autism in preschool years, and SES factors may
influence early identification process (Desposito, 2002)

A formal identification of an ASD can help to guide interventions
and promote understanding of why the student behaves as he does
Screening Tools for School-Aged Children

Social Communication Questionnaire (SCQ; Lord et al.,
2003): parent interview, very short version of ADI-R;
yes/no responses, best for children 5 and older, score
of 15 is “at risk”

Autism Behavior Checklist (Krug, 1989): Teacher or parent
checklist, symptoms consistent with classic as opposed to
atypical presentation, may over-identify kids with MR as having
autism…
Screening for high-functioning or
atypical autism

Asperger Syndrome School Questionnaire (ASSQ;
Ehlers, et al., 1989); normed on several thousand school-aged
children in Europe, being piloted in US through CADDRE
project

Children’s Communication Checklist (Bishop et al, 2003);
teacher or parent checklist or interview that captures information
on child’s use of pragmatics (social communication)
Sample Questions from the ASSQ

“can be with other children, but only on his/her terms”

“has clumsy or awkward movements or gestures”

“uses language freely, but fails to make adjustments for his
listener”

“has a literal understanding of language”

“has difficulties completing daily routine activities”
Implications for Assessment
Across childhood and adolescence
The Family’s Experience with Diagnosis:
Is it a ….








Hearing problem?
Language delay?
Global developmental
delay?
Is it a general behavior
problem?
Seizure disorder?
Genetic disorder
Metabolic or gastrointestinal disorder?
Auto-immune disorder?










Go to the audiologist
Go to Child Find
Go to the speech
pathologist
Go to a psychologist
Go to your pediatrician
Go to a neurologist
Go to a genetics clinic
Go to a GI doctor
Go to a nutritionist
Go to a DAN doctor
Areas of Assessment







Developmental/cognition/academics
Strengths, preferences, learning style
Play and social interaction
Communication, language, speech
Adaptive behavior
Fine/gross motor
Family functioning and resources
Developmental/Cognitive Assessments

Consider standardized measures that assess both verbal
and nonverbal functioning
Preschool: Mullen Scales of Early Learning or
Bayley Scales of Infant Development
Kindergarten +: Differential Abilities Scale,
Stanford-Binet-V, K-ABC, WISC-IV

Sometimes, examine nonverbal cognitive functioning
more deeply (e.g., Leiter-R, Merrill-Palmer, Ravens Matrices, CTONI)
Communication Skills

Range of communicative
functions



Behavioral regulation
Coordinating joint
attention
Ability to synthesize
forms


Gestures
Eye gaze

Spontaneity of use

Social directedness of
communication

Profile of receptive and
expressive abilities
Language Skills

Receptive ability

Expressive ability

Pragmatic skills

Functional/spontaneous use of language on a daily
basis (e.g., frequency and complexity)

Symbolic play
Speech Skills

Oral-motor integrity

Range of vocalizations

Spontaneity of vocalizations

Ability to imitate sounds or produce on cue

Volume, prosody, etc.
Adaptive Behavior Assessment

Scales of Independent Behavior - Revised (SIBR; Bruininks et al., 1996)

Vineland Adaptive Behavior Scales (Sparrow et
al. 1984; teacher and parent forms;
supplementary norms for autism)

AAMD Adaptive Behavior Scales (Lambert et
al., 1993)
Could the child have autism?
First Step: Parent Interview





Presenting problems and concerns
Medical and developmental History
Social and family history; family functioning and
resources
Current interventions and therapies
Autism Diagnostic Interview Revised (Lord et al., 1994)
 social relatedness, communication, ritualistic
behaviors; “gold standard”, requires training
Parent/Caregiver Questionnaires about
Social and Communicative Development

Social Communication Questionnaire: ages 4+
(SCQ; Berument et al, 1999)

Childhood Routines Questionnaire
(Evans et al, 1997)


MacArthur Communication Development
Inventory: best for young children or less verbal
children(CDI; Fenson et al, 1993; 1994)
Social Responsivity Scale (SRS; Constantino, 2001)
Direct Observation of
Social and Communicative Behaviors

Autism Diagnostic Observation Schedule (Lord
et al, 1999) is a commonly used assessment tool
that provides opportunities to observe subtle
social and communicative behaviors



Developmentally sensitive
Can inform interventions
Can be used across the lifespan
Challenges Using the ADOS

