Review article
just summarize the article in two different pages 2 paragraphs min for each tie up relevancy
Research in Autism Spectrum Disorders 6 (2012) 602–617
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Research in Autism Spectrum Disorders
J o u r n a l h o m e p a g e : h t t p : / / e e s . e l s e v i e r . c o m / R A S D / d e f a u l t . a s p
!!! -·-·–
Research In
Autism Spectrum
Disorders
Review
A systematic review of behavioral intervention research on adaptive
skill building in high-functioning young adults with autism spectrum
disorder
Annemiek Palmen a,b,*, Robert Didden c,d, Russell Lang e
a Dr. Leo Kannerhuis Doorwerth, Centre for Autism, The Netherlands
b Department of Special Education, Radboud University Nijmegen, P.O. Box 9104, 6500 HE Nijmegen, The Netherlands
c Behavioral Science Institute, Radboud University Nijmegen, The Netherlands
d Trajectum Zutphen, The Netherlands
e Texas State University-San Marcos, Clinic for Autism Research Evaluation and Support, TX, USA
A R T I C L E I N F O
Article history:
Received 30 September 2011
Accepted 4 October 2011
Keywords:
Autism spectrum disorder
High-functioning adolescents and adults
Adaptive skills
Behavioral interventions
A B S T R A C T
This review involved a systematic search and analysis of behavioral intervention studies
aimed at improving adaptive skills in high-functioning young adults with autism
spectrum disorders. Through electronic databases and hand searching, 20 studies were
identified meeting pre-determined inclusion criteria. Studies were summarized and
analysed in terms of (a) participants, (b) adaptive skill(s) targeted for intervention, (c)
intervention procedures, and (d) intervention outcomes. Certainty of evidence was
assessed through critical appraisal of each study’s design and other methodological
characteristics. Social interaction skills were the most common intervention targets
(n = 8), followed by practical academic skills (n = 6), vocational skills (n = 5), and domestic
skills (n = 1). Improvements in adaptive skills were reported by 19 studies. Interventions
consisting of low or high tech assisted procedures (e.g., video modeling, visual cues, self-
recording and self-reinforcement, self-prompting), reinforcement contingencies, and
corrective feedback using prompts were found to be most promising. Five studies were
identified as having the methodological rigor to provide conclusive results. Insufficient
control for alternative explanations for behavior outcomes and reliance on pre- or quasi-
experimental designs hindered the certainty of evidence for the remaining studies.
Implications for clinical practice and future research are discussed.
� 2011 Elsevier Ltd. All rights reserved.
Contents
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 603
2. Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 604
2.1. Search procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 604
2.2. Inclusion and exclusion criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 604
2.3. Data extraction and coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 604
2.4. Reliability of search procedures and data extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 605
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 605
3.1. Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 605
3.2. Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 611
* Corresponding author at: Department of Special Education, Radboud University Nijmegen, P.O. Box 9104, 6500 HE Nijmegen, The Netherlands.
E-mail addresses: a.palmen@pwo.ru.nl, a.palmen@leokannerhuis.nl (A. Palmen).
1750-9467/$ – see front matter � 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.rasd.2011.10.001
http://dx.doi.org/10.1016/j.rasd.2011.10.001
mailto:a.palmen@pwo.ru.nl
mailto:a.palmen@leokannerhuis.nl
http://www.sciencedirect.com/science/journal/17509467
http://dx.doi.org/10.1016/j.rasd.2011.10.001
A. Palmen et al. / Research in Autism Spectrum Disorders 6 (2012) 602–617 603
3.3. Targeted adaptive skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 611
3.4. Data collection and interobserver agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 611
3.5. Intervention procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 611
3.6. Treatment fidelity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 613
3.7. Study designs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 613
3.8. Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 613
3.9. Follow-up and generalization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 613
3.10. Social validity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 614
3.11. Certainty of evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 614
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 614
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 615
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 615
1. Introduction
Independent functioning is an important issue for people with high-functioning autism spectrum disorders (ASD).
Adults with ASD have difficulty developing reciprocal friendships, obtaining paid employment, engaging in recreational
activities, and living independently (e.g., Billstedt, Gillberg, & Gillberg, 2005; Eaves & Ho, 2008; Howlin, Goode, Hutton, &
Rutter, 2004; Orsmond, Wijngaarden Kraus, & Mailick Seltzer, 2004). Consequently, many adults with ASD rely on support
from parents or service agencies (e.g., Billstedt et al., 2005; Eaves & Ho, 2008; Farley et al., 2009; Howlin et al., 2004). Farley
et al. (2009) analysed variables related to adult outcomes in 41 high-functioning adults with ASD and found that among a
range of variables such as IQ and level of support, adaptive behavior measures (Vineland Adaptive Behavior Scales; VABS –
Sparrow, Balla, & Cicchetti, 1984) were the variables most closely related to overall social and independent living
functioning. Across adaptive behavior measures, the daily living skills domain (VABS) was found to be most closely related
to better outcomes.
In studies on adaptive functioning in persons with high-functioning ASD a discrepancy has been found between level of
adaptive skills and IQ. Specifically, the adaptive skills are lower than would be predicted by cognitive ability (Bolte & Poustka,
2002; Carter et al., 1998). Furthermore, there is evidence that this discrepancy between cognitive ability and adaptive
function may increase with age (Bolte & Poustka, 2002; Carter et al., 1998; Kanne et al., 2011; Klin et al., 2007). Given the
importance of adaptive skills and the tendency for deficits to grow more pronounced over the lifespan, it is not surprising
that a great deal of intervention research has focused on teaching adaptive skills to people with ASD.
Most studies on adaptive skill building have focused on children and adolescents with ASD, with and without intellectual
disability (ID), and behavioral techniques, such as task analyses, cue cards, modeling, self-management, prompt fading, and
reinforcement have proven to be highly effective (e.g., Koegel, Vernon, & Koegel, 2009; Paterson & Arco, 2007; Pierce &
Schreibman, 1994; Taylor, Hughes, Richard, Hoch, & Rodriguez Coello, 2004). The effectiveness of cognitive skills training
(e.g., Theory of Mind – TOM or Executive Functioning) on improving daily life behavior has also been studied. However,
results suggest that these procedures may be effective in improving conceptual skills, but they do not automatically (that is
without explicit training) lead to improvement in daily life use of TOM or executive skills, such as responding to indirect
hints, social tuning, orientation in time/place/activity, planning ahead, or following verbally given lists of instructions
(Begeer et al., 2011; Fisher & Happé, 2005).
Several literature reviews have analysed behavioral interventions in adaptive skill building in children, indicating early
intensive behavioral intervention (EIBI) is the most promising intervention approach for children (Granpeesheh, Tarbox, &
Dixon, 2009; Makrygianni & Reed, 2010; Peters-Scheffer, Didden, Korzilius, & Sturmey, 2011). Literature reviews on
behavioral interventions in heterogeneous samples of children and youth have also been conducted. For example, Rao,
Beidel, and Murray (2008) and Cappadocia and Weiss (2011) provided preliminary evidence for the efficacy of social skills
training groups (SSTGs) in improving social skills in children and youth with Asperger syndrome and high-functioning ASD.
Support has also been found for the efficacy of self-management (e.g., Lee, Simpson, & Shogren, 2007) and video (self)-
modeling (e.g., Bellini & Akullian, 2007) in children and adolescents with ASD. Machalicek et al. (2008) reviewed adaptive
skills interventions implemented only in schools (participants with ASD ranged in age from 3 to 21) and found that
behavioral interventions had been effective in improving academic, communication, functional life, play and social skills.
However, concerns regarding the variability of the skills targeted, participant characteristics, instructional procedures and
the magnitude of behavioral change prevented definitive conclusions.
Surprisingly, research on adaptive skill building in young adults (16 years and above) is limited, despite their lifelong
impairments in adaptive functioning. In a recent albeit not systematic review, Matson, Hattier, and Belva (in press)
summarized behavioral intervention research on improving work skills, self-help, leisure, hygiene, and feeding in
adolescents and adults with ASD. Authors concluded that, while behavioral procedures were effective, adaptive living skills
of adolescents and adults are understudied and should be researched more intensively given the impact of these skills on
quality of life and independent functioning. Almost all studies in Matson’s et al. review focussed on persons with ASD and ID.
As there is a need for intervention programs targeting adaptive skills in high-functioning young adults with ASD (e.g., Farley
et al., 2009) additional research is needed on the efficacy of behavioral interventions in this target group.
A. Palmen et al. / Research in Autism Spectrum Disorders 6 (2012) 602–617604
At present, no systematic review covering behavioral interventions for adaptive skill building in high-functioning young
adults with ASD has been published. Given the importance of independent functioning, the need to explicitly target adaptive
skills, and the financial cost associated with long term care of individuals with ASD (Järbrink, McCrone, Fombonne, Zandén, &
Knapp, 2007), a systematic review on this topic is warranted. The purpose of this review is to systematically examine the
state of research on behavioral interventions in improving adaptive behavior in young adults with high-functioning ASD in
order to (a) evaluate research areas, techniques, and outcome measures and to (b) identify limitations and promising areas in
need of future research.
2. Method
2.1. Search procedures
First, systematic searches were conducted in four electronic databases: Education Resources Information Center (ERIC),
PsycINFO, PubMed, and Web of Science. In all four databases the search was limited to articles written in English and
published between January 1990 and August 2010 in peer-reviewed journals. The keywords fields in all four databases were
searched using various forms and combinations of the terms ‘‘autism’’, ‘‘Asperger syndrome’’, ‘‘pervasive developmental
disorder’’, ‘‘youth’’, ‘‘adolescents’’, ‘‘adults’’, and ‘‘behavioral intervention’’, ‘‘adaptive’’, ‘‘daily living’’, ‘‘self-help’’, ‘‘social’’,
‘‘communication’’, ‘‘leisure’’, ‘‘academic’’, ‘‘vocational’’, ‘‘job’’, and ‘‘community’’. Abstracts identified in the search were
screened for possible inclusion (see Section 2.2). Following the database search, hand searches, covering August 2010 to
August 2011, were completed for the journals containing the included studies. Finally, the reference lists of the studies that
met inclusion criteria were reviewed to identify additional studies for inclusion. A total of 106 abstracts were identified for
further screening.
2.2. Inclusion and exclusion criteria
To be included in this review studies had to meet four inclusion criteria. First, at least one of the participants had to be 16
years or older, diagnosed with an autism spectrum disorder (ASD) and have a Full scale IQ or Verbal IQ of 70 or above. In
studies in which IQ data were not reported the participant had to be diagnosed with Asperger syndrome (AS), described as
‘‘high-functioning’’, and/or have age appropriate language skills (e.g., Dotson, Leaf, Sheldon, & Sherman, 2010; Fullerton &
Coyne, 1999; Gentry, Wallace, Kvarfordt, & Lynch, 2010). Second, the study had to involve at least one dependent variable
related to adaptive living skills. For the purpose of this review, an adaptive skill was defined as a behavioral skill that is
related to social interactions (e.g., initiating or maintaining conversations, voice intonation) or daily living (i.e., self help-,
domestic-, community-, leisure-, academic-, or vocational skills) (e.g., Kenworthy, Case, Harms, Martin, & Wallace, 2010;
Sparrow, Cicchetti, & Balla, 2005). Third, the intervention had to involve procedural components based upon applied
behavior analysis (ABA), such as task analysis, prompting, and reinforcement. Studies in which researchers explicitly
identified the intervention as cognitive behavioral in nature were also included (e.g., Turner-Brown, Perry, Dichter, Bodfish, &
Penn, 2008). Finally, the study had to contain systematic data-collection procedures (e.g., structured questionnaires, rating
scales, tests, and/or direct observations) and present at least two data points, for example one data point at pre-test/baseline
and one data point at post-test/intervention, or two data points during intervention with at least one data point at the
beginning and one data point at the end of the intervention (i.e., routine outcome monitoring).
