Natural Environment Training

13
Sarah Dufek and Laura Schreibman

Keywords
Naturalistic instruction · Pivotal response training · Incidental teaching

Traditional structured teaching paradigms that selected, targets general (as opposed to specific)
utilize the principles of applied behavior analy- behaviors, utilizes loosely applied prompt strat-
sis (ABA), such as discrete trial training (DTT), egies and reinforcement contingencies, and
have proven to be very successful in addressing applies natural reinforcement (Cowan and Allen
the behavioral deficits and excesses of children 2007; Ingersoll 2010b).
with autism spectrum disorder (ASD; National Naturalistic behavioral approaches to in-
Research Council 2001). However, such inter- tervention are designed for children with ASD
ventions often have been plagued with prompt and have a solid evidence base in the literature,
dependence, reduced child motivation, and a earning an “established” evidence level from the
lack of child generalization and maintenance National Research Council (2001), the National
of acquired skills (Brunner and Seung 2009; Autism Center (2009), and the National Profes-
Matson et al. 1996; Smith 2001). Subsequently, sional Development Center on Autism Spectrum
naturalistic behavioral approaches were devel- Disorders (2011). These treatments are effective
oped to address these limitations while simul- for teaching language, play, and social skills in
taneously preserving the use of the principles children, adolescents, and even adults with ASD
of ABA and adhering to the following rules of (Goldstein 2002; Matson et al. 1996; Schreibman
intervention implementation (Matson et al. 1996; and Anderson 2001). This chapter will provide
Mirenda and Iacono 1988; Mundy and Crowson an overview of the naturalistic behavioral ap-
1997). Naturalistic behavioral approaches typi- proaches available for the treatment of children
cally require that the intervention be applied in with ASD and will identify current and future di-
the child’s natural environment, is child initiated, rections in behavioral intervention research.
involves materials and activities that are child

Naturalistic Behavioral Approaches

Incidental Teaching
L. Schreibman () · S. Dufek
University of California, San Diego, UCSD Department Perhaps the “original” form of naturalistic be-
of Psychology, MC 0109, 9500 Gilman Drive,
La Jolla, CA 92093, USA havioral intervention is incidental teaching (IT),
e-mail: lschreibman@ucsd.edu

J. Tarbox et al. (eds.), Handbook of Early Intervention for Autism Spectrum Disorders, 255
Autism and Child Psychopathology Series, DOI 10.1007/978-1-4939-0401-3_13,
© Springer Science+Business Media New York 2014
256 S. Dufek and L. Schreibman

which was developed in the 1960s to increase rates may be slower for these children because
the language skills of underprivileged children there may be limited opportunities for learning
in preschool settings (Hart and Risley 1968). Ac- if the teacher is required to wait for the child’s
cording to Hart and Risley (1982), IT includes initiation. (Rogers-Warren and Warren 1980).
first arranging the child’s natural environment In order to address this limitation, research-
to include toys and activities of interest that are ers have begun to adapt the original IT paradigm
visible to the child but not accessible without to better address the specific needs of children
assistance or support. The teacher’s behavior in with ASD (Haring et al. 1987; Mirenda and Iaco-
IT follows the following steps: (1) wait for the no 1988). For example, the modified incidental
child to initiate (likely to obtain help, permis- teaching sessions (MITS) procedure, developed
sion, attention, and/or approval), (2) respond to by Charlop-Christy and Carpenter (2000), ad-
the child’s initiation immediately, (3) verify if dresses decelerated child learning as a result of
unsure of what the child wants after initiation, (4) a lack of spontaneous child initiations by allow-
request the child to elaborate the initiation, (5) ing mand-model adult initiations (e.g., adult en-
prompt and (if necessary) model the elaborated courages the child to request a preferred object
response if the child does not comply, and (6) by asking “What do you want?” and then mod-
verbally confirm the child’s request while pro- els the appropriate complex response if needed).
viding access to the preferred toy or activity con- Charlop-Christy and Carpenter (2000) also modi-
tingent on the child’s elaborated response. Hart fied traditional IT by utilizing parents as imple-
and Risley reported impressive improvement in menters of the MITS in the home environment
many aspects of the speech of the preschool chil- in order to further facilitate generalization. In a
dren in their studies (Hart and Risley 1968, 1974; comparison study of traditional IT, MITS, and
Risley and Hart 1968). Further, they found the DTT, these authors used a multiple baseline de-
children showed generalization of these language sign across subjects in combination with an alter-
improvements that was superior to the general- nating treatment design to determine the effect of
ization of language skills taught during highly MITS training on three children with ASD. They
structured training sessions (Hart and Risley found that all children showed better acquisition
1980). and generalization of the target behaviors learned
In the 1980s, researchers began in earnest to in the MITS condition as compared to the tradi-
investigate the utility of IT for the treatment of tional IT and DTT conditions (Charlop-Christy
communication deficits in children with ASD and Carpenter 2000).
(Green 2001). Early research documented the
successful use of IT to teach acquisition and
generalization of receptive object labels (McGee Milieu Teaching
et al. 1983), reading (McGee et al. 1986), and
sign language (Schepis et al. 1982). In addition, Originally developed as a specified combina-
comparison studies examining the difference be- tion of research-supported interventions to teach
tween teaching expressive use of prepositions language to children with language delay, mi-
and labels to children with ASD using IT proce- lieu teaching (MT) was quickly accessed as an
dures versus using traditional structured teaching intervention option to address communication
procedures revealed greater generalization and deficits in children with ASD (Mancil 2009).
more spontaneous use of the prepositions and MT comprises four well-established teaching
labels taught with IT procedures (McGee et al. techniques: (1) modeling and then correcting
1985; Miranda-Linne and Melin 1992). Despite the child’s behavior if necessary, (2) the mand-
these promising findings, many children with model technique described previously, (3) time
ASD have difficulty spontaneously initiating in- delay, as the adult will wait for a predetermined
teractions with others, even to request preferred amount of time after presenting the stimulus for
items (Mirenda and Iacono 1988). IT learning the child to respond, and (4) all components of IT
13 Natural Environment Training 257

