551384
research-article2014
BMOXXX10.1177/0145445514551384Behavior ModificationFleury et al.
Article
Learning How to Be a
Student: An Overview of
Instructional Practices
Targeting School
Readiness Skills for
Preschoolers With
Autism Spectrum
Disorder
Behavior Modification
2015, Vol. 39(1) 69­–97
© The Author(s) 2014
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DOI: 10.1177/0145445514551384
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Veronica P. Fleury1, Julie L. Thompson2, and
Connie Wong3
Abstract
Due to difficulties associated with autism spectrum disorder (ASD), many
children with ASD will require additional support to actively participate in
classroom activities. Therefore, it is important that professionals who work
with young children with ASD know what skills to teach and how to teach
them. Using the recent evidence-based practice review conducted by the
National Professional Development Center on ASD, we have identified
studies that targeted school readiness behaviors which can have implications
for academic skill development. In this article, we evaluate (a) the types of
skills that have been taught to preschool children with ASD, (b) the strategies
used to teach specific skills, and (c) other descriptive information, such as
who delivered the intervention and the setting in which the intervention
1University of Minnesota, Minneapolis, USA
2University of North Carolina at Charlotte, USA
3University of North Carolina at Chapel Hill, USA
Corresponding Author:
Veronica P. Fleury, Department of Educational Psychology, University of Minnesota, 56 East
River Road, Minneapolis, MN 55455, USA.
Email: vpfleury@umn.edu
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70
Behavior Modification 39(1)
took place. We conclude by offering suggestions for future research and
considerations for professional development.
Keywords
autism spectrum disorder, school readiness, evidence-based practice,
preschool
Inclusion of children with autism spectrum disorder (ASD) in general education settings has proven to be a significant challenge despite legal mandates
(Individuals With Disabilities Education Act, 2004; Kieron, 2013; Koegel,
Matos-Freden, Lang, & Koegel, 2012). Only 58% of children with ASD
spend more than 40% of their day in general education settings compared
with 82% of children from all other disability categories (U.S. Department of
Education, Office of Special Education and Rehabilitative Services, Office of
Special Education Programs, 2013). This statistic implies that a disproportionate number of children with ASD are educated in more restrictive environments, perhaps due to the complex needs of children with ASD that result
from deficits in social communication and social interaction, and restrictive,
repetitive patterns of behavior (American Psychiatric Association, 2013). In
school settings, children with ASD demonstrate significantly higher behavioral excesses such as aggression or self-injurious behavior and deficits
including limited communication and difficulty participating in school routines (Ashburner, Ziviani, & Rodger, 2010). These behaviors may lead to
placement in more restrictive settings (Machalicek, O’Reilly, Beretvas,
Sigafoos, & Lancioni, 2007; Scruggs & Mastropieri, 1996).
The trajectory of special education has moved beyond mere access to free
appropriate public education to a greater emphasis on educational achievement for all individuals with disabilities (Kieron, 2013; Koegel et al., 2012).
It is important for children with ASD to have full access to the general curriculum content for their assigned grade level regardless of whether they are
served primarily in self-contained or inclusive settings. Accordingly, we need
to have a better understanding about the foundational skills that will enable
children with ASD to appropriately participate in classroom activities,
thereby improving their opportunities to access the general education
curriculum.
School Readiness for Children With ASD
The National Governors Association (NGA; 2005) Task Force on School
Readiness described children’s school readiness as manifested in five areas:
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Fleury et al.
health and motor skill development (e.g., vision, hearing, gross and fine
motor skills), socio-emotional development (e.g., self-regulation, establishing reciprocal relationships with peers and adults), motivation to learn (e.g.,
persistence, sustained attention to educational tasks), language and early literacy skills (e.g., listening and story comprehension, phonemic awareness,
print concepts), and conceptual knowledge and application (e.g., vocabulary,
reasoning, associations, problem solving). All of these domains are important
to building a foundation for learning.
Characteristics of ASD (e.g., social communication deficits, restricted
interests) may place children with ASD at a distinct disadvantage for naturally developing some facets of school readiness skills. The Pre-Elementary
Longitudinal Study (PEELS) is a national study that addressed four key areas
of school readiness—emergent literacy, early math proficiency, motor performance, and social behavior—in preschool children with special needs
(National Center for Special Education Research, 2006). Data for children
with ASD show an uneven profile in school readiness behavior. As a group,
children with ASD performed above the population mean on their ability to
identify letters and words and were within normal limits in receptive vocabulary, quantitative concepts, and motor skills measures. As expected, the greatest skill deficit for children with ASD was in the domain of social behavior.
Children with ASD performed two standard deviations below the population
mean on the social skills subscale of the Preschool and Kindergarten Behavior
Scales (PKBS-2). This subscale is used to assess personal behaviors such as
“works or plays independently,” “follows rules,” “accepts decisions made by
adults,” and interpersonal skills such as cooperation, turn-taking, and comforting other children. Furthermore, children with ASD scored significantly
higher than the norm on the PKBS-2 problem behavior subscale. Higher
scores on this scale indicate greater concern about problem behavior and
include items such as “defies teacher or caregiver,” “takes things away from
other children,” “is restless or fidgety.” Children with ASD also had difficulty
on measures of independence, self-control, and personal responsibility
(Adaptive Behavior Assessment Scale, ABAS-II) which includes items such
as “follows adults request to quiet down and behave,” and “works independently and asks for help only when necessary.” In fact, children with ASD
had the poorest performance on the PKBS-2 problem behavior subscale and
the ABAS-II self-direction scale compared with all other disability groups.
