ABSTRACT

A COMPARISON OF DISCRETE TRIAL TRAINING AND THE NATURAL LANGUAGE PARADIGM IN NONVERBAL

AUTISTIC CHILDREN

Discrete trial training and natural language paradigm are two opposing

treatment methods that have been proven effective in improving speech production

within the autistic population. These two methods will be used in an alternating-

treatment design to determine which treatment is most effective in language

acquisition and generalization in children with autism with limited expressive

language skills. Two participants with limited expressive language abilities were

selected for the study. Each participant received treatment using discrete trial

training and the natural language paradigm. Progress was judged on the quantity

of language acquired in response to the two treatment methods.

Lisa Marie Evangelista May 2009

A COMPARISON OF DISCRETE TRIAL TRAINING AND THE

NATURAL LANGUAGE PARADIGM IN NONVERBAL

AUTISTIC CHILDREN

by

Lisa Marie Evangelista

A thesis

submitted in partial

fulfillment of the requirements for the degree of

Master of Arts in Communicative Disorders

in the College of Health and Human Services

California State University, Fresno

May 2009

UMI Number: 1472713

All rights reserved

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APPROVED

For the Department of Communicative Disorders and Deaf Studies:

We, the undersigned, certify that the thesis of the following student meets the required standards of scholarship, format, and style of the university and the student's graduate degree program for the awarding of the master's degree.

Lisa Marie Evangelista Thesis Author

Steven Skelton (Chair) Communicative Disorders and Deaf Studies

Don Freed Communicative Disorders and Deaf Studies

Sheri Roach Communicative Disorders and Deaf Studies

For the University Graduate Committee:

Dean, Division of Graduate Studies

AUTHORIZATION FOR REPRODUCTION

OF MASTER'S THESIS

X I grant permission for the reproduction of this thesis in part or in its entirety without further authorization from me, on the condition that the person or agency requesting reproduction absorbs the cost and provides proper acknowledgment of authorship.

Permission to reproduce this thesis in part or in its entirety must be obtained from me.

Signature of thesis author:

ACKNOWLEDGMENTS

I would like to thank my family and friends for their unending support in

this process. It is with their encouragement that this study has evolved into a

finished product. I extend my sincere gratitude towards Dr. Steven Skelton, Dr.

Donald Freed, and Sheri Roach for their guidance. Their knowledge and

dedication has made this study possible.

I must also express an immense appreciation for the contribution that

Christine Maul has made to this study. It is through her supervision and expertise

that this study was conducted effectively. Much gratitude is extended to IC, CH,

and their families. It is with their dedication and patience that this study was a

success.

TABLE OF CONTENTS

Page

LIST OF TABLES vii

LIST OF FIGURES viii

Chapter

1. INTRODUCTION AND REVIEW OF THE LITERATURE . . . 1

Autism: Definition and Deficits 1

Treatment 9

Statement of Purpose 25

2. METHODS 27

Research Design 27

Participants 27

Variables 31

Settings and Materials 31

Procedures 33

3. RESULTS 37

Discussion of Participants' Performance 38

Assessment Results 38

Treatment Results 40

Reliability 47

4. DISCUSSION 49

Methodology 49

Overview of Results 50

Analysis of DTT and NLP 51

vi

Page

Comparison of DTT and NLP 57

Limitations and Future Research 58

REFERENCES 60

APPENDICES 64

A. PARTICIPANT STIMULI LIST 65

B. TREATMENT DATA SHEET 68

LIST OF TABLES

Table Page

1. Comparison of DTT and NLP Procedures 21

2. Comparison of Participant Characteristics 30

3. Assessment Results 39

LIST OF FIGURES

Figure

1. Baselines and DTT treatment accuracy for participant IC

2. Baselines and DTT treatment accuracy for participant CH

3. Baselines and NLP treatment accuracy for participant IC

4. Baselines and NLP treatment accuracy for participant CH

5. Baselines, DTT, and NLP treatment accuracy for IC. .

6. Baselines, DTT, and NLP treatment accuracy for CH .

Chapter 1

INTRODUCTION AND REVIEW OF THE LITERATURE

With the varieties of treatment methods available to improve language

deficits in children with autism, it is often difficult to discern what therapy

techniques benefit nonverbal children in their acquisition and generalization of

language. It has been shown that many children with autism increase their

expressive language abilities through treatment; however, treatments may produce

differing outcomes due to their varying components (Goldstein, 2002). In this

present study, the experimenter compared discrete trial training (DTT) and natural

language paradigm (NLP) to determine which treatment method is most effective

in teaching expressive language skills. Although a plethora of treatments exist,

DTT and NLP differ in many characteristics, which will give insight to which

components of a treatment enhance language abilities of children with autism.

From previous research conducted (Delprato, 2001), the experimenter

hypothesized that treatment involving NLP would produce greater expressive

language gains in children with autism compared to treatment using DTT.

Autism: Definition and Deficits

The following section will detail the definition of autism, as well as

diagnostic criterion for the autistic disorder. A brief overview of genetics and

characteristics pertaining to the disorder are discussed.

Autism: Definition of the Disorder

In its highly publicized role in society and enigmatic existence in both

children and adults, autism has become a leading focus for many researchers. The

2

term "autism" was first introduced to the world of psychology by Dr. Leo Kanner

in 1943, upon his observation of children who exhibited abnormal responses to

sensory stimuli, poor ability to develop social relationships, and delayed

development in speech and language. Autism is characterized by stereotypical

repetitive behaviors (i.e., flapping of the arms and repetitive sequencing of

objects), impairments in receptive and expressive language abilities (i.e., inability

to use verbal language and errors in grammatical structure), and impairments in

social interaction (i.e., lack of interest in playing with other children and the

inability to reciprocate emotional responses) (Rutter, 1978).

Although the etiology of the pervasive developmental disorder is unknown,

the main causation theories of autism are directed at genetics. Through the use of

magnetic resonance imaging (MRI), neuroscientists have found marked

differences in brain size between individuals with autism compared to individuals

without autism. Abnormalities in the medial temporal lobe were noted in the

brains of individuals with autism (Dawson et al., 2002). Behavioral and cognitive

differences seen in autism may be attributed to abnormalities in brain size.

Neuroscientists are currently conducting research on the GABAA receptor gene

cluster to determine if there is an association between chromosomal abnormalities

and autism. Genetic predisposition has been researched through studies conducted

on twins and families. A vast majority of the cases studied show susceptibility of

several loci on a gene, which may indicate that many individuals are genetically

predisposed to autism (Volkmar, Lord, Bailey, Schultz, & Klin, 2004).

Researchers also have linked characteristic traits of autism to specific regions in

the brain. Deficits in language and phonological processing are affiliated to

abnormalities in the superior temporal gyrus, Broca's area, and the

temporoparietal cortex. Difficulty or lack of ability in processing facial

3

expressions of others is related to differences in the fusiform gyrus, superior

temporal sulcus, and amygdala. In addition, individuals with autism who exhibit

executive function or planning deficits may have prefrontal cortex abnormalities.

It is theorized that autism is not caused by one specific gene but rather a number of

susceptibility genes (Dawson et al., 2002). Autism also has been linked to a

genetic variation that disrupts the transcription of the MET gene. The MET gene

involved in cerebellar growth and maturation plays a specific role in the digestive

system, which may explain the coexisiting gastrointestinal difficulties many

individuals with autism experience. The variant that disrupts the MET gene is

rsl858830 allele C and is noted to be over transmitted in individuals with autism,

causing a two-fold decrease in MET activity (Campbell et al., 2006). Research on

specific chromosomes, alleles, and proteins is being conducted to determine a link

between certain gene abnormalities and the occurrence of autism spectrum

disorder (Volkmar et al., 2004).