(Kaiser et al. 1991; Mancil 2009). Kaiser et al. the natural language paradigm (NLP; Gillett and
(1992) reported MT to be effective for teach- LeBlanc 2007; Laski et al. 1988), a language in-
ing language skills ranging from single words to tervention originally developed as a combination
complex phrases to children and adolescents with of traditional operant and naturalistic procedures
language delay, intellectual disability, or ASD. In for children with ASD. NLP is presented in a nat-
addition, the acquired language skills generalized uralistic teaching paradigm where child choice,
across various settings and trainers in several of task variation, flexible prompting, and reinforce-
the studies (Kaiser et al. 1992). ment of child attempts are valued. Comparisons
However, as with other naturalistic behavioral of the NLP and more traditional structured teach-
approaches, traditional MT has been modified ing revealed the NLP to provide improved gener-
over time to better accommodate the specific alization and spontaneity of child language gains
needs of children with ASD. Enhanced milieu (Koegel et al. 1987).
teaching (EMT) consists of all of the components PRT targets the “pivotal” behaviors of motiva-
of traditional MT with the addition of increased tion and responsivity to multiple environmental
language expansions, turn taking, and follow- cues (Koegel et al. 1989). Pivotal behaviors are
ing the child’s lead. Hancock and Kaiser (2002) so-named because improvements in these be-
implemented a multiple baseline across subjects haviors are likely to affect change in collateral
design to examine the effects of EMT on four behaviors, which may improve overall child re-
children with ASD. All the children showed in- sponse to treatment and minimize the treatment
creases in their language targets that were main- time required to learn new skills. Motivation is a
tained at a 6-month follow-up. The children pivotal behavior for children with ASD because
also increased the complexity and diversity of increasing child motivation during intervention
their language. In addition, three out of four of will likely lead to increased language, play, and
the children generalized their acquired language social gains (e.g., increasing a child’s motivation
skills to their home environment. In order to ad- to respond to social approaches can reduce avoid-
dress the needs of children with ASD who have ance of social learning opportunities). It is often
not developed vocal language, prelinguistic mi- challenging to access high levels of child moti-
lieu teaching (PMT) utilizes the techniques of vation during treatment. PRT seeks to address
MT to specifically teach valuable preverbal com- limited child motivation levels directly (Koegel
munication skills such as gestures, vocalizations, et al. 1999; Schreibman 1988). For example, PRT
and coordinated eye gaze (Fey et al. 2006; Yoder targets child motivation by consistently follow-
and Stone 2006). In addition, Franco (2008) used ing the child’s lead including when to play, what
PMT to successfully teach school-age children to play, and how to play. All intervention is pro-
with ASD to increase the frequency and clarity vided in the context of a child’s individual inter-
of their communication skills in a home setting. ests and preferences. In addition, difficult tasks
are interspersed with easier tasks and children are
reinforced for good attempts at the target behav-
Pivotal Response Training ior to help create behavioral momentum.
Children with ASD also exhibit difficulties
Pivotal response training (PRT), sometimes re- with “stimulus overselectivity” (Lovaas et al.
ferred to in the literature as pivotal response 1979, 1971; Schreibman 1988), an attentional
treatment, is a child-directed therapy well sup- deficit wherein the child does not respond to
ported as an established evidence-based prac- simultaneous stimulus input. Stimulus overse-
tice intervention for children with ASD (e.g., lectivity may limit a child’s ability to generalize
Humphries 2003; National Autism Center 2009; previously learned behavior out of the interven-
National Research Council 2001; National Pro- tion context (Schreibman 1997). Fortunately,
fessional Development Center on Autism Spec- research supports that many children with ASD
trum Disorders 2011). PRT is an expansion of who display overselectivity can in fact learn to
258 S. Dufek and L. Schreibman

