ATHABASCA UNIVERSITY INTERVENING WITH AUTISM: A TRAINING MODULE FOR BEHAVIOURAL THERAPY PROGRAMS FOR CHILDREN WITH AUTISM BY MARGARET DAVIDSON A Final Project submitted to the Graduate Centre for Applied Psychology, Athabasca University in partial fulfillment of the requirements for the degree of MASTER OF COUNSELLING Alberta February 2010
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ATHABASCA UNIVERSITY
INTERVENING WITH AUTISM: A TRAINING MODULE FOR BEHAVIOURAL
THERAPY PROGRAMS FOR CHILDREN WITH AUTISM
BY
MARGARET DAVIDSON
A Final Project submitted to the
Graduate Centre for Applied Psychology, Athabasca University
in partial fulfillment of the requirements for the degree of
MASTER OF COUNSELLING
Alberta
February 2010
i
COMMITTEE MEMBERS
The members of this final project committee are:
Name of Supervisor Dr. Linda Chmiliar Dr. Simon Nuttgens
Name of Second Reader Dr. Noëlla Piquette-Tomei
ii
ABSTRACT
This project involves the development of a training module for individuals who work with
children with autism. The intent of the project is to address the need for cost effective and
accessible training for behavioural therapists. The training module focuses on the use of
reinforcement for shaping client behaviour. The theoretical and practical application of
reinforcement techniques for use with children with autism are discussed. A PowerPoint
presentation and workbook, complete with quizzes and exercises, were created to help
learners apply the material to their own work situation.
iii
TABLE OF CONTENTS
ABSTRACT p. ii
CHAPTER I: INTRODUCTION p. 1
CHAPTER II: THEORETICAL FOUNDATIONS p. 6
Characteristics of Autism p. 6
Need for Intervention p. 25
Why Reinforcement Is Needed p. 28
The Theory Behind Reinforcement p. 30
Types of Reinforcers p. 32
Use of Reinforcement p. 37
Finding Reinforcers p. 47
Summary p. 48
CHAPTER III: SYNTHESIS AND IMPLICATIONS p. 51
Impact of the Project p. 54
Strengths and Weaknesses of the Project p. 55
Implications for the Future p. 57
REFERENCES p. 60
APPENDIX A: Using Reinforcement with Children with Autism: A
PowerPoint Presentation p. 79
APPENDIX B : Using Reinforcement with Children with Autism: Workbook
to Accompany the PowerPoint p. 80
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CHAPTER I: INTRODUCTION
The focus of this project was the development of a training resource for staff working
with children with autism. The prevalence of autism is increasing (Baird et al., 2006;
Newschaffer, Falb, & Gurney, 2005), and with this increase there is a growing demand for
treatment services. There is a need for cost effective and accessible training in working with
children with autism (National Research Council (NRC), 2001; Scheuermann, Webber,
Boutot, & Goodwin, 2003).
Autism is a pervasive developmental disorder that is neurological in origin (Volkmar
& Pauls, 2003). Diagnosis of Autism Spectrum Disorder is based on three areas of deficit:
qualitative impairments in social interaction; qualitative impairments in communication; and
restricted, repetitive, and stereotyped patterns of behaviour, interest, and activities (American
Psychiatric Association, 2000). These deficits mean that children with autism have a number
of difficulties functioning in daily life. Impairments in social interaction can mean that
children with autism have difficulty forming social relationships with others. If young
children identified as meeting the characteristics of autism do not initiate social interactions
with others, they may miss out on learning opportunities (Rogers & Dawson, 2010). As well,
when children with autism do not react in expected ways to the social initiations of others,
other people may stop attempting to interact with them (Rogers & Dawson). This can result
in children identified with autism failing to develop relationships with siblings and family
members, and not making friends with peers. Impairments in communication can mean that
children with autism are not always able to get their needs met; they are unable to say when
they are hungry, thirsty, or in pain. Restricted interests and stereotyped patterns of behaviour
can mean that children identified with autism can miss out on learning opportunities (Rogers
2
& Dawson) and that they may be left out of activities their peers are engaged in, further
impeding their social development. Research has shown that children with autism can make
significant improvements in functioning with early intensive behavioural intervention
(Cohen, Amerine-Dickens, & Smith, 2006; Howard, Sparkman, Cohen, Green, & Stanislaw,
2005; Lovaas, 1987; McEachin, Smith, & Lovaas, 1993; Sallows & Graupner, 2005).
Much of the supporting evidence for behavioural treatments originated with Lovaas’s
(1987) study of intensive behavioural interventions for autism. The Lovaas study used highly
trained therapy staff; staff received training in learning theory and applied behavioural
analysis, followed by a nine-month internship (Lovaas, 2003). In many intensive behavioural
intervention programs, staff are trained in workshops followed by periodic supervision (Shea,
2004). Training workshops typically are one to three days, with supervision every one to
three months (Lovaas; Siegel, 2003). Lovaas expressed concern that therapists who had
received only workshop training would achieve poorer outcomes compared to better trained
staff.
Children with autism form a client group who require considerable resources to help
them to function in the community. Children with autism can benefit from home and
community based early intervention, special education classrooms and trained education
assistants in schools, and support programs to help them integrate into the community.
Scheuermann et al. (2003) conducted a review of the literature regarding training and
certification of special education teachers in the United States. They found that working
effectively with individuals with autism requires knowledge of specialized techniques. They
further found that many teachers and paraprofessionals did not have these skills. In many
jurisdictions, autism specific training is not available (Scheuermann et al.; Simpson, 2004).
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Simpson (2003) writes that “the uniqueness of students with autism and their requirements
for special methodology and professionals who are skilled in using such methodology make
the need for well trained autism-specific personnel particularly significant” (p. 195). The
NCR (2001) stated that staff training “remains one of the weakest elements of effective
programming for children with autistic spectrum disorders and their families” (p. 225). The
need for training is especially important as most home programs rely on relatively
inexperienced staff (NRC). Scheuermann et al. found that staff shortages have resulted in
untrained staff being hired. Ludlow, Conner, and Schechter (2005) found that staff
implementing early intervention programs needed specific training and different training than
those staff who worked with older children.
Heidgerken, Geffken, Modi, and Frakey (2005) studied the level of knowledge
healthcare providers have about autism. They found that healthcare providers have outdated
beliefs about autism and that many healthcare providers were not aware of recent research.
Many healthcare providers held myths about autism that dated to the 1950’s.
There is a need for staff to be trained both in techniques for working with children
with autism, and the theories behind those techniques. Maurice, Green, and Luce (1996)
suggested that therapists who are unaware of the research regarding why behaviour patterns,
such as stimming or disruptive behaviour, occur may inadvertently make the problem worse.
Smith, Parker, Taubman, and Lovaas (1992) discussed the failure of staff to generalize skills
from a training workshop to the workplace and suggested that a lack of theoretical
knowledge prevented staff from generalizing skills from a workshop to the workplace. In
addition, Siegel (2003) noted that a lack of theoretical knowledge can lead therapy programs
to drift, and result in poor quality programs.
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What training most often lacks is opportunities for the tutors to read about autism,
behavioural analysis, or development…As a result, most one-to-one tutors in
ABA/DTT programs are more like technicians than teachers in certain respects –
knowing what to do, but not always knowing why an activity is done in a particular
manner. (Siegel, p. 328)
Leblanc, Ricciardi, and Luiselli (2005) stated that training needs to be practical and
time efficient or it is unlikely that human services agencies will implement it. The NRC
(2001) suggested that staff training could be improved by the development of print training
manuals, as well as video and audio training materials. Moore et al. (2002) found that
training involving written instructions followed by modeling improved the accuracy of staff
in implementing behaviour analysis methods. Lerman, Vorndran, Addison, and Kuhn (2004)
found that instruction including lectures, handouts, and role modeling were effective in
teaching skills for working with children with autism. They found that preference assessment
and incidental teaching were successfully taught with the program, but direct teaching was
less successful.
McConkey and Bhlirgri (2003) studied the level of training that staff in community
preschool programs received specific to working with children with autism. They found that
62% of the staff did not feel they had adequate skills for working with children with autism.
Staff in this study reported that they saw a need for written material about the diagnosis of
autism. McConkey and Bhlirgri found that 16 % described the training they had received as
adequate; twenty-six (46%) thought it was inadequate; and twenty-one (38%) reported
having no training at all. Staff identified the two most important areas in which they needed
5
training were techniques and strategies for working with children with autism, and
background knowledge about autism.
This project is intended to address the need for training to work with children with
autism. Herein, a training module was developed to teach the use of reinforcement as a
technique in working with children with autism. The training module involves a PowerPoint
presentation and workbook with exercises designed to help the learner apply the material to
his or her own work situation. The module introduces the theoretical foundations of
reinforcement, as well as instruction on how to use reinforcement as an intervention strategy.
This module is designed for educating staff working in early intervention programs,
educational assistants working in a school setting, or community aids supporting children
with autism in the community. It may also benefit parents and caregivers of children with
autism.
This presentation is intended to address the identified need for training in the
theoretical background for therapy techniques (Maurice et al., 1996; Siegel, 2003; Smith et
al., 1992). As well, training needs to be practical and time efficient (Leblanc et al., 2005).
This training manual is designed as a self-study module. Staff can work through the material
at a time that is convenient to them, and they can review the material whenever needed. By
packaging this training module as a PowerPoint presentation it can be easily and
economically distributed to staff.
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CHAPTER II: THEORETICAL FOUNDATIONS
Characteristics of Autism
Diagnosis
There are two major diagnostic systems used to diagnose autism: the Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV-TR), published by the American
Psychiatric Association, and the International Classification of Diseases (ICD-10), published
by the World Health Organization (Volkmar & Klin, 2005). In North America formal
diagnosis with autism is generally made using the DSM-IV-TR. Autism Spectrum Disorders
are classified as Pervasive Developmental Disorders. According to the DSM-IV-TR,
Pervasive Developmental Disorders are characterized by “severe and pervasive impairment
in several areas of development: reciprocal social interaction skills, communication skills, or
the presence of stereotyped behavior, interests, and activities” (American Psychiatric
Association, 2000, p. 69). The DSM-IV-TR specifies that these impairments must be deviant
relative to the child’s developmental level (American Psychiatric Association).
The Pervasive Developmental Disorders include Autistic Disorder, Rett’s Disorder,
Childhood Disintegrative Disorder (CDD), Asperger’s Disorder, and Pervasive
Developmental Disorder Not Otherwise Specified (PDD-NOS). Rett’s disorder and CDD are
generally considered as distinct from autism (Schreibman, 2005), while Autistic Disorder,
Asperger’s Disorder, and PDD-NOS are generally considered Autism Spectrum Disorders
(ASD). For the purpose of this paper, autism, Asperger’s and PDD-NOS are all treated as
autism, since the interventions discussed can be used with all three disorders. The proposed
changes in the DSM-V include the diagnoses of Asperger’s Disorder and PDD-NOS being
subsumed into the diagnosis of Autistic Disorder (American Psychiatric Association, 2010).
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A substantial problem in the diagnosis of autism is that the diagnosis is made on the
basis of observed behavioural characteristics, rather than by medical tests (Bruey, 2004;
Schreibman, 2005). Diagnosis is further complicated by the fact that it is based on clusters of
behaviours, rather than on specific symptoms (Bruey).
Chakrabarti and Fombonne (2005) found that the average age at which symptoms
were first noticed was 18.6 months, and they found the average age for diagnosis was 3 years
and 5 months (Chakrabarti & Fombonne, 2001). It has been suggested that there is a form of
autism that involves normal development for one or two years, followed by regression and
the onset of symptoms of autism (Wing & Potter, 2002). Osterling, Dawson, and Munson
(2002) found evidence to support the existence of a late-onset autism. Volkmar, Koenig, and
State (2005) suggested that what is reported as developmental regression may be more
accurately described as developmental stagnation. Since young children make rapid
developmental growth, the slowing or stagnation of development may appear as if the child
is regressing.
Autistic Disorder
The diagnostic criteria for Autistic Disorder include “qualitative impairment in social
interactions”, “qualitative impairments in communication”, and “restricted repetitive and
stereotyped patterns of behavior, interests, and activities” (American Psychiatric Association,
2000, p. 75), with onset prior to three years of age. In order to be diagnosed with Autistic
disorder the child needs to have some but not necessarily all of the symptoms.
The impairment in social interactions can include symptoms such as (a) impaired use
of nonverbal behaviours such as eye contact, facial expression, or gestures, (b) a lack of
interest in peer relationships or an interest in social interaction but no understanding of social
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conventions, (c) no spontaneous sharing of interests with other people, marked by a lack of
showing or pointing to objects of interest, (d) a lack of social reciprocity, no joining in social
play (American Psychiatric Association, 2000).
The impairment in communication can include symptoms such as (a) a delay or
absence of spoken language, (b) impairment in the ability to initiate or sustain conversation,
(c) stereotyped or repetitive use of language, (d) a lack of pretend play or social imitative
play, (American Psychiatric Association, 2000).
Restricted, repetitive, and stereotyped patterns of behaviour, interests, and activities
can include symptoms such as (a) preoccupation with restricted interests that is abnormal in
focus or intensity, (b) inflexible adherence to routines or rituals, (c) repetitive body
movements such as hand flapping, (d) preoccupation with parts of objects (American
Psychiatric Association, 2000).