The age of onset has become a controversial topic in the field of autism.

Although 3 years of age is the most common age at which one may receive a

diagnosis, researchers often struggle with labeling a child around 3 years of age

since their motor and language skills are still developing (Rutter, 1978). A

diagnosis of autism is rare in later childhood, but an increase in diagnoses in early

adolescence has become prevalent. The incidence of autism has been found to

occur in 60 per 10,000 births. Males are four times more likely than females to

receive a diagnosis of autism. The reasoning behind the higher incidence in males

compared to females has yet to be discovered; however, exposure to high levels of

testosterone in fetal development has been suggested. Many researchers believe

that females with autism may go undiagnosed due to their tendency to comply

more than males in educational settings, but further research has proven that these

4

differences occur in IQ abilities and are not attributed to characteristics indicative

of autism (Frith, 2003).

Along with sensory deficits, an inability to develop relationships, and

delayed language development, many children and adolescents have been known

to have coexisting complications due to the disorder. Extreme aggression, outward

violent behavior towards others, and self-injurious behaviors have been observed

in children with autism. Many often experience dental and health complications

due to poor hygiene or resistance to hygienic care (Rutter, 1978). With a plethora

of research available, autism has generated debates about characteristics that are

indicative to the disorder and theories about its etiology.

According to the Diagnostic and Statistical Manual of Mental Disorders

(4th ed.; DSM-IV; American Psychiatric Association, 2000), several criteria must

be met to be considered to have autistic disorder. The diagnostic criterion for

autistic disorder is that an individual must meet at least six of the items from three

specific categories of impairments:

1. Impairments in social interaction—Impairments in social interaction

may include poor use of nonverbal gestures such as eye contact, a

lack of an ability to form peer relationships, diminished ability to

share in interests and enjoyments with others, and an inability to

reciprocate emotionality or sociability.

2. Impairments in communication—Deficits in communication may be

characterized by delays in verbal language in the absence of

compensating modes of communication, inability to maintain

conversation, idiosyncratic or echolalic speech, and lack of

appropriate imaginative play.

5

3. Stereotypical and repetitive behaviors exhibited by the individual.

Stereotypical patterns of behavior may include abnormal

preoccupation with certain interests, an inability to disengage from

ritualistic behaviors or routines, repetitive motor movements, and a

fixation with parts of obj ects.

In order to meet the criteria for autistic disorder, an individual must

demonstrate at least two impairments from the first category, and one behavior

from each of the second and third categories. An individual who demonstrates

abnormalities in social interaction, social communication, or symbolic prior to the

age of 3 years of age may receive a diagnosis of autistic disorder. Also, individuals

should not have coexisiting diagnoses of Rett's Disorder or Childhood

Disintegrative Disorder (DSM-IV). With findings that are still emerging about

autism, researchers hope to find a cure for the disorder that has perplexed many

families, educators, and healthcare professionals.

Deficits in Autism: Abnormal Responses to Sensory Stimuli

Individuals with autism often struggle with sensory input present in the

environment and often feel bombarded by various sensory stimulations.

Hyperreactivity and hyporeactivity have been observed as an abnormal response to

sensory stimuli. Sensory deficits can affect visual, auditory, tactile, vestibular,

olfactory, gustatory, and proprioceptive behaviors. Visual input may cause an

individual with autism to cover his or her eyes, have prolonged attention to detail,

become fixated on objects in motion, or deliberately avoid eye contact. Over

response, lack of response, covering of the ears, and attention to self-induced

sounds may be seen as reactions to auditory stimuli. Impairments in tactile

behavior may include oversensitivity or lack of sensitivity to temperatures, pain,

6

and touch. An individual with autism may exhibit repetitive rubbing of surfaces

and difficulty eating various foods in response to over stimulation of certain

textures. Vestibular stimulation may occur through spinning without experiencing

dizziness and a fixation with rapidly revolving objects. Stimulation to the olfactory

sense may result in hypersensitivity to smells that even lack pungency. Strict food

preferences or placing inedible objects in the mouth may be seen as a result of

stimulation to gustatory senses. Hand flapping, grimacing of the face, impulsive

gross motor movements, and abnormal posturing have been observed to trigger

proprioceptive stimulation. It has been theorized that children with autism

sometimes suffer from a suppressed central nervous system; therefore, their

stimulating behaviors are attempts to stimulate their central nervous system.

Although these mannerisms may seem absurd, the behaviors exhibited by

individuals with autism serve as compensatory strategies needed to function within

their environment (Ritvo & Freeman, 1977).

Deficits in Autism: Inability to Form Social Relationships

Individuals with autism may exhibit an inability to establish relationships

with people and objects in their environment. The manifestation of this inability

can arise from a lack of awareness of their environment. Failure to establish

physical contact with people who play significant roles in an individual with

autism's life is commonly seen. Socialization impairments stem from the inability

to recognize the intentions of certain behaviors of others. Children with autism

may fail to establish relationships with relatives because they often have difficulty

gauging their relative's good natured intentions. Gestures of greeting and

salutation from others may fail to be unrecognized by individuals with autism,

thus producing no reciprocated response. Due to these behaviors of unreciprocated

7

affection, parents of children with autism may feel alienated and often do not

understand why their children fail to establish normal parental-offspring

relationships (Ritvo & Freeman, 1977).

Children with autism often do not engage in peer play and prefer to not

interact with others. When engaged in recreational activities, many children do not

know how to play with their toys appropriately, which can arise from a lack of

recognition of the object's symbolic meaning (Frith, 2003). They may exhibit

perseverative actions with certain objects, such as arranging their toys in a single

line instead of playing with them. Disrupting sequencing of objects may cause

discomfort and insecurity in an individual with autism. Failure to respond to

environmental cues given by both people and events seems to be evident in all

individuals with autism but to varying degrees. As previously mentioned, lack of

responsivity towards both animate and inanimate objects arise from the failure to

recognize symbolic meaning (Ritvo & Freeman, 1977).

Deficits in Autism: Impaired Speech and Language

Disturbances in speech and language have been noted as a prominent

feature of autism. It has been noted that almost 50% of children with autism do not

develop functional language skills (Howlin, 1981). Speech abilities may range

from mutism to verbal expression with minor articulation impairments. Language

deficits can vary between an inability to understand symbolic meaning to the use

of neologisms, such as nonexistent words. Many children with autism present with

no verbal language except for the ability to utter sounds that have no functional

meaning, although some children eventually develop some functional language.

Echolalia, or the repetition of a phrase heard previously, has been observed in 75%

of children with autism. Individuals with autism often use peculiar idiosyncratic

phrases, which is indicative of autism rather than other developmental disorders.

The use of idiosyncratic speech may be the result of the child's inability to

recognize that others cannot comprehend what he or she is saying. Incorrect usage

of pronouns, such as substituting "you" for "I" and vice versa, has been theorized

to develop from dissociation from their own identity. The reversal of pronouns

may also arise from echolalic speech (Frith, 2003). If a child with autism hears a

speaker ask, "Do you want chocolate?" the child may repeat the phrase with intent

to convey his or her desire for chocolate. The variation in language abilities within

individuals with autism is correlated to the severity of impairment. Those who are

more severely affected by the disorder typically experience more speech and

language difficulties than their higher functioning counterparts (Ritvo & Freeman,

1977).

In order to communicate their needs, individuals with autism who have

impaired speech and language abilities may use nonverbal communication. The

usage of gestures, such as pointing, provides individuals with autism with

impaired verbal expression a means of communication. Similar to deficits in

verbal output, nonverbal communication can be impaired by delayed development

of gestures and inappropriate gesticulations due to an inability to attach symbolic

meaning to their actions. The use of such movements serves as a compensatory

strategy in which individuals with autism can relay their thoughts and needs to

others (Ritvo & Freeman, 1977).