Studies were excluded for three reasons. First, studies that only provided anecdotal data (e.g., narrative case reports or
descriptive observations) were excluded (e.g., Burt, Fuller, & Lewis, 1991). Second, studies that only presented results on
group level were excluded if participants’ characteristics showed that age and/or IQ ranged from below to meeting inclusion
criteria and the mean age of the group of participants was lower than 16 years and/or the total mean IQ score was below 70
(see e.g., Bauminger, 2002; Herbrecht et al., 2009; Tse, Strulovitch, Tagalakis, Meng, & Fombonne, 2007). Third, studies that
targeted only cognitive skills or overall competence (e.g., emotion recognition, Theory of Mind, friendships, employment)
were excluded in order to maintain the emphasis on interventions targeting behavioral performance (e.g., Golan & Baron-
Cohen, 2006; Smith, Gardiner, & Bowler, 2007). Finally, studies that primarily targeted decreasing problem behaviors were
excluded in order to maintain focus on increasing adaptive behaviors (e.g., Gerdtz, 2000). Ultimately, 20 studies were
selected for inclusion in this review.
2.3. Data extraction and coding
The following features of the included studies were summarized: (a) participant characteristics, (b) adaptive skills
targeted, (c) components of intervention procedures, (d) intervention outcomes, including measures on follow-up (FU),
generalization (Gen), and social validity (SV), and (e) certainty of evidence. Various procedural aspects were also noted,
including setting, intervention format, experimental design, method of data collection, interobserver agreement (IOA), and
treatment fidelity (TF).
Treatment outcomes for the included participants were first summarized as reported by the authors of the study (e.g.,
pre-post changes, statistical significance, and/or percentage of non-overlapping data). We further classified outcomes as
positive, negative, or mixed (Machalicek et al., 2008). Results were classified as ‘‘positive’’ if all the targeted adaptive skills of
605 A. Palmen et al. / Research in Autism Spectrum Disorders 6 (2012) 602–617
all the participants improved or if significant group improvements were found in all the targeted adaptive skills. Results were
classified as ‘‘mixed’’ if some but not all the targeted skills improved and some participants remained constant or declined.
‘‘Mixed’’ was also used if group means showed improvements in some but not all of the targeted skills. Results were classified
as ‘‘negative’’ if none of the participants benefited from the intervention and performance remained constant or declined for
all the targeted adaptive skills, or if no significant improvements were found.
Design and other methodological characteristics were considered when evaluating the quality of evidence for each
included study (Schlosser, Wendt, & Sigafoos, 2007). The certainty of evidence hierarchy described by Lang, Regester,
Lauderdale, Ashbaugh, and Haring (2010), Ramdoss, Lang, et al. (2011), and Ramdoss, Mulloy, et al. (2011) was used in which
studies are rated as either ‘conclusive’, ‘preponderant’, or ‘suggestive’ in their quality of evidence. Within the lowest level of
certainty, classified as suggestive evidence, studies did not use a true experimental design. Studies in the suggestive category
may have utilized a pre- or quasi-experimental design such as an AB-design, or pre-post control group design without
randomization and blinding. The second level of certainty, classified as preponderant evidence, contained studies utilizing a
true experimental design (e.g., group design with random assignment, multiple baseline/probe design, or reversal design)
and the following four qualities: (a) adequate interobserver agreement outcomes (i.e., 80% or higher agreement or reliability
in at least 20% of sessions), (b) adequate treatment fidelity measures/outcomes, (c) operationally defined dependent
measures, and (d) sufficient detail on intervention procedures to enable replication. In addition to these attributes, studies at
the preponderant level were found to be lacking in their control for alternative explanations for treatment outcomes (e.g.,
concurrent interventions targeting the same dependent variables). The highest level of certainty, classified as conclusive,
contained studies that (a) utilized true experimental designs, (b) contained the four qualities of the preponderant level and
(c) contained design features that provided at least some control for alternative explanations for intervention outcomes. For
example, a multiple baseline design in which the introduction of the intervention is staggered across at least three
participants and concurrent interventions and/or attention are held constant.
2.4. Reliability of search procedures and data extraction
Using the inclusion and exclusion criteria, a total of 106 studies were further screened for possible inclusion in this
review. After this initial screening 23 studies were identified for possible inclusion. The first and second author applied the
inclusion criteria to the list of 23 potential studies. Agreement was obtained on 21 of the 23 studies. Hillier, Campbell, et al.
(2007) and Mawhood and Howlin (1999) were identified for inclusion by one author and for exclusion by the other.
Ultimately, the study of Mawhood and Howlin (1999) was excluded because behavioral data contained only a single data
point. The study of Hillier, Campbell, et al. (2007) was included. Two studies were identified for exclusion by both authors.
The study by Barnhill, Tapscott Cook, Tebbenkamp, and Smith Myles (2002) was excluded because no systematic measures
were reported on the behavioral target of the study (i.e., responding to facial expressions) and Hillier, Fish, Clopper, and
Beversdorf (2007) was excluded because the counselling program did not contain procedural components based upon ABA.
As a result, 20 studies were included in this review.
After the list of included studies was agreed upon, the first author extracted information to summarize the studies. The
accuracy of these initial summaries was independently checked by the second author using a checklist including the
summary of the study and five questions on accuracy of the summary, specifically: (a) is this an accurate description of
included participants?, (b) is this an accurate description of targeted adaptive skills?, (c) is this an accurate description of the
intervention?, (d) is this an accurate summary of the results?, and (e) is this an accurate summary of the certainty of
evidence? In cases where the summary was not considered accurate the authors discussed disagreements and changes were
made to improve the accuracy of the summary. This process was repeated until the authors were in 100% agreement
regarding all of the summaries. Using this procedure, inter-rater agreement on data extraction and analysis could be
assessed. There were 100 items on which there could be initial agreement (i.e., 20 studies with 5 questions per study). Initial
agreement was obtained on 86 items (86%).
3. Results
Table 1 provides a summary of participant characteristics, adaptive skills targeted, intervention procedures, outcomes,
and certainty of evidence for each of the 20 included studies.
3.1. Participants
A total number of 116 persons participated in the studies. The sample size of participants ranged from 1 to 22 and seven
studies contained more than 6 participants (Fullerton & Coyne, 1999; Gentry et al., 2010; Hillier, Campbell, et al., 2007; Howlin
& Yates, 1999; Palmen, Didden, & Arts, 2008; Turner-Brown et al., 2008; Webb, Miller, Pierce, Strawser, & Jones, 2004). A total of
97 participants (83.6%) met the inclusion criteria and data are presented regarding these participants. Eight studies contained
19 participants who did not meet the inclusion criteria regarding age, diagnosis, or IQ. Of these 19 participants, 13 were younger
than 16 years (Delano, 2007; Dotson et al., 2010; Koegel & Frea, 1993; Songlee, Miller, Tincani, Sileo, & Perkins, 2008; Webb et al.,
2004), one person did not have a diagnosis of ASD (Dotson et al., 2010), and five persons had ID (Allen, Wallace, Greene, Bowen, &
Burke, 2010; Allen, Wallace, Renes, Bowen, & Burke, 2010; Mechling, Gast, & Seid, 2009).
6
0
6
Table 1
Summary and analysis of included studies.
Included studies Participant Targeted adaptive
Intervention procedures Outcomes and certainty of evidence
characteristics
skill(s)
Allen, Wallace,
Greene,
et al. (2010)
Allen, Wallace, Renes,
et al. (2010)
Bouxsein
et al. (2008)
Burke et al. (2010)
N = 3/2
2 males (PDD-NOS; IQ:
NR, cognitive
functioning within
typical and borderline
range), 22 and 19 years
old
N = 4/2
2 males (AS, Autism,
IQ: NR, cognitive
functioning within
typical and borderline
range), 16 and 17 years
old
N = 1/1
1 male (AS); 19 years
old
N = 6/6
6 males (AS: n = 4,
PDD-NOS: n = 2:
cognitive functioning
from above average to
borderline range); 18–
27 years old
Multiple tasks in a
mascot job (e.g.,
waving, hand shaking)
Multiple tasks in a
mascot job
Task engagement:
(a) task completion
(b) on task behavior
Occurrence of 63 job
tasks in a mascot job;
tasks were categorized
in three response
types:
(a) response to cues
from facilitator (e.g.,
responding within 5
sec of requests)
(b) response to cues
from audience (e.g.,
encouraging audience
by shaking head)
(c) response to cues
from scripts (e.g.,
initiating interaction)
General instruction was compared to video
modeling:
General instruction: general (verbal) task statement
Video modeling: watching video (i.e., job behaviors
are shown in scripted and naturalistic settings) and
general task statement
General instruction was compared to video
modeling:
General instruction: general (verbal) task statement
Video modeling: watching video (i.e., job behaviors
are shown in scripted and naturalistic settings) and
general task statement; video modeling was repeated
in case mastery criterion was not met within one 10-
min job session
General instruction was compared to specific
instruction:
General instruction: general (verbal) task statement,
non-specific praise
Specific instruction: verbal task statement on goal and
time frame, non-specific praise, fading schedule for
task goals
Study 1 (n = 3): General instruction was compared to
behavioral skills training (BST) that was followed by a
PDA-based, performance cue system (PCS) if criterion
was not
reached
Study 2 (n = 3): General instruction was compared to
PCS that was followed by BST (without instruction,
video-modeling, and home work) if criterion was not
reached
General instruction: modeling of basic mascot actions
followed by general (verbal) task statement
BST: instruction (script), live-, and video-modeling,
practice, feedback (i.e., specific praise, corrective
teaching), homework and practice log
PCS: display of text cues (one cue per task) on an iPod
inside the mascot, cues are applied by an assistant
Results: Positive: Improvements (almost) immediately followed video
modeling; mastery criterion was reached in both participants,
although performance was not stable;
FU: Yes;
Gen:
Yes; SV: Yes
Certainty: Preponderant: true experimental design; starting points of
intervention were staggered over small amounts of time across three
participants; results were replicated in third participant (mild ID).
Baseline and intervention consisted each of one (6–16 min) session
per participant (minute-by-minute analyses), indicating limited
control on data variability over time. The relative simple task set may
have effect outcomes positively. Adequate scores on IOA; TF not
reported, however, researcher ensured video ran as
designed
Results: Positive: Small improvements followed first video modeling;
mastery criterion was met by both participants following second
video viewing, performance was not stable; FU: Yes; Gen: No; SV: Yes
Certainty: Preponderant: true experimental design, starting points of
intervention were staggered over small amounts of time across four
participants. Findings were replicated in two participants: one of
them (mild ID) needed one video viewing in reaching criterion, the
other one (mild ID) needed a second video viewing. Given variability
in data and completion of baseline and intervention conditions within
one day, control for alternative explanations is limited. Adequate IOA
scores; TF not reported, however, researcher ensured video ran as
designed
Results: Positive: (a) task completion improved from stable baselines
to gradual increases, following (changes in) specific instruction, for
each task; (b) mean improvements in on task behavior for each task,
following specific instruction; FU: No; Gen: No; SV: No
Certainty: Conclusive: true experimental design, starting points of
intervention were staggered over time across three task types and
changes in criteria for task goals (different for each task type) were
followed by skill gains, providing control for alternative explanations.