These early deficits in school readiness, primarily in the social behavior
domain, can have implications for future academic success for children with
ASD. Lloyd, Irwin, and Hertzman (2009) conducted a longitudinal study that
compared kindergarten school readiness scores with fourth-grade assessment
outcomes for individuals with disabilities, including 175 children with ASD.
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Behavior Modification 39(1)
These researchers found that 88% of the children with ASD did not demonstrate school readiness when assessed in kindergarten and approximately
86% of children with ASD “did not meet expectations” in mathematics and
literacy following fourth-grade assessments. These results provide evidence
of a correlation between school readiness behavior and later school outcomes
for children with ASD.
If we expect children with ASD to be able to access and benefit from the
general education curriculum, professionals who work with young children
with ASD will need to identify what skills to teach and how to teach them. A
number of reports have been published that provide a broad overview of
focused instructional practices (National Autism Center, 2009; Wong et al.,
2014) and comprehensive treatment models (Dawson et al., 2010; Rogers &
Vismara, 2008; Strain & Bovey, 2011) that are supported by research to
improve developmental outcomes for children with ASD. The National
Professional Development Center (NPDC) on ASD recently published an
updated report of evidence-based practices for children, youth, and adults
with ASD. The NPDC report represents the work of a large systematic review
of focused intervention strategies for individuals with ASD that were published in peer-reviewed journals between 1990 and 2011. Content analysis of
these studies yielded 27 evidence-based practices that encompass a variety of
outcomes, including those that have been found to be effective in improving
pre-academic/academic skills and school readiness skills for individuals as
young as toddlers. In this report, the authors differentiated between studies
that improved pre-academic and academic skills from those that address
school readiness skills. The NPDC work group defined pre-academic/academic skills as outcomes broadly related to performance on tasks typically
taught and used in school settings, whereas school readiness was defined as
outcomes that are related to task performance but are not directly related to
task content. Accordingly, studies that targeted skills such as matching, sorting, reading, and letter identification were classified as pre-academic/academic skills whereas engaging in tasks, orienting to materials, remaining in
seat or activity area, and responding to instruction were considered school
readiness skills.
In addition to knowing what skills to teach and how to teach them, it is
also important to identify where these studies are conducted and who delivered the intervention to facilitate the translation of research to practice.
Historically, most studies have been implemented in clinical settings and/or
with highly trained behavior analysts (Kasari & Smith, 2013). Although this
may be helpful in identifying potentially effective strategies, it does not guarantee that classroom teachers and families will readily accept or be able to
implement these strategies in their classrooms or homes. To ensure strategies
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Fleury et al.
can become sustained practices which are practically implemented, it is
important to identify feasible and generalizable instructional strategies that
can be readily implemented in the public school setting where the majority of
children with ASD are educated (Kasari & Smith, 2013). As a result, it is
important to identify the interventionist and setting of implementation to
guide judgments regarding optimal strategies to support school readiness.
Focus of the Present Review
To date, a systematic literature review has not been conducted to gain broader
insights into preparing young children with ASD to be school ready and
equip professionals to effectively teach school readiness skills. The purpose
of this study is to review the school readiness literature to evaluate (a) the
types of skills that have been taught to preschool children with ASD, (b) the
strategies used to teach specific skills, and (c) other descriptive information,
such as who delivered the intervention and the setting in which the intervention took place. We anticipate that this information will both highlight areas
in need of further study for researchers and also serve as a valuable resource
to practitioners who wish to include evidence-based practices as the basis of
educational programming.
Method
Selection Criteria
We identified articles to include in our review through the NPDC report,
“Evidence-Based Practices for Children, Youth, and Young Adults With
Autism Spectrum Disorder” (Wong et al., 2014). The NPDC report lists article citations according to the specific evidence-based practices (EBP) they
support. Although there is general information about the overall number of
studies that were published for each target outcome, specific articles were not
organized by outcome categories. For this study, we used the NPDC database
of articles to identify 67 studies that targeted school readiness as an outcome
measure. We classified preschoolers by their age at the time of study. After
screening the participants section of each article, we found 26 studies that
included at least 1 child with ASD who was preschool age (between the ages
of 3 years 0 months and 5 years 11 months). We excluded one study in this
review because the intervention solely targeted the reduction of challenging
behaviors, and did not address corresponding improvement on any school
readiness behavior. In this article, we focus our review on the 25 intervention
studies (21 single-case design; 4 group design) that documented improvement in school readiness skills for preschoolers.
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Behavior Modification 39(1)
Coding Procedures
The reviewers who contributed to the NPDC report participated in a rigorous
training to evaluate studies for methodological rigor using criteria that were
developed specifically for the project. NPDC reviewers also coded descriptive features for each study that they determined to be methodologically
acceptable. Specifically, reviewers coded information about study participants (diagnosis, co-occurring conditions, age), intervention strategies used
by researchers (see the appendix), and dependent variables (name, description) measured in each study. Finally, reviewers selected outcome categories
that best described child outcomes in each study from 12 outcome categories
including social, communication, challenging/interfering behaviors, joint
attention, play, cognitive, school readiness skills, pre-academic/academic,
motor, adaptive/self-help, vocational, and mental health (refer to Wong et al.,
2014 for more detail about reviewer training, article inclusion criteria, and
coding procedures).
We limited our review to those studies that were classified as having a
school readiness outcome. Information about intervention strategies (evidence-based practices) and dependent variables were taken directly from the
NPDC data set. We did not need to further evaluate the studies for sample,
appropriateness of design, or quality of data analysis because all studies
included in the NPDC report were already evaluated for methodological
rigor. Rather, we evaluated each article on additional variables that were not
included in the NPDC review, specifically information pertaining to the setting where intervention procedures took place and who delivered intervention procedures.