Diminished pragmatic ability is a universal characteristic in autism. Joint

attention, or the coordination of attention with another person on an object, has

been seen to be a developmental milestone not acquired in children with autism.

Children with autism have the tendency to be unengaged with individuals in their

environment, which correlates with their inability to recognize the emotions of

9

others. Poor eye contact, a lack of responsiveness to their name being called, and

decreased occurrence of social smiles are evident in children with autism (Rutter,

1978). Nonexistent or delayed speech and language abilities serve as one of the

main topics in the abundance of autism research and still remain as a deficit to be

solved in deciphering autism.

Treatment

Intervention strategies for language impairments in children with autism are

vast and vary in theory and application. Such treatment methods may range from

attempting to evoke verbal utterances in nonverbal children to improving

phonologic disorders in individuals with fluent speech (Goldstein, 2002). In the

focus of producing language in nonverbal children, two competing treatment

styles have been researched. The use of strictly constructed treatment used in

Discrete Trial Training (DTT) opposes the design of incidental teaching used in

Natural Language Paradigm (NLP). DTT is a clinician-directed treatment that is

regimented around repetitive practice. NLP is a child-directed treatment that

utilizes naturalistic opportunities to enhance language development. DTT and NLP

are two language intervention strategies that substantially differ from each other in

theory and application, but have been shown effective in eliciting speech in

children with autism who have expressive language deficits (Koegel, O'Dell, &

Koegel, 1987).

Discrete Trial Training (DTT)

DTT is a method used to enhance communication skills in children with

autism. DTT is a structured treatment with systematic components and precise

target responses (Woods & Wertherby, 2003). The use of DTT gives a nonverbal

child exposure to vocabulary that can be used in the child's everyday life. The use

10

of DTT to teach expressive language skills is often followed by a receptive

teaching form of DTT in which the child points to an object in response to the

clinician's instructions (Lovaas, 1977). For purposes of comparison, the current

study focused on evoking expressive language only. Although it was designed to

teach new behaviors, such as expressive language in nonverbal children, DTT has

been effective in decreasing disruptive behaviors exhibited by children with

autism (Smith, 2001). Difficulties comprehending detailed instructions are often

seen in classroom settings amongst children with autism. Frustration, escape and

avoidance behaviors, and aggression may result from an inability to understand

adults in teaching situations. DTT serves as a treatment that provides opportunities

for learning by simplifying instructions and increasing motivation (Smith).

The materials needed for DTT involve object or picture stimuli used to

evoke the target response. In treating nonverbal children, the experimenter selects

the stimuli and has the child confrontationally name the target item. DTT is

repetitive in nature, meaning that one stimulus item is administered repetitively

until the experimenter moves on to another stimulus item once a determined

mastery criterion was met. Chosen stimuli are used over successive treatment

sessions until the child reaches a set criterion. Only the stimulus evoking the target

response is present without any other object or materials present to serve as a

distraction (Smith, 2001).

Reinforcement for correct productions and verbal approximations are

received after every appropriate attempt, such as candy or stickers. The child

receives reinforcers that are not the object the child labeled (Ferster, 1967). If the

child was requesting an item and it was given as the reinforcer, then that

specification of the reinforcer is a "mand" (Hegde & Maul, 2006). The reinforcers

that the child received in DTT were not being requested (manded) by the child.

11

For example, if a stimulus card with a picture of a dog was presented, the child

may have produced a verbal approximation such as /d/, but received a piece of

candy for his or her attempt.

DTT is most commonly used in the clinic setting; however, it has been

adapted to other settings, such as the home environment. Within each discrete trial

there were five steps to implement (Smith, 2001).

First there is a Cue: The experimenter presents a small unit of instruction

such as, "Say " while holding the stimulus item.

Second there is a Prompt: Immediately after the cue is presented, the

experimenter implements a prompt to assist the child in producing a response. In

the case of evoking expressive language in nonverbal children, the experimenter

most likely models the target response.

Third the child makes a Response: The child produces a response that was

either acceptable or unacceptable.

Fourth the clinician provides a Consequence: A reinforcer is rewarded to

the child if an appropriate response is produced. If the child states an incorrect

response, the experimenter responds with "No," or uses another manner to convey

that the child's production is inadequate.

Finally there is the Intertrial interval: After the consequence is given, the

experimenter progresses to the next trial after a brief pause is imposed. Prompts

used to aid the child in producing a correct response eventually are faded as the

child progresses through treatment. In the initial stages of treatment on a specific

stimulus, the clinician models the target response. As treatment progresses the

experimenter uses less intrusive prompts as acquisition of the target response

developed.

12

To reduce the likelihood of negative behaviors such as frustration, the child

receives a small break in between discrete trials. The frequency and duration of

breaks depend on the child's response to treatment. More breaks may be needed

for children who exhibited restlessness and an inability to maintain attention

(Smith, 2001).

Review of the DTT literature. Multiple studies have been done on DTT,

also referred to as operant language training, to show its ability to decrease

language deficits in children with autism. A study conducted by Howlin (1981)

used operant language training to treat 16 boys with autism. The participants

ranged from 3 to 11 years old. The participants presented with no coexisting

neurological impairments and all the subjects received nonverbal IQ scores of 60

or above when administered the Merrill-Palmer Scales of Mental Intelligence

(Stutsman, 1948) or Weschsler Preschool and Primary Scale of Intelligence-Third

Edition (Wechsler, 2001). The study also used a control group of children who

were diagnosed with autism. No intervention was provided for the control group

except for advice given to the parents on how to manage behavior issues.

Treatment occurred for 18 months, and progress was measured every 6 months

using both informal and standardized testing.

During treatment, each language program was tailored to the individual

participant's needs, which may have included improvement of syntactical

complexity and communicative speech. Improving syntactical complexity

included teaching sentence structure and morphology. Increasing communicative

speech included evoking vocalizations, either syllable, word, or phrase. Treatment

consisted of prompting, modeling, and arbitrary reinforcement that was

representative of procedures used in DTT. The target responses taught were

13

commensurate with the participants' cognitive skills and typical of other children

in that age range.

Results of the treatment were positive amongst all children involved in the

study. Improvement of language deficits was significant, and language skills were

acquired at a rapid rate. The participants were observed to have improved most

significantly in their ability to use language skills in social contexts. Improvement

in language structure such as syntax was less noted than increased usage of

functional language. The use of operant language training also decreased

problematic behaviors that coincided with each of the participants. Children who

presented with echolalia prior to the study benefited most from treatment;

however, the control group also presented improved language abilities in the

absence of treatment. Nonverbal children had little gains with treatment, but their

improvement in language function was higher than the nonverbal participants in

the control group who did not receive treatment. There were 12 nonverbal

participants within the study. Six of the nonverbal children received treatment, and

the other 6 were in the control group. Two nonverbal participants who received

treatment were able to produce functional phrases at the end of the treatment

period.

Differences in IQ scores may have been a factor in variation of results

across participants. The two nonverbal participants who were able to produce

functional phrases received IQ scores of at least 100. Both participants also

showed more developed skills in social and play behavior compared to other

participants in the study. Through these results it can be inferred that nonverbal

children may acquire some functional language if their comprehension is intact

and if they are able to produce some speech sounds. To strengthen the efficacy of

this study, more participants will be needed to confirm its results (Howlin, 1981).

In a study conducted by Hung (1980), discrete trials were used to teach the

production of "yes" and "no" as mands in children with autism. Two participants

who were diagnosed with autism were selected for the study. The first participant

was an 8-year-old male who presented with no expressive language skills. The

second participant was a 10-year-old female who presented with echolalic speech

but was able to verbalize personal information. Both participants were enrolled in

classes specialized for children with autism. Since the first subject was nonverbal,

treatment to teach verbal imitation of "yes" and "no" responses was administered

prior to the study.