Adequate scores on IOA; TF not reported, however, a single
component procedure was used
Results:
Study 1: Positive: one participant reached mastery criterion following
five BST sessions (without PCS); two participants reached mastery
criterion (almost) immediately following BST and PCS
Study 2: Positive: two participants reached mastery criterion
immediately following PCS; one participant needed additional use of
BST to reach mastery criterion
FU: Yes; Gen: Yes; SV: Yes
Certainty: Suggestive: true experimental design, starting points of
intervention were staggered across participants and a reversal
(removal and reintroduction of PCS or BST) was conducted with one
(study 1) or all participants (study 2), behavior changes followed
interventions and reversals. BST was needed by 1 participant in 2nd
study, refraining from attributing results solely to PCS; adequate
scores on IOA; insufficient detail on intervention procedures to enable
replication, TF was not reported
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Davis et al. (2010)
Delano (2007)
Dotson et al. (2010)
Fullerton and
Coyne (1999)
N = 3/3
3 males (AS); 16, 17
and 17 years old
N = 3/1
1 male (AS); 17 years
old
N = 5/3
2 females and 1 male
(Autism, PDD-NOS, and
AS respectively; IQ: NR,
described as having
‘‘good language’’); 18,
17, and 17 years old,
respectively
N = 8/8
2 females and 6 males
(HFA and/or AS);
16–27 years old
Time engaged in
others-focused
interaction, i.e., saying
name of partner,
presenting questions/
comments about
partner’s interest, and
listening while
maintaining eye
contact
Written language
performance:
(a) rate of words
written
(b) rate of functional
essay elements
Conversation skills:
(a) conversation basics,
i.e., eye contact, voice
tone, distance, body
posture
(b) delivering positive
feedback
(c) answering/asking
open-ended
questions
Quality of dyadic
conversations skills,
e.g., turn taking, eye
contact, paraphrasing
Conversational skill training was compared to Power
card strategy:
Conversational skill (pre-) training: model-lead-test,
practice, multiple exemplars, visual cues, praise,
error correction using guiding questions
Conversation probes: verbal prompt to discuss an
interest of the conversation partner
Power Card procedure:
Instructional format: explanation Power Card strategy
(including scripts on Special Interest Area-SIA),
instruction, rehearsal
Conversation probes: verbal prompt to use power
script and card during conversation, feedback
following probes
General essay prompt (i.e., verbally described goal)
was compared to self-regulated strategy
development (SRSD) via video self-modeling:
Creation of videos: sample essay, written script on
implementation self-regulation strategy, application
of the strategy by the participant using a mnemonic
and self-instruction, error correction using verbal
prompting
Video self-modeling: viewing video about self-
regulation strategies, i.e., goal setting, self-
instruction, self-monitoring, and self-
reinforcement
Social skills group (SSG):
Concept instruction, task-analyses, modeling,
response identification, role-play, social
reinforcement, corrective feedback using verbal
prompting
Communication program unit in SSG:
Concept instruction and discussion, visual and
written information on skills, response identification,
discussion, videotaped role-play, and self-reflection
on role-play using checklists
Results: Positive: all participants met mastery criterion following
power card intervention; M PND = 100; Fu: No; Gen: Yes; SV: Yes
Certainty: Preponderant: true experimental design; starting points of
intervention were staggered over time across three participants. The
concurrent use of a SIA script, prompts to use cards and feedback
following intervention probes may have effect outcomes
positively
and refrains from attributing results solely to the power card strategy.
Adequate scores
on IOA and TF
Results: Positive: mastery criterion met for each skill following SRSD;
FU: Yes;
Gen: Yes; SV: No
Certainty: Preponderant: start of intervention was staggered over time
for both skills; gradually skill improvements in skill (a) following the
intervention for that skill, improvements in skill (b) immediately
following intervention skill (b). No control for potential interference
from intervention skill (b) on increases in skill (a), following start
intervention skill (b). Replications across two participants confirm
findings; however, these participants did not meet the age criterion of
the present review, limiting evidence for review’s age group. The
concurrent use of video creation refrains from attributing results
solely to video self-modeling. Adequate IOA; TF was not reported,
however, researcher observed video was run
Results: Mixed: following program, all participants met mastery
criteria for skills (b) and (c); 2 out of 3 participants met mastery
criterion for skill (a); FU: Yes; Gen: Yes; SV: No
Certainty: Conclusive: true experimental design, intervention was
staggered across three skills and increases immediately followed start
of intervention, the design was replicated with five participants (also
one participant diagnosed with PDD-NOS, but <16 years old)
indicating fair control for alternative explanations; adequate scores
on IOA and TF
Results: Positive: 2 speech-language therapists identified post
responses adequately on dyadic scenario for all participants; FU: Yes;
Gen: Yes; SV: No
Certainty: Suggestive: pre-experimental design (no control group);
target skills not operationally defined; qualitative data; insufficient
detail on intervention to enable replication; adequate IOA; TF was not
reported; in analyzing data, therapists were familiar with the
participants and the intervention, this may have influenced results
positively
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Table 1 (Continued )
Included studies Participant
characteristics
Targeted adaptive
skill(s)
Intervention procedures Outcomes and certainty of evidence
Gentry et al. (2010)
Hillier, Campbell,
et al. (2007)
Howlin and
Yates (1999)
Koegel and
Frea (1993)
Mechling
et al. (2009)
N = 22/22
4 females and 18 males
(Autism; IQ: NR,
described as ‘‘high
functioning’’); mean
age = 16.5 years old
(range 14–18 years)
N = 9/9
1 female and 8 males
(AS: n = 6, Autism:
n = 3; mean Full scale
IQ = 111, IQ range
95–131); mean
age = 22 years (age
range 18–36)
N = 10/10
10 males (AS or
Autism; non-verbal IQ
range 86–138, no
significant language
deficits); mean age = 28
years (range: 19–44)
N = 2/1
1 male (Autism; Full
Scale IQ = 71); 16 years
old
N = 3/1
1 male (Autism; Full
Scale IQ = 75); 16 years
old
Task-management:
(a) performance in
everyday life tasks:
keeping appointments,
household-,
homework-and
medication
management
(b) satisfaction with
performance
Job skills:
(a) Vocational skills,
e.g., task transitioning,
asking for help
(b) Work-related social
skills, i.e.,
communication with
employer, greeting
Conversational skills:
(a) initiating and
maintaining
conversations
(b) use of general
statements
(c) inappropriate social
utterances, and
(d) appropriate
responses
Non-verbal skills:
(a) eye gaze and (b)
nonverbal mannerisms
Completing cooking
recipes using a
personal digital
assistant (PDA)
Intervention in use of PDA as task-management tool:
Training: stepwise procedure, instruction, modeling,
rehearsal, reinforcement
Post-training: participants may contact investigator
by email or phone with ‘‘trouble-shooting’’ questions
Supported employment:
Pre-placement services: assessment, instruction in job
search skills, ‘‘help’’ in search for employment,
practice, videotaped role-play, review of
performance
On-site job coaching support: ‘‘help’’ with
understanding job tasks or work place rules,
providing conversation topics, training in job tasks
(when necessary), psycho-education of employers
and co-workers
Follow-on support: evaluation, support in case of
problems or job changes (i.e., discussing solutions,
counselling, or training on the job)
Social skills group:
Concept instruction and discussion, multiple
exemplars, videotaped role-play, feedback from
video recordings, structured games, and team
activities (e.g., job interviews)
Self-management:
Pre-treatment: response identification/
discrimination, modeling, imitation, instruction in
self-recording
Treatment self-management: self-recording and self-
reinforcement using escalating intervals
Self-prompting using a PDA:
Pre-training (technical use PDA): instruction,
prompting
Training (use PDA in self-prompting, i.e., use of task-
steps and picture-, video-, auditory-, and combined
prompts in a least to most hierarchy per step):
corrective verbal and gesture prompts, social
reinforcement
Results: Positive: statistically significant pre-post improvement in
performance and satisfaction with performance of everyday life tasks;
FU:
No; Gen: No; SV: Yes
Certainty: Suggestive: pre-experimental design (no control group);
qualitative data, questionnaires were not validated; insufficient detail
on intervention procedures; IOA and TF were not reported, however,
use of PDA was registered in the device; additional prompts by
parents may have effect outcomes positively
Results: Mixed: (a) group mean ratings (n = 6) showed improvements
during support program (from 3 month to 12 month measures) in 3
items; performances on the other 14 items showed only slight
increases and decreases; (b) group mean ratings (n = 6) showed
improvements in all skills, from 3 month to 12 month measures; FU:
No; Gen: No; SV: Yes
Certainty: Suggestive: pre-experimental design (no control group);
qualitative data, questionnaires were not validated; insufficient detail
on intervention procedures; individual differences such as number of
hours worked or type of employment may have effected outcomes;
IOA and
TF were not reported
Results: Mixed: mean pre-post data on two simulated social
activities
reveal significant improvements in skill (a) and skill (d) following SSG;
a significant decrease in skill (c) was found on one of the social
activities and decreases (not significant) in skill (b) were found on
both social activities following SSG; FU: No; Gen: No; SV: Yes
Certainty: Suggestive: pre-experimental design (no control group),
target skills not fully operationally defined, insufficient detail on
intervention; TF was not reported despite compound procedure; IOA
range 75–100%
Results: Positive: improvements in both skills following self-
management;
FU: No; Gen: Yes; SV: No
Certainty: Preponderant: intervention was staggered over time across
2 skills in the included participant and across 1 other skill in another
participant (13 year old), limiting control for alternative explanations.
Description of (pre-) treatment sessions lacks some detail. Adequate
IOA; TF was not reported, participant’s use of self-management was
videotaped and recorded which may serve the same function as TF
Results: Positive: mastery criterion met for each cooking recipe,
following PDA-training; PND = 100%; FU: Yes; Gen: No; SV: Yes
Certainty: Conclusive: the design controlled for recipe order in
training, showing immediate improvements following intervention;
results were replicated with 2 other participants having moderate ID,
limiting evidence for review’s target group. Limited detail on
pre-training procedure; however, details on training were sufficient
to enable replication. Adequate scores on IOA and TF
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Palmen et al. (2008)
Shields-Wolfe and
Gallagher (1992)
Smith Myles
et al. (2007)
Songlee et al. (2008)
N = 9/9
2 females and 7 males
(ASD; Verbal IQ range:
82–131); age range
17–25 years
N = 1/1
1 male (Autism; IQ: NR,
described as ‘‘low-
average to borderline
ranges’’ based on
WAIS-R); 21 years old
N = 1/1
1 male (AS); 17 years
old
N = 4/2
2 males (AS; Full scale
IQ: 110 and 140); 17
and 16 years old
Question asking during
tutorial conversations
Vocational and
work-related
interpersonal skills:
(a) work rate
(b) task-accuracy
(c) initiating/
responding to
greetings, stating
‘excuse me’
Self-recording of
homework
assignments in a
planner, i.e.
(a) subject of
homework
(b) date
assignment
was due
(c) details of
assignment
Strategic performance
on taking tests:
(a) test preparation
(b) using test
instruction
(c)
answering
questions
Silence prompts were compared to behavioral skills
training (BST):
Baseline: silence prompts during tutorial
conversations; two group sessions (no training
principles in effect)
BST: concept instruction, task analyses, response
discrimination, modeling, descriptive feedback,
role-play and (self-) instruction using a flowchart,
specific praise, corrective feedback using least to
most prompting, table game, and rewards; tutorial
conversations as in baseline
Supported employment:
Job/skill match/selection: assessments, analyses of
assessments, job and company selection
Supportive employment: forward chaining, modeling,
feedback, verbal and physical prompting, cue cards,
verbal rehearsal, (fading out) physical proximity and
social reinforcement, weekly payment
Use of handwriting requirements was compared to
use of a PDA:
Pre-training (technological use PDA-system): specific
instruction
Training: prompts to enter homework in PDA at first
day of self-management sessions in each setting
Strategy training:
Strategy-instruction: feedback on pre-test probes,
goal setting, instruction conform Test-taking Strategy
Instructor’s Manual consisting of concept instruction,
modeling using mnemonic devices, verbal practice
(rehearsal), prompting
Strategy practice: review of strategy steps, corrective
and positive feedback, and discussion
Results: Positive: correct questions improved for all participants
following BST, a significant increase was found for group; FU: Yes;
Gen: Yes; SV: Yes
Certainty: Conclusive: a true experimental design was used,
intervention was staggered over time across three groups of
participants (n = 3); baseline group sessions to control for increased
attention during intervention and silence prompts during baseline
conversations provided control for alternative explanations.