Asperger’s Disorder
The diagnostic criteria for Asperger’s Disorder include qualitative impairments in
social interaction and restricted repetitive and stereotyped patterns of behaviour, interests,
and activities, but no significant delay in language and no significant delay in cognitive
development (American Psychiatric Association, 2000). There is ongoing debate as to
whether Asperger’s should be considered a separate disorder or simply high-functioning
autism (Schreibman, 2005). Individuals with Asperger’s are not delayed in language but tend
to have problems with pragmatics, or the use of language (Schreibman). Schreibman
described individuals with Asperger’s as tending to “engage in long, detailed monologues
while exhibiting no appreciation of the listener’s interests or needs” (p. 60). However, verbal
children with autism tend to do this as well. Children with Asperger’s are described as being
9
“socially clueless” as opposed to actively avoidant (Schreibman). Schreibman stated that
two-thirds of individuals with Asperger’s have depression or another mood disorder, while
individuals with high-functioning autism don’t.
PDD-NOS
Pervasive Developmental Disorder, Not Otherwise Specified (PDD-NOS) is a catchall
category used for those children who have characteristics of Pervasive Developmental
Disorder but who don’t meet the criteria for one of the other diagnoses. The diagnostic
criteria for PDD-NOS include severe and pervasive impairment in reciprocal social
interaction or the presence of stereotyped behaviour, interests, and activities (American
Psychiatric Association, 2000). PDD-NOS is often seen as a milder form of autism (Towbin,
2005).
Rett’s Disorder
Rett’s Disorder is a degenerative disorder and affects girls almost exclusively (Bruey,
2004). Diagnostic criteria include normal head circumference at birth and normal
psychomotor development for the first five months of life, followed by a deceleration of head
growth, loss of previously acquired purposeful hand movements and development of
stereotyped hand movements, loss of social engagement, poorly coordinated gait or trunk
movements, and severely impaired expressive and receptive language (American Psychiatric
Association, 2000).
Rett’s disorder is caused by a specific gene, allowing for genetic testing to confirm the
diagnosis (Schreibman, 2005). The long term prognosis for children with Rett’s disorder is
considered poor (Schreibman). Rett’s disorder has clear biological symptoms, including head
size up to thirty percent smaller than usual (Bruey, 2004). Children with Rett’s disorder
10
commonly suffer from a range of medical problems including seizures and scoliosis (Bruey).
Children with Rett’s disorder will benefit from the same intervention models used with
autism, although overall progress can be limited (Bruey).
Childhood Disintegrative Disorder
The diagnostic criteria for Childhood Disintegrative Disorder (CDD) include normal
development for at least two years, followed by significant loss of previously acquired skills
in expressive or receptive language, social skills, adaptive behaviour, bowel or bladder
control, play, and motor skills (American Psychiatric Association, 2000). CDD is an
extremely rare condition that affects mostly boys (Bruey, 2004; Schreibman, 2005). Children
with CDD are often profoundly impaired in all developmental areas and require support for
the remainder of their lives (Bruey).
History
Autism was originally described by two psychiatrists’, one working in the United
States and one working in Austria. Leo Kanner was an Austrian psychiatrist working in the
US with institutionalized mentally retarded individuals (Grinker, 2007). In 1943 he published
an account of a group of children who had delayed speech, a lack of functional
communication, stereotyped and repetitive activities, a compulsive demand for sameness, a
good memory for rote material, and a lack of imagination (Schreibman, 2005). In 1944 Hans
Asperger, an Austrian physician, described Asperger’s syndrome as a condition characterized
by the same features that Kanner described, expect that Asperger’s group did not display
delayed language or cognitive impairment (Schreibman). Because of World War II, Asperger
and Kanner were not aware of each other’s work.
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Kanner called his syndrome infantile autism, autism being a word for “self” used to
describe the withdrawn nature of people with schizophrenia (Schreibman, 2005). The choice
of the term “autism” led to a erroneous assumption that autism and schizophrenia were
related, and the label childhood schizophrenia was used in the 1940’s and 1950’s
(Schreibman). During the 1940’s and 1950’s psychiatry was dominated by psychodynamic
theory, which meant that early childhood attachment patterns were seen as the source of
psychological disorders. Bruno Bettelheim put the blame for autism on the mothers, using
Kanner’s term refrigerator mothers (Schreibman). In 1967 Bettelheim published The Empty
Fortress in which he suggested that autism was caused by poor parenting by mothers
(Grinker, 2007). Treatments based on psychodynamic theory, which mostly involved treating
the mothers and removing the children from the home and putting them in institutions, were
completely unsuccessful (Schreibman).
The tide began to turn in 1965 when Dr. Bernard Rimland, who was a psychologist
and the father of a child with autism, started the National Society for Autistic Children (now
the Autism Society of America) which was dedicated to advocating for the development of
effective treatments (Schreibman, 2005). In the 1960’s behavioural treatments were coming
into vogue. In the late 1960’s Ivar Lovaas began working with institutionalized autistic
individuals. Lovaas’s behavioural interventions showed success, even with clients with very
severe behaviour problems (Schreibman). In 1987 Lovaas published the results of a clinical
trial of an applied behavioural analysis based intervention. Lovaas reported that 47% of the
experimental group achieved normal academic functioning in a regular classroom at the end
of the intervention. These results generated a great deal of interest from families of children
12
with autism, and spawned the idea that early intervention could have a significant impact on
the outcomes for children with autism.
The advocacy groups that started in the 1960’s continued and are now worldwide
(Wolff, 2004). The efforts of advocacy groups and parents have led to increases in awareness
about autism, and increases in intervention programs and educational opportunities (Wolff).
Causal Theories
Autism is a neurological disorder with an as of yet undetermined cause. There are a
number of hypotheses about the cause of autism. The best supported hypotheses are genetics
(Szatmari et al., 2007) or genetic or prenatal factors that make a child vulnerable to
environmental challenges (Greenspan & Weider, 2006).
Wakefield et al. (1998) published a study suggesting that the measles, mumps, and
rubella (MMR) vaccine was linked to the cause of autism. The theory was that the mercury in
thimerosal, used as a preservative in immunizations, caused mercury intoxication and
therefore autism (Levy & Hyman, 2002). This study created a wide spread belief that autism
was caused by vaccines, however the Wakefield et al. study was later retracted by the journal
and by 10 of the 12 authors (Horton, 2004; Murch et al., 2004) due to methodological and
ethical problems. Subsequent studies found no correlation between MMR vaccine and autism
(Taylor et al., 1999).
A small proportion of children with autism have another medical condition that may
be causally related. These include tuberous sclerosis (Wing & Potter, 2002) and fragile X
syndrome (Feinstein & Reiss, 1998). However the degree of concurrence of autism with
these conditions is rare (Baieli, Pavone, Meli, Fiumara, & Coleman, 2003: Feinstein & Reiss,
1998) so it can’t explain the majority of cases of autism. Autism also co-occurs with medical
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conditions (seizure disorder (Volkmar & Pauls, 2003) and epilepsy (Deonna & Roulet, 2006)
that are not considered possible causes of autism. Estimates of the prevalence of this range
from 10 to 15 percent (Harvard Mental Health Letter, 2009).
Herbert et al. (2006) suggested that autism may be related to gastrointestinal or
immune system disorders, and that it may be triggered by environmental factors. Anderson,
Hooker, and Herbert (2008) suggested that autism may be caused by an infection or an
autoimmune insult to the brain which damages the DNA and causes chronic activation of the
immune system. Charman (2004) suggested that primary neurobiological deficits impact the
way that the child interacts with his environment by influencing the way the child processes
information from the environment, and that this can lead to secondary neurological and
psychological disturbance. Greenspan and Wieder (1999) suggested that the deficits seen in
autism may be due to sensory processing problems that prevent the child from learning from
the environment. Koegel and Koegel (2006) suggested that there is an element of learned
helplessness in autism in that children learn that they are unable to predictably influence the
world around them and give up trying.
Kanner believed that autism was caused by the interaction of a genetic predisposition
and a detached parenting style (Schreibman, 2005). Current theories about the cause of
autism lean toward a genetic component, in that a broad phenotype for autism may be
inherited, of which classic autism is the most severe expression (Schreibman). It is unclear
what determines how the disorder in expressed; one theory is that a risk for autism is
inherited and that environmental factors (such as exposure to toxins) trigger the expression of
autism (Schreibman). Kim et al. (2008) suggested that autism results from “a complex
interaction of genetic factors, environment, experience, and, possibly, chance” (p. 199).
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The hypothesis that autism is caused by genetic factors in supported by the results of
twin studies. Bailey, Palferman, Heavey, and Le Couteur (1999) reported that for
monozygotic (identical) twins there is a 60%-92% chance of the twin having autism if one
twin is diagnosed with autism, while for dizygotic (fraternal) twins the concordance rate is
0%-10% (as cited in Szatmari et al., 2007). Since dizygotic twins share most of their genetic
material, and monozygotic twins share much less genetic material, the high concordance
among dizygotic twins supports the hypothesis that genetic factors play a role in the
development of autism. First degree relatives (parents, siblings, children) of individuals with
autism often show autistic like characteristics, including social and communication
difficulties or narrow and restricted interests (Bailey et al., 1998; Schreibman, 2005). The
term spectrum families is sometimes used to refer to families where other family members
have sub-clinical characteristics of autism.
Szatmari et al. (2007) conducted a large scale investigation into genetic factors in
autism. They suggested that autism may be caused by combinations of chromosomal
abnormalities. Among the chromosomal abnormalities found are abnormalities to the genes
for neurexins and neuroligins (proteins that mediate synaptic transmission). Szatmari et al.
concluded that neurexins and neuroligins may play a role in autism. Neurexins and
neuroligins play a role in inducing the growth of dendrites (Szatmari et al.). In other words,
neurexins and neuroligins play a role in brain development. Neurons that are used grow
(develop more dendrites), neurons that are not used are pruned out during the process of
neural pruning. If a genetic abnormality in neurexins and neuroligins prevents the synapses in
some brain areas from functioning, then those areas may be underdeveloped. Kim et al.
(2008) found abnormalities on the neurexin gene (NRXN 1) were associated with autism, but
15
they also found abnormalities in the NRXN 1 gene in first degree relatives of people with
autism who did not themselves have autism. Kim et al. concluded that the NRXN 1 gene
interacts with other factors in contributing to autism.
Gallese, Keysers and Rizzolatti (2004) suggested that the human brain contains
‘‘neural mechanisms (mirror mechanisms) that allow us to directly understand the meaning
of the actions and emotions of others by internally replicating (‘simulating’) them without
any explicit reflective mediation’’ (p. 396). The mirror neuron system is a network of brain
areas and includes the inferior frontal gyrus, the inferior frontal cortex, the inferior parietal
lobule, and the superior temporal sulcus (Hadjikhani, Joseph, Snyder, & Tager-Flusberg,
2006). Hadjikhani et al. found that these areas of the cortex were significantly thinner in
people with autism. There was also thinning in areas of the cortex involved in recognition of
facial expression and in social cognition (Hadjikhani et al.). The mirror neuron system is
involved in our ability to understand the actions and emotions of other people (Hadjikhani et
al.).
Gallese and Goldman (1998) and Gallese et al. (2004) found that when an individual
observes someone performing a motor action, the same motor circuits that are activated when
that individual performs the same motor action are activated. In other words we mirror in our
head the actions of others. It is a logical assumption that this mirroring of cortical activation
would facilitate our imitating the motor action. Haduikhani et al. (2006) suggested that
‘‘imitation requires a shared representation of perceived and executed action’’ (p. 1276) and
that the mirror neuron system may facilitate this.
Gallese et al. (2004) found that the mirror neuron system works the same way for
understanding emotions. When an individual sees someone else make a disgusted face, the
same neurons are activated as when they feel disgusted (Gallese et al.). Gallese et al.)
16
described the process of mirror neurons as forming a bridge between ourselves and others.
Gallese and Goldman (1998) found that the mirror neuron system was located in “the cortex
of the left superior temporal sulcus (Brodmann’s area 21), of the left inferior parietal lobule
(Brodmann’s area 40) and of the anterior part of Broca’s region (Brodmann’s area 45)” (p.
495). Gallese and Goldman suggested that the purpose of the mirror neuron system may be to
allow “mind reading”. Adolphs (1999) found that “viewing dynamic information from faces
that convey socially relevant information (such as eye or mouth movements) activates
regions in the superior temporal sulcus” (p. 472).
Boddaert et al. (2004) found a bilateral decrease in the grey matter in the superior
temporal sulcus in children with autism. Boddaert et al. suggested that the superior temporal
sulcus is involved in high level cortical integration of both sensory and limbic information.
Hadjikhani et al. (2006) found a significant association between the degree of cortical
thinning in the mirror neuron system and the degree of severity of autism symptoms.
Hadjikhani et al. suggested that ‘‘early dysfunction of the MNS could generate abnormal
development of other areas of the social brain and result in several of the clinical features that
characterize autism, including the failure to develop reciprocal social and emotional
abilities’’ (p. 1279). As well, the cortical thinning seen in individuals with autism could be a
result of a lack of input into the specific brain areas (Hadjikhani et al.). This fits with the
finding that genetic differences in neurexins and neuroligins may be involved in autism.
