Timothy RunyonCD 768Case Study

Literature Review

The most current Diagnostic and Statistical Manual of Mental Disorders redefines

the disorder commonly known as autism by removing the previous classifications of

Asperger’s syndrome (often considered a “higher functioning” form of autism) and

Pervasive Developmental Disorder – Not Otherwise Specified (PDD-NOS) and creating

an all-encompassing label of autism spectrum disorder (ASD) (5th ed., text rev.; DSM-5;

American Psychiatric Association, 2013). Diagnostic criteria include “persistent deficits

in social communication and social interaction across multiple contexts, as manifested

by…deficits in social-emotional reciprocity… nonverbal communicative behaviors used

for social interaction…and in developing, maintaining and understanding relationships,”

(DSM-5, p. 50). Candidates for diagnosis must also exhibit “restrictive, repetitive

patterns of behavior, interests, or activities, as manifested by at least two of the

following…stereotyped or repetitive movements, use of objects, or speech…insistence on

sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal

behavior…highly restricted, fixated interests that are abnormal in intensity or focus…

and/or hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of

the environment,” (DSM-5, p. 50). With recent prevalence estimates in the United States

at 1 in 88, professionals treating this population – especially speech language pathologists

– must be adept in utilizing the latest research to make informed treatment decisions

(Baio, 2012).

According to Prizant and Wetherby, treatment methods for enhancing

communication and language in those individuals with ASD fall “along a continuum with

traditional behavioral approaches at one end and developmental social pragmatic (DSP)

approaches at the other end, which include ‘relationship-based’ approaches that are

individualized and grounded in a developmental model,” (Prizant & Wetherby, 1998, p.

334). The two researchers consider contemporary behavioral approaches as falling

between traditional behavioral approaches and DSP methods, incorporating elements of

both (Prizant & Wetherby, 1998). Traditional behavioral approaches include discrete trial

training, a methodology also considered “one of the many techniques used within the

realm of ABA,” or applied behavior analysis (Myers & Johnson, 2007, p. 1164). ABA “is

the process of applying interventions that are based on the principles of learning derived

from experimental psychology research to systematically change behavior and to

demonstrate that the interventions used are responsible for the observable improvement

in behavior,” (Myers & Johnson, 2007, p. 1164). The effectiveness of ABA methods to

increase, maintain, and generalize desirable behaviors while decreasing maladaptive

behaviors in those individuals with ASD has been well documented “through 5 decades

of research by using single-subject methodology and in controlled studies of

comprehensive early intensive behavioral intervention in university and community

settings,” (Myers & Johnson, 2007, p. 1164). The positive result of such intervention has

led to an almost standardized use of (or desire for) ABA-trained therapists in the homes

of very young people with ASD. Such therapists help these individuals conquer tasks of

daily living by dividing such events into small steps that can then be drilled and

positively reinforced. The use of ABA-style methods can be beneficial but limited in the

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area of speech and language development for those individuals with ASD. This will be

further examined by focusing on the aforementioned technique of discrete trail training.

Traditional behavioral approaches such as discrete trial training rely on adult-

directed methodology. In discrete trial training, a trial is considered to be a “single

teaching unit that begins with the presentation of stimulus (teacher’s instruction), the

child’s response, a consequence, and a pause (between-trial interval) before presentation

of the next stimulus by the teacher,” (Prizant & Wetherby, 1998, p. 334). Smith, Groen,

and Wynn of the UCLA Young Autism Project reported on a randomized trial of early

intervention for children with autism and PDD-NOS, all between 18 and 42 months at

time of referral, in which the researchers compared an intensive treatment group

(comprised of eight children with PDD-NOS and seven children with autism, all

receiving 30 hours per week of intervention for two to three years) with a parent training

group (comprised of seven children with autism and six children with PDD-NOS),

(Smith, Groen, & Wynn, 2000). “At the outset of treatment [for the intensive treatment

group],” the authors write, “student therapists [who were tasked with carrying out therapy

in the home, under the authors’ supervision] relied primarily on one-to-one, discrete trial

format,” (Smith et al., 2000, p. 272).