Additional prompts by personal coaches may have biased outcome,
however, this also may have been in effect during baseline. TF was not
reported, however, trainer used a flowchart of the procedure to
control for variations in implementation; adequate IOA scores
Results: Mixed: (a) work rate improved, (b) job-task accuracy
improved for 13 of 15 subtasks, and (c) both interpersonal skills
improved (changes measured between first five and last five
supportive sessions); FU: No; Gen: No; SV: No
Certainty: Suggestive: a pre-experimental, single subject, intervention
only design was used, without replications. Insufficient detail on
intervention and dependent measures to enable replication. IOA and
TF were not reported
Results: Mixed: mastery criterion was reached in 2 settings (following
6 and 8 PDA-sessions, respectively); no changes in third setting
(following 5 PDA-sessions) although there was an increasing trend in
the last 2 sessions; FU: No; Gen: No; SV: No
Certainty: Preponderant: intervention was staggered over time across
3 settings; in 2 settings skill improvements followed start of
intervention; in the baseline of setting 3, generalization could be in
effect, limiting control for alternative explanations. TF was not
reported, however, participant’s use of the PDA (= intervention) was
reported; adequate IOA data
Results: Positive: mastery criterion was reached for both included
participants following strategy training; FU: Yes; Gen: Yes; SV: Yes
Certainty: Preponderant: start of interventions was staggered over
time across three out of four participants. Start of intervention for the
participants �16 years was not staggered over time, gradual
improvements following intervention in one of both participants.
Results were replicated with two participants who were younger than
16 years of age, limiting evidence for review’s age group. Adequate
IOA. Scores on TF did not reflect accuracy in procedure, but accuracy in
observations of the procedure
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Included studies Participant
characteristics
Targeted adaptive
skill(s)
Intervention procedures Outcomes and certainty of evidence
Tiger et al. (2007)
Turner-Brown
et al. (2008)
Webb et al. (2004)
N = 1/1
1 male (AS); 19 years
old
N = 11/11
1 female, 10 males
(Autism: n = 8, ASD:
n = 3; Full scale IQ
range 84–144); age
range 25–55 years
N = 10/3
3 males (ASD; Full
Scale IQ: 85, 107, and
86); 16, 16, and 17
years old, respectively
Improving response
rate:
Study 1: Improving
short response
latencies in question
answering
Study 2: Improving
short response
latencies (and
accuracy) in math
problem solving
Social functioning, e.g.,
social appropriateness,
showing social interest
and affect, applying
fluency and clarity in
conversations
Social functioning:
(a) share ideas
(b) compliment others
(c) offer help
(d) recommend
changes nicely
(e) exercise
self-control
Differential reinforcement combined with rule
instruction:
Study 1:
Baseline: presenting questions to answer
Differential reinforcement (DR): similar to baseline,
combined with DR of short or long latencies (praise,
token), rule instruction, corrective feedback using
verbal instruction, and changing reinforcement
criteria
Study 2:
Baseline: presenting three problem types, specific
praise, reassuring statements in case of incorrect or
no responses
Differential reinforcement (DR): similar to baseline,
combined with DR of short latencies and/or correct
problem solving and changing rule instruction
Cognitive behavioral program: Modified version of
the Social Cognition and Interaction Training
(SCITT-A): concept instruction, discussion, response
identification, role-play, practice, and homework
Social skills instruction program:
Strategy program (SCORE Skills, Vernon et al., 1996):
concept instruction, task analysis, discussion,
modeling, verbal practice (rehearsal), role-play, game
activities
Results:
Study 1: Positive: short response latency increased following DR,
changes in response latency followed changes in DR-conditions
Study 2: Positive: short response latency and accuracy increased
following (contingency changes in) DR
FU: No; Gen: Yes; SV: No
Certainty: Conclusive: different experimental conditions were
conducted to reverse the effects of applied contingencies, indicating
that the reversing conditions controlled the outcomes. Adequate IOA.
Sufficient detail on intervention procedures to enable replication.
Although TF was not reported, the 2nd study served the same function
as TF by providing evidence that gains were due to DR. The second
study also provided control for alternative explanations for treatment
gains (i.e., type of questions, type of rule instructions)
Results: Negative: following SCITT-A, no improvements were found in
role-play performance in both groups and small improvements were
found in social self-reports in experimental group; no significant main
effects of group or time, or group � time interaction on both skill
measures, however, group � time interaction approached significance
(p < 0.10) on self-reports; FU: No; Gen: No; SV: No
Certainty: Suggestive: a quasi-experimental design was used (no
randomized group assignments). Limited detail on specific
intervention procedures refrains from replication. Adequate IOA, TF
was not reported despite compound procedure
Results: Mixed: pre-post data on performance were presented for one
skill per participant, showing improvements in skills (c), (d), and (e);
M pre-post group (N = 10) changes show significant increases in 4 out
of 5 skills, increase in ‘share ideas’ was not significant; FU: No; Gen:
Yes; SV: Yes
Certainty: Suggestive: intervention was staggered over time across 5
skills and 5 participants; this was replicated across 5 other
participants, data were collected only on one skill per participant;
number of data-points in the baseline of the multiple probe design
ranged from 1 to 3, indicating insufficient control on data variability
during baseline. Adequate IOA. Insufficient detail on compound
procedure refrains from replication, TF was not reported. Authors also
reported use of a multiple baseline design across skills in presenting
pre-post group means on skills. However, insufficient detail in
describing this design refrains from drawing conclusions regarding
the level of control for alternative explanations
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N: Total number of participants in study/number of participants included in review; PDD-NOS: pervasive developmental disorder not otherwise specified; NR: not reported; FU: follow-up; Gen: generalization; SV:
social validity; IOA: inter observer agreement; TF: treatment fidelity; AS: Asperger syndrome; PND: percentage non-overlapping data; HFA: high-functioning autism; ASD: autism spectrum disorder.
611 A. Palmen et al. / Research in Autism Spectrum Disorders 6 (2012) 602–617
Among the 97 included participants 12 were female (12%) and 85 were male (88%). This male to female ratio is consistent
with the more pronounced ratio within that of the ASD population without ID (Fombonne, 2003). The participants in 19 out
of the 20 included studies ranged in age from 16 to 55 years old. In one study (Gentry et al., 2010) participants’ age ranged
from 14 to 18 years, however, the study was included because mean age (M = 16.5 years) met our inclusion criterion (see
Section 2.2). Thirty-eight participants were diagnosed with Autism (39%), 21 with AS (22%), and five with PDD-NOS (5%).
Furthermore, eight (8%) participants were described as having high-functioning autism (HFA) and/or AS, 10 participants
(10%) were described as having Autism or AS, and 15 participants (16%) were identified as having an ASD but a specific
diagnosis of Autistic disorder, AS, or PDD-NOS was not stated. Across studies, the reported Full Scale IQ of the included
participants ranged from 71 to 144 (M = 101).
3.2. Settings
The setting was specified in 18 studies. The most often used settings were community locations such as employment
settings (e.g., Allen, Wallace, Greene, et al., 2010; Hillier, Campbell, et al., 2007), schools (e.g., Davis, Boon, Cihak, & Fore, 2010;
Mechling et al., 2009), or public agency settings such as university offices (e.g., Delano, 2007; Dotson et al., 2010). Home
locations (Gentry et al., 2010) and day or clinical treatment settings (e.g., Bouxsein, Tiger, & Fisher, 2008; Palmen et al., 2008)
were also used. Nine studies made use of multiple locations mostly within the same setting. In seven of these studies different
locations were used for training and data collection (Allen, Wallace, Greene, et al., 2010; Allen, Wallace, Renes, et al., 2010;
Burke, Andersen, Bowen, Howard, & Allen, 2010; Davis et al., 2010; Koegel & Frea, 1993; Palmen et al., 2008; Webb et al., 2004).
3.3. Targeted adaptive skills
Across all studies, targeted adaptive skills could be classified into four categories: (a) social interaction skills, (b) academic
skills (c) vocational skills, and (d) domestic skills. Studies in the social interaction skills category (n = 8) included interventions
designed to improve (non-)verbal social interaction skills such as using appropriate distance, eye contact, or voice tone (e.g.,
Dotson et al., 2010; Koegel & Frea, 1993), initiating and maintaining conversations (Howlin & Yates, 1999), asking and/or
answering questions (e.g., Davis et al., 2010; Palmen et al., 2008), delivering positive feedback (e.g., Dotson et al., 2010; Webb
et al., 2004), offering help (Webb et al., 2004), or quality of social functioning (Fullerton & Coyne, 1999; Turner-Brown et al.,
2008). Studies in the academic skills category (n = 6) included interventions designed to improve home work planning (Smith
Myles, Ferguson, & Hagiwara, 2007), strategic test performance (Songlee et al., 2008), management of every day living tasks
(Gentry et al., 2010), task engagement (Bouxsein et al., 2008), written language performance (Delano, 2007), and response
latency (Tiger, Bouxsein, & Fisher, 2007). Studies in the vocational skills category (n = 5) included interventions designed to
improve vocational and/or work-related social skills such as transitioning and task completion (Hillier, Campbell, et al.,
2007), asking for help (Hillier, Campbell, et al., 2007), task-accuracy (Shields-Wolfe & Gallagher, 1992), accurate greeting/
saying goodbye (Hillier, Campbell, et al., 2007; Shields-Wolfe & Gallagher, 1992), or multiple product promotion tasks in a
mascot job (WalkAround1 mascot; Signs & Shapes International, Inc. Omaha, NE, USA) (Allen, Wallace, Greene, et al., 2010;
Allen, Wallace, Renes, et al., 2010; Burke et al., 2010). Finally, one study was categorized as domestic skills. In that study
interventions were designed to improve the completion of cooking recipes (Mechling et al., 2009). See Table 1 for further
information on targeted skills.
3.4. Data collection and interobserver agreement
Data on targeted skills were mostly collected by direct observation. For example, social skill interactions were measured
between the participant and a non-disabled peer or an adult (Davis et al., 2010; Koegel & Frea, 1993; Palmen et al., 2008) or
during role play scenarios with the trainer (e.g., Dotson et al., 2010; Turner-Brown et al., 2008; Webb et al., 2004). Direct
observations of targeted academic, vocational and domestic skills were mostly conducted in the training setting of the study
or in an incidental job setting; however, Shields-Wolfe and Gallagher (1992) and Smith Myles et al. (2007) collected data in
regular settings (i.e., regular employment setting and regular classes, respectively). Next to direct observation, self-report
measures (Turner-Brown et al., 2008) and (semi-) structured interviews (Fullerton & Coyne, 1999; Gentry et al., 2010) were
used. In one study (Hillier, Campbell, et al., 2007) data were collected using questionnaires completed by a relative (i.e.,
participant’s supervisor).
In 17 studies (85%) data were collected on interobserver agreement (IOA) in at least 20% of the assessment sessions. Mean
agreement scores ranged from 87 to 100% (Kappa’s were not reported) and one study reported an adequate Chronbach’s
alpha of 0.7 (Turner-Brown et al., 2008). The studies that targeted on task management at home (Gentry et al., 2010) and
vocational skills in the regular job setting (i.e., Hillier, Campbell, et al., 2007; Shields-Wolfe & Gallagher, 1992) did not report
data on IOA.