Setting. The environment in which the study procedures took place was analyzed in terms of the following set of definitions: Classroom. A school setting
in which the child is taught alongside their peers. This term encompasses a
number of different educational settings, including: general education, special education, inclusive/integrated classrooms, and self-contained classrooms. Special education classrooms that also functioned as 1:1 settings were
coded here provided that other peers (with or without disabilities) were present in the environment. Study procedures that take place on the playground
during recess were classified here provided that peers were present at the
time of the intervention. Specialized setting (1:1 room). An environment in
which the child receives instruction in a 1:1 context separate from the classroom, such as therapy rooms, school office, testing rooms, and specialist
rooms. These settings have limited environmental distractions, typically
without peers present. We also classified any study that took place within a
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Fleury et al.
clinical setting here. Home. The setting where the child permanently resides.
Study procedures may take place in any room within the child’s residence,
such as the living room, kitchen, or therapy room within the home.
Interventionist. The person who was primarily responsible for carrying out the
intervention procedures was evaluated using the following definitions:
Researcher. A member of the research team primarily carries out the intervention procedure. This includes principal investigators, co-principal investigators, research assistants, graduate students, and others who were employed by
the research team. School Personnel. An individual with some professional
training carries out the intervention procedures as part of their job. The individual was not directly employed by the research group, but may have
received stipends for their participation in the research project. This includes
special education teachers, general education teachers, paraprofessionals,
and other specialists such as speech-language pathologists, occupation therapists, and/or physical therapists. Researchers who claim that “therapists” or
“interventionists” conducted the study were also classified in this category.
Parent. A child’s caregiver carries out the intervention procedure. Student/
Peers. The child or his or her classmate(s) or peer(s) are taught to carry out
the intervention procedures.
Setting and intervention variables are not mutually exclusive. We coded
all variables that applied for each intervention study. Although many studies
were conducted only in one setting by one interventionist type (e.g., a member of the research team who conducted the procedures in a 1:1 therapy
room), some studies were carried out across different settings and/or with
different interventionists (i.e., Buggey, Hoomes, Sherberger, & Williams,
2011; Kern, Wolery, & Aldridge, 2007; Shogren, Lang, Machalicek, Rispoli,
& O’Reilly, 2011).
Reliability
Information about article inclusion, intervention strategies, and child outcomes were taken directly from the NPDC database and were therefore not
included in reliability calculations. Interrater reliability was calculated on
100% of coding variables unique to this review (i.e., setting and interventionist) for 100% of included studies. We calculated reliability using a point-bypoint formula: (agreement/[agreement + disagreement]) × 100. Interrater
reliability reached acceptable levels (Horner et al., 2005) for both setting
(M = 86%) and interventionist (M = 82%) categories. The first author and the
coder reviewed all discrepancies and arrived at a consensus code to be used
in final analyses.
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Behavior Modification 39(1)
Results
Evidence-Based Practices
A complete list of studies included in this review, along with their corresponding instructional strategies and outcome definitions can be found in
Table 1. The NPDC reviewers identified the primary intervention strategy
used in each study that was included in the evidence-based practice report.
We pulled this information directly from the NPDC database for this review.
Our analysis revealed that 18 of the 27 identified evidence-based practices
were used by researchers to improve school readiness behaviors in preschoolers. Evidence-based practices used to improve school readiness included
antecedent-based intervention, differential reinforcement, exercise, discrete
trial teaching, functional behavior assessment, functional communication
training, modeling, parent-implemented intervention, prompting, reinforcement, response interruption and redirection, scripting, self-management,
technology-aided instruction and intervention, time delay, video modeling,
and visual supports. There were three additional intervention practices that
were used that did not meet the NPDC criteria for an evidence-based practice: behavioral momentum intervention, touch therapy, and music therapy.
Descriptions of instructional strategies used to promote school readiness
behavior are provided in the appendix.
Child Outcomes
School readiness is a broad term that encompasses a number of behaviors.
Our analyses revealed that specific child outcome variables differed across
studies, but could be organized into three general categories: classroom
behavior, social-communication, and challenging behavior. Several studies
addressed multiple behaviors that fit into several categories. Thirty-two percent of studies (n = 8) measured changes in classroom behavior. These behaviors relate to children’s ability to appropriately participate in independent
tasks within the classroom environment. Examples of classroom behavior
include: attending to activities, engagement, correct responding, complying
with teacher directions or classroom routines. Second, we categorized a number of child outcomes as improvements in social-communication or social
interaction skills (n = 7; 28%). Behaviors in this category support the child’s
ability to interact with his or her peers or adults. Examples include reciprocal
conversations in play, initiating social interactions, responding to peers’
social invitations, appropriately expressing needs or desires, and inquiries
about the environment or classroom schedule. All of the studies had at least
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Participant 1: male; age 3 years 6 months;
autism
Participant 2: male; age 5 years; autism
Participant 1: male; age 5 years; Asperger
Participant 2: male; age 5 years; Asperger
Participant 1: male; age 5; autism
Normand and Beaulieu (2011)
Tarbox, Ghezzi, and Wilson
(2006)
Shogren, Lang, Machalicek,
Rispoli, and O’Reilly (2011)
14 children (12 boys and 2 girls) with autism,
ages 3-6
Participant 1: male; 5 year, 4 month old;
autism
Participant 1: male; age 3 years 2 months;
autism; mild-moderate autism severity;
Caucasian
Participant 2: male; age 3 years 5 months;
autism; mild-moderate autism severity;
African American
Participant 1: male; age 4 years 4 months;
autism; Caucasian; middle class
Child demographics (gender, age, diagnosis,
other information provided)
Moore and Calvert (2000)
Kleeberger and Mirenda (2010)
Classroom behavior
Houlihan, Jacobson, and
Brandon (1994)
Kern, Wolery, and Aldridge
(2007)
Study
Reinforcement
Reinforcement and
self-management
Behavior momentuma
Technology-aided
instruction and
intervention
Video modeling
Musica
Behavior momentuma
Instructional strategy
Table 1. Intervention Studies That Targeted School Readiness Outcomes.