For the parent training group, the researchers and student therapists provided

families with 5 hours per week (divided into two sessions) of training for 3 to 9 months,

based on goals that parents had for their children and teaching the discrete trial methods

of Lovaas et al. (1981) (Smith et al., 2000). For example, a goal of increasing expressive

language may, in a discrete trial method of training, be taught by “first obtaining

cooperation with simple requests, followed by teaching imitation of nonverbal actions,

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increasing the child’s rate of vocalizations, teaching imitations of sounds, chaining

sounds together to form words, associating words with objects and events, and

generalizing this vocabulary to everyday settings,” (Smith et al., 2000, p. 272). The

researchers measured language development (receptive and expressive) using the Reynell

Developmental Language Scales prior to and following treatment, and the group that

received more intensive therapy showed a statistically significant advantage in total

scores, (Smith et al., 2000). The researchers used the Vineland Adaptive Behavior Scales

to measure adaptive functioning – including the only measure of social skills used in the

study (the Vineland Socialization Domain) – and found no difference between the two

groups (Smith et al., 2000). So although language development increased, generalization

and use of these language skills in social settings did not improve with more intensive use

of discrete trial training. These results underscore an important criticism of traditional

behavioral approaches to improving the language and communication skills of those with

ASD.

Other studies involving discrete trial training show similar limitations of

traditional behavioral approaches. In the United Kingdom, Remington et al. report on

outcomes for preschool children with autism who have received early intensive

behavioral intervention after two years (Remington et al., 2007). Using the Reynell

Developmental Language Scales (Third Edition) and the Vineland Adaptive Behavior

Scales (Survey Form), participants who received early intensive intervention displayed

significant improvement on both measures (Remington et al., 2007). Parental ratings

showed gains in the positive social behavior of their children, “but there was no evidence

of a similar change in the parents’ reports of their children’s behavior problems or ratings

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of their autistic behaviors” and “less marked improvements in joint attention,”

(Remington et al., 2007, p. 432). The authors contend that they expected the opposite, but

admit that since intensive behavioral intervention (and by extension, discrete trail

training) focuses primarily on education goals, “function-informed interventions for

problem behaviors are not the most prominent components,” (Remington et al., 2007, p.

432). Still, the authors go on, given the known link between behavior problems and

language/communication ability, one would expect problem behaviors to diminish

because their traditional behavioral approach had improved their subjects’ receptive and

expressive language skills so profoundly (Remington et al., 2007). As with Smith et al.’s

study in 2000, discrete trial training proved to be beneficial in developing the receptive

and expressive language skills of the child with ASD, but not in generalizing these skills

in ways that help promote positive social behaviors outside of the drilling condition. By

utilizing a method that relies heavily on education goals and less on functional behavior

(in this case, maintaining an emotionally regulated state), those practicing traditional

behavior approaches risk increasing the language and communication skills of an

individual with ASD while leaving him or her powerless to use such skills in a real world

context.

The development of contemporary behavioral approaches can be seen as a

response to the criticism that traditional behavioral approaches don’t allow those with

ASD to generalize their gains in communication and language ability to everyday

situations. Examples of contemporary behavioral approaches – also known as

“naturalistic intervention” – include Responsive Education and Prelinguistic Milieu

Teaching (RPMT), Reciprocal Imitation Training (RIT), and a more “naturalistic”

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approach to ABA therapy. All of these approaches move away from adult-directed

activity to incorporate more of the child’s interests and motivations. Koegel et al., in a

study of five children diagnosed with autism, concluded that a more naturalistic approach

to treatment of specific problem consonant sounds resulted in increased speech

intelligibility across three settings than a more traditional ABA approach (Koegel,

Camarata, Koegel, Ben-Tall, & Smith, 1998). To achieve a more naturalistic approach,

the researchers chose stimulus items based in part on their interest value for each child, as

opposed to the more “analog condition” in which researchers chose items “only with

respect to their containing the targeted sound, regardless of the child’s interest in the

item,” (Koegel et al., 1998, p. 245). Using the more naturalistic approach, researchers

reported that “large gains, usually near 100% correct conversational use of the target

sound, occurred during the language samples when treatment was conducted in the

naturalistic condition,” (Koegel et al., 1998, p. 246 & p. 248).

Yoder and Stone reported on two prelinguistic communication interventions on

the acquisition of speech in preschoolers with ASD (Yoder & Stone, 2006) – Responsive

Education and Prelinguistic Milieu Teaching (RPMT) versus the Picture Exchange

Communication System (PECS). Responsive education involves proper parental response

to a child’s bids at communication, while Prelinguistic Milieu Teaching “is a child-led,

play-based incidental teaching method designed to teach gestural, non-word vocal, gaze

use, and, later, word use as forms of clear intention communication for turn-taking,

requesting, and commenting pragmatic functions,” (Yoder & Stone, 2006, p. 699). RPMT

involves linguistic mapping (giving words to a child’s preceding action) and an eventual

move to Milieu Language Teaching (which uses “prompts for verbal imitation and

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questions to evoke spoken communication”) (Yoder & Stone, 2006, p. 699). PECS