3.5. Intervention procedures
A variety of intervention procedures were used by the studies in the social interaction skills category. Six out of the eight
studies used a group format in teaching social interaction skills. The group size ranged from 3 (Palmen et al., 2008) to 11
A. Palmen et al. / Research in Autism Spectrum Disorders 6 (2012) 602–617612
participants (Howlin & Yates, 1999; Webb et al., 2004). In these studies the therapist conducted some combination of the
following procedures: concept instruction (in general consisting of describing the skills, providing a rationale for using them,
providing guidelines in using the skills and discussing skill steps), task analyses, response identification/discrimination,
modeling, (video-taped) role play practice, and feedback (see Table 1). Five studies involved role playing a simulated
situation by participants (Dotson et al., 2010; Fullerton & Coyne, 1999; Howlin & Yates, 1999; Turner-Brown et al., 2008;
Webb et al., 2004). During role-play in the study of Palmen et al. (2008), the trainer provided the participant with a response
opportunity by presenting a discriminative stimulus (i.e., 5 s silence cue) and the participant used a flowchart for self-
instruction. Several studies also used game activities or homework assignments in practicing the skills (e.g., Howlin & Yates,
1999; Turner-Brown et al., 2008). Feedback consisted of descriptive feedback (i.e., explaining why a response is [in] correct)
(Davis et al., 2010; Howlin & Yates, 1999; Webb et al., 2004), positive reinforcement and corrective feedback using a
prompting procedure (Dotson et al., 2010; Palmen et al., 2008), and self-reflection (Fullerton & Coyne, 1999). Most studies
used praise in providing positive feedback or reinforcement; the additional use of tangible rewards for correct responding
was reported only by Palmen et al. (2008). Two studies used available social skills programs. Turner-Brown et al. (2008) used
a modified version of the Social Cognition and Interaction Training (SCITT), a group-based cognitive behavioral intervention
originally designed for adults with psychotic disorders (Penn, Roberts, Combs, & Sterne, 2007) and Webb et al. (2004) used
the SCORE Skills Strategy program, a program validated for students with learning disabilities (Vernon, Schumaker, &
Deshler, 1996). Davis et al. (2010) compared the effects of a regular conversational group training (n = 3) with the effects of
an additional power card strategy training consisting of a one-to-one instructional format session and practice sessions with
a non-disabled peer. Koegel and Frea (1993) used a self-management procedure consisting of self-recording and self-
reinforcement. Following a one-to-one pre-treatment session, practice sessions were conducted with a non-disabled adult.
All studies provided information on intervention density regarding the length and/or the number of sessions, and/or the total
length of the intervention period (in weeks or months). Length of sessions ranged from 5-min sessions (four to seven during
one day per week) (Koegel & Frea, 1993) to 2–3-h sessions per week (Fullerton & Coyne, 1999) or per month (Howlin & Yates,
1999). The total length of the intervention period ranged from 6 weeks with weekly 50-min sessions (Palmen et al., 2008) to
one year with monthly sessions (Howlin & Yates, 1999). In two studies (Davis et al., 2010; Dotson et al., 2010) a mastery
criterion was defined in finishing an intervention. The total length of the intervention period was about 12 weeks in the study
of Dotson et al. In the study of Davis et al. each participant needed five daily 15-min probe sessions to reach criterion;
however, no information was reported on the length of conversational pre-training.
All six studies in the academic skills category used a one-to-one format. In three studies a technology assisted, self-
management training was used. Delano (2007) conducted an available strategy instruction program (the Self-regulated
strategy development model; Graham, Harris, MacArthur, & Schwartz, 1991) which was delivered by video self-modeling,
Gentry et al. (2010) combined several procedures (e.g., stepwise instruction, modeling, rehearsal) to teach the use of a
personal digital assistant (PDA) in independent task management, and Smith Myles et al. (2007) compared the use of
handwriting requirements with the use of a PDA system in self-recording homework assignments. Songlee et al. (2008)
conducted an available strategy instruction program (the Test-Taking Strategy; Hughes, Schumaker, Deshler, & Mercer,
2002) using mnemonic devices and strategy practice. Finally, Bouxsein et al. (2008) compared general and specific verbal
task instruction and Tiger et al. (2007) compared the differential effects of differential reinforcement combined with verbal
rule instruction. In four studies a mastery criterion was defined in finishing an intervention. The length and number of
sessions needed to reach criterion varied from 4, 6- to 21-min sessions (Delano, 2007) to 21, 15-min sessions (Bouxsein et al.,
2008), and from 5 to 8 education class sessions (Smith Myles et al., 2007) to 9, 50-min sessions (Songlee et al., 2008). In the
study of Tiger et al. (2007), number and length of training sessions varied from 17, 10-trial sessions in study 1 to 19, 9-trial
sessions in study 2. Gentry et al. (2010) conducted one 90-min and three 60-min training sessions in a period from 10 to 14
days, per participant. Training was followed by an 8-week post-training period in which the investigator could be contacted
by email or phone.
All five studies in the vocational skills category used a one-to-one format. In the studies of Allen, Wallace, Greene, et al.
(2010) and Allen, Wallace, Renes, et al. (2010) general instruction was compared to video modeling in teaching eight mascot
job tasks. Baseline and intervention conditions were completed in one day. A mastery criterion was used in evaluating data
(minute-by-minute analyses). The two studies differed from each other in that Allen, Wallace, Renes, et al. repeated video
modeling when mastery criterion was not reached within a 10-min session following first video viewing, while Allen,
Wallace, Greene et al. conducted video modeling only once and video viewing was followed by only one session with a length
of 15–16 min. Burke et al. (2010) targeted on 63 mascot job tasks and general instruction was compared to behavioral skills
training (BST) (consisting of several procedures such as instruction, video-modeling, practice, feedback, and home work) and
a performance cue system (PCS) in which text cues were displayed on an iPod. A mastery criterion was used in evaluating
outcomes and two to six 1-h sessions were needed to reach criterion. In the other two studies the intervention consisted of
supported employment. In the study by Shields-Wolfe and Gallagher (1992) several behavioral procedures (e.g., forward
chaining, modeling, cue cards, and feedback) were used. Support sessions were conducted during 25 days in an 8-week
period and lasted 3–4 h per session. Although precise information is not reported, Hillier, Campbell, et al. (2007) used several
means in supporting employment such as ‘‘help’’ with training, providing conversation topics, training in job tasks (when
necessary) and psycho education of employers and co-workers. The amount of support ranged from 4 to 20 h per week until
independency in job position (i.e., ranging from 1 day to 6 months). Next to this, follow-on support was conducted consisting
of evaluations and support in case of problems and was faded from twice a week to once a month; the duration of the
A. Palmen et al. / Research in Autism Spectrum Disorders 6 (2012) 602–617 613
investigation was 2 years. In both studies, supported employment was preceded by a pre-placement program consisting of
skill assessments and job selection. In the study of Shields-Wolfe and Gallagher pre-training consisted of 20 sessions during
an 8-week period. Hillier, Campbell, et al. conducted pre-training during at least 1 h per week until a job was found (i.e.,
ranging from 1 to 8 months).
Finally, in the only study on domestic skills (Mechling et al., 2009), a one-to-one format was applied and training was
conducted once a day, 3–4 days a week until mastery criterion (i.e., ranging from three to six sessions). A technology assisted
self-management procedure was used consisting of self-prompting using a PDA. The PDA contained task analyses and a least
to most prompting strategy. Self-management training consisted of specific praise and corrective feedback. The intervention
contained a pre-training phase in which the participant was trained in the technical use of the tool. The pre-training phase
lasted until mastery criterion; its length was not reported.
3.6. Treatment fidelity
Across all studies, only four studies (20%) used procedures to assess accuracy of implementation of treatment procedures.
Mean treatment fidelity (TF) scores ranged from 95% to 100% (Davis et al., 2010; Dotson et al., 2010; Mechling et al., 2009;
Songlee et al., 2008). However, the TF measure used in the study by Songlee et al. did not reflect the accuracy in the procedure
as agreement between observers was calculated on steps (in-) completed by the trainer. In some studies in which no TF
scores were reported, other procedural aspects provided (at least partially) control for variations in implementation of
procedures. For example, in the studies of Koegel and Frea (1993), Smith Myles et al. (2007) and Gentry et al. (2010)
participants’ use of self-management tools (i.e., self-recording equipment and PDA’s) was reported indicating control for
treatment implementation and in the study of Palmen et al. (2008) the trainer used a flow chart of the procedure to control
for variations in treatment.
3.7. Study designs
In 15 studies (75%) some variant of the single-subject design (Horner et al., 2005) was used to evaluate the effects of the
intervention. In one single-case study, a pre-experimental (intervention-only sequences) design was used (Shields-Wolfe &
Gallagher, 1992). In the other 14 studies, the design could be classified as true-experimental in that a systematic introduction
and removal of the intervention was conducted using a reversal design (Tiger et al., 2007) or that a staggered introduction of
intervention was conducted using a multiple baseline or multiple probe design across (groups of) participants (e.g., Allen,
Wallace, Greene, et al., 2010; Palmen et al., 2008), across tasks or settings (e.g., Mechling et al., 2009; Smith Myles et al.,
2007), across skills (Delano, 2007; Dotson et al., 2010), or across participants and skills (Koegel & Frea, 1993; Webb et al.,
2004). Combinations of designs were also used, for example Bouxsein et al. (2008) combined a multiple baseline design with
a changing criterion design and Webb et al. (2004) combined a multiple baseline with a multiple probe design, although the
multiple baseline design could not be discerned from their description.
In five studies, a variant of the group research design (Gersten et al., 2005) was used. The designs of four studies could be
classified as pre-experimental in that they involved pre-post, no control group designs (Fullerton & Coyne, 1999; Gentry
et al., 2010; Howlin & Yates, 1999) or intervention-only sequences (Hillier, Campbell, et al., 2007). Turner-Brown et al. (2008)
used a pre-post control group design. However, group assignment was not randomized, indicating a quasi-experimental
design was used.
3.8. Outcomes
Thirteen studies (65%) reported positive outcomes (Allen, Wallace, Greene, et al., 2010; Allen, Wallace, Renes, et al., 2010;
Bouxsein et al., 2008; Burke et al., 2010; Davis et al., 2010; Delano, 2007; Fullerton & Coyne, 1999; Gentry et al., 2010; Koegel
& Frea, 1993; Mechling et al., 2009; Palmen et al., 2008; Songlee et al., 2008; Tiger et al., 2007). Mixed outcomes
(improvements in some but not all adaptive skills) were reported in six studies (Dotson et al., 2010; Hillier, Campbell, et al.,
2007; Howlin & Yates, 1999; Shields-Wolfe & Gallagher, 1992; Smith Myles et al., 2007; Webb et al., 2004). Negative
outcomes were found by Turner-Brown et al. (2008); comparison of pre-post group means on two measures did not show
statistically significant improvements following intervention. See Table 1 for further information on outcomes.
3.9. Follow-up and generalization
Eight studies (40%) included data on follow-up. In six of these studies the maximum length of the follow-up period ranged
from 1 week to 1 month following intervention and data were collected using direct observation (Allen, Wallace, Greene,
et al., 2010; Allen, Wallace, Renes, et al., 2010; Burke et al., 2010; Mechling et al., 2009; Palmen et al., 2008; Songlee et al.,
2008). In two studies, maintenance probes were also conducted at 14 weeks (Delano, 2007) or 3 months (Dotson et al., 2010)
following intervention. Most studies reported successful maintenance of targeted skills within a month following
intervention. At a longer term, decreases were found; however, outcomes stayed above baseline levels. Although Fullerton
and Coyne (1999) reported that post-intervention data were collected 8–10 weeks following intervention using structured
parent interviews, specific data could not be discerned from their description.
A. Palmen et al. / Research in Autism Spectrum Disorders 6 (2012) 602–617614
Generalization effects of intervention were measured in 11 studies (55%). In eight studies data were collected using pre-
post measures in participants themselves. Generalization was measured across types of task stimuli (Delano, 2007; Fullerton
& Coyne, 1999; Songlee et al., 2008; Tiger et al., 2007), across settings and/or conversation partners (Davis et al., 2010;
Dotson et al., 2010; Koegel & Frea, 1993; Palmen et al., 2008), and across skills (Koegel & Frea, 1993). Five studies reported
positive outcomes, and mixed results were found by Davis et al. (2010), Fullerton and Coyne (1999), and Dotson et al. (2010).
In the studies of Fullerton and Coyne (1999) and Webb et al. (2004) generalization across settings was measured using pre-
post ratings by parents. Fullerton and Coyne found mixed outcomes and Webb et al. found no statistically significant
increases. Only post-measures were used by Allen, Wallace, Greene, et al. (2010) and Burke et al. (2010) in evaluating
generalization across job settings and across persons (i.e., other audience), respectively; both studies reported positive
outcomes.