Selected materials for the study consisted of food items that the participants

found highly reinforcing and food items they found to be aversive. Prior to

treatment, the participants sampled food items while the experimenter noted their

reaction to the foods presented. Liquid food items were administered in 1.25ml

amounts and solid foods were cut into small pieces, both presented on a spoon.

Liquid and solid items were administered in a spoon to eradicate the possibility of

the participants attending to the presence of the spoon rather than the food items.

Baseline procedures were conducted prior to treatment to ensure that both

participants were unable to produce yes and no mands. Treatment procedures

involved the presentation of a food item by the experimenter. The experimenter

would state, "Do you want [name of the food object]?" and wait for the

participant's response. Responses were judged correct if the participant said "yes"

for desired items and "no" for highly disliked food. In the initial stages of

treatment, "yes" items were taught, and the correct production was modeled for

the participant. If the subject produced a correct response, the experimenter would

put the highly reinforcing item in the child's mouth in the absence of other

reinforcement. If the participant produced an incorrect response the experimenter

15

would impose a 5-second delay and model the target response for the child. Verbal

reinforcement was given if the child was able to model the target response

correctly. The participant with limited expressive language skills imitated the

experimenter's question rather than providing a "yes" or "no" response; therefore,

the manding question was faded out and only the presentation of the food item

evoked a response. Slowly the question was reinstated once the nonverbal

participant was able to provide 10 consecutive yes responses without modeling.

The second participant did not require fading of the manding question. Training of

the target response concluded once the participants were able to produce 10

correct consecutive responses to the manding question.

Once criterion of the first target response was reached, a second highly

desired item was trained. The same procedures used to teach the first target

response were implemented. Once the second target response was produced

consecutively over 10 trials, the first and the second target responses were

alternated at random. When the participants reached a criterion of 90% accuracy in

the production of a "yes" response without modeling, a "no" response in the

presence of an aversive food item was introduced. To teach the "no" response, the

experimenter implemented the same procedures used to teach the "yes" response.

If the participant produced a "no" response when a highly disliked item was

presented, the experimenter would withdraw the food item and provide no verbal

feedback. If the child produced a "yes" response, the experimenter fed the child

the undesirable food item. Modeling across two trials occurred if the participant

kept producing a "yes" response to the aversive stimuli; however, if the production

on the third trial was incorrect then the child would receive the disliked food item

again. Training was stopped on "no" responses when the participant was able to

provide 10 consecutive correct productions.

16

Alternating "yes" and "no" responses occurred following the previously

mentioned procedures. At random, favored and unfavored edibles and foods were

alternated. When a "yes" target response was expected but not produced, modeling

was reinstated until five consecutive responses occurred. Correct imitation

received verbal reinforcement, but correct productions without modeling received

the desired food item. When an incorrect response to an undesired item occurred,

the experimenter provided modeling across two trials and presented the aversive

food on the third trial. Once the participant was able to produce five consecutive

correct responses to the disliked food items, alternating "yes" and "no" responses

resumed.

To assess generalization, the experimenter presented new food items to the

participants. Both children were allowed to taste the items before the assessment

was conducted. Specific consequences (i.e., the withdrawal or receiving of food)

occurred when responses were produced. Results indicated that the nonverbal

child had difficulty generalizing "yes" and "no" productions to new food items in

the initial stages of generalization testing. Nine sets of different food items were

presented across 225 trials. The first participant did not respond with 90%

accuracy until the last 120 trials; however, the second child who initially repeated

the experimenter's question was able to generalize correct responses within the

first 70 trials without training. Results of this study showed that DTT was effective

in teaching verbal manding skills to children with autism, both who initially

presented with and without expressive language. In order for this study to increase

efficacy, a direct replication will need to be conducted, as well as a study that

alters the consequences of incorrect responses (Hung, 1980).

17 Natural Language Paradigm

Naturalistic treatment methods have been efficacious in both language

acquisition and generalization to other settings. The objective of NLP is to take

traditional language teaching methodologies and modify certain aspects of such

treatments to increase the client's motivation and opportunities to facilitate social

interaction (Koegel et al., 1987). The use of NLP focuses on treatment that is

child-initiated opposed to treatment that is structured by the experimenter (Woods

& Wetherby, 2003). Since treatment is child-directed, motivation plays a key part

in making NLP successful. According to Koegel, Koegel, and McNerney (2001),

motivation is an observable characteristic that increases an individual's response

to stimuli. Naturalistic teaching is loosely structured in a way that the child attends

to a preferred activity of his or her choice, rather than having the experimenter

choose the stimuli. NLP is a treatment method that provides several opportunities

for a child to produce language towards stimulus items that are highly motivating

through guidance from the experimenter (Gillett & LeBlanc, 2006).

Stimulus materials are composed of activities, toys, or food items that occur

in the child's environment. These items are age-appropriate and reinforcing to the

child. The stimuli used in the NLP also serve as the reinforcers for responses made

by the child. A direct response chain is made by having a child mand for a desired

object (Woods & Wetherby, 2003).

Treatment occurs within a play setting that represents the home setting.

Treatment does not need to occur at a table since a play setting is most desirable.

Stimulus items are selected before treatment if they are of high interest to the

child. A variety of preferred activities are laid out in front of the child but within

reach of the experimenter. If the child shows interest in one of the available

activities, he or she would have to produce an adequate response in order to

18

receive the item. NLP begins with evoking the production of the desired item, and

then proceeding to phrases and sentences until mastery criterion is met (Goldstein,

2002).

If the child fails to produce an acceptable response, the experimenter

models the word for the child and then engages in natural interaction with the

object and the child. The child receives the item upon an acceptable production of

the target response, and the experimenter restates the item name. This behavior

acknowledges that the child's production was correct. Both correct responses and

verbal approximations are valid productions for receiving the desired reinforcer

(Delprato, 2001).

Review of the NLP literature. The use of naturalistic settings and treatment

methods has become a research topic that examines the use of motivation to

improve language production. In a study conducted by Gillett and LeBlanc (2006),

NLP was implemented by parents of children with autism in order to increase

verbal production. The study consisted of 3 participants who were diagnosed with

autism and presented with limited expressive language abilities. All the

participants were either 4 or 5 years old. Treatment sessions were held in different

settings for each participant. The first participant engaged in treatment in a

university playroom. The second participant was treated in his home. The third

participant was exposed to treatment in a university center filled with computers

and one small child-sized table. The children's parents were trained to implement

NLP prior to the beginning of treatment.

A multiple baseline design across participants was used to conduct the

study. Baselines were determined through informal assessment using play

activities to evoke language production from all 3 participants. Parental training in

NLP occurred through demonstration. The parents placed three preferred items in

front of their child. If the participant attempted to reach for an object the parent

would withhold the object and wait for 5 seconds for the child to make a response.

If no response was made the parent would model the item for the child. The child

was allowed to play with the desired object for 30 seconds if an acceptable verbal

production was made. After 30 seconds of playtime, the parent withdrew the

object and continued the procedure, this time using a different vocalization that

described the object, such as physical attributes of the item. Data collection was

comprised of documenting incorrect and correct responses. Correct responses

entailed the production of the target response or a verbal approximation. Incorrect

responses consisted of an inaccurate attempt or no production at all. Towards the

end of parental training in NLP, the experimenter assessed the parent's

implementation of the treatment. If the parents implemented the treatment

correctly 9 out of 10 trials with accurate data collection, they were allowed to

conduct an entire session of treatment with their child.