(continued)
Appropriate classroom behavior: The extent to which
the child followed classroom rules (i.e., stay in your
space, keep your hands to yourself, and do what the
teacher says)
Attending: making eye contact with the adult for at
least 3 s prior to instruction
Imitation: 70 imitative motor actions were included
in the study. After the adult model and prompt,
participant scored a 0 for no response, 1 for
response without imitation, 2 for partial imitation,
and 3 for exact imitation
Attention to task: looking at the teacher or learning
materials
Motivation to work on task: children were given the
choice to stay working or go play. If children stayed
working, it was scored as being motivating
Vocabulary: receptive identification of nouns on
flashcards
Compliance: initiation of an instructed response
within 10 s of the instruction
Compliance: appropriate response that occurred
within 15 s of request delivery
Routine: child independently performs the behavior
required in each step of the morning greeting
routine
Child outcome
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Child demographics (gender, age, diagnosis,
other information provided)
Call, Pabico, Findley, and
Valentino (2011)
Participant 1: male; age 5 years; autism
Participant 1: male; age 6 years 2 months;
autism
Participant 2: male; age 5 years 7 months;
autism
Participant 3: male; age 3 years 9 months;
autism
Participant 4: male; age 4 years 10 months;
autism
Classroom behavior and challenging behavior
Ahrens, Lerman, Kodak,
Participant 1: male; age 6 years; autism
Worsdell, and Keegan (2011)
Participant 2: male; age 4 years; autism
Participant 3: male; age 5 years; autism
Participant 4: male; age 4 years; autism
West (2008)
Study
Table 1. (continued)
(continued)
Vocal stereotypic behavior: any nonfunctional or
noncontextual speech vocalization that is not
appropriate
Appropriate vocalization: independent vocalization
that is contextually appropriate
Motor stereotypic behavior: hand flapping (rapid
movement of the hand back and forth), body
rocking (forward and backward movement of the
body), clapping (rapid movement of hands hitting
together)
Compliance: child exhibits the requested vocal or
motor response following adult instruction
Elopement: frequency of elopement within 10-s
intervals (elopement as any part of the body passing
the plane of the doorway of the session room)
Prompted correct response: participant touched
correct picture within 5 s of a prompt
Attending behavior: participant looked at comparison
stimuli for at least 4 s, or 1 s each
Problem behavior: individually defined for each
participant
Response interruption
and redirection
Differential
reinforcement
Independent responses: unprompted correct
responses consisted of responses to the task prior
to the controlling prompt being provided
Child outcome
Visual support
Instructional strategy
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9 children (7 males and 2 females) ages 3-6
years (Mage = 5.2 years). Seven of the
children had a diagnosis of autism, 1 had a
diagnosis of intellectual disability, and 1 had
a diagnosis of developmental delay
Participant 1: male; age 4; autism and severe
cognitive delay Participant 2: male; age 4
years 6 months; autism spectrum disorder
and severe cognitive delay; moderate
autism severity
Participant 1: male; age 5 years; autism;
Caucasian participant 2: male; age 7 years;
autism and other health impairments;
Caucasian
Oriel, George, Peckus, and
Semon (2011)
Reichle, Johnson, Monn, and
Harris (2010)
Rispoli et al. (2011)
Participant 1: female; age 4; autism; severe
autism severity; Spanish spoken at home
Child demographics (gender, age, diagnosis,
other information provided)
Lang et al. (2011)
Study
Table 1. (continued)
Antecedent-based
intervention
Reinforcement
Exercise
Other–English vs.
Spanish instruction
in DTT
Instructional strategy
(continued)
Correct responses: correct performance following a
teacher’s direction
Repetitive behavior: audible click of the tongue during
instruction
Correct academic response: a child responds
correctly to a direction given by the teacher
Incorrect academic response: a child responds
incorrectly or provides no response to a directive
given by the teacher
Stereotypic behavior: repetitive behaviors that
included hand and arm flapping, body rocking, and
toe walking
On-task behavior: percentage of time the child is
seated and is consistently responding to teacher
directives
Task engagement: percentage of work units
successfully completed
Challenging behavior: percentage of work units in
which challenging behavior occurred (e.g., pushing
materials off the table)
Problem behavior: throwing objects (i.e., object
launched from hand), inappropriate vocalizations
(repeated sound “eeee”)
Child outcome
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Child demographics (gender, age, diagnosis,
other information provided)
Social communication/social interaction
Buggey, Hoomes, Sherberger,
Participant 1: female; age 4 years 2 months;
and Williams (2011)
PDD-NOS; moderate autism severity
Participant 2: male; age 4 years 2 months;
PDD-NOS; severe autism severity
Participant 3: male; age 3 years 10 months;
PDD-NOS; severe autism severity
Participant 4: female; age 4 years 2 months;
PDD-NOS; severe autism severity
Ganz, Flores, and Lashley
Participant 1: male; age 3 years 6 months;
(2011)
autism; mild-moderate autism severity
Participant 2: male; age 4 years 11 months;
autism; mild-moderate autism severity
Kaiser, Hancock, and Nietfeld
Participant 1: male; age 4 years 6 months;
(2000)
autism
Participant 2: male; age 2 years 11 months;
Asperger
Participant 3: male; age 3 years 1 month;
PDD-NOS
Participant 4: male; age 3 years 4 months;
autism
Participant 5: male; age 4 years 5 months;
autism
Participant 6: male; age 2 years 8 months;
PDD-NOS
Murdock and Hobbs (2011)
12 children between the ages of 4-6 years.