respond to compound stimuli if taught a series of single-subject and long-term outcome studies
conditional discriminations (i.e., discrimination have confirmed that PRT facilitates the function-
tasks requiring response to simultaneous multiple al use of language for many children with ASD,
cues; Koegel and Schreibman 1977; Schreibman including those with little to no functional speech
et al. 1982, 1977). PRT addresses stimulus over- (Humphries 2003; Koegel et al. 1987, 1999a, b;
selectivity directly as another pivotal behavior Laski et al. 1988). Moreover, when compared
by teaching children to respond to multiple cues with more structured behavioral techniques, the
simultaneously, thus removing a barrier to gen- specific components of PRT facilitate relatively
eralization. greater increases in verbalizations and spontane-
Subsequent research has identified self-initia- ous language use (Delprato 2001; Koegel et al.
tion and self-management as pivotal behaviors in 1988; Koegel and Williams 1980; Williams et al.
addition to motivation and responsivity to mul- 1981).
tiple cues. Self-initiation is considered a pivotal In addition to language acquisition, PRT has
behavior as it allows a child with ASD to spon- been shown to be effective for targeting play and
taneously approach others to manipulate her en- social skills in children with ASD (Pierce and
vironment for a variety of reasons (e.g., to obtain Schreibman 1997a, b; Stahmer 1999). Stahmer
items or engage in social interaction), providing (1995) taught seven children with ASD to engage
the child with a wealth of learning opportunities. in symbolic play behaviors using PRT. She found
Education in self-management allows an indi- that after receiving PRT targeting symbolic play,
vidual with ASD to monitor her own behavior children with ASD engaged in symbolic play at
and provide appropriate consequences in order levels comparable to typically developing chil-
to manage her own behaviors. Individuals with dren of the same language ability. In addition, the
ASD have effectively utilized self-management children increased their interactions with adults
to increase desirable target behaviors (e.g., lan- during play. The children also generalized these
guage, play, and social skills) and decrease unde- skills to new toys, adults, and settings and main-
sirable target behaviors (e.g., stereotypic behav- tained skills over time. Thorp et al. (1995) tar-
ior; Cowan and Allen 2007; Matson et al. 1996). geted sociodramatic play using PRT with three
PRT is typically implemented during play children with ASD. Sociodramatic play consists
but is a highly flexible intervention that can be of the interaction of a group of children cooperat-
used throughout the child’s day wherever there ing to elaborate together around a central theme,
is a learning opportunity. As noted, the key com- and the study found that PRT was effective in
ponents of PRT focus on increasing the pivotal increasing this form of play. Importantly, in ad-
behaviors of motivation and responsivity to mul- dition to their improved play skills, the children
tiple cues. These components include how to de- showed collateral improvements in language and
liver the opportunity for a target behavior by: (1) social skills.
providing the child clear instructions or questions
that are relevant to the current task or activity, (2)
interspersing easy tasks with difficult tasks, (3) Reciprocal Imitation Training (RIT)
allowing child choice of activity or objects used
during sessions, (4) taking turns with the child, Reciprocal imitation training (RIT; Ingersoll
and (5) presenting learning opportunities that re- and Gergans 2007) draws from naturalistic be-
quire the child to respond to simultaneous mul- havioral approaches such as IT, MT, and PRT to
tiple stimuli (i.e., conditional discriminations). specifically teach imitation skills to children with
PRT also addresses how to respond to the target ASD using contingent imitation (imitation of the
behavior once it occurs by: (6) utilizing direct or child’s movements and vocalizations), linguistic
natural reinforcement, (7) ensuring reinforcement mapping (narrating the child’s play), and imita-
is contingent, and (8) reinforcing appropriate at- tion training (modeling actions, prompting, and
tempts to respond (Koegel et al. 1989). Multiple reinforcement). Targeting imitation skills during
13 Natural Environment Training 259