Both the parents and the children were observed during treatment. Parents

were assessed based on their ability to present three preferred items to the child,

withhold the item when an attempted reach by the child was made, wait 5 seconds

before modeling a response for the child, model the target response if a production

was not made, provide correct reinforcement, and continue the procedures using

new target responses. A second independent observer scored the parents' ability to

implement the procedures previously mentioned. Agreement between the two

observers was averaged at 96% for the parents' performance and 100% for

verbalizations made by the participants. By the end of treatment, the first

participant was able to imitate 100% of the trials administered and produced

spontaneous vocalizations during 20% of the trials. The second and third

20

participants were prompted in the first session of treatment but were able to make

spontaneous vocalizations with limited prompting during the rest of the treatment

period.

Differences in language acquisition rates may be related to previous

language in the participant's repertoire before treatment. The second and the third

participants were able to produce simple phrases through echolalia and were able

to produce a few words, opposed to the first participant who could only babble. To

further the efficacy of NLP, observation of the participants' ability to generalize

productions to various settings is needed. Related research using NLP may be

extended to the language productions made by children with autism in the

presence of siblings and peers during play activities (Gillett & LeBlanc, 2006). A

comparison of the components of DTT and NLP are described in Table 1

(Delprato,2001).

Review of comparative literature. Since both DTT and the NLP have both

been shown to be effective in treating expressive language deficits, comparison of

the two treatments have been made to determine which treatment most benefits

nonverbal children with autism. Koegel et al. (1987) conducted a study using NLP

and DTT to evoke language from nonverbal children with autism. The study

consisted of two children who were diagnosed with autism and presented with no

functional language skills. The first participant was 4 years old, and the second

participant was 5 years old. Both participants exhibited self-stimulatory behavior,

poor attention, and inappropriate social behavior. When administered the Vineland

Social Maturity Scale to assess social development, both participants scored under

a 3-year-old functioning level.

21

Table 1. Comparison of DTT and NLP Procedures

Components Discrete Trial Training Natural Language Paradigm

Setting

Sessions

Stimuli

Antecedent Preceding Response

Targeted Response

Reinforcer

Clinician and participant are both Clinician follows the child to seated at a table with stimuli various locations in the treatment present. room. A play setting is used.

Treatment is initiated by the Treatment is initiated by the clinician. The clinician present participant. Treatment begins opportunities for the participant to when the participant attends to a produce a response. desired stimulus.

The clinician selects the stimuli used in each treatment session.

Clinician evokes a response by stating a question (i.e., "What is it?").

The same response is targeted until a determined mastery criterion is met.

An item that is unrelated to the treatment stimuli

The participant selects stimuli to engage in, which may vary each treatment session.

Clinician withholds the desired stimulus item from the participant to evoke a response.

Responses may vary when requesting the stimulus item.

Related to target response.

Treatment occurred in a 3.048 m by 4.572 m clinic room for 2 hours per

session, twice a week. Initially, DTT was used to treat the expressive language

deficits in both participants. The experimenter would say a word and the

participants were expected to imitate the experimenter. If the child failed to imitate

the experimenter, the child was prompted through tactile means, such as receiving

a light touch to the cheek, while the stimulus item was presented again. Social and

arbitrary reinforcements were obtained if the child produced a verbal

approximation or a correct response. Participant 1 engaged in DTT for 2 months,

while participant 2 continued with DTT for 19 months. After DTT was

administered, both participants proceeded to receive treatment using the NLP.

NLP was implemented using a multiple baseline design. Stimulus items

consisted of activities that were reinforcing to the participants. The experimenter

would play with the preferred objects and modeled the target response for the

participants. Objects were obtained upon an appropriate verbal attempt, but if the

participant produced no attempt, the target response was modeled again. During

each 2-hour session, the amount of verbal productions was documented. Fifteen-

minute breaks were allowed during treatment, and the experimenter measured the

number of verbal utterances produced by the participants in the absence of

treatment, then multiplied by 100.

Data were recorded across all treatment sessions by two independent

researchers. The number of corresponding data was divided by the sum of

disagreements and agreements. The two independent observers noted phonetic

transcriptions of each participant's utterances. Agreement was made on

corresponding responses and the percent for agreement was 80% for in-clinic

treatment and 78% for productions made during break time. The results of the

study show that treatment using DTT produced less favorable outcomes than

treatment using NLP. In DTT, both participants were only able to imitate a few

utterances, and did not produce any spontaneous speech. When NLP was

implemented, both children were able to make spontaneous utterances in the clinic

setting and outside in a more natural environment. Continued gains were noted to

be made in both children after NLP was used in treatment. The increase in

expressive language skills during NLP treatment is theorized to be based on the

naturalistic properties of the method. The participants were motivated by the direct

reinforcers. Since DTT did not reinforce the child with the object they manded for,

the participants were not motivated to earn the desired object but received a

secondary and more arbitrary reinforcer instead. The phenomenon of a direct

23

reinforcer used to increase speech production in nonverbal children with autism

stems from the idea that language is mainly used for social interaction and

obtaining preferred objects (Bloom & Lahey, 1978). Although the two treatments

were similar in presentation of the stimulus item and delivery of prompts, the main

difference was the reinforcers that were received upon production of a response.

The relative difference between direct and indirect reinforcers played a significant

influence on the acquisition and generalization of language (Koegel et al., 1987).

In a study conducted by Koegel, Camarata, Koegel, Ben-Tall, and Smith

(1998), a comparison of DTT and NLP was conducted to improve speech

intelligibility in children with autism. Five participants were chosen for the study,

four male and one female. The participants' ages ranged from 3 to 5 years. Each

participant exhibited speech and language delays, and were unintelligible to their

conversational partners. All of the participants were previously enrolled in speech

therapy to improve their language deficits. Normal hearing acuity was observed in

all 5 participants.

An ABA across subjects research design was used to conduct the study in

order to control for order effects that may have occurred if another research design

was implemented. Target behaviors were determined based on speech samples that

were collected prior to treatment. Incorrect productions and unintelligible sounds

that an individual participant produced were chosen for treatment. Target

behaviors were randomly assigned to be taught through either DTT or NLP. A

minimum of 20 treatment sessions were administered for each treatment method.

Treatment sessions occurred twice a week for 45 minutes each session. Target

behaviors were judged to be mastered if the participant could produce the sound

with 80% accuracy in conversation across four consecutive treatment sessions.

Baselines were administered in the clinic, home, and school setting through

informal assessment. Conversation between the participants and people in the

environment served as the informal assessment. In DTT, stimuli of the target

behaviors were chosen by the experimenter, which consisted of picture cards.

Treatment began at the word level and target responses were initially modeled. If

the participants produced a correct response, they would receive an arbitrary

award, such as a favored item or an edible reinforcer. If an incorrect production

was made, the experimenter would provide motor placement cues for the child to

be able to produce the correct response. After the participants were able to reach

80% accuracy across 20 trials, treatment progressed to the word level, phrase

level, and sentence level using the same procedures and criterion.

Treatment involving NLP consisted of 20 items for each target sound that

the participants would have normal interaction with. The stimulus items were

chosen only if they were highly reinforcing to the participants and if they

contained the target sound in the label of the item. Treatment involved engaging in

play activities with the child and the preferred item. If the child produced the

correct target response, the clinician reinforced the child with verbal praise,

restatement of the target response, and an opportunity for the child to play with the

desired object. A procedure known as "contingent recast," in which the clinician

makes a correct production immediately after the child's incorrect verbalization in

response to the target stimuli, was implemented by the experimenter after the child

made a verbal approximation or failed to produce a response (Camarata, Nelson,

& Camarata, 1994).