Children had a diagnosis of Autism or
PDD-NOS
Study
Table 1. (continued)
Play dialogue: number of scripted and novel utterances
during play
Scripting
(continued)
Imitated request: requesting with item present after a
verbal model
Spontaneous request: request with item present
before a verbal model
Child social-communication skills: child social
communication during observations
Child language development: developmental measures
Reinforcement and
modeling
Parent-mediated
instruction and
intervention
Social initiations: number of social initiations with
peers on the playground during a 15-min recess
period. Physical approach (lasting at least 5 s, peer
within arm’s length proximity), attending, vocal
initiations
Child outcome
Video modeling
Instructional strategy
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Participant 1: male; age 3 years 6 months;
autism
Participant 2: male; age 5 years; autism
Participant 3: male; age 5 years; autism
Participant 1: female; age 4 years; PDD-NOS
Participant 2: male; age 3 years; ASD
Participant 3: male; age 4 years; autism
Participant 1: male; age 9 years; autism
Participant 2: female; age 5 years; autism
Participant 3: female; age 9 years; autism
Child demographics (gender, age, diagnosis,
other information provided)
Participant 1: male; 4 years old; autism
Participant 1: male; 4 years old; autism and
communication delay
Gibson, Pennington, Stenhoff,
and Hopper (2010)
Miguel, Clark, Tereshko, and
Ahearn (2009)
Social communication/social interaction and challenging behavior
Field et al. (1997)
22 preschool children with autism (12 male;
10 female); average age 4 years 6 months
Taylor and Harris (1995)
Ostryn and Wolfe (2011)
Odom and Watts (1991)
Study
Table 1. (continued)
Response interruption
and redirection
Functional
communication
training
Touch therapya
(continued)
Orienting to irrelevant sounds: not defined, observed
in the classroom
Stereotypic behaviors: not defined, observed in the
classroom
Joint attention: Early Social Communication Scales
Behavior regulation: Early Social Communication
Scales
Social behavior: Early Social Communication Scales
Elopement: Child getting outside of his defined area
on rug during circle time
Appropriate request: raising hand to gain access to
preferred items
Vocal stereotypy: any instance of noncontextual
or nonfunctional speech that included sustained
vowel sounds, varying pitches of a sound, and spit
swooshing at an audible level
Appropriate vocalization: a request or label that was
appropriate in the context
Asking “What’s this?”: independently pointed to an
unknown stimulus and asked the question
Receptive vocabulary: pointing to the correct picture
when instructed to “Point to ___”
Time delay
Prompting
Peer social interactions: 5 min samples during two
routines of the social interactions between peers
with autism and typical peers (7 positive and 2
negative categories) all initiation and responses
Unprompted pictorial communication: Pointing to the
item and a “what’s that” card in either order
Child outcome
Peer-mediated
instruction and
intervention
Instructional strategy
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Participant 1: male; age 5 years; autism and
Charge Syndrome
Participant 2: female; age 4 years; autism
Participant 3: male; age 4 years; autism
Child demographics (gender, age, diagnosis,
other information provided)
Functional
communication
training
Instructional strategy
Challenging behavior: the percentage of direct
intervals in which the student engaged in screaming,
whining, biting, pinching, hitting
Functional communication training skills: socially
appropriate responses that were perceived as (a)
equal or more efficient than problem behaviors and
(b) produced the same maintaining functions as the
problem behaviors
Child outcome
Note. Child demographics reflect information that was reported by the authors of the original study. Researchers who reported autism severity used the Childhood Autism
Rating Scale (CARS; Schopler, Reichler, & Renner, 1988). Information regarding instructional strategy and child outcome measures was taken from the NPDC evidencebased practice report (Wong et al., 2014). DTT = Discrete trial teaching; PDD-NOS = pervasive developmental disorder–not otherwise specified.
aThese strategies did not meet the NPDC criteria for an evidence-based practice due to insufficient evidence.
Schindler and Horner (2005)
Study
Table 1. (continued)
83
Fleury et al.
one outcome measure that improved classroom behavior or social communication/social interaction skills. However, many studies (n = 10) simultaneously decreased occurrences of challenging behavior. We defined challenging
behavior as problematic behavior that may prevent the child’s and his or her
or peers’ ability to learn including, but not limited to: stereotypic behavior;
elopement; pushing materials away; inappropriate vocalizations; aggressive
behaviors such as hitting, biting, and pinching. Improvements in classroom
behavior and decreased challenging behavior were reported in six studies
(24%). A total of four studies (16%) addressed both social communication or
social interaction skills and challenging behavior. Figure 1 illustrates the
instructional strategies that addressed specific child outcomes.
Setting
Based on our definitions of environmental setting, the majority of studies
were based solely out of the classroom (n = 9; 36%) or in a specialized setting
(n = 9; 36%). The remaining studies were conducted in the child’s home (n =
2; 8%) or in a combination of the settings (n = 5; 20%).
Interventionist
In the majority of the studies, the researcher (n = 11; 44%) or school personnel (n = 8; 32%) were solely responsible in delivering the intervention procedures. Parents were trained to serve as the interventionist in 16% of the
studies, either as the sole interventionist (n = 2; 8%) or in combination with
school personnel (n = 2; 8%). The student or peers were trained to carry out
intervention procedures in 8% of the studies alongside school personnel and/
or researchers (n = 2). The exact combination of setting and interventionist
classification by study is displayed in Table 2.