3.10. Social validity
In 11 studies (55%) systematic measures of social validity were conducted following intervention. In 10 studies a
questionnaire or checklist was used that was completed by participants only (Allen, Wallace, Greene, et al., 2010; Allen,
Wallace, Renes, et al., 2010; Hillier, Campbell, et al., 2007) or by participants and related persons such as conversation
partners, classmates and/or parents (Burke et al., 2010; Davis et al., 2010; Gentry et al., 2010; Howlin & Yates, 1999; Palmen
et al., 2008; Songlee et al., 2008; Webb et al., 2004). Questionnaires consisted of items rating skill improvements, and/or
satisfaction with the learned skill, the intervention procedures, or overall program. Across studies, most participants as well
as relatives were positive about the outcomes and were satisfied with the learned skill and procedures used, although mixed
outcomes were also found in which positive ratings by participants were not fully supported by parents’ ratings or vice versa
(i.e., Davis et al., 2010; Webb et al., 2004). In the study by Mechling et al. (2009), participants were asked only one question
following intervention assessing their preferred prompting system: included participant preferred a DVD-player to the PDA
(despite its positive effects), because of DVD’s possibility to watch movies.
3.11. Certainty of evidence
Five studies were rated as providing a conclusive level of certainty of evidence. Two of these studies targeted on social
interaction skills (Dotson et al., 2010; Palmen et al., 2008), another two studies targeted on academic skills (Bouxsein et al.,
2008; Tiger et al., 2007), and the study in the domestic skills category was also rated as conclusive (Mechling et al., 2009). All
studies provided positive intervention outcomes, except Dotson et al. (2010) (i.e., mixed, see Table 1). All studies used a true
experimental design and provided at least some control for alternative explanations and reported accurate interobserver
agreement, operational definitions of dependent measures and sufficient detail on intervention to enable replication. Next to
this, all studies provided (at least partially) control on treatment implementation in reporting treatment fidelity (Dotson
et al., 2010; Mechling et al., 2009) or in using procedural aspects that limited variations in implementation of procedures.
Seven studies were rated as providing a preponderant level of certainty of evidence (Allen, Wallace, Greene, et al., 2010;
Allen, Wallace, Renes, et al., 2010; Davis et al., 2010; Delano, 2007; Koegel & Frea, 1993; Smith Myles et al., 2007; Songlee
et al., 2008). All studies provided positive intervention outcomes, except Smith Myles et al. (2007) (i.e., mixed, see Table 1).
Preponderant ratings were mainly assigned due to limited control for alternative explanations for treatment outcomes.
Eight studies were classified as providing a suggestive level of certainty of evidence. Three of these studies provided
positive intervention outcomes (Burke et al., 2010; Fullerton & Coyne, 1999; Gentry et al., 2010). The others provided mixed
outcomes except Turner-Brown et al. (2008) (i.e., negative). In six studies, suggestive ratings were due to reliance on pre- or
quasi-experimental designs (Fullerton & Coyne, 1999; Gentry et al., 2010; Hillier, Campbell, et al., 2007; Howlin & Yates,
1999; Shields-Wolfe & Gallagher, 1992; Turner-Brown et al., 2008). Although Burke et al. (2010) and Webb et al. (2004) used
true experimental designs, studies were classified as suggestive because detail on the procedure was insufficient to enable
replication and TF was not reported despite the use of compound procedures. See Table 1 for the specific reasons each study
was rated at a certain level.
4. Discussion
Our systematic review summarized 20 studies involving behavioral interventions to improve the adaptive skills of young
adults with high functioning ASD. Despite the increase in amount of research on behavioral treatment with persons with ASD
(see Matson, Turygin, et al., in press), there is still a paucity of intervention studies targeting adaptive skills in adults (Matson,
Hattier, et al., in press). However, in this review 16 of the 20 studies (80%) were published after January 2000 and six studies
(38%) were published as of January 2010, suggesting that this topic is being given more attention. Almost all studies (n = 19)
reported improvements in adaptive skills and 12 of these studies (63%) were rated as providing a conclusive (n = 5) or
preponderant (n = 7) level of certainty of evidence. However, a limitation is that six studies (including the one with negative
outcomes) used designs that could only provide a suggestive level of certainty of evidence and two studies provided
insufficient detail on the procedure and lacked measures on TF which also resulted in a suggestive level of certainty, despite
their true experimental designs. Overall, it may be concluded that a fair amount of evidence exists indicating that behavioral
A. Palmen et al. / Research in Autism Spectrum Disorders 6 (2012) 602–617 615
interventions can be successfully used to improve adaptive skills in young adults with high functioning ASD. However, future
research involving true experimental designs and methodological transparency are still warranted.
In terms of our aim to provide recommendations for practitioners and to outline directions for future research, several
important points do emerge. First, the use of technology assisted procedures seems promising in adaptive skill building in
high-functioning young adults with ASD. In general, these procedures may make individuals less dependent on adult
prompts and treatment contingencies and the procedures may be considered as a cognitive aid (Gentry et al., 2010) in
executive function-related skills (e.g., organization, planning, and goal-direction). However, studies in this area should
explicitly focus on fading prompts in using tech devices (e.g., Mechling et al., 2009) as persons may remain dependent on
supervisor prompts (e.g., Davis et al., 2010; Gentry et al., 2010). Furthermore, intervention approaches consisting of specific
instruction and differential reinforcement contingencies seem to be promising for improving task engagement and response
rate and could be considered as a component of supported employment. Finally, interventions on social skill building
utilizing multifaceted procedures containing corrective feedback seem to be more promising than traditional SSTGs using
descriptive feedback; however, this preliminary conclusion should be interpreted with caution as more methodological
robustness is needed in studies on traditional SSTG approaches.
In addition, there are a number of gaps in reviewed studies that need further research. For example, 9 of the 20 studies
contained only one or two participants who did meet the inclusion criteria of our review, indicating that replications are
necessary to improve generalizability of their conclusions (Horner et al., 2005). Furthermore, the range of focus of studies on
daily living skills should be broadened as for example three of the five studies on vocational skills targeted on one specific job
(mascot job) and not one study focused on improving leisure skills despite the problems in this area among adolescents and
adults with ASD (e.g., Orsmond et al., 2004). Next to this, given the relatively high rate of unemployment in adults with high-
functioning ASD, there is a need for more methodological rigor and transparency in studies on supported employment as the
studies on this approach were strongly limited in these features. Also, all group design studies lacked a control group or failed
to randomize. As it may be difficult to match groups and use randomization given the differentiations in the characteristics of
the disorder in clinical practice, the use of multiple baseline designs across groups of participants (e.g., Palmen et al., 2008)
may be an alternative to include more participants and improve certainty.
Finally, although data were mostly collected by direct observation, data collection in natural settings was limited. Next to
this, data on generalization were mostly collected within the location of the training albeit in another room. Given the
problems in the area of transfer of skills from acquisition in the treatment setting to performance in the natural living setting,
the collection of data in natural settings should be the focus of future research and generalization should be explicitly
programmed in intervention procedures. Another point of concern in case of generalization refers to maintenance of skills
over time as only two studies collected data at 3-month probes following intervention. Although skill performance stayed
above baseline levels, decreases in skill performance were the rule rather than the exception, indicating that for long-term
maintenance of skills additional measures should be taken (e.g., booster sessions, longer intervention periods, or fading out
intervention).
In summary, this review reveals that behavioral interventions in adaptive skill building are encouraging for young adults
with high-functioning ASD and should be an explicit component of intervention programs aimed at improving independent
functioning.
Acknowledgement
We thank Maaike Jacobs for her assistance in systematic searches.
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- A systematic review of behavioral intervention research on adaptive skill building in high-functioning young adults with autism spectrum disorder
Introduction
Method
Search procedures
Inclusion and exclusion criteria
Data extraction and coding
Reliability of search procedures and data extraction
Results
Participants
Settings
Targeted adaptive skills
Data collection and interobserver agreement
Intervention procedures
Treatment fidelity
Study designs
Outcomes
Follow-up and generalization
Social validity
Certainty of evidence
Discussion
Acknowledgement
References11*Study included in the review.
ournal of
Applied Behavior Analysis
JOURNAL OF APPLIED BEHAVIOR ANALYSIS 2017, 50, 590–599 NUMBER 3 (SUMMER)
NONCONTINGENT REINFORCEMENT WITHOUT EXTINCTION
PLUS DIFFERENTIAL REINFORCEMENT OF ALTERNATIVE
BEHAVIOR DURING TREATMENT OF PROBLEM BEHAVIOR
JENNIFER N. FRITZ, LYNSEY M. JACKSON, NICOLE A. STIEFLER,
BARBARA S. WIMBERLY, AND AMY R. RICHARDSON
UNIVERSITY OF HOUSTON-CLEAR LAKE
The effects of noncontingent reinforcement (NCR) without extinction during treatment of
problem behavior maintained by social positive reinforcement were evaluated for five individuals
diagnosed with autism spectrum disorder. A continuous NCR schedule was gradually thinned
to a fixed-time 5-min schedule. If problem behavior increased during NCR schedule thinning, a
continuous NCR schedule was reinstated and NCR schedule thinning was repeated with differ-
ential reinforcement of alternative behavior (DRA) included. Results showed an immediate
decrease in all participants’ problem behavior during continuous NCR, and
problem behavior
maintained at low levels during NCR schedule thinning for three participants. Problem behavior
increased and maintained at higher rates during NCR schedule thinning for two other partici-
pants; however, the addition of DRA to the intervention resulted in decreased problem behavior
and increased mands.
Key words: concurrent schedules, differential reinforcement, noncontingent reinforcement,
problem behavior
Problem behavior in the form of aggression,
self-injurious behavior (SIB), and disruption is
common among individuals with intellectual
disabilities and can prevent skill acquisition,
hinder the development of social relationships,
and affect family relationships (Matson, Wilk-
ins, & Macken, 2009). Due to these and other
reasons, assessment and treatment of problem
behavior is important to produce improved
outcomes for these individuals. Since the devel-
opment of functional analysis methodology for
identifying the reinforcers that maintain prob-
lem behavior (Iwata, Dorsey, Slifer, Bauman, &
Lynsey Jackson is now at Endeavor Behavioral Insti-
tute, Nicole Stiefler is at Spectrum of Hope, Barbara
Wimberly is at Trumpet Behavioral Health, and Amy
Richardson is at Spectacular Kids. This study was con-
ducted in partial fulfillment of the requirements for the
second author’s master’s degree at the University of
Houston-Clear Lake. We thank Kelsey Campbell, Rachel
Hoffman, Dorothea Lerman, and Lorena Rodriguez for
their assistance with this study.
Correspondence should be addressed to: Jennifer
N. Fritz, 2700 Bay Area Blvd., MC 112, Houston, TX
77058. E-mail: fritzj@uhcl.edu
doi: 10.1002/jaba.395
Richman, 1982/1994), researchers have been
able to more precisely develop interventions
that effectively decrease the behavior. These
interventions often consist of various combina-
tions of extinction, noncontingent reinforce-
ment (NCR), or differential reinforcement
(Iwata & Worsdell, 2005).
NCR has been used to treat problem behav-
ior maintained by automatic and social rein-
forcement (Carr et al., 2000). When problem
behavior is maintained by social reinforcement,
NCR typically involves the delivery of the func-
tional reinforcer (i.e., the reinforcer that main-
tains problem behavior) on a time-based
schedule, independent of a response (Vollmer,
Iwata, Zarcone, Smith, & Mazaleski, 1993).
NCR schedules have been shown to be effective
at reducing problem behavior maintained by
social positive reinforcement (e.g., Hagopian,
Fisher, & Legacy, 1994; Lalli, Casey, & Kates,
1997; Vollmer et al., 1993) and social negative
reinforcement (e.g., Kodak, Miltenberger, &
Romaniuk, 2003; O’Callaghan, Allen, Powell, &
Salama, 2006; Vollmer, Marcus, & Ringdahl,
© 2017 Society for the Experimental Analysis of Behavior
590
mailto:fritzj@uhcl.edu
591 NCR THINNING WITHOUT EXTINCTION PLUS DRA
1995). There are several potential advantages to
NCR. First, it may be easier to implement than
procedures requiring response monitoring. Sec-
ond, it may result in higher rates of reinforce-
ment than differential reinforcement procedures
(Vollmer et al., 1993). Finally, it may attenuate
side effects of extinction, such as extinction
bursts (Vollmer et al., 1998).