“incorporates ABA and developmental-pragmatic principles, and the child is taught to

initiate a picture request and persist with communication until the partner responds,”

(Myers & Johnson, 2007, p. 1165). Results of the randomized group experiment

(consisting of 36 preschoolers with ASD) indicated that the group utilizing PECS saw

greater increases in the number of different nonimitative words and the number of

nonimitative spoken communication acts, while RPMT better aided those children with

initially low object exploration (Yoder & Stone, 2006). The latter result supports the idea

that the play component of RPMT helps teach these children with initially low object

exploration that objects can be interesting and, by extension, can be utilized to support

their interaction with the others in their world (Yoder & Stone, 2006). Play – an aspect of

childhood language development not utilized in traditional behavioral approaches of

teaching language and communication – proves essential in the communicative

development of an important subset of this study’s participants.

Developmental social pragmatic (DSP) interventions occupy the side of the

communicative and language treatment spectrum opposite traditional behavioral

approaches. Adherents to developmental social pragmatic (DSP) interventions assume

that all children (with our without a disability) progress through a similar social-

communication development trajectory and that all children learn language and

communication skills from responsive caregivers (Ingersoll, 2011). In DSP interventions,

“teaching follows the child’s lead or interest, all communicative attempts (including

unconventional and preintentional communication) are responded to as if they were

purposeful, emotional expressions and affect sharing are emphasized by the adult, and

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language and social input are adjusted to facilitate communicative growth,” (Ingersoll,

2011, p. 35). DSP interventions and contemporary behavioral approaches share common

characteristics, in particular the focus on a child’s interests to promote meaningful growth

in language and communicative ability. But both also differ in important ways. For

example, contemporary behavioral approaches will often only focus on one goal or one

area of the communicative spectrum at a time. The Koegel et al. study explored the

method’s effects on speech intelligibility, while Yoder and Stone measured the

effectiveness of RPMT through gains in speech production. DSP interventions “place

greater emphasis on multi-modal communication and more natural teaching so that

multiple goals are often targeted within a particular activity,” (Prizant & Wetherby, 1998,

p. 342). Perhaps most importantly, contemporary behavioral approaches still rely most

heavily on the traditional behavioral method of extracting and assessing discrete

behavioral responses to gauge success, while DSP methodology places “more emphasis

on children’s successful participation in extended interactive sequences and episodes,”

(Prizant & Wetherby, 1998, p. 342).

Developmental social pragmatic interventions that have been utilized with

children with Autism Spectrum Disorder include the Denver model, Responsive

Teaching, Hanen, and DIR/Floortime (Ingersoll, 2011). Greenspan and Wieder’s DIR

(developmental, individual-difference, relationship-based) model focuses on floor-time

sessions involving play and other methods that they claim enhance relationships, in

addition to therapies to remediate “biologically based processing capacities such as

auditory processing and language, motor planning and sequencing, sensory modulation,

and visual-spatial processing,” (Myers & Johnson, 2007, p. 1165). An unblinded review

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of case records (with “significant methodological flaws, including inadequate

documentation of the intervention, comparison to a suboptimal control group, and lack of

documentation of treatment integrity and how outcomes were assessed by informal

procedures” (Greenspan and Wieder, 1997)) and a “descriptive follow-up study of a

small subset (8%) of the original group of patients” (Wieder and Greenspan, 2005)

provide limited evidence of DIR/Floortime’s effectiveness (Myers & Johnson, 2007, p.

1165). It should also be noted that the creators of DIR/Floortime’s methodology,

Greenspan and Wieder, coauthored both studies. A lack of empirical evidence supporting

successful and generalized speech and language intervention for those with ASD –

especially when compared with contemporary behavioral approaches – not only applies

to the DIR/Floortime model, but to DSP interventions in general. Knowing this, why then

has the author of the present case study chosen to utilize the Social Communication,

Emotional Regulation, and Transactional Support (SCERTS) model, a DSP approach?