Differences in neurexins and neuroligins could impair input into the mirror neuron areas and
cause the cortical thinning.
Characteristics of Autism
Children with autism have an array of developmental differences that combine to
make the world unpredictable. They often have receptive language delays, meaning that they
17
don’t understand what people are saying to them (Rogers & Dawson, 2010). They often have
difficulty interpreting facial expressions and body language, meaning that they are less able
to understand other people’s emotional states (Rogers & Dawson). They are often delayed in
developing theory of mind, meaning that they can’t predict other people’s behaviour
(Schreibman, 2005). They are often delayed in expressive communication, so that they are
unable to tell other people what they need. They often have sensory processing problems that
mean that sensory input may be unpredictable or overwhelming (Yack, Aquilla, & Sutton,
2002). All this can mean that children with autism live in a very chaotic and unpredictable
world, where incomprehensible and unexpected things constantly happen, and where they
have no control over what happens.
Lovaas (2003; Lovaas & Smith, 1989) suggested that autism can be seen as a
mismatch between the normal environment and a nervous system that is atypical but not
necessarily diseased, and that it can be ameliorated by manipulating the environment. Lovaas
pointed out that many of the behaviours considered typical of children with autism are also
shown by neurotypical children, only to a lesser degree and for a shorter period of time.
Handflapping, rocking, headbanging, and echolalia are all seen in neurotypical children
(Lovaas). While neurotypical children can show all these behaviours, they typically learn to
control them when they are not socially appropriate. Social pressure will reduce or eliminate
the behaviours fairly quickly. Children with autism, who tend not to be socially aware
(Rogers & Dawson, 2010), may continue the behaviours.
The fact that children with autism have difficulty labelling or communicating their
emotions has lead to a myth that children with autism don’t feel love and other strong
18
emotions (Greenspan & Wieder, 2006). Children with autism feel all the same emotions that
everyone else does; they just have difficulty expressing them.
Common Behaviour Patterns
Every child with autism is different, but within this diversity there are some common
patterns that can be considered as being typical of autism. It is important to keep in mind that
no child with autism has all of these characteristics, and the characteristics they have they
may not have all the time. The important thing is the overall pattern of behaviours, rather
than any one behaviour.
Lack of engagement.
Children with autism have difficultly establishing intimacy and warmth with another
person (Greenspan & Wieder, 2006). Chawarska and Volkmar (2005) identified three
characteristics that indicate the possibility of autism in an infant; not responding to his or her
name, not looking at people, and not looking at objects held by people. Children with autism
are often less socially motivated than neurotypical children (Rogers & Dawson, 2010). They
sometimes appear not to notice other people, even if those other people are talking to them,
or physically bumping into them. Children with autism may treat people as if they were
furniture. They may sit on an adults lap, but as if they were sitting on a chair. They
sometimes don’t appear to notice other people’s reactions and don’t change their behaviour
in response to social disapproval (Rogers & Dawson). They frequently appear to not notice
other people’s emotional states.
Stereotyped behaviours.
Stereotyped behaviours are sometimes referred to as stims. The term stim come from
self-stimulatory; the hypothesis was that these behaviours were done to seek sensory
19
stimulation (Koegel & LaZebnik, 2004; Schreibman, 2005). Lovaas (2003) suggested that
there may be a biological need for sensory stimulation, and that stimming may help to fill
this need. Another theory is that repetitive behaviours are regulating; that children engage in
repetitive behaviours to regulate, reduce, or increase sensory input (Koegel & LaZebnik). Yet
another theory suggests that repetitive behaviours increase the production of endorphins, the
body’s natural opiates (Koegel & LaZebnik). Stereotyped behaviours can be motor
movements; hand flapping, finger flicking, rocking, banging on things. They can involve
objects; spinning wheels on a car, flicking string, flipping the pages of a book. They can be
verbal; chanting sounds or words repeatedly, or making noises. They can be visual; looking
at things out of the corner of the eye, looking at lines, moving the head along a line. They can
involve complicated series of movements; walking around the room touching certain objects
in a certain order, lining up toys, or building the exact same block formation over and over. If
you disrupt this process or move the lined up toys it usually results in a meltdown
(Schreibman, 2005). Stereotyped behaviours tend to disappear naturally as a child’s
appropriate behaviours increase (Koegel & LaZebnik).
Narrow and obsessive interests.
Children with autism tend to have a narrow range of interests and activities (Rogers &
Dawson, 2001). Children with autism might memorize information that other people find
strange, like memorizing bus schedules or license plate numbers or doing calendar
calculations. Some children with autism insist on collecting and carrying certain objects
(sticks, rocks, certain toys) at all times (Schreibman, 2005). Sometimes children with autism
will insist on carrying an object in each hand, to the point that they are unable to use their
hands to do other things. Individuals with autism may talk obsessively about one topic, such
20
as a favourite TV show, and it can be almost impossible to divert them from the topic
(Schreibman). This narrowed range of interests results in fewer learning opportunities, and
means that the child has fewer experiences of the world (Rogers & Dawson).
Rigidity.
Children with autism tend to be very rigid about schedules, travel routes, etc.
(Schreibman, 2005). Yack et al. (2002) suggested that rigidity may be related to sensory
processing difficulties. Children with sensory processing deficits may experience all
sensations as new and unfamiliar, in contrast to neurotypical individuals who habituate to
sensations quickly. If all sensations are experienced as unfamiliar the world may seem like
confusing place. Rigidity over schedules and routines may be an attempt to create
predictability in a confusing world (Yack et al.). Rigidity may also be the result of impaired
communication or impaired understanding of the world.
Echolalia.
Echolalia; repeating words or phrases spoken by others, is extremely common. In
immediate echolalia (usually just called echolalia) the child repeats what has just been said.
For example the adult says “do you want a cookie” and the child says “do you want a cookie”
(Schreibman, 2005). In delayed echolalia, the child repeats something that was said at some
point in the past. Delayed echolalia can be completely out of context and can sound bizarre
(Schreibman). Children often echo with the exact intonation patterns of the person they are
echoing (Koegel & LaZebnik, 2004).
Children may echo because they don’t understand what others are saying or because
they don’t know how to respond (Koegel & LaZebnik, 2004; Schreibman, 2005). As well, in
21
my opinion, echolalia tends to get reinforced. Parents say “do you want a cookie?” and the
child echoes “cookie” and the parents give him the cookie.
Children are likely to use delayed echolalia under conditions of high arousal
(Schreibman, 2005), when children with autism are stressed their language tends to break
down and they may revert back to echolalia. Echolalia can interfere with the development of
functional speech, and echolalia typically does not go away without intervention (Koegel &
LaZebnik, 2004). It is important to note that echolalia is not a form of imitation, rather is part
of the auditory rehearsal loop (Rogers, Cook, & Meryl, 2005).
Dysprosody.
Individuals with autism who are verbal often have dysprosody; their speech is
characterized by irregular melodic features (Schreibman, 2005). They may speak in a
monotone, or too fast or too slow, or be unusual in rhythm, pace or inflection (Schreibman).
People with autism often sound as if they speak English as a second language.
Problems with non-literal language and humour.
Children with autism often have problems with analogies, metaphors, idioms and
humour (Schreibman, 2005). Their language is often very literal. One boy laughed when a
peer called him a chicken, and said “I’m not a chicken, I’m a boy”. After I explained that the
peer meant that he thought he was afraid, he cheerfully agreed that in that case he was a
chicken. Their play is often very literal as well. If a peer picks up a pen and says “this is my
magic wand” they will say “that’s not a magic wand it’s a pen”. Children with autism often
don’t “get” jokes that are dependent on words. They often do like physical humour like Mr.
Bean or Mr. Noodle. Children with autism sometimes laugh at things that are not considered
funny by social standards. For example a boy who would laugh uproariously if another child
22
fell off the climbing equipment at the playground. This is likely in large part due to not
understanding how other people feel; he couldn’t understand that the other child was hurt, so
it seemed funny to see him fall.
Sensory issues.
Sensory processing difficulties are not part of the DSM-IV diagnostic criteria for
autism. However, studies have indicated that most children with autism also have some
sensory processing issues (Hilton, Graver and LaVesser, 2007). At this point there is no real
agreement on how those sensory problems should be categorized. Sensory processing
disorder (SPD) is a separate diagnosis from autism, although some researchers believe that it
co-occurs with autism in many children (Miller & Fuller, 2006).
Tomchek and Dunn (2007) found that 95 percent of children with autism tested as
having some degree of sensory dysfunction on the Short Sensory Profile (SSP). They found
the greatest degree of difference in the areas of under-responsiveness/sensory seeking, with
90 percent of the autism sample seeking sensation for a variety of modalities. Seventy eight
percent of the autism sample had difficulties with auditory filtering, having difficulty
attending to language and having difficulty focusing in the presence of background noise
(Tomchek & Dunn). Sixty one percent of the autism sample had tactile sensitivity (Tomchek
& Dunn). Sensory processing difficulties make it difficult for the child to attend to relevant
stimuli and further impair his ability to learn (Yack et al., 2002). Hilton et al. (2007) studied
the correlation between sensory processing difficulties and social competence in children
with autism. They found that 89 percent of the children with autism studied had some degree
of sensory processing difficulty.
23
Dyspraxia.
Many children with autism suffer from dyspraxia. Praxis is the ability to
conceptualize a motor plan, organize the body to carry out the plan, and to execute the plan
(Kranowitz, 2005). The lack of praxis is called dyspraxia; praxis is also called motor
planning. Children with dyspraxia have difficulty learning new motor tasks, and when they
do learn the task, with repeated practice, the competence is specific to the task practiced and
does not generalize to similar tasks, as it would for neurotypical children (Yack et al., 2002).
Motor planning problems may contribute to the symptoms of autism. Children’s limited play,
and preseverative behaviours may be due in part to the fact that dyspraxia limits their ability
to manipulate toys or to make novel motor movements (Yack et al.).
Eating and sleeping issues.
It is common for children with autism to have difficulties with eating (Koegel &
LaZebnik, 2004). Children with autism often have very narrow selections of food which they
are willing to eat. This may in part be due to their dislike of novelty. It also may be due to
sensory issues. Children with autism may be only willing to eat foods with certain textures,
or they may be unable to tolerate certain tastes and textures. Sleep issues are also very
common in autism (Koegel & LaZebnik).
Core Deficits
Two core areas of deficit in autism are joint attention and imitation. Roos, McDuffie,
Weismer, and Gernsbacher (2008) defined joint attention as “those non-verbal behaviors
used by a child to monitor and respond to an interaction partner’s solicitation of attention or
to solicit the attention of an interaction partner” (p. 277). Osterling and Dawson (1994)
studied videotapes of children later diagnosed with autism. They found that lack of joint
24
attention behaviours (pointing, looking at faces, showing objects to others, and orientating to
their name) was an indication of autism, and that these deficits could be seen at one year of
age. A second study by Osterling, Dawson, and Munson (2002) found very similar results; in
this study children with autism could be distinguished based on failure to look at people,
failure to look at objects held by people, and failure to orientate to their name.
Charman’s (2004) research examined the effect of joint attention and imitation ability
on language development in children with autism. He found that joint attention and the
ability to imitate correlated with gains in language use. Of the two, Charman found that joint
attention correlated more strongly with gains in language use than did imitation. In my view
joint attention and imitation are important because they are vital for learning. Most learning
depends on the child attending to relevant stimuli, that is, the same stimuli the teacher is
attending to, and imitating an action.
For neurotypical children, imitation is a skill that emerges in the early days of life. It
has been suggested that the core function of early imitation is to share emotional states,
motives, and intentions (Rogers et al., 2005). Children with autism have a deficit in their
imitation skills, and this deficit is autism specific (Rogers et al.). Imitation may be an
intrinsically reinforcing behaviour. McEwen et al. (2007) speculated that “mutual imitation
may act as particularly rewarding form of behavior” (p. 474). This may be because being
imitated may create a feeling of closeness to the person imitating (McEwen et al.). Lovaas
(2003) suggested that the ability of humans to imitate is what allows us to rapidly acquire and
pass on complex behaviours and this ability has allowed humans to survive changing
environments. Therefore humans have evolved to find imitation reinforcing (Lovaas).
25
Need for Intervention
Numerous authors assert that early intervention can result in significant
improvements in functioning for children with autism (Cohen et al., 2006; Harris &
Handleman, 2000; Howard et al., 2005; Lovaas, 1987; McEachin et al., 1993; Sallows &
Graupner, 2005). Early intervention may be effective because the behavioural deficits of
autism prevent the child from learning from his environment. If early intervention changes
this behaviour, the child can begin learning and “catch up”. As well, the atypical behaviour
may affect the way that others in the environment respond to the child, leading to social
stigmitization (Schreibman, 2005). Early intervention may prevent this social stigmatization
(Schreibman).
Behavioural Therapy
Applied Behavioural Analysis (ABA) is the study of using behavioural principles to
change human behaviour and solve human problems. Grant and Evans (1994) described
ABA as “an organized and systematic approach to understanding behavioral processes and
solving behavior problems through behavior change” (p. 2). The most important concept of
ABA is the idea that behaviour is controlled by its consequences. In ABA programs
therapists attempt to change behaviour by controlling the consequences of the behaviour.