Extinction is typically included as a compo-
nent of NCR and involves withholding rein-
forcement following problem behavior
(i.e., reinforcement is delivered on the time-
based schedule but is not delivered contingent
on problem behavior; Wallace, Iwata, Hanley,
Thompson, & Roscoe, 2012). A few studies
have evaluated NCR without extinction; how-
ever, there is a paucity of research on this treat-
ment strategy (Carr, Severtson, & Lepper,
2009). Furthermore, results of these studies
have been somewhat mixed in that the inter-
vention has been effective in some studies
(e.g., Lalli et al., 1997) but not others
(e.g., Hagopian, Crockett, Van Stone,
DeLeon, & Bowman, 2000; Wallace et al.,
2012) as the NCR schedule is thinned. For
example, Lalli et al. (1997) evaluated NCR
without extinction for one participant. The rate
of problem behavior gradually decreased to zero
as they thinned the NCR schedule and main-
tained at low levels at the terminal schedule.
Conversely, Hagopian et al. (2000) and Wal-
lace et al. (2012) both observed increases in
problem behavior when the NCR schedule was
thinned without extinction, and the inclusion
of extinction was effective in decreasing prob-
lem behavior when it was used. Although NCR
with extinction effectively decreased problem
behavior in both studies, extinction cannot be
implemented in all situations. For example, it
might be impossible to prevent physically large
individuals from accessing preferred items fol-
lowing problem behavior, such as when they
hit or shove a caregiver who is blocking access
to preferred items, or caregivers might not be
able to refrain from providing attention
following aggression directed toward them.
Therefore, research on additional strategies to
improve the effectiveness of NCR without
extinction is needed.
One potential solution might be to combine
NCR with differential reinforcement of alterna-
tive behavior (DRA) without extinction. Stud-
ies have shown that this combined intervention
strategy can be highly effective in decreasing
problem behavior and increasing appropriate
behavior when extinction is included (Goh,
Iwata, & DeLeon, 2000; Marcus & Vollmer,
1996). For example, Goh et al. (2000) used
NCR combined with DRA to decrease problem
behavior maintained by social positive rein-
forcement, but an increase in the alternative
response did not occur until the NCR schedule
was thinned. It is unknown if the treatment
would be similarly effective if extinction was
not included.
Although combining DRA with NCR may
increase the effort of implementing treatment
(compared to NCR alone), it might be a viable
alternative when extinction is not possible. In
those cases, caregivers interact with the individ-
ual when problem behavior occurs, but also on
a time-based schedule and following appropri-
ate, alternative behavior (mands). This strategy
would be desirable if mands increase and low
rates of problem behavior maintain as the NCR
schedule is thinned. Furthermore, if the inter-
vention results in significant decreases in prob-
lem behavior, the effort of the intervention
should decrease as NCR is thinned. Even if
mands are emitted at a similar rate as problem
behavior during baseline, the intervention
should be at least no more difficult to imple-
ment than baseline procedures.
The purpose of this study was to evaluate
the effects of thinning NCR schedules without
extinction for problem behavior maintained by
social positive reinforcement. This study
extends previous research by evaluating a com-
bined intervention of NCR schedule thinning
plus DRA without extinction when NCR
592 JENNIFER N. FRITZ et al.
schedule thinning alone is not effective in
maintaining low rates of problem behavior.
METHOD
Participants and Setting
Five individuals who engaged in problem
behavior maintained by social positive rein-
forcement were included in this study. All par-
ticipants attended day treatment centers for at
least 15 hr per week where they had been
referred for assessment and treatment of prob-
lem behavior. Charley was a 9-year-old male
diagnosed with autism whose problem behavior
consisted of property destruction. (Charley also
infrequently engaged in aggression, which was
not included in this study.) Gilbert was a 7-
year-old male diagnosed with autism who
engaged in screaming. Dyson was a 6-year-old
male diagnosed with autism who kicked people
and other surfaces. Alan was a 3-year-old male
diagnosed with autism who engaged in scream-
ing. Harry was a 7-year-old male diagnosed
with autism and obsessive-compulsive disorder
who engaged in SIB.
All sessions took place at a day treatment
center in rooms (approximately 3 m by 3 m)
containing a table, chairs, and the materials
necessary to conduct the sessions.
Response Measurement and Reliability
The dependent variables (problem behavior
and mands) were measured using frequency or
10-s partial interval recording (Gilbert only). The
frequency data were converted to responses per
min (RPM) and the partial interval data were
converted to percentage of intervals. A secondary
analysis of latency (in seconds) from the time lei-
sure items were removed to the first instance of
problem behavior also was conducted during the
first 5 min of Dyson’s baseline (sessions 1, 2, and
4; problem behavior did not occur in session 3)
or during the tangible condition sessions of the
functional analysis for Alan. Problem behavior
included screaming (Gilbert and Alan), property
destruction (Charley), kicking self and objects
(Dyson), and SIB (Harry). Screaming was
defined as a nonfunctional, vocal response that
was paired with an open mouth and negative
facial affect (e.g., frowning, crying). Property
destruction was defined as audible contact
between the participant’s hands or feet with
objects in the environment, throwing objects,
and audible contact between two or more objects
in the participant’s hands. Kicking was defined as
extension of the leg with contact between the
participant’s foot and surfaces or a person (did
not include contact while rolling on the floor).
SIB was defined as any audible contact between
the hand and head or body of the participant.
The mand taught during DRA was defined as
placing a card in the therapist’s hand. Alan
exchanged a card that contained a picture of his
preferred items, and Harry exchanged a card that
had the word “toys” printed on it.
A second independent observer collected
data for 18% to 100% of sessions during each
condition to assess reliability. Proportional
agreement scores for frequency data were deter-
mined by comparing the observers’ recorded
frequencies for each response in each 10-s
interval. The smaller number of responses was
divided by the larger number of responses in
each interval, the fractions were averaged across
intervals, and the result was multiplied by 100.
Interval agreement scores for partial interval
data were determined by comparing the obser-
vers’ recording of occurrence or nonoccurrence
of the response in each interval. If the records
matched within the interval, the interval was
scored as an agreement. The number of agree-
ment intervals was divided by the total number
of intervals in the session and multiplied by
100. For latency measures, two observers
recorded the number of seconds from leisure
item removal until problem behavior occurred,
and agreement was scored if the observers’
records differed by 5 s or less.
Mean interobserver agreement scores for
problem behavior were 92% (range, 76%-
593 NCR THINNING WITHOUT EXTINCTION PLUS DRA
100%) in baseline, 99% (range, 90%-100%)
in NCR, and 98% (range, 80%-100%) in
NCR plus DRA (Alan and Harry only). Mean
interobserver agreement scores for mands were
99% (range, 90%-100%) in NCR plus DRA
(Alan and Harry only). Mean interobserver
agreement scores for latency to problem behav-
ior were 90% (range, 67%-100%).
Procedure
A functional analysis (FA) was conducted
with all participants prior to treatment using
procedures similar to those described by Iwata
et al. (1982/1994). A tangible condition also
was included for all participants because their
caregivers reported that problem behavior
occurred when preferred items were removed,
and all participants engaged in problem behav-
ior at the highest rates (or almost exclusively)
in the tangible condition. Results are available
from the corresponding author.
During the treatment evaluation, the same
highly preferred items were delivered on the
NCR schedule (all conditions), contingent on
problem behavior (all conditions), and contin-
gent on mands (NCR plus DRA only).
Sessions
were 5 min (Alan only) or 10 min in duration.
Experimental control was demonstrated using a
nonconcurrent multiple baseline across partici-
pants design.
Baseline. Participants were given at least 30-
s, presession access to a variety of highly pre-
ferred leisure items. The items were removed at
the start of the session and remained visible but
out of the participant’s reach. Participants were
given 20-s access to the preferred items contin-
gent on problem behavior. All other behavior
was ignored, and the therapist did not interact
with the participant during session. Baseline
sessions were conducted until stable or increas-
ing rates of problem behavior were observed.
NCR. During this condition, preferred items
were delivered for 20 s on a time-based sched-
ule and for 20 s contingent on problem
behavior. The therapist wore a vibrating pager
to discretely signal when the preferred items
should be delivered on the NCR schedule. The
initial NCR schedule for all participants was
three reinforcer deliveries per min
(i.e., continuous reinforcement in which the
participant had uninterrupted access to the pre-
ferred items). Problem behavior that occurred
during the reinforcement interval was scored
but did not result in additional reinforcement
time (i.e., the items were removed after 20-s
access, regardless of whether problem behavior
occurred during the reinforcement interval).
The NCR schedule thinning procedure was
identical to the procedures used by Marcus and
Vollmer (1996), in which the NCR schedule
was thinned to two deliveries per min, 1 per
min, 0.5 per min, 0.33 per min, 0.25 per min,
and 0.2 per min, if problem behavior main-
tained at or below 20% of baseline rates for at
least three consecutive sessions. If at any time
during the schedule thinning rates of problem
behavior were greater than 20% of baseline
levels and were without a decreasing trend for
at least five consecutive sessions, mand training
was initiated.
Mand training. Prior to the NCR plus DRA
condition, mands for access to the preferred
items were taught to the participants using a
backward chaining procedure (Hagopian,
Fisher, Sullivan, Acquisto, & LeBlanc, 1998).
The three steps were: (a) moving the partici-
pant’s hand toward the card, (b) picking up the
card, and (c) handing the card to the therapist.
Initially, the minimal amount of physical guid-
ance necessary was used to prompt the partici-
pant to engage in each step of the alternative
communication procedure. Next, minimal
physical guidance was used to prompt the par-
ticipant through all steps except the final step
in the chain (step c). If the participant failed to
independently complete the final step within
5 s, physical guidance was used. The final stage
involved guiding the participant to complete
the first step in the chain (step a), and then
5
BL NCR
,___
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*
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~
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E
3
Charley
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(I) 2 Cl
t 0.
2
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,___
ell
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i – 60 ~ * Gilbert
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-r
40
tJ 20
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40
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,,…._ 30
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~ 25
l>fl 20
J2yson
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5 0.2
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10 20 30 40 50 60
Sessions
594 JENNIFER N. FRITZ et al.
allowing 5 s to pass for the participant to inde-
pendently emit the correct response before
prompting was provided. Each session consisted
of 10 trials. The criterion for moving through
each stage in the mand training process was
independent completion of the targeted steps
for at least 80% of trials for two consecutive
sessions. During mand training, all participants
were given 5 s to independently engage in the
response before any prompting was provided to
promote independent responding. Preferred
items were delivered following each prompted
and unprompted response. The mand was con-
sidered mastered when independent
(unprompted) responding occurred for at least
80% of trials for two consecutive sessions. The
therapist blocked problem behavior that
occurred during mand training sessions, did
not provide access to the preferred items, and
did not provide eye contact or any other
attention.
NCR plus DRA. During this condition, pre-
ferred items were delivered (a) contingent on
problem behavior, (b) on the fixed-time
(FT) schedule of reinforcement, and
(c) contingent on a mand. The participants had
continuous access to the reinforcers at the
beginning of this phase, and the subsequent
NCR schedule thinning procedure was identical
to the NCR-only condition. The card was avail-
able throughout sessions once NCR schedule
thinning began for Alan (i.e., the card was not
available during continuous NCR due to experi-
menter error) and during all sessions for Harry
(i.e., the card was available during continuous
NCR and all subsequent sessions). Problem
behavior and mands that occurred during the
reinforcement interval were scored but did not
result in additional reinforcement time (i.e., the
items were removed after 20-s access).
RESULTS
Results of baseline and treatment are
depicted in Figure 1 for Charley, Gilbert, and
Figure 1. Results of treatment during NCR. Asterisks
indicate sessions in which the NCR schedule was thinned.
Arrows indicate sessions in which the terminal NCR
schedule was initiated.