A study by Ingersoll, Meyer, Banter and Jelinek comparing DSP (responsive

interaction), naturalistic behavioral interventions (milieu teaching), and a combination of

the two on social engagement and language use in children with ASD helps to explain

(Ingersoll et al., 2012). The study used a single-subject, ABACAD design for five

participants – males, ages 36 to 66 months – who attended an intervention center twice a

week for 12 weeks (Ingersoll et al., 2012). The researchers conducted two weeks of

baseline treatments followed by three weeks of each treatment condition, and the order of

treatment conditions “was counterbalanced across participants, with 1 day of baseline

between each treatment condition,” (Ingersoll et al., 2012, p. 1304). The responsive

interaction condition consisted of “language modeling and expansions emphasizing the

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child’s language targets,” the milieu teaching condition “consisted exclusively of direct

elicitation of children’s language targets using prompting,” and in the combined

condition “therapists modeled language every 20 to 30 seconds as per the responsive

interaction condition and attempted to prompt for language every 30 to 60 seconds as per

the milieu teaching condition,” (Ingersoll et al., 2012, p. 1304-1305). Results showed that

all five children exhibited higher rates of total language targets than at baseline in a least

one of the treatment conditions, but that “responsive interaction produced substantially

lower rates of total language targets than the milieu teaching and the combined

interventions,” (Ingersoll et al., 2012, p. 1305-1306). The authors claim that this might

have resulted because the DSP intervention that they used (responsive interaction) does

not involve withholding of desired materials to elicit language, but that “some DSP

interventions do advocate the use of communication temptations to elicit child language

(e.g., the SCERTS model),” (Ingersoll et al., 2012, p. 1310). Had the SCERTS model

been utilized in Ingersoll’s study, the DSP method may have proven more beneficial in

helping children produce desired targets.

In other words, the SCERTS model promotes a flexibility that other DSP models

do not. The authors of the SCERTS model (Prizant, Wetherby, Rubin, Laurent, and

Rydell) want clinicians to use methods of eliciting language supported by the literature

but wish for them do it as a part of a larger framework that promotes language across the

daily activities of a child’s life. For the client in this case study who receives ABA

therapy separate from speech and language services, it is even more important that

communication and language development spring from a mode of delivery that can be

applied to all areas of the child’s life. The social communication domain of the SCERTS

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model “strives for social competence and active participation in social activities by

promoting joint attention and symbol use,” (Ogletree, Oren, & Fischer, 2007). In this

domain of intervention, the authors of the SCERTS model don’t so much specify what

activities to use with the child, but promote allowing the child to indicate what methods

work best to elicit language, and this may or may not include contemporary behavioral

approaches. Even the use of interventions that owe their developmental basis to

traditional behavioral approaches – including PECS – are encouraged if those methods

allow the child to communicate in a variety of settings and with a variety of

communication partners. In addition, a key component of the generalization of

communicative ability – the ability to remain emotionally regulated (the “ER” in

SCERTS) – is built into the SCERTS curriculum, whereas traditional and contemporary

behavioral approaches often relegate this aspect of therapy to secondary status in favor of

promoting or modifying a specific communicative skill (speech intelligibility, for

example). Transactional Supports (the “TS” in SCERTS) ensures that any primary

communicative partner in the child’s life (including parents and professionals other than

speech language pathologists) will be fully aware of the child’s communicative goals and

therefore help promote those ambitions across settings. The authors of the SCERTS

model take the parental involvement incorporated successfully into some contemporary

behavioral interventions (RPMT, for example) and expand the pool of positive

communicative partners, filling the child’s life with natural positive reinforcement.

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Purpose

The purpose of the clinical study will be to determine if the SCERTS model can

help a young girl with autism increase her expressive language ability.

Research Question

Does the SCERTS model positively affect the integration across settings of three

additional, developmentally appropriate consonant + vowel (CV) combinations into the

child’s spontaneous verbal vocabulary?

Methodology

The client (herein also referred to as “C”) is a 4 year, 2 month old female of

mixed background (Hispanic and Caucasian) who received a diagnosis of autism in

August 2011. Her birth history was otherwise unremarkable, based on the parent’s report.

The client lives with her mother, father, and aunt, and English is the primary language

spoken in the household. C attends a special day class at a local elementary school five

days a week for four hours a day. Her typical weekly schedule includes approximately 1

hour of occupational therapy, 1 hour of speech and language therapy, 15 hours of applied

behavior analysis therapy (ABA), and a one and half hour playgroup.

On July 8th, 9th, and 11th, 2013, the client was assessed using SCERTS

methodology by a student clinician under the supervision of a licensed speech language

pathologist. According to C’s assessment report, the student clinician observed the client

in two environments – an unstructured play environment (the local playground) and a

structured occupational therapy appointment. According to the “SCERTS Worksheet for

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Determining Your Child’s Communication Stage,” the client was determined to be at the

Social Partner Stage, considered by the SCERTS curriculum to be the beginning stage of

communication development. A modified version of the Social Communication portion

of the SCERTS Assessment Process for Social Partner Stage was used to determine

strengths and weaknesses in the areas of joint attention and symbol use. The student

clinician, clinic supervisor, and client’s family members jointly scored the assessment. In

the area of symbol use, the client received a score of 3/8 in the category of “Uses

vocalizations to communicate (SU 5)” (Prizant, Wetherby, Rubin, Laurent, and Rydell,

2006).