ABA is intensive; Lovaas (1993) described ABA as needing to
intervene on all behaviors, in all environments, with the help of all significant
persons. The treatment may have to start early in life and continue for most or all of
the clients' waking hours, for a long period of time. (p. 628)
Because children with autism have difficulty learning from their environments, they
fall behind their peers. In order to catch up, they not only need to begin learning, they need to
26
learn faster than the normal rate for long enough to close the gap (Howard et al., 2005).
Outcome Research
Intensive behavioural intervention (IBI) programs have been shown to result in
significant functional improvements in children on the autism spectrum. Most outcome
studies report that approximately 50% of children receiving early intensive intervention made
exceptional gains (Cohen et al., 2006; Lovaas, 1987; Sallows & Graupner, 2005). Dawson
(2008) reported that 75% to 95% develop useful language following early intensive
intervention.
There have been a number of clinical trials that have shown IBI to be an effective
treatment. The best known study is Lovaas’s (1987) study of IBI, conducted as part of the
UCLA young autism project. Lovaas studied three groups of children. The experimental
group received 40 hours per week of intensive behavioural intervention from trained
therapists, one control group received 10 hours per week of less intensive intervention from
trained therapists, and a second control group received 10 hours per week of treatment from
another agency (Lovaas). Lovaas reported that 47% of the experimental group achieved
normal academic functioning in a regular grade one class, as compared to 2% of the control
group. As well, the children in the experimental group gained on average 30 IQ points over
those in the first control group (Lovaas). McEachin et al. (1993) conducted a follow-up to
Lovaas’s 1987 study. Of the nine children identified at the end of the Lovaas study as having
normal functioning, eight children continued to function in regular classrooms, had IQ scores
ranging from 99 to 136, and were rated as indistinguishable from children with no history of
developmental problems by blind raters (McEachin et al.).
27
Since Lovaas’ influential research in 1987, several replication studies have been
published. A study by Sallows and Graupner (2005) replicated Lovaas’s results, finding that
48% of 23 children studied achieved average IQ scores and “were succeeding in regular first
or second grade classes, demonstrated generally average academic abilities, spoke fluently,
and had peers with whom they played regularly” (p. 433). Another replication study by
Cohen et al. (2006) found that 10 of 21 children (47.6%) in an early intensive behavioural
therapy program achieved average range scores on test measures, and were in regular
classrooms either independently or with a part time aid.
Howard et al. (2005) compared an IBI program with two eclectic treatment programs.
The IBI program included 35 to 40 hours per week of 1:1 intervention including discrete
trials, incidental teaching, other behaviour analytic techniques, and supervised play dates
with neurotypical peers. The IBI group was compared to two eclectic treatment programs, an
intensive program designed for children with autism that included 25 to 30 hours per week of
1:1 or 1:2 intervention including discrete trial training, the use of Picture Exchange
Communication System (PECS), sensory integration therapy, and activities based on the
TEACCH model, and a non-intensive program for children with a range of disabilities that
included 15 hours per week of 1:6 intervention including developmentally appropriate
activities focusing on language, play skills, and sensory experience. At follow-up the IBI
group had significantly higher mean scores in all domains than did the eclectic groups. The
IBI group also showed normal or above normal mean learning rates for all domains, while
the other two groups showed near normal rates only for non-verbal skills (Howard et al.).
Other follow up studies have looked at the intensity of the programs and have found
that less intensive programs were less successful. Smith, Groen, and Wynne (2000)
28
conducted a replication of the Lovaas (1987) study which used the same manualized
treatment as the Lovaas study, with the exception that intensive treatment was provided for
25 hours per week rather than 40 hours per week. Smith et al. found that 27% of children
receiving intensive services where in a regular classroom without an aid, as opposed to 47%
found in the Lovaas (1987) study. Eldevik, Eikeseth, Jahr, & Smith (2006) compared a low-
intensity IBI program to a low-intensity eclectic program. In the IBI group children received
10-20 hours per week of 1:1 behavioural therapy, based on manuals by Maurice and Lovaas.
In addition to the 1:1 therapy children spent 10 or more hours per week in a kindergarten
program with typical peers. In the eclectic group children got 10 to 20 hours per week of a
variety of treatments, and 10 or more hours per week in a kindergarten with typical peers.
Eldevik et al. found that while the IBI group had larger gains than did the eclectic group, the
gains were small enough to be of questionable clinical significance. Eldevik et al. also found
that despite being integrated into a mainstream kindergarten, the children did not make
significant gains in play or social skills.
IBI programs have been shown to be an effective treatment for children with autism
(Cohen et al., 2006; Howard et al., 2005; Lovaas, 1987; McEachin et al., 1993; Sallows &
Graupner, 2005). Several studies reported that approximately 50% of children receiving early
IBI intervention made exceptional gains provided the intervention was done with sufficient
intensity (Cohen et al., 2006; Lovaas, 1987; Sallows & Graupner, 2005). Less intensive
programs were found to be less successful (Eldevik et al., 2006; Smith et al., 2000).
Why Reinforcement Is Needed
Children with autism have difficulty attending, do not always spontaneously imitate,
and are often not socially motivated (Siegel, 2003). This means that affiliative responses,
29
such as smiles and positive voice tone, are often not reinforcing for these children (Siegel).
Social reinforcers, which are so important to other children, are not effective. “One of the
greatest challenges of teaching children with autism is their lack of motivation to do all the
things that other people do just because other people do them” (Siegel, p. 356). Unlike
neurotypical children, children with autism will generally not do things merely to please or
get attention from an adult. In order for these children to participate in therapy, the therapist
needs to give them a reason to participate. Reinforcement is that reason. It gets the child to
“buy into” the therapy process, to attend, and to attempt tasks that he or she may find
difficult.
In my view, it is conceivable that the difficulty children with autism have with joint
attention prevents them from learning what is socially relevant. In essence, socially relevant
stimuli are what others pay attention to. We learn what other people are paying attention to
through joint attention. Without joint attention children with autism have no way of knowing
what is socially relevant.
Lovaas and Smith (1989) conceptualized the challenges seen in autism as a difficulty
with learning. It is generally accepted that children with autism do not attend to other people
and do not imitate, and because of this they lose out on many learning opportunities.
Children who do not engage with others lose opportunities to learn social and play skills
(Lovaas & Smith). Children who do not explore the environment lose opportunities to
practice motor skills and these skills become delayed (Yack et al., 2002). The failure to learn,
or at least the failure to learn socially relevant skills, means that children with autism get left
behind their neurotypical peers.
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There is evidence that reinforcement is essential to effective therapy. Gena, Couloura,
and Kymissis (2005) studied the use of video and in-vivo modeling to teach appropriate
affective responding to preschoolers with autism. They noted that
It is interesting that the participants spoke in full sentences and had extensive training
in motor and vocal imitation before they entered the study, yet did not begin to
imitate the therapist’s models of affective responding until reinforcement and
prompting procedures were implemented. (p. 553)
The Theory Behind Reinforcement
There are two theories important to reinforcement: operant conditioning and classical
conditioning. The term operant conditioning was first used by B.F. Skinner (Staddon &
Cerutti, 2003). Skinner differentiated operant conditioning, where the behaviour affects (or
operates on) the environment, from classical conditioning, where the behaviour is reflexive.
Operant Conditioning
The key to operant conditioning is that “behavior changes as a result of response-
dependent consequences” (Grant & Evans, 1994, p. 381). In behavioural intervention
programs, desirable behaviours and responses are followed by reinforcement, and this
reinforcement increases the level of desirable behaviours. The use of reinforcement is a
fundamental principle underlying Applied Behavioural Analysis (ABA) therapy models.
Reinforcement
Operant conditioning is based on the belief that an action or behaviour elicits a
consequence. Some consequences result in the behaviour being performed more often in the
future, other consequences result in the behaviour being performed less often in the future. If
the consequence results in the behaviour being performed more often, this is said to be
31
reinforcement. Increasing the rate of the target behaviour is essential; if it does not increase
the behaviour then it is not reinforcement (Grant & Evans, 1994).
If the reinforcement takes the form of something being added, such as giving your
child M & M’s when he1 sits still, then it is positive reinforcement. If the reinforcement
consists of removing something, such as stopping nagging when your child cleans his room,
then it is negative reinforcement (Kearney, 2007). Positive reinforcement is commonly
confused as meaning anything good (like praise) that is given to the child; however positive
reinforcement does not have to be subjectively pleasant. Positive reinforcement is something
added to the situation that increases the rate of the target behaviour. Negative reinforcement
is something removed from the situation that increases the rate of the target behaviour (Grant
& Evans, 1994).
Punishment
Punishment is something that causes the target behaviour to decrease. Positive
punishment is a something that is added to the situation which causes the behaviour to
decrease, while negative punishment is something that is taken away from the situation that
causes the behaviour to decrease. Greitemeyer and Kazemi (2008) found that reinforcement
was more successful at maintaining behaviour over the long term than was punishment.
Extinction
Behaviour is extinguished when the stimuli which had been reinforcing the behaviour
is removed, causing the behaviour to stop. When the reinforcement is consistently removed
the behaviour will stop, or be extinguished. The difference between extinction and
punishment is that during extinction the behaviour results in no stimulus change, whereas in
1 In the spirit of gender neutral language, in this paper I have alternated the use of male and female pronouns.
32
punishment the behaviour results in a stimulus that causes the behaviour to be reduced (Grant
& Evans, 1994).
Neurological Basis for Operant Conditioning
Reynolds, Hyland, and Wickens (2001) stated that “positive reinforcement helps to
control the acquisition of learned behaviours” (p. 67). Pessiglione, Seymour, Flandin, Dolan,
and Frith (2006) found that there was a functional link between dopamine, which modulates
the efficacy of cortico-striatal synapses, and reward seeking behaviour. Reynolds et al. found
that dopamine levels increased in response to reinforcing stimuli, and that the increase
resulted in the potentiation of cortico-straital synapses, which led to reward related learning.
Other researchers agree that dopamine mediates learning in response to reinforcement
(Owesson-White, Cheer, Beyene, Carelli, & Wightman, 2008; Pessiglione et al.; Pizzagalli et
al., 2008). Pizzagalli et al. noted that unpredicted rewards were correlated with increases in
dopamine. Pessiglione et al. also found that dopamine influences the perceived value of
rewards.
Classical Conditioning
The second theory important to reinforcement is classical conditioning. In classical
conditioning an unconditioned stimulus leads to an unconditioned response. A neutral
stimulus is paired with the unconditioned stimulus which leads to the unconditioned
response. Eventually the neutral stimulus will become a conditioned stimulus leading to the
same response, which is now called a conditioned response (Grant & Evans, 1994). Classical
conditioning involves behaviours that are reflexive; that is they are elicited by the
environment and they are not learned (Grant & Evans).
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Classical conditioning can be used to make a previously neutral stimulus, such as
social praise, into a reinforcer by pairing it with a previously reinforcing stimulus, such as
food (Sundberg & Micheal, 2001). Classical conditioning implies that if you pair an activity
with reinforcement for long enough, the activity itself will become reinforcing.
Types of Reinforcers
Reinforcement is the process of reinforcing a behaviour, and a reinforcer is the action
or object that is used to do the reinforcing. A reinforcer is different from a reward in that a
reward does not necessarily change behaviour, whereas a reinforcer must change the target
behaviour to be a reinforcer (Grant & Evans, 1994). Reinforcers can be divided into two
basic types: natural reinforcers, those that are intrinsic to the situation such as getting a
cookie in response to saying cookie, and external reinforcers, those that are unrelated to the
response but are added as a reinforcer, such as getting a gummy bear in response to making
eye contact.
Natural Reinforcers
Natural reinforcers have a direct relation to the response, such as getting juice in
response to asking for juice (Delprato, 2001). Natural reinforcers have the advantage that
since they are intrinsic to the situation they continue to reinforce the target behaviour without
manipulation by a therapist. A study by Koegel and Williams (as cited in Delprato) found
primary reinforcers presented in an arbitrary reinforcement condition resulted in 40 percent
correct responding. Primary reinforcers presented in a natural reinforcement condition
resulted in 100 percent correct responding (Koegel & Williams as cited in Delprato). This is
perhaps because the natural reinforcement condition made the correlation between the
response and the reinforcer clearer. Clarifying the relationship between the response and the
34
reinforcer will motivate the child to produce the response if he or she wants the reinforcer.
The disadvantage of using functional reinforcers is that the natural reinforcer for a behaviour
may not be immediate enough to influence behaviour, particularly for children with autism.
As well, it is not always possible or practical to use natural reinforcement.
External Reinforcers
External reinforcers are not related to the target behaviour and are added artificially to
a therapy situation (Grant & Evans, 1994). External reinforcers can be divided into primary
reinforcers, those that are intrinsically reinforcing and do not need to be conditioned, and
secondary reinforcers, those that are not initially reinforcing but which can be conditioned as
reinforcers.