Progress was determined by outside researchers who were unfamiliar with

the participants. Speech samples that were recorded prior to treatment and after

treatment were analyzed for correct productions. A 6-point Likert scale was used

25

to rate the children's productions. Zero points represented unintelligibility and 5

points indicated high intelligibility. The speech samples also were transcribed by

researchers who were familiar with the participants to determine correct and

incorrect productions of target sounds. To establish reliability, two independent

investigators calculated the data from the samples using a point-by-point

agreement system. Agreement between the two investigators averaged at 89%

reliability. Results were consistent across all 5 participants. After using DTT, no

significant improvement in speech intelligibility was noted. Contrary to the lack of

improvement observed from the DTT method, treatment utilizing NLP resulted in

significant improvement in all the participants' productions. All participants were

able to reach 100% accuracy across trials on their target behaviors in

conversational speech after treatment using NLP. When rated on the 6-point Likert

scale after treatment, the participants received ratings that suggested their speech

was "mostly" intelligible.

The results of this study demonstrated that significant gains in speech

intelligibility were made in response to NLP method opposed to DTT. It was

observed that more disruptive and avoidance behaviors occurred during treatment

involving DTT. The participants were observed in various settings after treatment,

and target sounds taught using the NLP generalized to other environments. This

study confirmed the outcomes of the study conducted by Koegel et al. (1987). The

researchers of this study also theorized that the direct reinforcers used in the NLP

motivated the participants to produce correct responses (Koegel et al., 1998).

Statement of Purpose

The use of DTT and NLP in treatment has been shown effective in

increasing language production in children with autism. The focus of this study is

on treatment of verbal language deficits in children with autism by comparing the

two treatment methods on children with autism who have limited expressive

language skills to see which method is most effective in both acquisition and

generalization of language. The purpose of the study seeks to determine whether

DTT or NLP is more effective in increasing verbal language in children with

autism.

Chapter 2

METHODS

This study sought to determine whether DTT or NLP was more effective in

treating children with autism with limited verbal skills. To determine which

treatment was more effective over a period of time, the accuracy of words

produced verbally in response to stimuli was calculated each session.

Research Design

An alternating-treatment design was implemented to conduct this study.

The alternating-treatment design exposed a single client to two separate treatments

while comparing the effects of those treatments. A baseline phase was applied

prior to the initiation of treatment, in which data were documented on the clients'

ability to produce verbal language before any treatment has occurred. The

alternating-treatment design consisted of an equal number of sessions for each

treatment; however, the order of these sessions was randomized to prevent an

overlap of effects from one treatment method to the next. Treatment was

alternated amongst participants to show that one therapy was not dependent on the

other to be effective (Hegde, 2003). For example, if participant 1 received

treatment through DTT on a given day, NLP was used to treat participant 2 that

same day.

Participants

The participants who were selected for the study were diagnosed with

Pervasive Developmental Disorder-Autistic Disorder. Participant IC was 3 years

of age and received contradicting diagnoses of autism spectrum disorder (ASD) by

two separate facilities. Participant CH was 3 years of age and was diagnosed with

ASD. Both participants had limited expressive language abilities characterized by

a production of no more than six words during assessment and baselines. IC and

CH were asked to commit to 20 treatment sessions that were conducted for 50

minutes per session, and four pre-therapy sessions for assessment and baselines

over 6 to 8 weeks.

During the course of the treatment sessions the investigator conducted

therapy in the Speech and Hearing Clinic at California State University, Fresno.

The treatment sessions were scheduled at the convenience of the participants and

were scheduled four sessions per week. The clinician provided the materials for

both treatment methods; however, if the participants did not engage in materials

the clinician provided for NLP, the parents were allowed to bring more reinforcing

items.

Participant IC

IC was a 3-year, 8-month old male who lived with his mother and father

and two older siblings. IC was referred to receive a psychological evaluation based

on his expressive language delay. He did not receive a diagnosis of ASD by the

Central Valley Regional Center when he underwent assessment since it was

determined that he did not meet the necessary criteria to receive a diagnosis of

ASD. Ruling out of the diagnosis was determined based upon his results of Social

Communication Questionnaire (Rutter, Bailey, & Lord, 2003), Weschler

Preschool and Primary Scale of Intelligence-Third Edition (Wechsler, 2001), and

the Vineland II Adaptive Behaviors Scales (Sparrow, Balla, & Cicchetti, 1984).

However, IC was diagnosed with ASD by his school district at 30 months.

Developmental milestones were age appropriate; however, IC did not use verbal

language until 3 years of age. IC cried and gestured to his communicative partner

to express his needs and wants. He demonstrated screaming and hitting his head

when he became frustrated. IC was enrolled in a special day class in his

elementary school and received 20 minutes of group speech therapy twice a week

at the school site.

Participant CH

CH was a 3-year, 4-month old male who lived with his mother and father.

He was diagnosed with ASD by the Central Valley Regional Center at 3 years of

age. This diagnosis was determined based upon his results of Social

Communication Questionnaire (Rutter et al., 2003), Wechsler Preschool and

Primary Scale of Intelligence-Third Edition (Wechsler, 2001), and the Vineland II

Adaptive Behaviors Scales (Sparrow et al., 1984). CH meets several of the criteria

for receiving a diagnosis of autistic disorder according to the DSM-IV. The criteria

met are as follows:

1. Impairment in use of nonverbal behaviors

2. Failure to develop peer relationships appropriate to developmental level

3. Lack of spontaneous seeking to share enjoyment, interests, or

achievement with other people

4. Lack of social/emotional reciprocity,

5. Delay in or total lack of development of spoken language

6. Stereotypic and repetitive use of language and idiosyncratic language

7. Lack of varied, spontaneous make-believe play or social imaginative

play appropriate to developmental level

8. Encompassing preoccupation with one or more stereotyped or repetitive

patterns of interest that is abnormal either in intensity or focus, and

stereotyped or repetitive motor mannerisms.

CH attended the CITI Kids preschool program and was receiving 20 hours

of applied behavioral analysis therapy, 2 hours of occupational therapy, 4 hours

with a play tutor, and 1 hour of speech-language therapy per week. Developmental

milestones were age appropriate for CH with the exception of the production of

expressive language. CH produced single words at 21 months and combined

words at 24 months. In the home setting, CH's parents used a Picture Exchange

Communication System (PECS) and sign language in conjunction with verbal

language to help CH's expressive his needs and wants. Characteristics of each

participant are detailed in Table 2.

Table 2. Comparison of Participant Characteristics Characteristics IC CH Age

First Words

Diagnosis

3-year, 8-months

3 years of age

3-year, 4-months

21 months

ASD (by school district) at ASD (by CVRC) at 3 years of age 30 months

Services Received Special day class

20 minutes of speech therapy, twice a week

Current Communicative Methods

Gestures

CITI Kids preschool program

20 hours of ABA therapy

2 hours of occupational therapy

4 hours with play tutor

1 hour of speech therapy per week

Picture Exchange System (PECS)

Sign language

31 Variables

Two independent variables were present during this study, both of which

were compared throughout the duration of the study. DTT was the first

independent variable that was implemented, while the second independent variable

was NLP. The dependent variable was the verbalizations produced by the client in

response to the stimuli presented. In order to be counted as a correct production,

the child verbalized a whole word in response to the discriminative stimulus.

Although verbal approximations were encouraged, they did not account for correct

responses.

Settings and Materials

This study was conducted within two settings. Treatment utilizing DTT

occurred in a clinic room at the California State University, Fresno Speech-

Language and Hearing Clinic. The participant was seated at a table with the

clinician and the participant sitting adjacent to each other. A three-sided barrier

was placed in the clinic room that housed the treatment table to minimize

distractions. Only treatment materials, reinforcers, the clinician, and the

participant were present in the clinic room. The families were allowed to observe

the treatment session through a one-way mirror while listening to the experimenter

and their child through headphones or a speaker.