The SU 5 category score is tabulated by observing the client’s use of

vocalizations in 4 different categories – uses differentiated vocalizations (SU 5.1, the

child uses at least two different vocalizations), uses a variety of consonant + vowel

combinations (SU 5.2, the child uses at least five different consonant + vowel

combinations as communicative signals), uses words bound to routines (SU 5.3, the child

uses at least three words that are bound to a routine as communicative signals), and

coordinates vocalizations with gaze and gestures (SU 5.4, the child uses gaze in

coordination with vocalizations), (Prizant et al., 2006). A score of 2 indicates that

criterion has been met consistently (across two partners in two contexts), a score of 1

indicates that criterion has been met inconsistently or with assistance, and a score of 0

indicates that a criterion has not been met, (Prizant et al., 2006). The client received a

score of 0 in SU 5.2 and SU 5.3, a score of 1 in SU 5.4, and a score of 2 in SU 5.1 for a

total score of 3 out of a possible 8 total points. The current case study will look at the

influence of the SCERTS method in helping the client achieve gains in the symbol use

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categories of SU 5.2 and SU 5.3. It is important to note that in the symbol use category

SU 5.3, a “word bound to a routine” needn’t be a true word, but rather a “protoword or an

early word-like form [which] may be spoken or signed or may be a picture that is used as

a word or lexical form and is defined as 1) a consistent sound pattern or sign that

approximates a conventional word and 2) a form that is used to refer to a specific object,

action, or attribute and that is used only in a highly specific context (e.g., ‘muh’ to

request ‘more’),” (Prizant et al., 2006, Volume I, p. 173).

Because the client has already been assessed, two baseline sessions will be

utilized to determine current skill. Sessions will take place in the child’s home and will

consist of observing free play on two consecutive weekend afternoons for one hour per

session. Parents will be encouraged to interact with the child as they normally would

across a range of activities, including snack time and playing in the back yard. Any words

or CV combinations will be recorded along with frequency of use. Therapy notes from

Summer 2013 note the use of vowel-consonant-vowel (VCV) combination “uppa,” so

one key question will be whether or not the client continues to use this utterance. The

therapist will make no verbal initiations to the child, but keep within a reasonable

distance to hear any of the child’s spontaneous vocalizations. Parents will also be asked

about what words or vocalizations they notice their child producing on a daily basis, and

about what words they eventually hope for their child to produce.

The independent variable, or the procedures to be used for intervention, will

involve creating communicative temptations to elicit speech from the child in a clinical

setting, and making sure that these communicative temptations can be incorporated into

other settings in the child’s life, particularly at home. Consonant-vowel targets will be

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based on a developmental model and the parent’s goals for their child’s communication

growth. At the present time, the parents have expressed an interest in the words “more”,

“help,” and “down.” While the /h/ phoneme does not represent an early consonant sound

developmentally, /d/ and /m/ do. If the child has trouble making any of the phoneme

combinations in the word “help,” a graphic symbol can be introduced and, if generalized

by the child to everyday situations, would still signal growth in SU 5.3. A reduction of

the word “help” to “ep” – as long as the client used such an utterance in routine situations

– would also signal growth in symbol use. The following methods will be performed by a

student clinician under the supervision of a licensed speech language pathologist. A total

of seven clinic sessions will take place in a university setting, each lasting one hour, over

the course of a fall semester (September 30th through December 2nd). The first six clinic

sessions will take place on a biweekly basis, with the seventh clinic session occurring for

one hour, acting as a follow-up to a final home visit. Methods will also be carried out for

four hours of therapy in the client’s home, in addition to baseline sessions. The student

clinician will work with parents to continue therapy activities outside of clinic and home-

based work with the student clinician and clinic supervisor, as will be described.

To elicit the word “down,” the therapy activity would include a shade capable of

vertical movement, covering an area that the clinician would hide behind, ready to do

something motivating for the child – in this case, blowing bubbles. The clinician would

model the word “up” while raising the shade, blow bubbles, and then lower the shade

while modeling the word “down.” After three “up/down” episodes, the clinician would

wait for the client’s vocalization before raising the blind again. If the child struggles, the

clinician would initiate another “up/down” cycle before again waiting for the child’s

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vocalization. Graphic aids will also be added to the activity (for the child to point to “up”

or “down”) in the event that a client continues to have trouble vocalizing. In the home

environment, “up” and “down” will be practiced on the way to school, as mom and dad

have installed a “down” graphic icon next to the window where the client sits in the back

seat. By engaging the window lock function (so that the client can’t control the window),

the parent will roll down the child’s window while verbally describing the motion –

“Look, C, down!” As the parent rolls the window back up (making sure, of course, to

check for little fingers), the parent will again describe the motion of the window. As the

client becomes more comfortable with this exercise, mom or dad will then directly ask C

whether she wants the window “up” or “down.” C’s special education teacher and

occupational therapist could also be told of her goal of vocalizing the word “down” so

that they can incorporate the utterance into their time with the client.