Requires clinical experience with autism
spectrum disorders

Requires a lot of practice to administer and
score

Requires that you sit back and not
over-scaffold or do your job too well
Best Practice

Seek training through the University of Chicago or certified

Maintain a core group of staff to administer and co-score

Practice regularly

Use in combination with other measures - Especially parent

Know the limits and the strengths of the tool

Know how to talk to the parents about the results
trainer and follow the recommended training protocol
assessments
report
Implications for Intervention
For Young Children
Cascade Theory
(Rogers, Pennington, Loveland)

Maybe there are several early deficits that conspire to
pull the child away from active involvement with the
social world

And maybe this restricts their access to social learning,
so that they miss out on learning opportunities

And maybe that’s why some kids get worse and worse,
and others get better and better
The key to outcome for children with autism
might be…

Active engagement in the social world





Active involvement with peers and adults
Lots of practice with difficult social and
communicative interactions
Consistent exposure to new situations
Persistence, even when it’s hard
Setting small goals and ensuring success
Which is best delivered through…



Early intervention in an integrated, multifaceted
intervention program
Developmentally-focused approach
Delivered in many different formats


1:1 and highly structured
Natural routines and daily activities
For a review: see National Council on Research, 2001
Goals for Intervention with Young Children



Increase active engagement in social and
communicative interactions
Teach in multiple real-life settings
Increase the opportunities for sharing attention and
affect with the child with autism



Use routines and predictable, physical activities
Alternate following child’s lead with leading the child
Actively teach following and initiating joint attention, as well as
imitation skills
Teaching Joint Attention (cont.)

Set up motivating activities that encourage
attention and interest

Prompt the shared attention response and
reinforce with continued activation of the toy (or
another natural consequence)

Practice, practice, practice – Kasari et al. (2004) are
doing 10-minutes per day for 5 days a week and
showing strong skill development in preschool
children within 7 weeks
Imitation

Imitation is the basis for cultural learning

Imitation ability is strongly influenced by one’s
ability to generalize

Imitation leads to language learning in typically
developing children, as well as social-emotional
understanding
Implications for Intervention
For School-aged children
Overview of Interventions

Supporting the “Master Planner of the Brain”

Educational modifications

Minimizing interfering behaviors in the classroom

Improving social competence



Naturalistic or Peer-Mediated
Narrative or Cognitive-Behavioral
Direct Instruction
I. Supporting the “Master Planner”
of the Brain
Helping with attention,
organization,
inhibition,
initiation, and
sustaining attention
3 Kinds of Attention Problems

Shifting attention

Sustaining attention
From own agenda to another’s
agenda


From favorite topic to less
preferred topic


From internal world to external
world



Missing the forest for
the trees


From self to other
Short attention span
Tendency not to finish what
has been started
Easily distractible

Overly focused on details
Missing the “big picture”
Helping Children Shift Attention

Visual cues to focus attention

Advanced warning of shift in attention

Clear endpoints for activities

Routine for shifting attention

Practice attending to nonverbal cues
Helping Children Sustain Attention

Clear indication of how long attention should be sustained

Provide frequent breaks

Reinforce/reward appropriate attending

Give them a task to do – need some kind of active
involvement in activity

Reduce distractors in the environment

Give directions 1 step at a time
Sustaining attention (cont.)

Consider seating the child towards the front of the
classroom near good peer models

Be aware that too much auditory information without
visuals is difficult to attend to for most of these kids

Give specific listening assignments (e.g., list of words to
check off when heard)
Helping Children to Focus on the
Whole as the Sum of the Parts

Provide verbal and visual cues concerning the
“big picture”

Highlight the most important concepts

Explicitly link main ideas and supporting ideas
Structured Teaching
Structured teaching examples were downloaded from the Wisconsin Department of Special
Education website:
www.specialed.us/autism/early/ear11.htm
Stokes, S. (2005). Effective Programming for Young Children with Autism (Ages 3-5).
“Written by Susan Stokes under a contract with CESA 7 and funded by a discretionary
grant from the Wisconsin Department of Public Instruction.”
Allow a headstart on transitions




Student may need more time to organize self for
next activity
For some students, chaos of other children
making a transition is overwhelming – see if
student can start earlier or later than other
students
Whenever possible, reduce transitions
Use buddy system for room changes
II. Educational Modifications
Contributions by:
Sally Ozonoff, Sue Thompson, Jennifer Stella
How to teach new concepts
(Klin & Volkmar, 2001)