an early intervention program may help children increase maintenance and generalization of IT
with ASD learn a wide range of other functional skills in the classroom. Ryan et al. (2008) found
behaviors (Ingersoll 2010b; Schreibman 2005). that a brief 30-min group IT training that includ-
RIT has been used to successfully teach joint at- ed didactic lecture, modeling, and role-playing
tention (Meindl and Cannella-Malone 2011), play with feedback was similarly effective as multi-
(Stahmer et al. 2003), object imitation (Ingersoll ple individualized training sessions for training
and Schreibman 2006), and descriptive gestures teachers to use IT to increase student initiations
to children with ASD (Ingersoll et al. 2007). In in the classroom. In addition, the teachers rated
fact, in the RIT studies where the authors tar- IT favorably and reported it useful (Ryan et al.
geted object imitation and descriptive gestures, 2008).
the treatment gains generalized to new thera- IT is the primary intervention used at the
pists, settings, and materials, and maintained at Walden Early Childhood Program, an inclusion
a 1-month follow-up. In addition, although only program for children with ASD (McGee et al.
imitation skills were targeted, Ingersoll and Sch- 1999). The Walden Early Childhood Program
reibman (2006) found collateral effects of RIT on consists of multiple classrooms: toddler, early
language, pretend play, and joint attention skills preschool, preschool, and pre-kindergarten serv-
of the five children with ASD in their study. In ing typically developing and children with ASD
a randomized controlled trial, Ingersoll (2010a) up to 4 years of age. The Walden model has been
found that RIT was effective at increasing object replicated at multiple sites (McGee et al. 1999).
and gesture imitation skills in a group of children Teachers in all classrooms are trained to utilize
with ASD in comparison to a control group, rep- IT during all activities throughout the day and the
licating the previous single-subject research find- classroom environment is conducive to imple-
ings. mentation of IT (e.g., preferred items are observ-
able but inaccessible to the children and gates
divide areas of the classroom to facilitate child
Implementation requests to move from area to area). Children
with ASD who have attended the Walden Early
Naturalistic Teaching in the Classroom Childhood Program have shown good language
and social skill outcomes (McGee et al. 1999).
In a very promising direction of application, In addition to teachers, paraprofessionals
naturalistic behavioral approaches have been ef- (often described as classroom aides) can effec-
fectively utilized in classroom settings. Lerman tively use naturalistic behavioral approaches to
et al. (2004) found increases in student commu- improve child behaviors in the classroom. Rob-
nication behaviors after providing teachers with inson (2011) taught paraprofessionals to utilize
a week-long workshop, approximately 18 h of PRT using a 45-min modeling session and sub-
training, where IT was one component (teach- sequent video-based feedback sessions. During
ers were also taught other behavioral techniques the video-based feedback sessions, a PRT trainer
like preference assessment and direct teaching). and paraprofessional watched videotapes of the
Teachers were provided lectures, handouts, role- paraprofessionals utilizing PRT together while
playing with feedback, and in vivo practice with the PRT trainer provided feedback. The parapro-
feedback. All intervention skills learned gener- fessionals greatly improved their PRT implemen-
alized to other students in the classroom. There tation and the author also found increased social-
is some evidence to show teacher acquisition of communication behaviors of the children with
IT skills can be accomplished with less training ASD in the target classroom. In addition, Rob-
time. Haring et al. (1987) taught teachers some inson (2011) found good maintenance and gen-
IT procedures with only self-instruction materi- eralization of the PRT implementation skills of
als including daily preplanned activities. In their the paraprofessionals. When surveyed about the
study, teacher self-monitoring was enough to PRT training they received, the paraprofessionals
260 S. Dufek and L. Schreibman