“More” can be practiced most easily across contexts at snack time. Whether in the

clinic, school, or home, the client can be given a small-enough amount of the requested

snack so that the client needs to request “more.” Again, the adult models the utterance

and then slowly (after approximately three to four prompts in one episode) waits for the

child’s spontaneous utterances. “Help” can also be elicited relatively easily through

various activities in both clinic and at home. In the clinic, a Play-Doh activity can be

utilized to elicit the vocalization of “help” by presenting the Play-Doh in jars with a tight-

fitting lid. After struggling, a prompt may be given, asking if the child “needs help”.

Generalization can be promoted across settings by placing various desirable objects (toys

or food, for example) in a close-fitting lid or on an out-of-reach shelf in order to elicit

“help,” prompting if needed. Again, professionals working with the child will also be

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notified of these goals. Graphics representing each utterance will also be made available

across settings if the client struggles with vocalization.

By creating communicative temptations and by moving from prompting to waiting for the

child to vocalize across settings using the above procedures, the client will hopefully add

to her repertoire of consonant-vowel combinations based on the words “down,” “help,”

and “more”. The intervention would be considered successful if the client added the full

words to her spontaneous repertoire, or C-V versions of the words (“duh,” “heh,” and

“moh”, for example). Graphics representing each utterance will also be available for the

client to use in at least the home and clinic settings for support, and if the client

continually utilizes these supports in routine situations then the intervention would be

considered successful as well. The outcome measure against which the procedures will be

measured is the following:

The client will spontaneously vocalize, sign, or use graphic icons to express the

words “down,”, “more”, and “help” four times each during various clinic and

home-based activities designed to teach the words’ meanings with 80% accuracy.

Results

The child achieved the goal of spontaneously vocalizing, signing, or using graphic

icons to express the words “down”, “more”, and “help” four times each during various

clinic and home-based activities designed to teach the words’ meanings, and did so with

at least 80% accuracy. The only word that the child produced during the baseline

measurements was “more”, and she did so three times during the second home session.

The researcher did not create a separate goal for the word “more” (requiring a greater

number of expressions) because the child did not show the behavior over both of the

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baseline sessions. The goal for all words, then, consisted of four expressions via

vocalizations, sign, or graphic icons in both the home and clinic setting. The child

spontaneously used a graphic icon and/or vocalized the word “more” a maximum of 14

times in both the home and the clinic. Vocalizations of the word “more” consisted of full

word utterances and an approximation of the word with final consonant deletion (“mo-”).

At times, the child would point to the graphic icon and vocalize simultaneously while

communicating “more”. The child spontaneously used a graphic icon and/or vocalized

the word “help” a maximum of 4 times in both the home and clinic. The child

communicated “help” on most occasions by utilizing a graphic icon. Vocalizations of the

word “help” consisted of initial consonant deletion and final cluster reduction (“-ep”).

The child spontaneously communicated “down” a maximum of 5 times in both the clinic

and the home. The child communicated “down” on most occasions by utilizing a graphic

icon. Any vocalizations of the word “down” consisted of initial consonant deletion

(“duh-”).

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Discussion

Results indicate that the dependent variable – utilization of vocalizations, signs, or

graphic icons to communicate three designated words – increased as a result of the

procedure. The results support the use of the SCERTS method to both assess and develop

treatment for the participant, a young girl on the autism spectrum. The SCERTS

assessment accurately indicated the child’s weaknesses in the areas of social

communication and (more specifically) her ability to use vocalizations to communicate.

The SCERTS model – a developmental social pragmatic intervention – also allowed the

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researcher enough flexibility in the procedures to discover what worked best for the child.