Explicitly

Rote/rule-governed


Verbally (if Aspergers’)
Visually (if High-functioning Autism)

Parts-to-wholes

Sequentially
If the child processes slowly:

Avoid timed tests

Encourage completion – provide visual cues for
starting and stopping and require only enough work
that child can finish with other students and experience
closure

Require completion of part of assignment
If the child struggles with
handwriting…







Consider oral tests or projects instead of papers
Encourage typing assignments
Reduce amount of copying that must be done
Make sure worksheets have enough response space for
large writing
Use multiple choice instead of fill in the blank
Emphasize quality, not quantity
See if child can purchase school books and highlight
(instead of taking notes)
If the student has visual-spatial
weaknesses that make math
difficult…





May need visual cues to align numbers in math
problems, use decimal points,dollar signs, etc.
Provide a step-by-step approach to solving problems
Encourage “talking through” word problems
Try to reduce amount of repetitive writing
Give an example of a completed assignment
Monitor for reading comprehension

Some students will become expert “decoders” without
truly understanding what they are reading

Actively teach how to identify main ideas, supporting
points, character perspectives, etc. Can be done in a
rule-based approach.

Provide the student with the text the night before so
that he/she can preview it
Be ready for “parallel activities”

If an activity is appropriate for the other
students, but is likely to be frustrating for the
student with HFA, consider designing a parallel
activity that teaches the same concepts but in a
different way. Allow students to choose which
activity to do.
Use Computer-Based Instruction

Practice skills with educational software


Fast ForWord for phonological processing and other
important literacy and language skills
Interactive CD-ROMs for narrative structure, science, math,
special interests

Practice writing via email

Practice research via internet
Be careful about overwhelming the
student with homework

Families often report that homework is a significant
stressor

When giving homework, be sure to give complete
instructions

Whenever possible, provide study hall towards the end
of the day with a tutor available to complete homework

Whenever possible, set a homework routine
Use an assignment notebook



Teacher takes the lead in monitoring its use
Student will need to be prompted to add/delete
assignments
Use existing systems that look “normal” –
Daytimer, etc.
Break assignments down into steps

Use clearly numbered sequences to illustrate
progression

Webs or flowcharts might be useful

Actively involve student in monitoring
completion of assignments
For large assignments…

Show student how to 
break large tasks into
steps and check-off
when each step is

completed – observe
completed steps,
student may not report
well
Have regular meetings
with student to monitor
progress
Send written description
of large assignments
(with due dates and
steps) to parents
III. Minimizing Problem Behaviors
that interfere in classroom activities
Commonly reported challenging
behaviors in the classroom





Interrupting and other 
impulsive verbal
behaviors

Resistance to changes

in routine
Insistence that certain 
rules be followed

Concrete style

Poor handwriting
Difficulty accepting
mistakes
Little patience
Driven quality
Social vulnerability
Distractibility
Perseverations or
obsessions
Consider the message the behavior is
sending






Is confused, needs help but has difficulty
communicating under pressure
Feels negative affect (e.g., anxiety, worry, sad, mad) and
doesn’t know how to manage it physiologically and
behaviorally
Wants to escape
Craves predictability
Wants to interact, doesn’t know how
Thinks he can’t do something well, so doesn’t try
Avoid Contingencies and Instead….
Catch the Student Being Good

Always be on the look out to praise or reinforce
good attention, effort, participation, waiting,
tolerance, acceptance of change, coping, etc.

Link rewards to effort and participation but
provide intermittently and not with a formalized
contract ahead of time
Set Clear Limits




Anticipate challenging situations
Share written rules/guidelines with student for
specific situations
Be explicit, rule-governed, clear, consistent
Pick and choose battles
Use clear and specific language to
shape behavior

Avoid phrases like “behave yourself ” – not specific
enough

Tell the student exactly what is expected and for how
long: “You need to be sitting quietly and reading your
science book until 11:15.”