Primary Reinforcers
Primary reinforcers are unconditioned. They have intrinsic value because they meet a
biological need (Grant & Evans, 1994; Wallin, 2004). The primary reinforcers commonly
used are edibles such as food or drinks. Primary reinforcers have the advantage of being
unconditioned (Wallin). They are reinforcing for all children, even those who not reinforced
by other things (Adelinis, Piazza, & Goh, 2001; Lovaas, 2003; Siegel, 2003). Primary
reinforcers do not extinguish; however, they can be subject to satiation (Wallin). Primary
reinforcers have the disadvantage of generally not being available from the natural
environment (Wallin). The use of primary reinforcers, mostly edibles, to reinforce correct
responding has been a standard approach since the early days of applied behaviour analysis
therapy (Litt & Schreibman, 1981).
Primary reinforcers have been criticized as leading to decreases in generalization. The
principle of reinforcer contrast effect suggests that when a high quality reinforcer is followed
35
by a lower quality reinforcer, there will be a decrease in responding (Grant & Evans, 1994).
This leads to the conclusion that using a highly desired primary reinforcer will mean that less
desired natural reinforcers are not as effective. Cohen (1998) suggested that use of primary
reinforcers led children to lose motivation as soon as the reinforcer was not available.
Children learn to look for the reinforcers before they are willing to work. Adelinis et al.
(2001) suggested that in order to reduce satiation, primary reinforcers should be used only
during high-demand or low-attention conditions.
Tangible reinforcers. Tangible reinforcers are any tangible object that can be
physically handed to the child. They include edibles and toys. Technically, primary
reinforcers are only those that meet a biological need; however, tangible reinforcers are
considered primary reinforcers as long as they are unconditioned. Any object that the child
finds intrinsically reinforcing is generally considered a primary reinforcer.
Sensory reinforcers. Sensory reinforcers are objects or actions that give sensory input,
such as tickles, hugs, high fives, swings, odors, music, or lights. These are considered
primary reinforcers because they are not conditioned; the child finds them intrinsically
reinforcing. However, not all children are reinforced by the same things. Reinforcement is
highly individualized.
Secondary Reinforcers
Secondary reinforcers are conditioned reinforcers (Wallin, 2004). They are items that
have become reinforcing through being paired with primary reinforcers (Grant & Evans,
1994; Lovaas, 2003; Wallin). Secondary reinforcers have the advantage of being more
natural; they are generally more convenient to use and fit better into the everyday
environment (Wallin). Secondary reinforcers also have the advantage of not requiring the
36
therapist to be in physical proximity to the child (Wallin). Secondary reinforcers include
social reinforcers such as praise, and token reinforcers which can be exchanged for backup
reinforcers. Lovaas suggested that secondary reinforcers need to be maintained by
occasionally pairing them with primary reinforcers.
Social reinforcers. “Social reinforcers involve the actions of other people” (Grant &
Evans, 1994, p. 35). Examples of social reinforcers include smiles, kisses, praise, hugs, and
applause (Grant & Evans). Grant and Evans described social reinforcers as being one of the
most effective reinforcers for most people. This does not apply to children with autism, who
have to learn to be reinforced by social reinforcers. Charlop, Kurtz, and Milstein (1992)
found no significant difference between no reinforcer and praise as a reinforcer for children
with autism. For children who do not find social or symbolic reinforcers reinforcing, primary
reinforcers may be the only choice. In contrast to neurotypical children, children on the
autism spectrum show a delay in acquiring social and symbolic reinforcers (Lovaas, 2003).
Token reinforcers. Token reinforcers are tokens such as stickers, pennies, or poker
chips which are given as reinforcers in response to behaviour, and then exchanged for back-
up reinforcers such as edibles, toys, or activities (Grant & Evans, 1994). Token systems,
sometimes called token economies, are an effective way to defer reinforcement to the end of
an activity or the end of the day (Siegel, 2003). Token systems allow longer periods between
reinforcement, which means that there is less disruption to therapy activities and less risk of
satiation (Wallin, 2004). In order for token systems to work, the child must have an
understanding of cause and effect (Siegel). Tarbox, Ghezzi, and Wilson (2006) found that
token reinforcers successfully increased the attending behaviour of a child with autism.
Charlop-Christy and Haymes (1998) found that token systems were particularly effective
37
when objects of obsession were used as the tokens. This is perhaps due to an increase in
attending to the tokens, as children are more likely to attend to those items they are obsessed
with. It is also possible that the tokens representing objects of obsession has some intrinsic
reinforcing value (Charlop-Christy & Haymes).
Use of Reinforcement
Factors Making Reinforcement Effective
There are several factors that determine how effective reinforcement will be. These
include establishing operations (EO), the value of the reinforcer, and the way the reinforcer is
delivered.
Establishing Operations
Reinforcers do not always have the same value; the reinforcement value of any one
thing can vary from moment to moment (Delmolino & Harris, 2004). The term EO is used to
describe what makes a certain stimulus a reinforcer for an individual at a specific moment in
time, and what specific behaviour the reinforcer will lead to (Delmolino & Harris). The term
motivational operation (MO) is also used (Moher, Gould, Hegg, & Mahoney, 2008).
EO can work in several ways. An EO can temporarily increase the effectiveness of a
reinforcer; this is known as the reinforcer establishing effect (O'Reilly, Edrisinha, Sigafoos,
Lancioni, & Andrews, 2006). EO can also produce an evocative effect, when the EO
produces an increase in a behaviour that has previously been reinforced by that stimulus
(O'Reilly et al.). EO can also work in the opposite directions, decreasing the effectiveness of
a reinforcer (an abolishing effect) or abating the behaviour that has previously been
reinforced by that stimulus (O'Reilly et al.).
38
Delmolino and Harris (2004) discussed the effects of deprivation and satiation on
reinforcement. The following paragraph follows their work. The two most prevalent types of
EO are deprivation and satiation. Deprivation results in a reinforcer establishing effect. More
deprivation results in a stronger establishing effect. Free access results in satiation and an
abolishing effect. If Timmy has not eaten for several hours, food is established as a
reinforcer. Timmy may then engage in behaviour that has in the past been reinforced by food,
such as pointing to the refrigerator. This is an evocative effect. The EO of hunger evoked the
behaviour of pointing to the fridge. If Timmy is then given free access to food, he will eat
until he is no longer hungry, and food will be abolished as a reinforcer.
Events unrelated to the reinforcement can act as EO. For example sleep disruption can
act as an EO for task avoidance (O'Reilly, Edrisinha, Sigafoos, Lancioni, Cannella, et al.,
2007). The research on EO suggests it may be helpful to extend functional analysis beyond
the standard antecedent-behaviour-consequence model (Lohrmann-O'Rourke & Yurman,
2001). Once the EO affecting the situation have been identified then steps can be taken to
eliminate or neutralize them (Lohrmann-O'Rourke & Yurman).
The Value of the Reinforcer The child has to want the reinforcer in order for it to be useful; it has to have value for
the child. Children with autism often lack reinforcer saliency; there are a limited number of
things that the child wants enough to work to get them (Siegel, 2003). There are a number of
factors that influence whether a child will work for a particular reinforcer including the
quality of the reinforcer (Delmolino & Harris, 2004), the quantity of the reinforcer (Hoch,
McComas, Johnson, Faranda, & Guenther, 2002; Lovaas, 2003), choice (Geckeler, Libby,
Graff, & Ahearn, 2000), novelty among reinforcers (Lovaas; Najdowski, Wallace, Penrod, &
Cleveland, 2005), and whether reinforcers are stimulus specific (Litt & Schriebman, 1981).
39
For children who are not reinforced by anything else, objects of obsession or self-stimulatory
behaviours (stimming) may be useful as reinforcers (Lovaas; Siegel). It is important to pair
primary reinforcers to secondary reinforcers in order to develop a more functional range of
potential reinforcers (Wallin, 2004).
The quality of the reinforcer. The effectiveness a reinforcer is influenced by how
desirable it is in the eyes of the person being reinforced. The principle of response effort
holds that the more effort that is needed to get the reinforcer, the more valuable the reinforcer
has to be to have the same effect (Delmolino & Harris, 2004). In order to overcome this
effect, difficult tasks need to be met with higher quality reinforcement. The most powerful
reinforcers should be reserved for the hardest behaviours (Grant & Evans, 1994).
The quantity of the reinforcer. Hoch et al. (2002) found that both the magnitude of the
reinforcer and the quality of the reinforcer influenced the play behaviour of children on the
autism spectrum, with higher levels of reinforcers producing more gains. Hoch et al. found
that the gains in social behaviour produced by higher magnitude and quality of reinforcer
continued after the level of reinforcement was reduced. Lovaas (2003) suggested that
reinforcement should be exaggerated at the beginning of therapy, and then gradually faded.
While higher levels of reinforcers may be needed at the beginning of therapy, or when task
demands are difficult, the quantity of reinforcers needs to be carefully managed. Presenting
too large a quantity of a reinforcer increases the speed with which the child will satiate
(Lovaas). Generally, you want to use the least amount of reinforcement that will get the
desired behaviour. As the behaviour becomes easier, less reinforcement is needed, so
reinforcement should be faded out.
40
Choice of reinforcers. Geckeler et al. (2000) examined the effects of choice on
reinforcement. The following paragraph is based on their findings. One way to make
reinforcers more effective is to give the child a choice. Preference for reinforcers may vary
day by day or even moment to moment. By providing the child with a choice of reinforcer
you ensure that you are using the most desirable reinforcer at that moment. As well, choice
can give your child a sense of control over the situation; that sense of control is reinforcing
and therefore makes the reinforcer reinforcing. Geckeler et al. found that giving children with
autism a choice between several primary reinforcers resulted in a higher rate of responding
than did the presentation of one primary reinforcer.
Novelty of reinforcers. Even when carefully managed, reinforcers do satiate. To
address this, new reinforcers need to be introduced on an ongoing basis. Lovaas (2003)
suggested that novelty in reinforcers can increase interest in the reinforcer and therefore
increase reinforcement value. Presenting a variety of reinforcers helps to prevent satiation;
Lovaas recommended that 10 to 20 reinforcers be identified for each child. Najdowski et al.
(2005) found that a variety of low preference reinforcers presented in a quasi-random manner
were equally effective as one high preference reinforcer.
Stimulus specific reinforcers. Several researchers have found that stimulus specific
reinforcers, where a specific reinforcer is paired with the specific desired response, resulted
in significantly faster rates of learning than non-differential reinforcers for neurotypical
children (Estévez et al., 2007; Maki & Overmier, 1995; Martínez, Estévez, Fuentes, &
Overmier, 2009). Litt and Schreibman (1981) found that stimulus specific reinforcers were
significantly more effective for children with autism. In Litt and Schreibman’s study, primary
reinforcers (edibles) were more effective if a specific reinforcer was paired with a specific
41
response, over a condition where both responses resulted in the same reinforcer. Litt and
Schreibman concluded that the correlation between the reinforcer and the stimulus was
crucial to improving performance. This conclusion matches that of Koegel and Williams (as
cited in Delprato, 2001). Making the connection between the reinforcer and the response that
triggers the reinforcer is critical.
Another factor that may be important is predictability. It is generally accepted that
children on the autism spectrum have an affinity for sameness and predictability. Litt and
Schreibman (1981) suggested that stimulus specific reinforcers allowed both predictability
and novelty, and that this led to superior results. When using stimulus specific reinforcers, it
is important that the reinforcers are of equal salience (Litt & Schreibman). Litt and
Schreibman found that if one reinforcer was preferred, the child would respond to the more
salient reinforcer and not respond to the less salient reinforcer.
Objects of obsession and stims as reinforcers. It is vital that at least one reinforcer be
identified before reinforcement procedures can take place. Sometimes at the beginning of
therapy a child will have very low reinforcer saliency. The child might not respond even to
primary reinforcers. For children who engage in self-stimulatory behaviour (stimming),
access to the stim is highly motivating (Lovaas, 2003; Siegel, 2003). Devany and Rincover
(as cited in Litt & Schreibman, 1981) found that allowing the child to stim was as effective as
food in reinforcing correct responding. “If carefully titrated, objects or events that engender
repetitive motor stereotypies may be useful for teaching purposes as reinforcers” (Siegel, p.
233). Lovaas and Siegel both described having success with using access to a self-
stimulatory ritual as a reinforcer for a child not reinforced by anything else. Using stims as
reinforcers needs to be done cautiously, as it involves limiting access to stims. Care needs to
42
be exercised when limiting access to things that are calming or regulating for the child.
However, stims are highly motivating so they are a good strategy with children who have
lower reinforcer saliency, particularly at the beginning of therapy. Objects of obsession can
also be effective reinforcers as children are highly motivated to get them (Charlop-Christy &
Haymes, 1998).
Pairing primary to secondary reinforcers. It has long been established that pairing a
reinforcer to another stimulus can make the second stimulus reinforcing. Johnson and
Frankel (1978) found that pairing physical contact with tangible reinforcers caused physical
contact to be reinforcing on its own, once the tangible reinforcers had been faded. They
further found that physical contact as a reinforcers generalized across people and situations
(Johnson & Frankel). Wallin (2004) stated that primary reinforcers should always be paired
with social reinforcers. Social reinforcers are the most common reinforcers delivered to
typical children, and not finding social interaction reinforcing is one of the main deficits of
autism. Conditioning social reinforcers is critical. Lovaas (as cited in Grindle & Remington,
2004) found that praise became reinforcing after it was repeatedly paired with food as a
reinforcer.