While the authors of the SCERTS model provide several suggestions related to direct

treatment, the authors strongly promote the clinician finding evidenced based practice to

implement and test with a prospective client. While this case study has very little, if any,

external validity, the results should encourage future researchers to investigate the

SCERTS methods, particularly in large, dynamic settings such as public schools. The

SCERTS assessment and intervention methods incorporate various professionals from a

wide array of different fields. Molteni, Guldberg, and Logan (2013) provide one of the

first published research studies regarding the specific use of SCERTS methodology. The

researchers conducted a “collaborative and participatory case study focused on the point

of view of professionals and on understanding the teamwork process through analysis of

three teams working together to implement SCERTS,” (Molteni et al., 2013, p. 137). The

research was conducted in an English special school in the West Midlands region of the

United Kingdom. The researchers found that the SCERTS model can aid the support

team in “promoting good daily practice and planning educational work together,”

(Molteni et al., 2013, p. 137). The current study took place in a small, university-based

clinic environment, and the SCERTS methodologies helped the researcher plan and

collaborate with the child’s parents and the clinic supervisor. Early evidence suggests that

the SCERTS model of treatment may also prove beneficial in larger school environments.

The flexibility of the SCERTS treatment method allowed the researcher to

utilize a variation of milieu therapy, which includes “modeling desired responses and

correcting responses, providing a mand, time delay, and incidental training,” (Mencil,

Conroy, & Haydon, 2009). For example, to tempt the use of “more” in the clinic, the

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researcher used incidental training by making sure the child had access to Play-Doh (a

favorite toy) at some point during the session. When the child showed interest in the

particular toy, the researcher then utilized another appropriate milieu strategy – modeling

(“You want Play-Doh”), providing a mand (“What do you want?”), or a time delay

(usually 5 – 10 seconds) prior to introducing a model or mand to encourage spontaneous

communication. The use of milieu therapy with children who have autism spectrum

disorder has been documented in the literature. Christensen-Sandfort and Whinnery

(2011) concluded that milieu strategies “are an effective means of providing

communication skills instruction for young children with ASD in an ECSE classroom,”

(p. 211). Their study took place over five months and integrated milieu teaching

strategies in “two activities per day per target” in the context of early childhood special

education (ECSE) classrooms (Christensen-Sandfort & Whinnery, 2011, p. 211). Mancil,

Conroy, and Haydon (2008) combined milieu teaching strategies with functional

communication training (FTR) in 3 male children with ASD who attended preschool or

were elementary-school age. The researchers concluded that the children “maintained

communication and low rates of aberrant behavior, and generalized their communication

from home to the classroom,” (Mancil, Conroy, & Haydon, 2008, p. 149). Utilizing the

SCERTS method of assessment, milieu intervention strategies, and therapy suggestions

provided by the SCERTS manuals, the researcher helped the current study’s participant

increase her expressive language ability.

Conclusion

The research question proposed initially asked if the SCERTS model positively

affected the integration across settings of three additional, developmentally appropriate

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CV combinations into the child’s spontaneous verbal vocabulary. The answer to this

question would be “yes” for two words in the study – “more” (approximated as “mo-”)

and down (approximated as “duh-”). The child’s verbal approximation for “help”

consisted of the utterance “ep”, which doesn’t meet the criteria for CV classification.

More important than the original research question, the child now recognizes (and

utilizes) multiple modes of communication – whether through graphic icons or

vocalization. Future work with the client should focus on further expansion of her

vocabulary and the introduction of simple two-word utterances. Towards the end of the

treatment period, the child occasionally combined her vocal approximations for the words

“more” (“mo-”) and “Play-Doh” (“Puh-Duh”) to vocalize “mo- Puh-Duh”. The child

therefore understands that certain words can be combined, and should be actively

encouraged to do so in the future.

Multiple limitations of the case study exist. The case study involved one

individual, as opposed to a classroom of individuals or even the entirety of the autism

clinic at San Francisco State University. External validity will therefore be extremely

confined. At most, the case study could inspire other researchers to pursue investigations

of the SCERTS methods with a larger population of people. The authors of the SCERTS

model, Prizant, Wetherby, Rubin, and Laurent (2010), state that “a federally funded,

large, randomized controlled trial is underway to document the efficacy of the SCERTS

model in public school settings from Kindergarten through 2nd grade,” (p. 5). This study

will provide important information regarding not only the efficacy of SCERTS, but the

feasibility of implementing the model in a larger environment. The SCERTS authors’

study also highlights additional limitations of the current study. The current study lacks a

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control group and therefore randomized assignment of participants. At the very least,

additional pre-therapy testing sessions would have helped to confirm the client’s true

abilities prior to intervention. Due to time spent working on the client’s other goals, one

missed session by the client, and work dedicated exclusively to the child’s parents, home

and clinic-based therapy did not always include activities designed to elicit the target

words. With more uniform therapy sessions – focused only on the three target words – a

greater number of successful, spontaneous attempts at communication might have been

recognized.