Discussion
There has been much debate regarding appropriate educational placements
for children with ASD. Some studies report that children with ASD who are
served in inclusive settings spend more time participating in curricular activities and demonstrate significant gains in academic achievement compared
with those in self-contained settings (Kurth & Mastergeorge, 2012). Others
argue that inclusive settings are less appropriate, and therefore less beneficial, for children with ASD than alternative settings in which school personnel are able to provide intensive interventions that are necessary to support
the complex needs of children with ASD (Ashburner et al., 2010; Osborne &
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84
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st
ue
sp
te on
re
eq
n/
ria ati
ar
l atio
op aliz
a
r
ke
ci iti
a
pp oc
o
A v
S in
M
se
on
u
c
pi
ty ior
eo v
er eha
t
S b
t
o te
en
lt a
sa cip
em
fu arti
op
e
l
R p
E
i
D
ty
ili
tib
ac
str
Challenging Behavior
Note. This figure illustrates different instructional strategies that researchers used in studies to address classroom behavior, social communication,
and/or challenging behavior in preschoolers with ASD. Information regarding instructional strategy and child outcome measures was taken from the
National Professtional Development Center on Autism Spectrum Disorder (NPDC) evidence-based practice report (Wong et al., 2014).
aThese strategies did not meet the NPDC criteria for an evidence-based practice.
Fo
s
ea
m
al
rm
s
re
Social Communication and Social Interaction
Figure 1. Intervention strategies used to improve school readiness skills.
Instructional Practice
Antecedent-based intervention
Behavior momentuma
Differential reinforcement
Discrete Trial Training
Exercise
Functional behavior assessment
Functional communication training
Modeling
Music therapya
Parent implemented intervention
Peer-mediated instruction
Prompting
Reinforcement
Response interruption/redirection
Scripting
Self-management
Technology-aided instruction
Time delay
Touch therapya
Video modeling
Visual support
t
en
sk
r
m
to
e/ ta
ss
to age
n
la
nc o
io
/c
on ng
ia d t n
at
pl on ctio low tine s enti k/e
v
i
k
m sp re
l u le tt s
ot or
Co re di Fo ro ru A Ta
M w
m
oo
Classroom Behavior
85
Fleury et al.
Table 2. Setting and Interventionist Information by Study.
Setting
Interventionist
School
Student/
Classroom 1:1 Room Home Researcher personnel Parent peer
Study
Classroom behavior
Houlihan, Jacobson, and
Brandon (1994)
Kern, Wolery, and Aldridge
(2007)
Kleeberger and Mirenda (2010)
Moore and Calvert (2000)
Normand and Beaulieu (2011)
Shogren, Lang, Machalicek,
Rispoli, and O’Reilly (2011)
Tarbox, Ghezzi, and Wilson
(2006)
West (2008)
X
X
X
X
X
X
X
X
X
X
X
Classroom behavior and challenging behavior
Ahrens, Lerman, Kodak,
Worsdell, and Keegan (2011)
Call, Pabico, Findley, and
Valentino (2011)
Lang et al. (2011)
Oriel, George, Peckus, and
X
Semon (2011)
Reichle, Johnson, Monn, and
X
Harris (2010)
Rispoli et al. (2011)
X
Social communication/social interaction
Buggey, Hoomes, Sherberger,
X
and Williams (2011)
Ganz, Flores, and Lashley (2011)
Kaiser, Hancock, and Nietfeld
(2000)
Murdock and Hobbs (2011)
Odom and Watts (1991)
X
Ostryn and Wolfe (2011)
Taylor and Harris (1995)
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Social communication/social interaction and challenging behavior
Field et al. (1997)
X
Gibson, Pennington, Stenhoff,
X
and Hopper (2010)
Miguel, Clark, Tereshko, and
X
Ahearn (2009)
Schindler and Horner (2005)
X
X
X
X
X
X
X
X
X
X
X
X
X
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X
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Behavior Modification 39(1)
Reed, 2011; Panerai et al., 2009; Reed, Osborne, & Waddington, 2012;
Simpson, Mundschenk, & Heflin, 2011). Regardless of the educational setting, the relationship between social skills and academic performance has
been well established by research. Children who enter formal schooling lacking social and emotional competence will likely have difficulty succeeding in
school (McClelland, Morrison, & Holmes, 2000; National Center for Special
Education Research, 2006). Deficits in social-communication and social
interactions are a benchmark characteristic of ASD (American Psychiatric
Association, 2013). These difficulties, combined with restricted, repetitive
behaviors can make it especially challenging for children with ASD to fully
participate in classroom activities. These behaviors may limit their access to
the general education curriculum and typically developing peers, thereby
reducing opportunities that children with ASD have to develop both the academic and social skills that relate to positive school outcomes. Because of
characteristics associated with ASD, children with ASD may present with
several behaviors that teachers will need to address if children are to benefit
from classroom instruction. The results presented in this review provide practitioners and researchers with an overview of different instructional practices
that have been used to prepare preschool children with ASD to engage in
classroom routines and activities.
Implications for Classroom Practice
Children who are unresponsive to a teacher’s direction, unable to independently complete tasks, or engage in stereotypic behaviors usually cannot fully
participate in, and thereby benefit from, classroom activities. Many of these
behaviors, however, are amenable to early intervention. In fact, several of
these behaviors were the target of interventions summarized in this review.
Analyses reveal 18 evidence-based practices that directly or indirectly
improved independent classroom behavior (i.e., compliance, following classroom routine, engagement in tasks), social communication and social interaction skills (i.e., making requests, social initiations, social responses), and/or
reduced challenging behavior (i.e., stereotypy, refusal to participate, elopement). It should be noted that three practices that addressed school readiness—behavior momentum interventions, music, and touch therapy—did not
meet the NPDC criteria to be called an evidence-based practice. Practitioners
should be cautious about using these strategies until more research is published that demonstrates clear positive effects for children with ASD.