reported that they were completely satisfied with of utilizing outside resources. Third, such train-
the training protocol and felt better able to help ing can reduce parent frustration levels by allow-
their students with ASD after training. ing parents to better manage their children’s chal-
Social validity (i.e., social importance and lenging behaviors. Fourth, parent training can
acceptability; Foster and Mash 1999) is an im- improve child generalization and maintenance of
portant consideration for interventions intended skills learned in intervention (Kaiser 1995; Koe-
for classroom use, as social validity can greatly gel et al. 1996; National Research Council 2001;
impact effective dissemination (Stahmer 2007). Symon 2005).
There is some evidence that naturalistic behav- There is a great deal of evidence in the litera-
ioral approaches such as PRT may be more dif- ture to support the effectiveness of a parent edu-
ficult for teachers to implement than traditional cation component for the naturalistic behavioral
structured teaching techniques (Zandi et al. approaches mentioned thus far. Parents have ef-
2011). However, Lerman et al. (2004) found that fectively utilized MIT (Charlop-Christy and Car-
teachers in their study showed better acquisition penter 2000; Kaiser et al. 1995) and EMT (Kaiser
of IT techniques than of direct teaching tech- et al. 2000) to increase communication by their
niques during their teacher training sessions. De- children with ASD. Parents have also learned
spite mixed research findings regarding the ease to implement PRT to improve communication
of teacher adoption of naturalistic behavioral ap- (Coolican et al. 2010; Minjarez et al. 2011), as
proaches, successful dissemination of these ap- well as adaptive functioning (Baker-Ericzén
proaches is essential given their potential for im- et al. 2007), and joint attention skills (Rocha
proved child maintenance and generalization of et al. 2007). Ingersoll and Gergans (2007) suc-
acquired skills. Thus, in order to ease the transi- cessfully trained three parents to use RIT to teach
tion of PRT from the laboratory to the classroom, spontaneous object and gesture imitation to their
an adaption of PRT called classroom pivotal re- children with ASD.
sponse teaching (CPRT; Stahmer et al. 2011) has In addition to well-documented parent and
been developed by intervention researchers in a child gains during treatment, most of the above
collaborative relationship with classroom teach- parent implementation studies measured gener-
ers. CPRT is currently under careful study to alization and maintenance of parent and child
determine if the adjustments made will simulta- skills after treatment concluded. Overall, the
neously uphold the integrity and positive student majority of the parents and children in these
outcomes of the intervention while allowing PRT studies were able to generalize skills learned
to be more easily translated into the classroom from the clinic to the home setting and often
setting (Stahmer et al. 2011). these skills were maintained over time for both
the parents and the children. Recent research
also suggests that parent education in natural-
Parent-Implemented Intervention istic strategies can be conducted in less time
(Coolican et al. 2010) and more easily (Min-
Educating parents of children with ASD to imple- jarez et al. 2011) than originally thought. For
ment naturalistic behavioral interventions can be example, parent education programs typically
highly beneficial, as parent-implemented natu- consist of parent education implemented over
ralistic behavioral approaches may improve child many individual sessions. Minjarez et al. (2011)
outcome. There are several specific benefits of successfully utilized a group training format
parent education. First, children spend the major- over 10 weeks to instruct 17 parents to imple-
ity of their time with their parents, thus providing ment PRT to improve the communication skills
a wealth of valuable intervention opportunities. of their children with ASD. The parents in their
Second, training parents saves families and the study learned to implement PRT with high lev-
service system time and costly resources because els of fidelity and their children showed associ-
parents can provide treatment themselves instead ated gains in functional language.
13 Natural Environment Training 261