Emphasize words that indicate when – “now”, “later”,
etc. and gently redirect if student acts before it is time
Encourage Choice-making

Autonomy is often very important for these
students; use it to prevent problems and
reinforce effort

Help student identify how choices are perceived
by other people
Use Visual Reminders


Use post-it notes or index cards on the child’s
desk to remind him/her of appropriate behavior
(e.g., “raise your hand”)
Instead of verbally reminding child, simply
touch the card to send the message
Use the Buddy System



Encourage the child to watch what another
student does and model that behavior
Rotate buddies
Whenever possible, use same-gender buddies
Minimize down time

Give the child 2-3 functional activities to engage
in when he/she has completed work and is
waiting for the next activity

Provide clear rules about behavior during “down
time” or independent work.
Use a “ticket out” system





Provide a limited number of tickets out of the
classroom per day
Provide written guidelines to the student for where to
go, how long, etc.
Determine a safe place to go and/or supervision
Teach the student when to use the tickets
Reinforce appropriate use
Plan for alternative activities

For example, if cafeteria is too noisy and
upsetting, create a plan for eating and going
elsewhere

It may not be useful for some students to
participate in all classes, assemblies, field trips
etc.– make these decisions with parents
When problem behaviors occur




Label the misbehavior in a calm, neutral manner
Whenever possible, allow natural consequences
to arise
Do not process/discuss problem behavior in the
moment
Wait for a calm time to discuss what the student
could have done differently
Encourage self-reflection




Help student to identify situations that are particularly
challenging for them
Help student to create a list of options for responding
to these situations in the future
Use self-reflection to strengthen self-esteem
Demonstrate differences between student’s perspective
and others’ perspective
IV. Improving social competence
A. Naturalistic Teaching

Narrating situations (Tony Attwood calls this “being an
anthropologist”)

Setting up play/social situations that you can subtly
observe and teach through



Bring good models into your house/classroom and structure
play activities to encourage active participation
Prime or prepare student with ASD
Choose shared activities that emphasize strengths and are
cooperative, not competitive
Peer Mediated Interventions:
Improving Social Relationships
Among Children with Autism
in Inclusive Settings
Audrey Blakeley-Smith, Ph.D.
JFK Partners
University of Colorado at Denver and Health Sciences Center
Audrey.blakeleysmith@uchsc.edu
Research on Inclusion for Students
with ASD

Changes in problem behavior (stereotypies,
self-injury) (Lee & Odom, 1996; McGee, Paradis &
Feldman, 1993)

Changes in academic performance (SaintLaurent & Lessard, 1991; Saint-Laurent, Fournier &
Lessard, 1993)
Social Inclusion:
What Does the Research Say?

Students in integrated settings spend more
time engaged in interactions than students in
segregated settings (Center & Curry, 1993)
But What Does this Mean…

Interactions between students with special
needs and their peers, are often one-sided and
didactic
78% of student interactions were
instructional
 <5% of student interactions were social

(Farrell, 1997; Hilton & Liberty, 1992)
Social Inclusion:
What Do the Peers Say?

Typical peers often report that they have
insufficient knowledge and inadequate
communication strategies (York & Tundidor,
1995)

Most peers prefer to interact with each
other rather than children with HFA
(Chamberline, Kasari, Rotheram-Fuller, 2007)
Social Inclusion:
What do Children with ASD say?

Children with HFA tend to view
themselves as more socially involved
than their peers report (Chamberlin, Kasari,&
Rotheram-Fuller, 2007)

Children with HFA report greater
loneliness than their typical peers
(Bauminger & Kasari, 2000)
Peer Mediated Interventions

Choose Peers Who Are…

A part of the child’s social world

Interested

Attentive to adult instruction

Responsive to adult praise
Preparing Peers

Learn about their interests and motivations

Discuss goals of group

Teach how to prompt/help

Role play prompting/helping

Systematically fade reinforcement
Does sharing the autism diagnosis with
peers help?

Negative attitudes frequently persist despite
providing children with information about ASD
(Swaim & Morgan, 2001)

By the 5th grade, students are no longer as receptive
to explanatory information regarding ASD (Cambell,
2006)
Guidelines for Peer Prompting

Teach peers to provide visual and gestural prompts as
well as “sentence starters”, “help” cards

Encourage peers to help more in the beginning and less
at the end of a task

Teach peers to wait for a response from target child

Focus peers on prompts and praise, not criticism or
correction
Teach Peers to Respond Appropriately





Follow and redirect
Persistence
Patience
Change their expectancies regarding the nature
of the interaction
Change their attributions for the child’s behavior
B.
Cognitive-Behavioral Approaches*