How Reinforcers Are Presented
For reinforcers to be effective they must be presented in the correct manner.
Reinforcers must be response dependent (Grant & Evans, 1994; Lovaas, 2003), they must be
presented immediately following the response (Grant & Evans; Lovaas; Staddon & Cerutti,
2003), they must be combined with a task hierarchy that sets the child up for success
(Ducharme, Harris, Milligan, & Pontes, 2003; Gena et al., 2005; Koegel, Koegel, Harrower,
& Carter, 1999), and ideally they should be presented in a natural manner. Once the target
43
behaviour is mastered, it is important to begin fading reinforcement (Cicero & Pfadt, 2002;
Lovaas). Reinforcement can be faded by gradually increasing the delay before reinforcement,
and by controlling the reinforcement schedule (Lee, Sturmey, & Fields, 2007; Lovaas).
Response dependent reinforcers. In order for reinforcers to be effective, they must be
response dependent, that is, they must be available only following the target response (Grant
& Evans, 1994). The child must discriminate the reinforcement contingency (make a
connection between the behaviour and the reinforcers) before the reinforcer will be effective
(Lovaas, 2003). If the child does not make a connection between the behaviour and the
reinforcer, then no reinforcement can take place.
Lovaas (2003) stated that reinforcers should be available only in the therapy
environment because if the child had access to the reinforcer outside of therapy, he or she
would not be motivated to work for the reinforcer in therapy. Other researchers have
disagreed with this point. Koegel, Egel, and Williams (1980) found that use of primary
reinforcers in therapy sessions was correlated with decreased performance of the target tasks
outside of therapy, when reinforcers were available only during therapy. However, they also
found that this effect could be reversed by making the reinforcers available for a task similar
between the therapy and non-therapy situations (Koegel et al.).
Timing of reinforcement. Lovaas (2003) stated that reinforcement must be delivered
immediately after the response, ideally within one second of the response. Other researchers
have found that reinforcement can be delayed if something is used to bridge the delay
between the response and the reinforcer (Grant & Evans, 1994). A method that can
successfully delay reinforcer delivery is the use of token systems. In these systems tokens are
delivered during a therapy session, and following a delay the tokens can be exchanged for a
44
backup reinforcer (Grant & Evans). Staddon and Cerutti (2003) stated that the longer the
delay between the behaviour and delivery of the reinforcer, the less effective the reinforcer is.
Therefore when reinforcement is delayed using a token system, a larger amount or a higher
value of reinforcer is generally needed, compared to when reinforcers are given immediately
following the target behaviour.
Schedules of reinforcement. There are two categories of schedules of reinforcement:
continuous reinforcement schedules and partial or intermittent reinforcement schedules.
Continuous reinforcement schedules provide one-to-one reinforcement; every incidence of
correct responding results in a reinforcer (Wallin, 2004). Continuous reinforcement schedules
have the advantage of producing high rates of responding, but the disadvantage of producing
responding that is subject to extinction once the reinforcement is removed (Lee et al., 2007).
This is a substantial disadvantage in working with children with autism, because the goal is
to create behaviours that will be maintained in the long term without artificial reinforcement.
In contrast to continuous reinforcement, partial reinforcement schedules provide a
reinforcer for only some incidences of correct responding (Wallin, 2004). Partial
reinforcement schedules are more natural than continuous schedules, and are better at
maintaining behaviour gains (Wallin). Partial reinforcement schedules include fixed-ratio
schedules, variable-ratio schedules, fixed-interval schedules, and variable-interval schedules
(Grant & Evans, 1994).
Fixed ratio schedules provide reinforcement after a fixed number of correct
responses. Fixed ratio schedules tend to result in high rates of responding before
reinforcement is due, but a pause in responding immediately after reinforcement (Grant &
Evans, 1994). Variable ratio schedules provide reinforcement after a variable number of
45
correct responses. Research has shown that variable ratio schedules lead to the highest rates
of responding with no pause in responding after reinforcement (Grant & Evans). As well,
ratio reinforcement schedules produce less variability in the response than do interval
schedules (Lee et al., 2007).
Fixed interval schedules provide reinforcement after a fixed period of time since the
last reinforcement. Fixed interval schedules are the least effective as they tend to result in a
low rate of responding for most of the time interval and a spike in responding right before the
reinforcement is due (Grant & Evans, 1994). Variable interval schedules provide
reinforcement after a variable period of time since the last reinforcement. Variable interval
schedules tend to result in a low but steady rate of responding. The rate of responding is
lower than with variable ratio schedules because a higher rate of responding will not result in
more reinforcement; the time has to pass, but there is not a post reinforcement pause in
responding because the timing of the next reinforcement is unpredictable (Grant & Evans).
Lovaas (2003) suggested that continuous reinforcement is needed for teaching new
tasks. After a response is mastered, gradually moving from a continuous reinforcement
schedule to an intermittent reinforcement schedule will maintain behaviour with less risk of
satiation (Lovaas). The intermittent schedule should then be “thinned” gradually, presenting
reinforcers less often (Lovass).
Task hierarchy. Reinforcement alone may not be sufficient to produce the desired
behaviour. The child needs to be capable of performing the desired behaviour before
reinforcement procedures will be successful. Ducharme et al. (2003) found that
reinforcement of compliant behaviour was not sufficient to increase compliance. However,
when reinforcement was combined with a graduated task hierarchy that began with tasks the
46
child was able to comply with and gradually increased in difficulty, the child showed
substantial improvement (Ducharme et al.). In addition to gradually increasing task difficulty,
prompting can be used to help the child successful perform the task. Gena et al. (2005) found
that prompting in combination with reinforcement was more effective than reinforcement
alone.
Koegel et al. (1999) suggested that children with autism lack motivation due to
repeated failure. They suggested that reinforcing attempts rather than correct responses may
help to overcome this (Koegel et al.). Minassian, Paulus, Lincoln, and Perry (2007) found
that the performance of individuals with autism improved in situations where their success
rate was high and their error rate was low. This supports Koegel et al. suggestion that
repeated failure decreases motivation for children with autism.
Fading reinforcers. Lovaas (2003) suggested that primary reinforcers are appropriate
at the beginning of therapy, but must be gradually faded and replaced by natural reinforcers.
Cicero and Pfadt (2002) reported successfully fading all tangible reinforcers, with the
behavioural gains remaining. Dunlap, Koegel, Johnson, and O’Neill (1987) found that
behaviours could be successfully generalized to community settings by gradually thinning
the reinforcement schedule, and gradually increasing the delay before reinforcement. Charlop
et al. (1992) found that inappropriate behaviours decreased or remained constant when
primary reinforcers were faded for mastered tasks. As well, they found no decrease in the
percentage correct performance of the mastered tasks, once there was no primary reinforcer
associated with them (Charlop et al.).
Problems can arise if reinforcers are not faded. If the child learns that primary
reinforcers are readily available for previously mastered, and now easy, tasks, the child does
47
not need to learn new and difficult tasks to obtain the desired reinforcer (Charlop et al.,
1992). Tasks that are already in the child’s repertoire are easier for the child than are
acquisition tasks, therefore reinforcing maintenance tasks with the same reinforcer as
acquisition tasks makes it more likely that the child will be reinforced for maintenance tasks
than acquisition tasks (Charlop et al.). This can interfere with the child learning the
acquisition task.
Finding Reinforcers
The most important consideration is finding a reinforcer that works; the effectiveness
of the reinforcer is more important that what is used. Pairing primary reinforcers with
secondary reinforcers will develop new reinforcers and can be used to make natural
reinforcers effective (Wallin, 2004). In my opinion it is particularly important to develop
social reinforcers, since this type of reinforcer is readily available in natural settings and is so
important for neurotypical children. It is generally accepted that no form of reinforcer is
definitively correct. The reinforcer and the reinforcement presentation must be appropriate
for the child and the situation. Therapists should not lose focus on the fact that reinforcement
is about eliciting the desired behaviour.
Reinforcers can often be identified simply by observing the child and noting what she
shows interest in, or by asking the parent to list what the child likes. If reinforcers for a
particular child are not obvious, then a formal reinforcers preference assessment can be done.
Formal reinforcer preference assessments
Pace, Ivancic, Edwards, Iwata, and Page (1985) described a procedure for assessing
reinforcement preference. This procedure involved presenting various objects or stimuli to
the child and recording whether the child approached the object. The objects were presented
48
in groups of four, with each object presented five times per trial in a counterbalanced order.
After the objects had all been presented the percentage of approaches were calculated and the
objects were ranked in order of preference. Pace et al. found that the identified reinforcers
were effective in increasing target behaviours.
Fisher et al. (1992) described a modification of the Pace procedure in which potential
reinforcers were presented in pairs and the child was asked to make a choice between the two
objects. Each object was paired once with each other object, in random order. Fisher et al.
concluded that the paired presentation was more effective at identifying objects that would
act as reinforcers.
DeLeon and Iwata (1996) compared the paired stimulus procedure described by
Fisher et al. (1992) to a multiple stimulus without replacement (MSWO) procedure. In this
procedure 16 items were presented to the child and the child was asked to pick one. After
being given 30 seconds of access to the chosen item, the child was again asked to pick one
item from the remaining items. This continued until the child did not choose any item.
DeLeon and Iwata concluded that that the MSWO procedure produced as reliable a ranking
of reinforcers as the paired stimulus procedure, but in approximately half the time. DeLeon
and Iwata also tested a multiple stimulus with replacement (MSW) procedure which was
similar to the MSWO procedure except that the chosen item was replaced in the assortment
before the child was asked to choose again. DeLeon and Iwata concluded that this procedure
was the most effective at identifying one or two highly motivating reinforcers but it was less
effective in identifying a range of reinforcers.
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Summary
Two core areas of deficit in autism are joint attention and imitation. These deficits
mean that children with autism have difficulty learning socially relevant skills, and this
failure to learn means that they are left behind their neurotypical peers (Lovaas & Smith,
1989; Yack et al., 2002). Intervention is needed that will allow children with autism to learn
and catch up to their peers (Howard et al., 2005). However, the deficits in joint attention and
imitation also mean that children with autism are less motivated to participate in intervention
than neurotypical peers would be. Their deficits in joint attention mean that they do not
always find social reinforcement motivating (Siegel, 2003). Social reinforcers such as praise
are the most important reinforcers for neurotypical children (Grant & Evans, 1994), however
they are often not effective for children with autism. In addition, much of the process of
learning involves imitation, and imitation is an intrinsically reinforcing activity (Lovaas,
2003; McEwen et al., 2007), however children with autism do not spontaneously imitate, so
they do not receive that reinforcement.
These core deficits combine to mean that while children with autism need intensive
interventions to catch them up to neurotypical peers, they are not motivated to participate the
way a neurotypical child would be. In order for intervention to be successful professionals
need to find ways to motivate children with autism to participate. One way of motivating
children with autism is through the use of reinforcement.
Reinforcement is based on the theory of operant conditioning which states that the
consequences of a behaviour can increase or decrease the rate at which the behaviour is
performed in the future (Grant & Evans, 1994). Reinforcement as a therapy technique
50
involves controlling the consequences of the behaviour in order to increase desirable
behaviours and decrease undesirable behaviours.
The use of reinforcement can effectively motivate children to participate in
intervention (Lovaas, 2003). As well, reinforcement programs can develop social reinforcers
for children with autism. Social reinforcers are what motivate most children, so learning to be
reinforced by social feedback helps children with autism function in the world.
An important theme that emerged in the literature is the relationship between
reinforcement and attending. Reinforcement appears to work if it increases attending. Several
studies concluded that reinforcers were effective because they increased attending (Charlop-
Christy & Haymes, 1998; Grindle & Remington, 2004). Failure to attend to relevant stimuli
is one of the core deficits of autism. These studies indicate that reinforcement is useful in
treating this core deficit.
51
CHAPTER III: SYNTHESIS AND IMPLICATIONS
Autism is a disorder characterized by severe impairment in social interaction and
communication skills, and by the presence of stereotyped behaviours and interests (American
Psychiatric Association, 2000). Autism is classified as a Pervasive Developmental Disorder
by the DSM-IV-TR. The Pervasive Developmental Disorders include Autistic Disorder,
Rett’s Disorder, CDD, Asperger’s Disorder, and PDD-NOS. Autistic Disorder, Asperger’s
Disorder, and PDD-NOS are generally considered ASD, while Rett’s Disorder and CDD are
generally considered as distinct from ASD (Schreibman, 2005).
Autism was originally described in the mid 1940’s by Leo Kanner and Hans Asperger
(Grinker, 2007; Schreibman, 2005). Kanner’s choice of the name autism led to the erroneous
assumption that autism was related to schizophrenia, and the label childhood schizophrenia
was used to describe autism in the 1940’s and 1950’s (Schreibman). Throughout the 1950’s
and 1960’s autism was thought to be caused by cold and uncaring mothers. This idea of
autism being caused by bad parenting was overturned in the 1960’s and 1970’s, largely due
to the advocacy of parents of children with autism (Grinker; Schreibman). In 1987 Lovaas
published results of a clinical trial of an ABA based intervention showing very positive
results (Lovaas, 1987). Since the 1980’s behavioural interventions for autism have become
common.