Naturalistic behavioral approaches are partic- Typically, these approaches consist of the
ularly well suited to parent education programs peer trainer modeling and role-playing the in-
as they are implemented in a variety of natural tervention techniques for the peer tutor, provid-
settings and circumstances and at different times ing feedback to the peer tutor, and providing the
of day. Thus, it is not surprising there is some peer tutor with a visual checklist composed of
evidence that parents may favor such an ap- words or pictures to ensure proper implementa-
proach over more traditional structured teach- tion. Then the trainer fades herself from the in-
ing approaches. For example, Schreibman et al. tervention sessions slowly when the peer tutor is
(1991) found that parents implementing PRT comfortable with the intervention and is reliably
exhibited more positive affect (i.e., parent en- implementing the intervention with acceptable
thusiasm, interest, and happiness) than parents fidelity levels. In addition, peer trainers may pro-
implementing traditional DTT with their children vide reinforcement (often in the form of a token
with ASD when rated by naive observers during system) to the peer tutors contingent on their use
a parent education program. The authors propose of the intervention with the peer learners in the
the parent affect difference may be the result of natural environment. Peer tutors utilizing natu-
the more “natural” interaction style of a natural- ralistic behavioral approaches to intervention for
istic behavioral approach such as PRT over the peer learners with ASD are often taught to wait
more contrived style of a traditional structured for the peer learner to initiate toward an item
approach such as DTT. They also suggest the (e.g., reach, look at), ask the peer learner for a tar-
improved parent affect may be due to increased get behavior (e.g., label, point), provide the item
child motivation during intervention sessions that when the peer learner exhibits the target behav-
is directly targeted with PRT (Schreibman et al. ior, and praise the peer learner after a successful
1991). interaction. Peer tutors are also taught to provide
prompts as needed and take turns with the peer
learner to increase opportunities for interaction
Peer-Implemented Intervention (Chan et al. 2009).
Research has supported the effectiveness of
In addition to parents as interventionists, edu- these strategies, as peer tutors of various ages
cating peers (peer tutors) to implement natural- have been successfully taught to provide natu-
istic behavioral approaches for individuals with ralistic behavioral interventions to peer learners
ASD (peer learners) can be valuable for several with ASD. For example, typical preschool chil-
reasons. Peers are often readily available in the dren were taught to use IT with three children
individual’s natural environment and the avail- with ASD during free play in their classroom,
ability of peers as interventionists provides subsequently increasing the peer learners’ use
more opportunities for learning. Educating of verbal labels and reciprocal interaction dur-
peers to be interventionists is relatively easy ing play (McGee et al. 1992). After training, the
and educating peers may foster better inclu- peer tutors themselves also increased their ap-
sion, as individuals with ASD will have more proaches toward children with ASD. General-
experience interacting successfully with their ization of these research findings were mixed in
peers. In addition, typical peers may provide their study, but the teachers and peers involved in
better models for age-appropriate language, the study rated the intervention favorably. Farm-
play, and social skills than other intervention- er-Dougan (1994) reports successfully utilizing
ists, and utilizing peers themselves as interven- IT-trained adult peer tutors of adult peer learners
tionists may improve generalization and main- with intellectual disability and ASD in a group
tenance of language, play, and social skills to home setting to increase appropriate requests
community settings such as school where peers during lunch. She found good generalization of
will be present (Chan et al. 2009; Pierce and the learned skills for the adult peer tutors and the
Schreibman 1997a, b). adult peer learners from lunchtime to dinnertime.
262 S. Dufek and L. Schreibman

In addition, there was a promising increase in the ris 1993), and communication skills (Schreibman
overall interactions between all the residents and et al. 1983) that often maintained over time and
staff. generalized to new settings. Sibling tutor training
Typically developing peer tutors also have is often implemented as other peer intervention
been taught to use a modified version of PRT to training programs, usually consisting of 1:1 in-
increase social interactions, initiations, toy play, struction, modeling, role-playing, and feedback
and language skills in peer learners with ASD. during practice (Ferraioli and Harris 2011). In
Pierce and Schreibman (1997a, b) designed a one study, parents themselves served as train-
manual specifically to teach the components of ers of their own typically developing children
PRT to school-age peer tutors, with simple pic- to intervene with their siblings with ASD. Par-
tures and words. Peer trainers also explained and ents successfully taught the sibling tutors to gain
modeled the PRT techniques, role-played, gave their sibling’s attention, model appropriate play,
feedback to the children, and subsequently faded maintain the interaction, and provide praise after
themselves from the classroom. In addition to a successful interaction. As a result, they saw im-
language and social skill gains during treatment, proved sibling interactions overall in the home
fairly good generalization was observed (Pierce during play (Strain and Danko 1995).
and Schreibman 1997a, b). Most sibling-implemented intervention re-
search focuses on educating siblings to utilize in-
dividual components of behavioral intervention
Sibling-Implemented Intervention strategies. More recent research has focused on
utilizing sibling tutors to successfully implement
Perhaps the best peer tutor option for a child with complete naturalistic behavioral approaches such
ASD is his/her own sibling. Compared with sib- as PRT combined with components of DTT (Fer-
lings of children with other developmental dis- raioli et al. 2011). Ferraioli et al. (2011) stress
abilities such as Down syndrome, siblings of the importance of using naturalistic behavioral
children with ASD report less emotional close- approaches for sibling tutor training as educat-
ness and are more pessimistic about their affected ing siblings in a naturalistic setting may reduce
siblings’ future (Orsmond and Seltzer 2007). The the demands on the sibling and the child with
mechanism of this disparity is not clear, but may ASD during intervention. Ferraioli and Harris
possibly be ameliorated by educating siblings to (2011) taught sibling tutors to utilize a PRT and
serve as “sibling tutors” for their siblings with DTT combination intervention to increase joint
ASD (Henderson 2010; Schreibman et al. 1983; attention skills in their siblings with ASD. They
Smith and Elder 2010). The limited research also found the joint attention skills learned by the
available on sibling tutors suggests that educat- children with ASD maintained and generalized to
ing siblings to act as interventionists may be ben- adults in other settings. Collateral effects of the
eficial for children with ASD as well as their sib- training included increases in rates of imitation
lings (Henderson 2010; Smith and Elder 2010). and behavioral requests during play for the chil-
Sibling tutors have successfully learned to im- dren with ASD (Ferraioli and Harris 2011).
plement various behavior modification techniques More research in this area is certainly warrant-
such as prompting, shaping, reinforcement, mod- ed as addressing the impact of having a sibling
eling, responding to initiations, and turn taking with ASD is important for sibling tutors. Sibling
to improve their interactions with their siblings tutors would be greatly impacted, as they are
with ASD during play (Kim and Horn 2010; Sch- more likely to be readily available as interven-
reibman et al. 1983). After sibling tutors began to tionists than other peers. Providing siblings with
use the behavioral techniques, their siblings with the opportunity to have an active role in their sib-
ASD showed subsequent improvements in social lings’ intervention programs may afford siblings
skills (Tsao and McCabe 2010; Tsao and Odom of children with ASD an outlet for their will-
2006), appropriate play skills (Celiberti and Har- ingness to help and be involved in intervention
13 Natural Environment Training 263