Using narrative strategies (scripts, video examples,
comic strips, social stories) to clarify basic social
concepts

Relying on a child’s cognitive strengths to compensate
for lack of social insight
*This section relies heavily on contributions from
Audrey Blakeley-Smith: Audrey.blakeleysmith@uchsc.edu
Social Narratives
Purpose:
 To teach social rules and the reasons why situations
are handled in certain ways
 Provide alternatives and/or coping strategies
How to:
Review Carol Gray’s website or see Gray, 1993; Gray,
1994; Fullerton, Stratton, Coyne, & Gray, 1996
Differentiating situations
Behavior in library……
….is the same as in the
bank, dentist office, etc.
Behavior with little
sister……
…..not the same as
behavior with friends
Behavior on the
playground…
…not the same as
behavior in the car
Comic Strip Conversations
Purpose:
 Increase social understanding of difficult
situations
 Incorporates the use of color and simple
drawings to improve the student’s
understanding of language and social
interactions (Gray, 1994; Fullerton, Stratton, Coyne, &
Gray, 1996)
Conversation
symbols
representing:
Talk
Think
quiet
LOUD
words
words
Interrupt
Listen
Colors Representing Emotions:



Green = good ideas, happy, friendly
Red = bad ideas, teasing, angry, unfriendly
Combined colors = confusion
Setting symbols to indicate the setting for the
social situation
Comic Strip Conversations
How to:
 Review –With the student, draw the difficult social
situation;support the student in identifying thoughts
and emotions
 Practice –Help the student identify more appropriate
ways to respond in similar social situations in the
future; draw these pictures
Using comic strip conversations to
understand social situations

Who is challenging me?

Where are we?

What are the rules?

Who is on my side here?

What happened just
before?

What happened just
after?

What should I do next
time?
Social Scripts
How to:
 Identify age-appropriate social interactions,
language and behaviors
 Develop a script
 Practice the script with the student
 Alter the language/behaviors to reduce rigidity
 Support the student to initiate and complete the
script with a peer(s)
Social Scripts
 Scripted conversations and interactions
 E.g.,: Scripts for entering/leaving classroom/activity, going to
McDonalds etc.
 Scripts for classroom jobs
 E.g., paper distributor: make eye contact or tap shoulder
and make eye contact, “Here’s your paper ____”
Video
Purpose:
 View videos to:
 Highlight salient social cues
 Highlight specific social communicative behaviors
 Create videos to teach:
 Imitation, play, community expectations,
replacements to challenging behaviors, language and
conversation skills
How to View Videos/TV
 Have the student observe and interpret
nonverbal messages in the show
 Have the student make predictions about
behaviors
 “Video Detective” (Smith Myles &
Southwick, 1999; Attwood, 1998)
How to Create Videos
 Identify target social behaviors & situations
 Videotape familiar peers in those situations
engaging in appropriate social behavior
 Make the social cues and target behavior the most
salient aspects of the video
 Have the child view the video and critique their
own and others’ behaviors
From: Quill, K. A. (2000). Do-Watch-Listen-Say
How to Use the Created Video
 View the video regularly (daily)
 Preview the video just prior to the relevant situation
 Pair the video with other visual cues to use as
instructional prompts in the actual situation
 Fade video viewing as the skills are mastered in the
actual setting
Modeling and Rehearsal
Purpose:
 To highlight the key behaviors that the child should
attend to in developing a social sequence
How to:
 Peer or adult demonstrates the appropriate social
skill for the child to imitate
 do in vivo, during role play, or set up situations
for practice
Acting Lessons
Purpose:
 Role-playing and acting may help the child
to express emotions verbally and
nonverbally
 The child may learn to interpret others’
emotions, feelings, and voices
C. Direct Instruction

Adult-directed activities

“Lesson-like”

Involves lots of practice and repetition

Reinforce effort and attention and scaffold
enough to ensure success

Goal is to master basics – think of learning a
foreign language!!
Individual Work

Include parents whenever possible

Incorporate homework

Use a notebook system

Clearly define goals and review progress regularly in
sessions with child and parent
Individual Work (cont.)