Autism is a highly complex disorder marked by an array of developmental
differences. Children with autism have an impairment in communication skills. This can
mean impairments in receptive and expressive language, an inability to understand non-
verbal communication, an overly literal use of language leading to problems understanding
idioms and humour, and atypical patterns of speech such as echolalia and dysprosody
52
(Schreibman, 2005). Children with autism also have an impairment in social interaction
skills. This can mean difficulties engaging with others, and a lack of social motivation
(Greenspan & Wieder, 2006, Rogers & Dawson, 2010). Children with autism show a pattern
of repetitive, stereotyped behaviours, interests, and activities. Typical stereotyped behaviours
are motor movements such as hand flapping or rocking, fascination with parts of objects such
as the wheels on a car, as deep interest in things others find trivial, such as memorizing bus
schedules (Schreibman). While not part of the diagnostic criteria, many children with autism
have difficulty with sensory processing, dyspraxia, and difficulties with eating and sleeping
(Koegel & LaZebnik, 2004; Yack et al., 2002)
Two of the core areas of deficit in autism are joint attention and imitation (Charman,
2004; Osterling et al., 2002; Rogers et al., 2005). Joint attention and imitation are vital for
learning, as most learning is dependent on the learner attending to relevant stimuli and then
imitating an action. Joint attention and imitation emerge early in life for neurotypical children
(Walden, Geunyoung, McCoy, & Karrass, 2007); however, both are delayed in children with
autism (Osterling et al.).
The deficits in joint attention and imitation that children with autism experience
impair their ability to learn. The lack of joint attention is correlated with deficits in language
use (Charman, 2004). The deficits in joint attention and imitation result in children with
autism falling behind neurotypical peers.
If children with autism are to have any chance to close the gap between their skills
and those of their typically developing peers, their developmental trajectories must be
increased sharply while they are young, before the gap widens even further. That is,
53
their learning rates need to exceed the normal rate for an extended period of time.
(Howard et al., 2005, p. 377)
Early intervention has been shown to be effective in helping children with autism
(Cohen et al., 2006; Howard et al., 2005; Lovaas, 1987; McEachin et al., 1993; Sallows &
Graupner, 2005), however children with autism often have difficulty with engagement
(Siegel, 2003). Before children can benefit from intervention they need to engage in the
intervention (Siegel). The deficits in joint attention and imitation that cause children with
autism to fall behind in learning also result in decreased social motivation. One of the core
functions of imitation may be to share emotional states (Rogers et al., 2005). McEwen et al.
(2007) suggested that imitation is an intrinsically rewarding form of behaviour and Lovaas
(2003) suggested that humans have evolved to find imitation reinforcing. Joint attention is
needed both to engage with other people and to recognize other people’s emotional states.
Social reinforcers, such as praise and attention, are the most important motivators for
neurotypical children (Grant & Evans, 1994). Because children with autism are less socially
motivated, they do not find affiliative responses, such as smiles and verbal praise, rewarding
(Siegel, 2003). In order to ensure that children with autism benefit from intervention, it is
important to find ways to motivate them to participate. One way to motivate children with
autism is through the use of reinforcement.
Reinforcement has been shown to be an effective method for working with children
on the autism spectrum (Gena et al., 2005; Hoch et al., 2002; Lovaas, 2003). For example,
Gena et al. found that the use of reinforcement and prompting procedures resulted in
preschoolers with autism imitating affective responding, where the same preschoolers had
not imitated previous to the reinforcement and prompting being introduced.
54
Reinforcement as a therapy technique is based on operant conditioning. The intent of
this training module is to provide the background theory that supports the use of
reinforcement as an intervention technique, so that staff will understand how the technique
works and how to use it effectively. Reinforcement is a fundamental technique in many early
intervention programs. The training module provides both the theoretical foundations of
reinforcement, as well as instruction on its use.
Providing behavioural therapists with information about autism is important because
many individuals come to the field with limited knowledge about autism (NRC, 2001;
Scheuermann et al., 2003). Although public knowledge about autism is increasing (Wolff,
2004), many people still have misconceptions about autism. Even individuals working in the
health professions may not be aware of recent research on autism interventions (Hiedgerken
et al., 2005). The NRC pointed out that even individuals who have specialized training in
working with special needs children may not have received training in the specific techniques
typically used with children with autism.
Impact of the Project
Numerous authors have identified a need for more training in working with
individuals with autism (Lovaas, 2003; Ludlow et al., 2005; Scheuermann et al., 2003;
Siegel, 2003; Simpson, 2004). This project was intended to address that need.
The NRC (2001) suggested that staff training could be improved by the development
of print training manuals as well as video and audio training materials. This project features a
PowerPoint training resource that can be easily used by new behavioural therapists. The
presentation was designed to highlight the most important aspects of using reinforcement
procedures in interventions with autism. The PowerPoint presentation is accompanied by a
55
workbook. The workbook includes a self-test quiz to help the learner test his mastery of the
material. Quizzes let the learner know if she is correctly interpreting the information
presented, which can help to prevent mistakes. The workbook also contains questions and
exercises designed to help the learner apply the material in the PowerPoint to her own work
situation. These exercises are intended to make the material more personal to each learner by
encouraging him to reflect on the child that he is working with. As well, the exercises are
intended to help the learner begin to apply the material presented in the PowerPoint to the
learner’s work situation. The NRC listed “active involvement in learning” (p. 189) as an
important aspect of staff training. The inclusion of the workbook and self-test quizzes are
intended to facilitate active involvement on the part of the learner.
Leblanc et al. (2005) stated that in order for agencies to implement training the
training needs to be practical and time efficient. The module for this project was designed as
a self-study training exercise, which allows staff to work through the training at their own
convenience, thus eliminating the need to bring staff together for training. Providing training
that staff can complete independently makes the training time efficient. The training module
can also be implemented at a low cost to agencies. Traditional training sessions involve a
cost for the facility as well as for the presenter; these costs are eliminated with this training
module.
Strengths and Weaknesses of the Project
This project is intended as a training resource that can be used by agencies to train
their staff. The intent is that the material will be applicable for most individuals working with
children with autism. This project was not intended as a comprehensive overview of ASD
and its treatment. Such an undertaking would go beyond the length guidelines associated
56
with this project. Rather, the intent of this project was to address a therapy technique that is
central to all behaviour-based therapy models. The intent was that training in the technique of
reinforcement would be useful to a range of agencies. Reinforcement is not used in the
developmental, individual-difference, relationship-based (DIR) therapy models, so this
training module will not be useful to agencies using a DIR approach. However, it will be
useful for agencies using ABA or eclectic therapy models.
The project was formatted as a PowerPoint with an accompanying workbook. The
project can be distributed on a CD or by email. This packaging means that the project can be
distributed easily at a low cost. This increases the project’s accessibility. A future goal is to
make the presentation available via the internet. This would make the presentation available
to individuals worldwide.
A weakness of this presentation is that in attempting to keep the presentation brief,
some of the material has been oversimplified, and some more advanced material has been left
out. However, I hope that after working through this presentation, staff will go on to read
more in-depth material about operant conditioning and the use of reinforcement in working
with individuals with autism. The intent of this project was to provide a brief introduction to
the theory behind the technique, not to provide a comprehensive review. It was my intent to
present sufficient information for learners to begin using the technique and for them to gain a
basic understanding of the theory behind the technique. As well, this project focused on only
one technique for working with individuals with autism. There are a great many empirically
validated techniques for working with individuals with autism that are not covered in this
presentation. The information presented about the characteristics, history, and possible
57
causes of autism are only a very brief overview. There is a great deal of information about
autism that is not included in this presentation due to space limitations.
Another weakness of this presentation is that the effectiveness of this training
program has not yet been evaluated. Once this program has been implemented, it will be
important to evaluate the effectiveness of this presentation as a training resource.
Future Implications for This Project
Immediate goals for the future include attempting to create awareness about the
training module in order to increase the number of agencies using it. At the time of writing,
two agencies in Alberta had expressed interest in using the training module. I hope to make
this module available to agencies outside of Alberta. In May 2009, I presented this project at
the Pacific Rim International Conference on Disability. A number of people from around the
world expressed interest in using the training module. I hope to be able to distribute this
training model internationally. As well, I will explore the possibility of making the module
available via the internet. In the future, I intend to create more training modules exploring
more therapy techniques.
The Future for Autism Therapy in Alberta
There is a current trend away from traditional behavioural approaches such as ABA
toward eclectic models such as the social communication, emotional regulation, transactional
support model (SCERTS) and play based models that integrate elements of ABA with
elements of DIR or other models. The eclectic models combine techniques from other
models, in an attempt to address the specific needs of each individual client. When eclectic
models work well, they can combine the advantages of several models in order to optimally
address the needs of the client. However, in my opinion, there is a risk that an eclectic model
58
can lack structure and direction, and can result in techniques being used randomly or
ineffectually. Eclectic models are popular with funders because they can be implemented at a
lower cost that more intensive behavioural programs which can involve up to 40 hours per
week of direct intervention.
The move from behavioural approaches to less intensive approaches has created some
controversy. Sturmey (2006a) argued that cognitive behavioural and psychodynamic
treatments have not been proven effective with individuals with intellectual disabilities. He
criticized the move to using treatments other than ABA on the grounds that ABA treatments
have been proven effective and therefore ethically should be the intervention of choice.
Emerson (2006) argued that treatment decisions can not be made solely on the basis of
evidence of clinical effectiveness, but rather that evidence of cost effectiveness must be
considered as well. He further argued that ABA treatments have not been proven to be cost
effective. Sturmey (2006b) responded that interventions can not be considered to be cost
effective if they are not clinically effective. Sturmey (2006b) pointed out that non-
behavioural interventions have not been proven to be clinically effective, therefore can not be
considered cost effective. Jacobson and Mulick (2000) conducted a cost benefit analysis of
ABA therapy and estimated that ABA intervention could save $1,000,000 over the lifespan
of an individual with autism by reducing the need for further intervention and residential
placements.
In my opinion, and in keeping with Sturmey (2006b), interventions that do not get
good results cannot be considered cost effective, even if they are cheaper in the short term.
Further, I believe that treatment decisions should be based on the needs of the child, rather
than on the cost of the intervention. Finding adequate funding should be a separate issue from
59
choosing the best intervention, and treatment decisions should not be made based on the cost
of treatment.
As we move forward with autism treatment in Alberta, it is important that we
continue to monitor the effectiveness of the programs being used. Eclectic and integrated
models may be appropriate; however, it is important that these programs are monitored to
ensure that they are being implemented effectively and that they are producing good
outcomes for children.
60
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APPENDIX A
Using Reinforcement with Children with Autism
A PowerPoint Presentation
The PowerPoint presentation is attached as a separate file.
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APPENDIX B
Using Reinforcement with Children with Autism:
Workbook to Accompany the PowerPoint
1
Using Reinforcement with Children with Autism: Workbook to Accompany the PowerPoint
2
Welcome to the workbook that accompanies the PowerPoint module on using reinforcement.
This workbook contains some exercises and thought questions to help you apply what you
are learning in the PowerPoint to the child that you are working with or may be working with
in the future. As well, there is a quiz so you can see how well you are doing. The thought
questions can be used to check how you are doing and to help you to be more creative with
each child you are working with. As you work through the PowerPoint, it will indicate when
you should complete the exercises. The answers to the quiz and the case study questions are
at the back of this workbook.
3
Section One – What is Autism. Section one self test quiz –
1. Diagnosis of Autism Spectrum Disorder is based on… a) Impairments in social interaction and impairments in communication. b) Impairments in communication, impairments in social interaction, and
stereotyped and repetitive behaviours and interests. c) Impairments in communication, impairments in social interaction, and
impairment in sensory processing. d) All of the above.
2. Autism is caused by… a) Vaccines. b) Genetics. c) Environmental factors. d) The cause of autism is not known at this time.
3. Common behaviour patterns seen in autism include… a) Hand flapping. b) Echolalia. c) Lack of engagement. d) Narrow and obsessive interests. e) All of the above.
Check your answer on page 15. Now return to the PowerPoint presentation.
4
Section Two – Why Use Reinforcement. Section two self test quiz –
1. Why is verbal praise not a good reinforcer for a child with autism at the beginning of an intervention program? a) Children with autism often do not find social praise reinforcing. b) Children with autism often have receptive language delays so they do not
understand verbal praise. c) Children with autism often don’t attend to other people so they do not notice that
you are praising them. d) All of the above.
Check your answer on page 15. Things to think about – Think of the child you work with – to what extent is he or she socially motivated? How many times in the past week have you found a situation where the child you work with was not motivated to participate in an activity? List the activities that you want the child you work with to participate in that he or she is not motivated by. Now return to the PowerPoint presentation.
5
Section Three – The Theory Behind Reinforcement Section three self test quiz -
1. The “super-duper lottery” pays out $20,000,0000 each week. Every week Jane buys a lottery ticket. Jane has won $1 several times. What reinforcer is maintaining Jane’s behaviour of buying lottery tickets?
a) The prospect of winning $20,000,000. b) Winning $1.
2. My neighbour is playing his music really loud. I ask him to turn it down and he does.
In the future I am more likely to ask him to turn down his music. This in an example of:
a) Positive reinforcement. b) Negative reinforcement. c) Positive punishment. d) Negative punishment. e) None of the above.