(Henderson 2010; Smith and Elder 2010). In fact, communication skills in three nonverbal children
teaching siblings of children with ASD the be- with ASD within a multiple-baseline probe de-
havior modification procedures of reinforcement, sign. All children learned to use the voice output
shaping, chaining, and discrete trial increased the communication aid to request during play and
sibling tutors’ positive statements about their sib- one child even began to vocalize. Mancil et al.
lings with ASD (Schreibman et al. 1983). (2009) combined MT with functional communi-
Acting as a sibling tutor may make a sibling cation training in order to simultaneously teach
more satisfied with the sibling relationship as the functional communication skills and reduce dis-
sibling with ASD will be more likely to respond ruptive behavior in three children with ASD. All
to a sibling’s initiations after training which can the children increased their communication and
increase overall engagement for both children decreased their disruptive behavior, which main-
during play. These effects may strengthen the tained over a short follow-up time period and
sibling bond and provide a wealth of intervention generalized from the home to the classroom.
benefits, as the sibling is prone to be an ideal be- Intervention programs can also be augment-
havior model and source of reinforcement for the ed to address specific parent variables in order
child with ASD. Also, because the sibling tutor is to maximize child benefits from treatment. For
likely to be present in most other environments example, Yoder and Warren (1998) determined
where the child with ASD spends time, an in- that amount of maternal responsivity influences
crease in maintenance and generalization of skills the child’s generalization of intentional commu-
learned in intervention sessions may be expected. nication skills learned during PMT for children
In addition, parents of the sibling dyads may also with developmental disabilities. Children whose
benefit from sibling tutor training, as it may be mothers were more responsive to the intentional
less necessary to monitor their children’s interac- communication skills that the children learned
tions (Ferraioli et al. 2011). Of course, one must during a course of PMT helped increase the chil-
also be aware of potential negative effects of this dren’s generalization of these skills to the home.
expectation of participation of siblings since the To address this finding, Yoder and Stone (2006)
added responsibility, and possible stress, might utilized a responsive education component in ad-
not make it a suitable treatment approach in all dition to PMT, which encourages parents to talk
cases. If no clear benefit to the sibling tutors can and play with their children to facilitate language
be identified, reinforcement strategies can also be learning.
applied to the sibling tutors to ensure a positive Traditional structured teaching interventions
experience (Ferraioli et al. 2011). may have an initial advantage over naturalistic
behavioral approaches to intervention for more
rapid acquisition of skills (Cowan and Allen
Current and Future Directions 2007). However, the benefits of naturalistic be-
for Research havioral approaches may outweigh an early ac-
quisition advantage by providing better mainte-
Upcoming intervention research on naturalis- nance and generalization of skills learned over
tic behavioral approaches will ideally focus on time. In a comparison study of IT and traditional
identifying methods to maximize treatment ef- DTT when teaching children with ASD expres-
fectiveness for children with ASD. One way to sive use of color adjectives, Miranda-Linne
improve intervention programs may be to adjust and Melin (1992) found that children in their
or combine effective treatments to target a child’s study initially learned the target skills faster in
specific needs (Schreibman and Anderson 2001). DTT. Although it took longer for the children
For example, EMT can be augmented for use to learn the same type of skills in IT, the skills
with children who have very limited language they learned in IT showed increased spontaneous
skills. Olive et al. (2007) combined EMT with usage and better maintenance and generalization
a voice output communication aid to improve than skills learned in DTT (Miranda-Linne and
264 S. Dufek and L. Schreibman