In many cases, different strategies were used to address a target skill. For
example, a number of studies in this review demonstrated improvements in
children’s ability to attend to tasks. However, researchers took different intervention approaches to improve children’s task engagement including
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Fleury et al.
antecedent-based interventions (Rispoli et al., 2011), exercise (Oriel, George,
Peckus, & Semon, 2011), functional behavior assessment (Kodak, Fisher,
Clements, Paden, & Dickes, 2011), reinforcement (Reichle, Johnson, Monn,
& Harris, 2010; Tarbox, Ghezzi, & Wilson, 2006), self-management (Shogren
et al., 2011), and technology-aided instruction (Moore & Calvert, 2000). All
of the intervention strategies that are included in this review are considered
focused intervention practices—strategies that are designed to address a single skill or goal (Odom, Collet-Klingenberg, Rogers, & Hatton, 2010). A
major advantage of focused intervention practices is that practitioners can
select and combine different evidence-based practices that best suit the
child’s individual needs and the learning environment.
Almost half of the studies included in the present review were conducted
in classrooms, and the number of studies in which school personnel delivered
intervention procedures equaled those in which a researcher implemented the
intervention. The applied nature of this research holds promise for having
direct benefits for children with ASD who are being educated in classrooms,
homes, and in specialized 1:1 settings. To improve school outcomes for children with ASD, educators must have access to empirically validated strategies such as those reported in this review. We merely provide a broad
overview of strategies related to specific child outcomes in this review. If
educators are expected to include these strategies as part of a child’s educational programming, this information will need to be supplemented by additional training. Pre-service and in-service educators may find publicly
available training resources particularly useful such as those provided by the
NPDC on ASD (http://autismpdc.fpg.unc.edu/) and the Autism Internet
Modules available through the Ohio Center for Autism and Low Incidence
(OCALI; www.ocali.org).
Implications for Research
This review complements a growing body of research dedicated to helping
educators provide effective classroom instruction. While previous researchers have focused on one particular learning environment such as inclusive
classrooms (Crosland & Dunlap, 2012; Harrower & Dunlap, 2001), this
review examined strategies that have been successfully used in different
environments where learning can occur including classrooms, specialized
settings, and homes. We found only a few studies (Kaiser, Hancock, &
Nietfeld, 2000; Schindler & Horner, 2005) that were conducted in homes in
which a caregiver served as the primary interventionist. Given that homebased experiences contribute to children’s accomplishments (Dunst, Trivette,
Masiello, Roper, & Robyak, 2006) and that many young children may not be
attending preschool full-time, there is a need to examine how to best support
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Behavior Modification 39(1)
families so they are able to implement specific strategies in their homes. In a
similar vein, social validity—determining whether the focus of the intervention and behavioral changes align with the expectations of the child’s community—is an integral component of applied intervention work (Kazdin,
1982; Schwartz & Baer, 1991). The inclusion of social validity measures was
not a variable of focus in this review; however, this valuable information will
allow researchers to determine whether educators and families view strategies as being acceptable and the child outcomes as being relevant to their
unique situations.
Limitations
The corpus of studies reviewed here was obtained from the NPDC database
and was flagged by the NPDC reviewers as targeting school readiness.
Because school readiness is a broad term that encompasses several developmental domains, we may have excluded a number of relevant studies if they
were categorized under a different outcome category, such as pre-academic/
academic skills, social skills, and communication skills.
This review solely focuses on a subset of skills children with ASD need
to improve the likelihood that they are successful in school. It is important
for us to stress that school readiness involves much more than children’s
readiness. If we expect to improve academic outcomes for children with
ASD, we will need to improve our knowledge about child-focused intervention strategies as well as ways to prepare families, communities, early childhood programs, and schools to create supportive environments that meet the
unique needs of children with ASD (Carta, 2009; NGA, 2005). Several
resources have been published about the characteristics of high-quality educational environments that incorporate developmentally appropriate practices for young children (e.g., Bredekamp & Copple, 1997; Davis, Kilgo, &
Gamel-McCormick, 1998; Sandall, McLean, & Smith, 2000). Although a
further description of such environments are beyond the scope of this article,
we feel that it is important to emphasize that quality programs are essential
for all young children, especially those with disabilities. Such environments
provide a solid foundation on which practitioners can embed appropriate
learning opportunities for young children with ASD (Sandall & Schwartz,
2002). For many children with ASD, however, educators will also need to
provide individual support to children using specific child-focused intervention strategies. It is our intention that this review will guide educators in
selecting empirically validated strategies to address specific behaviors that
act as barriers to effective classroom instruction for many children with
ASD.
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Appendix
Definitions of Instructional Practices Used to Address School
Readiness Behavior
Evidence-based practice
Definition
Antecedent-based
intervention (ABI)
Arrangement of events or circumstances that precede
the occurrence of an interfering behavior and
designed to lead to the reduction of the behavior.
Differential reinforcement of Provision of positive/desirable consequences
alternative, incompatible,
for behaviors or their absence that reduce
or other behavior (DRA/
the occurrence of an undesirable behavior.
I/O)
Reinforcement provided: (a) when the learner
is engaging in a specific desired behavior other
than the inappropriate behavior (DRA), (b)
when the learner is engaging in a behavior that is
physically impossible to do while exhibiting the
inappropriate behavior (DRI), or (c) when the
learner is not engaging in the interfering behavior
(DRO).
Discrete trial teaching (DTT) Instructional process usually involving one teacher/
service provider and one student/client and
designed to teach appropriate behavior or
skills. Instruction usually involves massed trials;
each trial consists of the teacher’s instruction/
presentation, the child’s response, a carefully
planned consequence, and a pause prior to
presenting the next instruction.