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References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). Washington, DC: American Psychiatric Publishing.

Baio, Jon. (2012). Prevalence of autism spectrum disorders – autism and developmental disabilities monitoring network, 14 sites, United States, 2008. SurveillanceSummaries 61(SS03), 1 – 19. Centers for Disease Control and Prevention.

Christensen-Sandfort, R.J. & Whinnery, S. (2013). Impact of milieu teaching on communication skills of young children with autism spectrum disorder. Topics in Early Childhood Special Education, 32(4), 211 – 222. doi: 10.1177/0271121411404930

Greenspan, S. & Wieder, S. (1997). Developmental patterns and outcomes in infants andchildren with disorders in relating and communicating: a chart review of 200cases of children with autism spectrum diagnosis. The Journal of Developmentaland Learning Disorders, 1(1), 87 – 141.

Ingersoll, B.R. (2010). A comparison of naturalistic behavior and development, social pragmatic approaches for children with autism spectrum disorders. Journal of Positive Behavior Interventions, 12(1), 33 – 43.

Ingersoll, B., Meyer, K., Bonter, N., Jelinek, S. (2012). A comparison of developmental social-pragmatic and naturalistic behavioral interventions on language use and social engagement in children with autism. Journal of Speech, Language, and Hearing Research, (55), 1301 – 1313.

Koegel, R.L., Camarata, S., Koegel, L.K., Ben-Tall, A., Smith, A.E. (1998). Increasing Speech Intelligibility in Children with Autism. Journal of Autism and Developmental Disorders 28(3), 241 – 251.

Mancil, G.R., Conroy, M.A., Haydon, T.F. (2009). Effects of a modified milieu therapy intervention on the social communicative behaviors of young children with autismspectrum disorders. Journal of Autism and Developmental Disorders, 39(1), 149-163. doi: 10.1007/s10803-008-0613-3

Molteni, P., Guldberg, K., & Logan, N. (2013). Autism and multidisciplinary teamwork through the SCERTS model. British Journal of Special Education, 40(3), 137- 145. doi: 10.1111/1467-8578.12030

Myers, S. & Johnson, C. (2007). Management of children with autism spectrum disorders. Pediatrics, 120(5), 1162 – 1182.

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Ogletree, B., Oren, T., Fischer, M. (2007). Examining effective intervention practices for communication impairment in autism spectrum disorder. Exceptionality: A Special Education Journal, 15(4), 233 – 247.

Prizant, B. & Wetherby, A. (1998). Understanding the continuum of discrete-trail traditional behavioral to social pragmatic developmental approaches in communication enhancement for young children with autism/PDD. Seminars in Speech and Language, 19(4), 329 – 353.

Prizant, B. M., Wetherby, A. M., Rubin, E., Laurent, A. C., & Rydell, P. J. (2006). The SCERTS Model: A Comprehensive Educational Approach for Children with Autism Spectrum Disorders (Volume I). Baltimore: Brookes.

Prizant, B. M., Wetherby, A. M., Rubin, E., Laurent, A. C., & Rydell, P. J. (2006). The SCERTS Model: A Comprehensive Educational Approach for Children with Autism Spectrum Disorders (Volume II). Baltimore: Brookes.

Prizant, B.M., Wetherby, A.M., Rubin, E., & Laurent, A.C. (2010). The SCERTS Model and Evidence-Based Practice. Retrieved from: www.scerts.com/docs/SCERTS_EBP%20090810%20v1.pdf

Remington, B., Hastings, R.P., Kovshoff, H., Espinosa, F., Jahr, E., Brown, T., Alsford, P., Lemaic, M., Ward, N. (2007). Early intensive behavioral intervention: outcomes for children with autism and their parents after two years. American Journal on Mental Retardation, 112(6), 418 – 438.

Smith, S., Groen, A., Wynn, J. (2000). Randomized trial of intensive early intervention for children with pervasive developmental disorder. American Journal on Mental Retardation, 105(4), 269 – 285.

Wieder, S. & Greenspan, S. (2005). Can children with autism master the core deficits and become empathetic, creative, and reflective? A ten to fifteen year follow-up of a subgroup of children with autism spectrum disorders (ASD) who received a comprehensive developmental, individual-difference, relationships-based (DIR) approach. Journal of Developmental and Learning Disorders, 9, 39 – 61.

Yoder, P. & Stone, W. (2006). A randomized comparison of the effect of two prelinguistic communication interventions on the acquisition of spoken communication in preschoolers with ASD. Journal of Speech, Language, and Hearing Research, 49, 698 – 711.

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