Melin 1992). Lydon et al. (2011) also found su- study showed different outcomes based on the in-
perior generalization of pretend play skills taught tervention received for the target skills and their
with PRT when compared to a course of video verbal and cognitive functioning at intake. Chil-
modeling, further supporting the notion that natu- dren who had higher verbal and cognitive skills
ralistic behavioral approaches may be ideal for in their study yielded more improvements in their
enhancing generalization. play skills during IT and greater increases in their
Combining interventions to maximize their communication skills during the traditional struc-
strengths can be a very effective teaching strat- tured teaching (Kok et al. 2002).
egy for children with ASD (Ingersoll 2010b). Variability in treatment outcome is noted for
Jones et al. (2006) combined DTT and PRT tech- all forms of behavioral (and other) interventions
niques to teach acquisition and generalization of (Kaiser et al. 1992; Kok et al. 2002; Schreibman
joint attention skills to preschool children with 2005; Sherer and Schreibman 2005). Differential
ASD. They found combined benefits of increased response to treatment has long intrigued research-
joint attention behaviors in addition to collateral ers and therefore searching for child variables
effects on expressive language and other social- that predict outcome has become an important
communicative behaviors. Ingersoll (2011) com- focus of much of the research in the intervention
pared the effects of a responsive interaction in- field over the last 15 years (Bristol et al. 1996;
tervention, MT, and a combined MT-responsive Gabriels et al. 2001; Sigman 1998; Weiss 1999).
interaction intervention on expressive language Sherer and Schreibman (2005) identified a pre-
levels of preschoolers with ASD. Responsive in- dictive profile for young children with ASD that
teraction is based on the developmental literature is specific to PRT. The Predictive PRT Profile
and focuses on modeling language and providing Assessment (PPPA) was developed using archi-
expansions. In Ingersoll’s study, MT led to more val data gathered from years of research examin-
requests and overall prompted language than the ing PRT efficacy. They identified five behaviors
responsive interaction intervention. In turn, the that predicted how well a child would respond
responsive interaction intervention led to more to PRT: toy contact, approach, avoidance, verbal
comments than MT. The combined MT-respon- self-stimulation, and nonverbal self-stimulation.
sive interaction intervention yielded the benefits Based on each child’s incidence of these be-
of both interventions (Ingersoll 2011). haviors, the authors were able to predict which
Another promising way to maximize interven- children would make substantial gains during a
tion outcome is to tailor intervention programs course of PRT (responders) and those who would
based on individual child characteristics (Sch- not (nonresponders). To validate the findings of
reibman and Anderson 2001). Although many their archival data analysis they conducted a pro-
children with ASD benefit from naturalistic be- spective study in which three children who were
havioral approaches to intervention, there are classified as nonresponders and three children
some children who do not make the expected who were classified as responders participated.
gains. For example, Ingersoll (2011) found some All six children received an intensive course of
evidence to support that children with lower- PRT. The children with the “responder” pro-
language levels in her study were more likely to file made significant gains in language, play,
benefit from MT whereas children with higher- and social skills after treatment. In contrast, the
language levels were more likely to benefit from children with the “nonresponders” profile did
the responsive interaction intervention. Kok poorly, rarely making even limited gains in any
et al. (2002) also found support for individual- skill area. A further examination of the use of the
izing interventions based on child variables and/ PPPA with a different set of children with ASD
or the skills targeted in treatment. They increased showed that the predictive PRT profile is likely
communication and play skills in some preschool to be specific to PRT. Children who were non-
children with ASD using traditional structured responders to PRT in their study had a variable
teaching and IT methods. The children in their response to DTT (Schreibman et al. 2009). By
13 Natural Environment Training 265

identifying children early as treatment respond- approaches from the developmental literature in
ers or treatment nonresponders to specific inter- order to maximize intervention program effec-
ventions, researchers can save time and resources tiveness. Only by methodically examining these
as well as develop further appropriate treatment treatment similarities and differences and how
techniques for children with ASD. they interact with child intervention needs can
Jobin et al. (2012) recently conducted a study we truly understand the ideal combinations for
to simultaneously evaluate the effects of combin- each individual child with ASD.
ing treatments and the role of child variables in
maximizing intervention outcome. Specifically,
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