Exercise (ECE)
Increase in physical exertion as a means of reducing
problem behaviors or increasing appropriate
behavior.
Functional behavior
Systematic collection of information about an
assessment (FBA)
interfering behavior designed to identify functional
contingencies that support the behavior. FBA
consists of describing the interfering or problem
behavior, identifying antecedent or consequent
events that control the behavior, developing a
hypothesis of the function of the behavior, and/or
testing the hypothesis.
Functional communication
Replacement of interfering behavior that has a
training (FCT)
communication function with more appropriate
communication that accomplishes the same
function. FCT usually includes FBA, DRA, and/or
extinction.
(continued)
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Behavior Modification 39(1)
Appendix (continued)
Evidence-based practice
Modeling (MD)
Parent-implemented
intervention (PII)
Peer-mediated instruction
and intervention (PMII)
Prompting (PP)
Reinforcement (R+)
Response interruption/
redirection (RIR)
Scripting (SC)
Self-management (SM)
Definition
Demonstration of a desired target behavior that
results in imitation of the behavior by the learner
and that leads to the acquisition of the imitated
behavior. Modeling is often combined with other
strategies such as prompting and reinforcement.
Parents provide individualized intervention to their
child to improve/increase a wide variety of skills and/
or to reduce interfering behaviors. Parents learn to
deliver interventions in their home and/or community
through a structured parent training program.
Typically developing peers interact with and/or help
children and youth with autism spectrum disorder
(ASD) to acquire new behavior, communication,
and social skills by increasing social and learning
opportunities within natural environments.
Teachers/service providers systematically teach
peers strategies for engaging children and
youth with ASD in positive and extended social
interactions in both teacher-directed and learnerinitiated activities.
Verbal, gestural, or physical assistance given to
learners to assist them in acquiring or engaging in
a targeted behavior or skill. Prompts are generally
given by an adult or peer before or as a learner
attempts to use a skill.
An event, activity, or other circumstance occurring
after a learner engages in a desired behavior that
leads to the increased occurrence of the behavior
in the future.
Introduction of a prompt, comment, or other
distracters when an interfering behavior is
occurring that is designed to divert the learner’s
attention away from the interfering behavior and
results in its reduction.
A verbal and/or written description about a specific
skill or situation that serves as a model for the
learner. Scripts are usually practiced repeatedly
before the skill is used in the actual situation.
Instruction focusing on learners discriminating
between appropriate and inappropriate behaviors,
accurately monitoring and recording their own
behaviors, and rewarding themselves for behaving
appropriately.
(continued)
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Fleury et al.
Appendix (continued)
Evidence-based practice
Technology-aided instruction
and intervention (TAII)
Time delay (TD)
Video modeling (VM)
Visual supports (VS)
Other Practices
Behavior momentum
Music therapy
Touch therapy
Definition
Instruction or interventions in which technology is
the central feature supporting the acquisition of a
goal for the learner. Technology is defined as “any
electronic item/equipment/application/or virtual
network that is used intentionally to increase/
maintain, and/or improve daily living, work/
productivity, and recreation/leisure capabilities
of adolescents with autism spectrum disorders”
(Odom, Thompson, et al., 2013).
In a setting or activity in which a learner should
engage in a behavior or skill, a brief delay occurs
between the opportunity to use the skill and any
additional instructions or prompts. The purpose
of the time delay is to allow the learner to
respond without having to receive a prompt and
thus focuses on fading the use of prompts during
instructional activities.
A visual model of the targeted behavior or skill
(typically in the behavior, communication, play, or
social domains), provided via video recording and
display equipment to assist learning in or engaging
in a desired behavior or skill.
Any visual display that supports the learner engaging
in a desired behavior or skills independent of
prompts. Examples of visual supports include
pictures, written words, objects within the
environment, arrangement of the environment
or visual boundaries, schedules, maps, labels,
organization systems, and timelines.
Definition
Organization of behavior expectations in a
sequence in which low probability/preference
behaviors are embedded in a series of high
probability/preference behaviors to increase the
occurrence of the low probability/preference
behaviors
Songs and music used as a medium through which
student’s goals may be addressed
Systematic touch or massage
Source. Evidence-based practices and definitions used in the National Professional
Development Center on ASD review, Wong et al. (2014, pp. 20-22). Copyright 2014 by
Samuel Odom.
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Behavior Modification 39(1)
Authors’ Note
The opinions expressed represent those of the authors and do not necessarily represent
views of the Institute or the U.S. Department of Education.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research,
authorship, and/or publication of this article: The work reported here was supported
by the Institute of Education Sciences, U.S. Department of Education through Grant
R324B090005 awarded to University of North Carolina at Chapel Hill.
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Fleury et al.
Author Biographies
Veronica P. Fleury, PhD is an Assistant Professor of Special Education at the
University of Minnesota. Her research is focused on facilitating learning of individuals with Autism Spectrum Disorder (ASD), specifically identifying and validating
instructional strategies to address early academic and social-communication difficulties for young children with ASD.
Julie L. Thompson, PhD, BCBA, is a Research Associate in Special Education at
Michigan State University. Julie conducts research examining procedures and efficiencies of using explicit group instruction to teach students with autism spectrum
disorder in public school settings. She is currently working with a team investigating
the use of a comprehensive approach to teach reading using behavioral and instructional supports to students with autism spectrum disorder.
Connie Wong, PhD is a research investigator at the Frank Porter Graham Child
Development Institute at the University of North Carolina at Chapel Hill. She has
been involved with several studies and projects involving children and youth with
autism. She currently serves as the Principal Investigator of the Toddlers and Families
Together study funded by the Maternal and Child Health Bureau.
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