Use: children’s books, art, music, games,
physical activities, worksheets, puzzles,
videotape, roleplays, snack time
Remember: if you use this approach alone -- you
won’t get much
carry-over of skills
Dyads

Same focus of individual work, but with another child
attending also

Choose a peer from the school or neighborhood

Parents still attend and homework is often focused on
fostering interaction between the two kids
Small Social Skills Groups

4-6 children

1-2 adults

Target to Peer ratio of
2:1 or 1:1

Stable vs. variable peers
Adult Interaction

Model and narrate appropriate social behavior in
a very obvious way

Use humor and lighthearted approach

Provide frequent praise and reinforcement for
effort and attention
Choose a Focus for the Group

Cooperative Play

Pragmatic Language

Problem-Solving

Emotional Regulation

Emotional
Understanding

Basic Social Interaction

Leisure Skills

Social Understanding
Determine Setting/Logistics

Where?

How Often?

How long?

Rules?

Materials?
Planning a Session

Emphasize routine

Provide visual structure

Apply the “70/30 Rule of Repetition”

Incorporate special interests
Planning (cont).

Alternate tasks by difficulty, activity level

Teach using multiple modalities

Start each session with a snack

End each session with R+

Maintain close contact with families
Teaching Activities

Use existing social skills curricula
(see reference list)

Use actual situations to fuel lessons within a
predictable framework

Know the child’s peer group and be
developmentally informed
Dealing with Teasing and Bullies
(Ozonoff, 2002)



Establish peer buddies and foster good peer
relations
Teaching classes on tolerance, diversity, learning
styles
Assertiveness training

Asking for help, finding safe places, walking away,
using humor
Resources for Teasing/Bullying



Bully-proofing your child: A parent’s guide by Garrity,
Mitchell, & Porter (2000).
Bully-proofing your school: A comprehensive
approach for elementary schools. Garrity et al. (2000).
For children: Bullies are a pain in the brain by Trevor
Romain
Talking to a Child About Having Autism

Often best to wait until they have questions; often
comes up at around age 10 or so

Many good books available to help to educate kids
about their condition; see www.futurehorizons.org

Be matter of fact and calm and positive

Discuss it as a way to describe a person’s strengths and
challenges, not as a way of capturing the whole person

Have the conversation several times
In Conclusion

Need to think developmentally when planning
screening, assessment, or intervention

There are many good resources for intervention
for kids of different ages and functioning levels
Thanks to…

Families who participate in our research and
clinical activities at JFK Partners of the
University of Colorado at Denver and Health
Sciences

The Nebraska Autism Spectrum Disorders
Network

Laura Maddox, State ASD Coordinator
This work has been funded by:









National Institute of Child Health and Development (U19
HD035468)
National Institute of Communication Disorders and Deafness (R21
DC005574-03)
Association of University Centers on Developmental Disabilities
University Centers of Excellence
Cure Autism Now
March of Dimes
Organization for Autism Research
Autism Speaks
Doug Flutie Foundation
Research Team at JFK Partners and the
University of Colorado at Denver
and Health Sciences Center
Director:
Susan Hepburn, Ph.D.
Mentors:
Sally Rogers
Bruce Pennington
Corry Robinson
Linda Crnic
www.jfkpartners.org
Collaborating scientists:
Deborah Fidler, Ph.D.
Judy Reaven, Ph.D.
Audrey Blakeley-Smith, Ph.D.
Amy Philofsky, Ph.D.
Ann Reynolds, M.D.
Daniel McIntosh, Ph.D.
Eric Moody, Ph.D.
Don Rojas, Ph.D.
Hilary Coon, Ph.D.
Kathy Culhane-Shelburne, Ph.D.
With Appreciation to Many Students
and Research Assistants Over the Years











Katy Ridge
Galit Mankin, M.S.W.
Athena Hayes, M.S.
Angela John, M.S.
Benjamin Yerys, Ph.D.
Erin Flanigan
Helga Simons
Mark Guiberson, Ph.D.
Elizabeth Eno, M.S.
Susan Murray, CCC-SLP
Kym Gilchrist












Nancy Lee, Ph.D.
Terry Hall, CCC-SLP
Renee Charlifue-Smith, CCC-SLP
Alison Herndon, MPH
Kristina Kaparich, MPH
Marissa Sellinger, M.S.
Lila Kimel, M.S.
Shana Nichols, Ph.D.
Tracy Stackhouse, OTR
Megan Martins, Ph.D.
Mim Ari
Norbert Nguiya