Treatment utilizing NLP occurred in clinic room that resembled a play

room. The naturalistic focus of the treatment gave a less structured approach;

therefore, treatment was not restricted to sitting at a table. The clinician and the

participant engaged in therapy on the floor, table, or wherever the participant's

activity of choice was located. Only the participant, clinician, and treatment targets

which dually served at the reinforcers were present in the clinic room. As noted in

the setting for DTT, the families observed the treatment session through an

observation room. Both DTT and NLP vary in their setting which helped to

differentiate what environment promotes language acquisition and generalization.

Materials that were used throughout the duration of treatment varied

depending on what method was implemented and what was motivating to the

participant. In DTT, object and picture stimuli were used to evoke verbal

productions of words from the participants. These words were generally nouns

commonly seen in the child's environment, such as food, toys, and clothing items.

Picture stimuli used in DTT were presented on 10.16 cm by 15.24 cm cards. The

clinician had five boxes with a colored square on each box which corresponded to

colored squares on a visual schedule. The participant would select a colored

square from the visual schedule and have to produce a production in response to

the treatment target in the corresponding box. To prevent memorization of

treatment target order, the clinician randomly rotated the treatment targets in the

boxes after three consecutive correct responses for any one target was produced.

Reinforcers for DTT were not related to the response. Food items, stickers, or toys

were paired with verbal reinforcement if the participant produced an appropriate

target response.

Only object stimuli were used in NLP. These stimuli consisted of activities

or objects the child attended to or initiated interest with based upon the

reinforcement sampling administered during the assessment. Reinforcers used in

NLP were the stimulus items, such as receiving an object if the participants

properly manded for the items. The use of different reinforcement such as

arbitrary and naturalistic gave insight on how direct and indirect reinforcers

influenced the participants' level of motivation to engage in treatment.

Procedures

In the following sections, pretreatment procedures will be discussed, as

well as procedures followed during treatment in DTT and NLP. Assessment of the

participants, baseline phase, and treatment phrase consisting of DTT and NLP

were included in this study.

Assessment

Before treatment was implemented, the subjects were informally assessed

through play activities. Through informal assessment, the clinician was able to

gauge what activities enticed the participants' interaction and obtain an indication

of their level of expressive language ability. Since the participants were limited in

their verbal skills, a formal assessment of expressive language skills was not

possible. From this assessment, the experimenter obtained information on what

stimulus items to use and avoid in treatment.

During the assessment, parent interviews were conducted to determine date

of diagnosis, services received by the participant, communicative methods and

functions the participants currently used, as well as providing a description of the

study and what it entailed. The Receptive Expressive Emergent Language Test-

Third Edition (REEL-3) (Bzoch, League, & Brown, 2003) was completed by the

participants' parents to evaluate the participants' expressive and receptive

language abilities. A reinforcement sampling was administered during the

assessment to determine which objects were reinforcing to each participant.

Objects that were determined to be highly motivating during the reinforcement

sampling were used as treatment targets for NLP.

34 Baseline Procedures

Baseline procedures consisted of determining which stimulus items each

participant was unable to verbally produce in both DTT and NLP. Treatment

stimuli included the targets that the participants were unable to produce over four

consecutive baseline sessions. By administering the same treatment items over

four consecutive sessions, the clinician determined that the participants did not

verbally produce the label for the object or picture stimuli. See Appendix A for the

list of both participants' probed word productions and word productions acquired

throughout treatment.

DTT Procedures

Treatment using DTT began at the word level. The experimenter held up a

picture card or an object for the participant to see and stated, "What is this?" After

the subject attended to the item, the experimenter verbally modeled the response.

The participants were required to produce a response in order to obtain a

reinforcer. If the participant produced the correct target response or a verbal

approximation, he received a tangible reinforcer, such as candy and proceeded to

the next trial. The participant was told "No" and reinforcement was not given if

their response is incorrect. Progression to the next trial occurred once the

experimenter signaled to the participant that his response was inadequate.

Treatment on five target words occurred as many times as behaviors and time

allowed for in a treatment session; therefore, multiple target responses were taught

throughout treatment at one time. Echolalic responses were not counted as correct;

however, separate data were taken on these responses since a verbal attempt was

produced. If the participant produced an echolalic response, the clinician modeled

the correct target. An example of an echolalic response that may have occurred is

if the clinician said, "What is this?" and the participant said, "What is this?" The

clinician would then model the correct target response or the label of the object

and have the participant imitate. If the participant produced the trained target

response with 90% accuracy across two consecutive treatment sessions, that

treatment target was considered to have reached mastery level. Once a target

response has been mastered, a new target response was introduced.

NLP Procedures

Treatment using NLP began with the participant being required to say a

word in response to object stimulus. Five motivating objects or activities were

available to the participant. The participant would attend to one of the preferred

objects but the experimenter would withhold the item for 5 seconds to allow the

participant to make a production. Verbal modeling of the target response by the

experimenter would occur if the participant failed to respond. Once the participant

provided an adequate response of the target item, the experimenter engaged in a

play activity with the participant using the desired object. The withholding and

receiving of an object depended on the duration the participant expressed interest

in a stimulus item and the amount of undesirable behaviors in a 50-minute

treatment session. If the participant did not express interest in an activity by

neglecting the stimulus he was previously engaged in and found interest in one of

the four other activities available, treatment of the new target response will occur.

A mastery level was reached if the participant could provide a correct production

of the word without being provided a model, with 90% of the time across two

consecutive therapy sessions.

Scoring

Data were recorded on score sheets on which the experimenter wrote a

statement of the activities used and for scoring the correct whole word responses,

36

and incorrect or prompted responses. A plus sign was used to indicate a correct

response and a minus sign was used to note an incorrect response. Incorrect

responses included prompted responses provided by the clinician. Spontaneous

productions other than the target response also were documented each session on

the data sheets. These productions were considered to be related to NLP since they

were not produced in response to a DTT format. See Appendix B for the data

scoring sheet.

A target behavior was considered mastered when a participant produced

whole word responses 90% of the time over two consecutive treatment sessions.

Statistical analysis of the data was not needed since a single case design was used

to conduct the study (Hegde, 2003). Once the treatment phase ended, data were

analyzed visually and graphs of verbal productions in response to DTT and NLP

were made.

Chapter 3

RESULTS

The purpose of this study was to determine whether DTT or NLP was more

effective in treating expressive language deficits in children with autism who

exhibit limited verbal language abilities. Prior to treatment, each participant was

administered the Receptive Expressive Emergent Language Test-Third Edition

(REEL-3) to provide information on communication abilities each participant had

prior to receiving treatment. A reinforcement sampling also was conducted during

the assessment period to determine what objects were motivating to each

participant, thus establishing treatment targets for NLP. Four baseline sessions

were conducted to determine treatment targets for DTT and NLP. In the initial

stages of treatment, each participant received treatment on five treatment stimuli

for the two treatment methods. As treatment progressed, new treatment stimuli

were introduced according to participants' abilities to reach the mastery criterion

of a single treatment target. Treatment utilizing DTT and NLP occurred across 10

sessions for each treatment methods.

Sessions of DTT and NLP were semi-randomized and alternated

throughout the course of treatment. Each treatment session was 50 minutes in

duration, regardless of the treatment method. Direct treatment time depended on

the behaviors exhibited by each participant on a given day, which will be

discussed later. The remainder of this chapter discusses the outcome of DTT and

NLP by comparing data gathered during baseline, and the treatment sessions.

Information on generalization of treatment target also will be provided, as well as

a detailed analysis of the results provided for both participants.