Dyson. NCR schedule thinning without extinc-
tion was effective in reducing the problem
behavior of these three participants. Charley’s
property destruction averaged 1.4 RPM during
baseline, and continuous NCR produced near-
zero levels of problem behavior. As the NCR
schedule was thinned, Charley intermittently
engaged in moderate to high levels of problem
BL
3
NCR NCR+DRA
Alan
2 Mand 0.2 Scream
r * t (1) ‘§ .,…,
::;s
& 0
00
(1)
00
s::1 12
0 p.
~ 10 SIB H!!!IY.
~ i 8
6
0.2
4
* * …
2
0
10 20 30 40 50 60
Sessions
595 NCR THINNING WITHOUT EXTINCTION PLUS DRA
behavior; however, problem behavior returned
to below 20% of baseline rates. The NCR
schedule was successfully thinned to the termi-
nal schedule of 0.2 reinforcers per min in
42 sessions. Gilbert’s screaming averaged 25%
of intervals during baseline and immediately
decreased to zero when continuous NCR was
introduced. Screaming increased to baseline
levels during the first NCR thinning session;
however, problem behavior decreased in the
subsequent session and remained at near-zero
levels for the remainder of the treatment. The
NCR schedule was thinned to the terminal cri-
terion in 21 sessions for Gilbert. Dyson’s kick-
ing occurred at increasing rates during baseline
and averaged 8.8 RPM. His problem behavior
decreased to zero immediately when continuous
NCR was introduced and remained at zero as
the schedule was thinned. The terminal NCR
schedule was reached in 18 sessions for Dyson.
Results of baseline and treatment are
depicted in Figure 2 for Alan and Harry.
Although NCR was initially effective when
they had continuous access to the reinforcers,
problem behavior increased once the NCR
schedule was thinned. Alan’s screaming aver-
aged 1.4 RPM during baseline and immediately
decreased to zero during continuous NCR.
During the first NCR schedule thinning ses-
sion, Alan’s screaming increased to baseline
levels and maintained at steady rates for eight
sessions. After mand training, continuous NCR
again was implemented, which produced near-
zero rates of screaming, and the picture card
was introduced during the first step of NCR
schedule thinning (i.e., the card was not availa-
ble during continuous NCR). Alan engaged in
zero rates of screaming and increasing rates of
mands during the NCR schedule thinning plus
DRA condition.
Harry’s SIB averaged 4.3 RPM during base-
line and immediately decreased to zero during
continuous NCR. Although SIB initially
remained low during the first step of NCR
schedule thinning, it subsequently increased
Figure 2. Results of treatment during NCR and
NCR + DRA. Asterisks indicate sessions in which the
NCR schedule was thinned, and a bold asterisk (session
28 for Harry) indicates a return to the previous NCR
schedule.
and maintained during sessions when NCR
was thinned further. We returned to the first
step of NCR schedule thinning in session 28;
however, SIB persisted at near baseline levels
for five sessions under these conditions. There-
fore, the card was available and continuous
NCR was again implemented after mand train-
ing. Harry did not engage in SIB during the
remainder of treatment. He also did not engage
in mands during continuous NCR; however,
mands gradually increased as the NCR schedule
was thinned. The terminal criterion for the
NCR schedule was reached in 18 sessions for
both Alan and Harry.
It was interesting that NCR schedule thin-
ning without extinction was effective for three
1-.
0 400 Bl B2B4 ….
~
..c:: • ~ 300 i:Il
§ • – 200 ‘8 • Qxson p…
0 100 …..
1 “~——-.—–r—–,—~
~ 400
t
FA4 FA8 FA12
] 300
4 8 12 16
Opportunities
596 JENNIFER N. FRITZ et al.
of the five participants, especially in eliminating
Dyson’s problem behavior. It seemed possible
that the latency to problem behavior from the
removal of the preferred items might predict if
NCR thinning without extinction might be an
effective intervention. Therefore, we calculated
the latency from toy removal until the first
instance of problem behavior occurred during
the sessions for the best and worst responders
during NCR schedule thinning without extinc-
tion (i.e., Dyson, whose problem behavior
never occurred, and Alan, whose problem
behavior increased to baseline rates as soon as
NCR thinning started). We analyzed the first
three sessions of baseline in which problem
behavior occurred for Dyson (i.e., sessions 1, 2,
and 4 of baseline, because problem behavior
never occurred in session 3; shown in Figure 1)
and the three sessions of the tangible condition
from the FA for Alan in which he received 30-s
access to preferred items contingent on prob-
lem behavior (overall rate of problem behavior
was 1.2, 1.8, and 1.2 RPM in these sessions,
respectively). These sessions were selected
because greater differences in responding might
be expected during early exposure to the rein-
forcement contingency for problem behavior
(i.e., before problem behavior became more
efficient due to a recent history of reinforce-
ment), and this is when a clinician would likely
make a determination regarding potential treat-
ment strategies (i.e., lengthy baselines are not
common in clinical practice). Results are shown
in Figure 3. The average latency to problem
behavior following the removal of preferred
items was 246 s for Dyson and 14 s for Alan.
Furthermore, the shortest latency to Dyson’s
kicking was 173 s, and Alan consistently
engaged in screaming within a few seconds of
toy removal (median latency was 5 s).
DISCUSSION
NCR without extinction was effective in
reducing problem behavior maintained by social
Figure 3. Latency in seconds from toy removal to
problem behavior during the first 5 min of baseline ses-
sions 1, 2, and 4 for Dyson and functional analysis ses-
sions 4, 8, and 12 (tangible condition) for Alan.
positive reinforcement for three of five
participants—replicating the results of some
previous studies (Hagopian, LeBlanc, &
Maglieri, 2000; Lalli et al., 1997). Systemati-
cally thinning the NCR schedule resulted in
continued low levels of problem behavior for
three participants, even though problem behav-
ior occurred at moderate to high levels and con-
tacted the reinforcement contingency during
some sessions of the schedule thinning process
for two of three participants. The terminal
NCR schedule of FT 5 min was achieved in an
average of 30 sessions for these three partici-
pants and accounted for only 3–7 hr of treat-
ment. These results are promising for situations
in which NCR is a desirable intervention but
extinction is not feasible or caregivers do not
implement extinction with integrity.
597 NCR THINNING WITHOUT EXTINCTION PLUS DRA
For the two participants for whom NCR
schedule thinning without extinction was not
effective in maintaining low rates of problem
behavior, the addition of a DRA component
was effective in decreasing problem behavior to
zero rates and maintaining mands. This pro-
vides a promising approach to treatment with-
out extinction that requires a relatively short
time commitment, as the terminal NCR sched-
ule of FT 5 min was achieved in only 1.5-3 hr
(18 sessions) for both participants.
These results extend the findings of previous
studies that showed a combined strategy of
NCR thinning and DRA with extinction can
be effective in decreasing problem behavior
(Goh et al., 2000; Marcus & Vollmer, 1996)
by showing this treatment can be effective
without extinction. Furthermore, these results
extend the work of Wallace et al. (2012) by
demonstrating that lean schedules of NCR can
be effective in reducing problem behavior with-
out extinction when the NCR schedule is grad-
ually thinned and combined with DRA. Given
the elimination of problem behavior during this
treatment, it is possible that the systematic
thinning of the NCR schedule might have been
a critical treatment component, as other studies
that have used DRA without extinction have
not produced such favorable outcomes
(e.g., Hagopian et al., 1998; Shirley, Iwata,
Kahng, Mazaleski, & Lerman, 1997; Worsdell,
Iwata, Hanley, Thompson, & Kahng, 2000).
If practical implementation was a primary
concern, additional treatment strategies would
be necessary for these individuals to reduce the
reinforcement rate provided. For example, Alan
engaged in nearly identical rates of problem
behavior (1.4 RPM) in baseline as rates of
mands during the last three sessions of NCR
plus DRA (1.6 RPM). Similar results were
observed with Harry (4.3 RPM of problem
behavior in baseline and 2.3 RPM of mands in
the last four treatment sessions). Therefore, this
treatment strategy did not reduce the overall
reinforcement rate for either participant from
baseline to the final treatment phase. Addi-
tional strategies, such as establishing stimulus
control of the mand through the use of multi-
ple schedules (e.g., Hanley, Iwata, & Thomp-
son, 2001; Saini, Miller, & Fisher, 2016) or
strengthening other contextually appropriate
behavior through contingency-based delays
(Ghaemmaghami, Hanley, & Jessel, 2016)
might be effective in reducing rates of mands
while maintaining treatment effects. Future
research might evaluate this possibility in the
absence of reinforcement for problem behavior.
Results of the secondary analyses suggest that
patterns of responding during early exposure to
contingent reinforcement for problem behavior
(i.e., FA or baseline sessions) might be useful in
predicting if NCR schedule thinning without
extinction will be an effective intervention. Spe-
cifically, results of the secondary analysis sug-
gested that longer latencies from removal of
preferred items until problem behavior
occurred might be predictive of the relative
effectiveness of NCR schedule thinning with-
out extinction. The latency to Dyson’s problem
behavior (average of 246 s) was significantly
longer than the latency to Alan’s problem
behavior (average of 14 s) following the
removal of preferred items, and NCR schedule
thinning without extinction eliminated Dyson’s
problem behavior. Future research should
examine this possibility more systematically
with additional individuals in order to draw
more definitive conclusions.
It also is unknown whether NCR schedule
thinning without extinction would have been
as effective at leaner schedules. We selected FT
5 min as the terminal NCR schedule based on
the termination criteria of previous research;
however, longer NCR schedules might be more
desirable for caregivers, especially when the
reinforcer is access to highly preferred activities.
The FT 5-min schedule might be more appro-
priate for problem behavior maintained by
attention, and future research might examine
social validity related to this issue.
598 JENNIFER N. FRITZ et al.
The reason NCR plus DRA without extinc-
tion was effective for the remaining two partici-
pants remains unknown. As noted previously,
it is possible that it was simply the combination
of gradually thinning the NCR schedule while
simultaneously providing contingent reinforce-
ment for a relatively low-effort response (card
exchange). However, there are no data to show
that the mand was less effortful than problem
behavior for the current participants, and it
seems a tenuous hypothesis that card exchange
was less effortful than screaming for Alan.
Another possibility is that the mand training
procedures influenced responding during this
condition. Although backward chaining and
prompting strategies were used to teach the
card exchange response, extinction was in place
for problem behavior during training
(i.e., reinforcement was not delivered following
problem behavior for both participants, and
Harry’s SIB was blocked). This preceding his-
tory might have caused a sequence effect in
which problem behavior was lower than it oth-
erwise might have been at the start of the NCR
thinning plus DRA intervention, potentially as
a result of stimulus control (i.e., the card might
have functioned as an S-delta). It is possible
that the mand could have been taught without
extinction or blocking, using procedures similar
to Richman, Wacker, and Winborn (2001). In
that study, one participant engaged in aggres-
sion to access preferred items, and the research-
ers taught the participant to hand a card to the
caregiver without the use of extinction. Under
conditions of continuous reinforcement for
mands and aggression, the participant generally
engaged in the mand and little problem behav-
ior occurred. Therefore, the prior exposure to
extinction for our participants might have
accounted for why problem behavior never
occurred during the NCR thinning plus DRA
phase rather than occurring at low rates, as in
the Richman et al. study.
Despite these limitations, results of this
study suggest that adding DRA to NCR is a
promising approach to the treatment of prob-
lem behavior without extinction, especially dur-
ing the schedule thinning process. NCR is
often viewed as a straightforward and
reinforcement-based behavioral intervention,
and this study provides a means of program-
ming the intervention when caregivers cannot
or will not implement extinction to produce
clinically significant reductions in problem
behavior.
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- NONCONTINGENT REINFORCEMENT WITHOUT EXTINCTION PLUS DIFFERENTIAL REINFORCEMENT OF ALTERNATIVE BEHAVIOR DURING TREATMENT OF…
METHOD
Participants and Setting
Response Measurement and Reliability
Procedure
Baseline
NCR
Mand training
NCR plus DRA
RESULTS
DISCUSSION
References