3. Tommy pinches his younger brother and makes him cry. Tommy’s mother gives
Tommy a time out in his bedroom. Tommy pinches his brother more often. The time out was an example of:
a) Positive reinforcement. b) Negative reinforcement. c) Positive punishment. d) Negative punishment. e) None of the above.
4. Sally consistently gets B’s and C’s at school. One day, Sally gets an A. Sally’s
mother is very happy and gives Sally $50 for getting the A. Afterward, Sally continues to get B’s and C’s and does not get another A. This is an example of:
a) Positive reinforcement. b) Negative reinforcement. c) Positive punishment. d) Negative punishment. e) None of the above.
5. What process can make verbal praise reinforcing for a child with autism? a) Operant conditioning. b) Negative reinforcement. c) Classical conditioning. d) Explaining that verbal praise is supposed to be a good thing.
Check your answer on page 15.
6
Section three case study questions 1. Fahimah is four years old and has a diagnosis of autism. Fahimah’s parents report that
Fahimah is very rigid about schedules. If her parents make even a small change in the schedule of daily routines, Fahimah will scream until the schedule is changed back. As a result of Fahimah’s reaction and behavior, Fahimah’s parents try very hard to keep everything the same at home, so that Fahimah does not scream. What types of reinforcement are happening in this situation?
2. Yeka has had many medical problems in her life, and this has meant many trips to the doctor. Many of her visits to the doctor have involved things that Yeka has found frightening or painful. Yeka’s doctor always wears a white coat. Lately, Yeka starts to scream if she sees someone wearing a white coat.
What is happening in this situation?
7
3. Sam has a number of OT exercises that he is supposed to do every day. He does not like to do them and needs lots of prompting to get through the exercises. Sam’s mother has begun giving Sam a candy at the end of each exercise. Sam still needs the same amount of prompting to do the exercises.
What is happening in this situation?
Check your answers on page 16.
8
Things to think about – Reinforcement works even when we are not using it intentionally. Think about the child you are working with; what things are reinforcing his or her behaviour? Can you think of times when the child you are working with has used reinforcement on you? (For example stopped screaming when you removed a task demand?) How can you use classical conditioning to develop new reinforcers for the child you are working with? What sort of things would you like the child you are working with to be reinforced by? Now return to the PowerPoint presentation.
9
Section Four – How to use Reinforcement. Section four self test quiz -
1. Why is it important to clearly identify the target behaviour? a) So that you know when to give the reinforcement. b) So that you will know whether you need natural or external reinforcers. c) So you will know which reinforcer to pair with the behaviour d) So that you will have something to write on the data sheet.
2. When deciding how much of a reinforcer to give, a good rule is:
a) The more the better. b) You can’t get too much of a good thing. c) Less is more. d) Give as much as you can afford.
3. When should the reinforcer be given?
a) At the end of the activity. b) Immediately after the target response. c) When the child asks for it. d) Whenever you think of it.
4. You are working with Abdul. Abdul does the target behaviour of putting a piece in a
puzzle and you reach for the reinforcer. Before you can give Abdul the reinforcer Abdul throws the puzzle on the floor. What should you do?
a) Give Abdul the reinforcer because he earned it. b) Have Abdul pick up the puzzle and then give him the reinforcer. c) Don’t give the reinforcer, because you would reinforce throwing things on the
floor.
5. You are looking for reinforcers that will be effective for Susan. Which of the following should you try?
a) Observe Susan to see what she shows an interest in. b) Ask Susan’s parents what she likes. c) Present a variety of commonly reinforcing items and see if Susan shows interest
in any of them. d) All of the above.
6. You can develop new reinforcers through the process of:
a) Operant conditioning. b) Extinction. c) Satiation. d) Classical conditioning.
10
7. You are working with Jane. What reinforcers should you use at the beginning of your intervention program?
a) Squishy toys. b) Tickles and high fives. c) Edibles. d) Anything that Jane is willing to work for.
8. An advantage to using a token system is that…
a) Token systems are a way to delay reinforcement and therefore work in situations where you can’t give the reinforcer immediately.
b) Token systems make the reinforcement visual and help the child see how he is doing.
c) Token boards are a good way to fade out reinforcement. d) Children can learn to use token systems to self-monitor their own behaviour. e) All of the above.
Check your answer on page 17
11
Section four case study questions
1. Maya is three years old and just beginning an intervention program. Maya is very active and enjoys things that involve movement, such as climbing and jumping. Maya will not sit still, even to eat meals. Maya shows very limited interest in toys. When an adult attempts to play with Maya she screams and flops on the floor. Your target behaviour is for Maya to engage with an adult for 1 minute without screaming or flopping.
What kind of reinforcers could you use in this situation?
2. Kaito is four years old and has been in an intervention program for six months. He will engage with adults for limited periods of time but does not participate in structured games or activities. Kaito is very interested in novel toys, especially tops. Your target behaviour is for Kaito to hold a crayon and get some colour onto a colouring page. Kaito does not find this activity motivating.
What kinds of reinforcers could you try in this situation?
12
3. Tom’s parents want him to use more verbal language, so they will not give him candy or treats unless he makes a word approximation to request them. Tom’s grandparents give Tom candy and treats without him having to make any effort to request them. Lately Tom has begun bringing a picture of his grandparents to his mother, to request to go to his grandparent’s house.
What is happening in this situation?
4. Jed is five years old and has been in an intervention program for two years. His therapist has been using M & M’s as a reinforcer for Sam for the past year. Initially Jed responded really well to the M & M’s but over the past couple of months he seems to have lost interest in them. He still eats them when he gets them but does not seem willing to work to get them.
What is happening in this situation?
Check your answers on page 18.
13
Things to think about – Think about your last session with the child you work with. How many activities did you do that included natural reinforcers? How many activities did you do that included external reinforcers? What kinds of external reinforcers are you using? Based on what you have learned so far make a list of 10 possible new reinforcers for the child you work with. Think about your last session with the child you work with; what reinforcers were you using? What other reinforcers were available? How can you control those other reinforcers?
14
How often do you give the child you work with a choice of reinforcer? How do you know that the reinforcers you are using are still motivating? Think about the reinforcers you are using with the child you work with. Does the child have access to these reinforcers without working for them (from Grandma, school, friends?) Giving the reinforcer within two seconds of the desired behaviour is ideal. How often do you give the reinforcer within two seconds? How could you increase the speed at which you give the reinforcer? Think about the past few sessions with the child you work with; did you find your self saying “if you want your token then…” or “do you want a token? Then …”? How can you avoid this in the future?
15
Quiz answers Section one quiz answers
1. Diagnosis of Autism Spectrum Disorder is based on… Answer – b) Impairments in communication, impairments in social interaction, and stereotyped and repetitive behaviours and interests. These are the areas that make up the diagnosis. Sensory processing issues are a very common feature of autism but are not part of the diagnosis.
2. Autism is caused by…
Answer d) the cause of autism is not know at this time, however the best supported hypotheses are genetics or an interaction of genetics and the environment.
3. Common behaviour patterns seen in autism include…
Anwer e) All of the above. However it is important to note that it is the overall pattern of behaviours that is indicative of autism, not any specific behaviour.
Section two quiz answers
1. Why is verbal praise not a good reinforcer for a child with autism at the beginning of an intervention program?
Answer – d) All of the above.
Section three quiz answers
1. The “super-duper lottery” pays out $20,000,0000 each week. Every week Jane buys a lottery ticket. Jane has won $1 several times. What reinforcer is maintaining Jane’s behaviour of buying lottery tickets?
Answer - b) Winning $1 is reinforcing Jane’s behaviour. Winning $20,000,000 is not a reinforcer because Jane has never won that much (remember that we are reinforced by things that have happened in the past not things that might happen in the future). If Jane never won at all she would likely conclude that she was never going to win and stop buying tickets (the behaviour would be extinguished). If Jane won the $20,000,000 she would have all the money she needed and would stop buying tickets (satiation). By winning $1 occasionally, Jane is reinforced and continues to buy lottery tickets (this, of course, is why lotteries pay out small prizes).
2. My neighbour is playing his music really loud. I ask him to turn it down and he does.
In the future I am more likely to ask him to turn down his music. This in an example of:
16
Answer - b) Negative reinforcement. My neighbour removed something (the loud music) which increased my behaviour (asking him to turn down the music).
3. Tommy pinches his younger brother and makes him cry. Tommy’s mother gives
Tommy a time out in his bedroom. Tommy pinches his brother more often. The time out was an example of:
Answer - a) Positive reinforcement. The timeout was added to the situation and the behaviour increased. We often think of time out as a punishment – but what counts is the effect on the behaviour. If the behaviour increases it was reinforcement.
4. Sally consistently gets B’s and C’s at school. One day, Sally gets an A. Sally’s
mother is very happy and gives Sally $50 for getting the A. Afterward, Sally continues to get B’s and C’s and does not get another A. This is an example of:
Answer - e) None of the above. The $50 was a reward, but not reinforcement because Sally’s behaviour did not change (remember that reinforcement has to change behaviour).
5. What process can make verbal praise reinforcing for a child with autism?
Answer - c) Classical conditioning. By pairing verbal praise with primary reinforcers we can condition it as a reinforcer.
Section three case study answers
1. Both positive and negative reinforcement are happening here. Fahimah is receiving positive reinforcement when her parents keep the schedule the same in response to her screaming. As well, Fahimah’s parents are receiving negative reinforcement when Fahimah stops screaming in response to their keeping the schedule the same.
2. This is an example of classical conditioning. The previously neutral stimulus of the
white coat has been associated with the aversive stimulus of going to the doctor so that now seeing a white coat has become aversive.
3. The candy is not serving as a positive reinforcement since it is not changing Sam’s behaviour. It is likely not working as a reinforcer because Sam’s mom has not made it contingent on Sam’s behaviour; Sam gets the candy every time, whether he needs prompting or not. Sam’s mother would likely have better success if she gave Sam the candy only when he did the exercise with less prompting.
Section four quiz answers
17
1. Why is it important to clearly identify the target behaviour? Answer - a) So that you will know when to give the reinforcement. You need to have it clear in your head what you are reinforcing. The more clearly you can define the target behaviour, the easier it will be for you to recognize when the child has preformed the behaviour, and therefore when you should give the reinforcer.
2. When deciding how much of a reinforcer to give, a good rule is:
Answer - c) Less is more. The more of a reinforcer you give, the faster the child will satiate. While more of the reinforcer is technically more reinforcing, it is important to keep in mind that we are trying to maintain the behaviour. In other words we want the child to keep doing the behaviour, and keep getting the reinforcer. The less reinforcer he gets at a time, the longer he will want it, and the longer he will maintain the behaviour.
3. When should the reinforcer be given?
Answer - b) The reinforcer should be given immediately after the target response. The reinforcer reinforces the last response so it is important to give the reinforcer before the child has time to make another response.
4. You are working with Abdul. Abdul does the target behaviour of putting a piece in a puzzle and you reach for the reinforcer. Before you can give Abdul the reinforcer Abdul throws the puzzle on the floor. What should you do?
Answer - c) Don’t give Abdul the reinforcer. Remember that the reinforcer reinforcers the last behaviour so if you give it after he throws the puzzle on the floor you are reinforcing him throwing things on the floor. Give Abdul the reinforcement the next time he does the target behaviour.
5. You are looking for reinforcers that will be effective for Susan. Which of the
following should you try? Answer - d) All of the above.
6. You can develop new reinforcers through the process of:
Answer - d) Classical conditioning.
7. You are working with Jane. What reinforcers should you use at the beginning of your intervention program?
Answer - d) The bottom line with reinforcers is you need to use something that the child wants enough to work for. This will vary from child to child. Edibles, squishy toys, and sensory motor actions are generally reinforcing for a lot of kids, but there are no guarantees. You may need to be creative in finding something that is motivating for the child you are working with.
8. An advantage to using a token system is that…
Answer - e) All of the above.
18
Section four case study question answers
1. This would be a good time to try natural reinforcers. Movement based activities like
blanket swings, airplane swings, or you bouncing Maya on an exercise ball will likely be reinforcing for Maya. These activities also have the advantage that they require your presence, i.e. you are giving the squishes or bouncing her on the ball, so you are also conditioning yourself -and hopefully people in general- as a reinforcer.
2. This might be a good time to try primary reinforcement. Kaito likes tops and other novel toys, so may respond well if you use them as reinforcers for the target behaviour of colouring. You could also try having Kaito colour pictures of his obsessive interests, if he has any. You could try both these strategies together, using a picture of Kaito’s interests as a natural reinforcer and using a top as an external reinforcer.
3. In this case, there is a competing source of reinforcement. Tom is able to get the reinforcer (candy and treats) by using a picture to request to go to his grandparent’s house, which is an easier task for him than making a word approximation. Once at his grandparents house, Tom has unlimited access to the candy and treats, while at home he would have to continue to work for each treat. Tom’s parents would have better success with this if they ensured that candy and treats were only available when Tom did the target behaviour of making a word approximation.
4. M & M’s seem to have lost their value as a reinforcer. Over time most children will
get tired of things, so reinforcers tend to lose value over time. To prevent this it is a good idea to use a variety of reinforcers, and to introduce new ones on a regular basis. In Jed’s case, he seems to have lost interest in the reinforcer so his therapist needs to find a new reinforcer.
19
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