Discussion of the Participants' Performance

Each participant completed the assessment period, 4 baseline sessions, and

20 treatment sessions. The investigator predicted that both DTT and NLP would

have a positive effect in increasing expressive language abilities in both

participants; however, determining which method was most effective was the

research question. Data collected for both participants varied in the extent of

outcomes produced by each treatment; however, NLP was observed to produce

higher rates of language acquisition and generalization for both IC and CH.

Rates of responses for both participants varied depending on behaviors

exhibited on a given day, which may have been attributed to environmental and

health factors. IC exhibited behaviors such as screaming and hitting his head with

his hand during the initial stages of both treatments. These behaviors were thought

to be characteristic of an adjustment period since IC had not received any form of

previous speech therapy. CH exhibited behaviors throughout the duration of the

study. These behaviors may have occurred as result of environmental and health

factors that arose throughout conduction of the study. At baseline, IC was able to

produce zero words spontaneously during NLP treatment and correctly verbalize

zero words during DTT. CH was able to produce 0 words spontaneously during

NLP treatment and verbalize three correct productions during DTT at baseline. At

the end of the 20 treatment sessions, IC and CH were able to produce 55 and 34

spontaneous words, respectively.

Assessment Results

During the assessment, both participants were observed while they engaged

in interaction with various toys. Their means of requesting and protesting were

evaluated, as well as their receptive and expressive language abilities. A parent

interview also was conducted to evaluate the medical, educational, and social

39

history of the participants. The information obtained from this interview is

discussed in the second chapter.

IC was able to produce six words during the assessment and exhibited

variegated babbling. He was able to follow simple one-step directions and

receptively identify common objects. IC requested particular items by pointing

and grunting in hopes that the clinician would obtain the object for him. He

protested through screaming and pushing away certain objects that he did not want

to engage in. IC did not verbally respond to questions asked by the clinician such

as "How are you?" and "What is your name?" He exhibited a willingness to

engage in interaction with the clinician and imitated actions made by the clinician,

such as flying a toy airplane through the air.

During the assessment, CH was able to verbally request "juice" when he

was thirsty. He was able to follow simple one-step directions. CH demonstrated

pacing behaviors in which he walked from wall to wall in the clinic room. He

protested by whining and crying, and requested objects by pulling his

communicative partner to an object he desired. CH seemed more interested in

physical activities, such as jumping and running around the room.

In addition to the parent interview and observation, the REEL-3 was

administered, an inventory that assesses the participants' receptive and expressive

language abilities. Table 3 presents the outcome for each participant.

Table 3. Assessment Results

Participant Receptive Language Expressive Language

IC Raw Score: 27 Raw Score: 34

Age Equivalent: 8 months Age Equivalent: 11 months

CH Raw Score: 34 Raw Score: 39

Age Equivalent: 10 Age Equivalent: 12

Treatment Results

The outcome for DTT and NLP treatment sessions will be discussed in this

section. Data collected for both participants will be evaluated.

DTT Treatment Results for Participant IC

Treatment utilizing DTT resulted in a steady acquisition of expressive

language. Picture stimuli were used for IC since he was able to produce verbal

approximations in response to picture stimuli compared to object stimuli during

the assessment and baseline sessions. In the first four treatment sessions of DTT,

IC was able to answer 4% to 16% of the trials correctly. He had difficulty

imitating models provided by the clinician and often did not attempt producing

approximations. IC demonstrated behaviors that served as protests against the

DTT tasks. Resistant behaviors were demonstrated characterized by screaming,

hitting, and escaping the treatment area in response to the clinician's attempts to

evoke verbalizations in response to treatment stimuli. The treatment stimuli that

were used were clothing items (shoes, shirt, pants, hat, "jammies" for pajamas)

and were not reinforcing to IC.

As the treatment sessions progressed, the clinician switched the treatment

stimuli to pictures of more enticing objects such as toys and food items with the

possibility of reducing the undesirable behaviors that IC was exhibiting during

DTT treatment. When the treatment stimuli of more reinforcing items were

introduced, IC's ability to correctly produce verbal responses increased to 58% of

the trials. Resistant behaviors were no longer observed and IC was willing to

participate in DTT. The use of the visual schedule served as a tool to allow IC to

know what tasks was expected of him to complete and he was compliant for the

remainder of DTT treatment sessions. During the sixth DTT treatment session, IC

41

was able to correctly verbalize 89% of the trials. This increase may be linked to

IC's increase in motivation from the treatment stimuli introduced in the fifth

treatment session. During the remainder of the DTT treatment sessions, IC was

able to answer 40% to 59% of the trials correctly, which may be due to the lack of

novelty and the regimented procedures of DTT. By the seventh session, IC

demonstrated resistant behaviors by showing affection to the clinician through

hugs to avoid participating in DTT tasks. His ability to correctly respond to

treatment stimuli was reduced by his lack of interest in DTT, which was

characterized by playing with the treatment stimuli and manding for reinforcers

used during break time.

IC was allotted 2-minute breaks after every 10 trials to reduce undesirable

behaviors and frustration with the tasks. During these breaks, the clinician

engaged in NLP structured play in which IC would mand for a reinforcer before

obtaining it. The clinician documented to requests and utterances expressively

produced by IC and found that treatment targets used in NLP were generalized to

the DTT setting during breaks. IC developed an ability to correctly mand for

reinforcers during breaks and was able to verbalize descriptors of those objects,

such as color and size. When the clinician signaled that breaks were coming to an

end and DTT therapy would resume, IC demonstrated avoidance behaviors such as

hiding behind furniture or directly requesting reinforcing items before attempting

DTT. A graph is provided to show baseline data and accuracy of treatment targets

produced during the treatment sessions in Figure 1.

DTT Treatment Results for Participant CH

Treatment results for CH provided stagnant results throughout the treatment

sessions. Object stimuli were used to increase CH's interest, which was noticed

100

so

40

20

Baselines Treatment

DTT

S 9 10

Figure 1. Baselines and DTT treatment accuracy for participant IC

during the baseline phase. After the first DTT treatment session, CH was able to

answer 19% of the trials correctly. He displayed difficulty following the visual

schedule, which was characterized by grabbing all of the colored icons at once or

pointing to the various treatment targets. By the second session, CH exhibited

resistant behaviors such as crying and screaming, which carried on through the

duration of the DTT treatment sessions. During the third and fourth treatment

sessions, CH was able to correctly answer 27% and 43% of the trials respectively

during the first 15 minutes of treatment. After 15 minutes of DTT treatment, CH

displayed resistant behaviors such as falling out of his chair and lying on the floor.

His tantrums became more violent and were characterized by hitting and kicking

the clinician, pulling the clinician's hair, hitting his head with his hand, and

scratching the clinician and himself. This heightened anxiety and resistant

behaviors became prominent upon entering the DTT treatment clinic room during

the remainder of the treatment sessions. During the 5 to the 10 DTT treatment

sessions, CH was able to answer 10% to 26% of the trials correctly. Majority of

the treatment sessions were directed at mitigating CH's resistant behaviors

allotting only 10-15 minutes of actual DTT treatment time per session. A graph is

43

provided to show baseline data and accuracy of treatment targets produced during

the treatment sessions in Figure 2.

S3

45 • t5 43 • 2 35, S 30-gi 25

£ 15-1 10-

0 -

Baseline

T *

Treatment

/

A / \

A .

y \ / ^ /

*—~^-

BL BL 1 2 3 1 2

4 5 6

Sessions

- • - B T T

/ ^

V

7 S 9 10

Figure 2. Baselines and DTT treatment accuracy for participant CH

CH was allotted 2-minute breaks every 10 trials in which he was allowed to

engage in reinforcing activities such as blowing bubbles or bouncing on a therapy

ball. The clinician documented CH's verbalizations that were produced to request

certain reinforcers, similar to the procedures used in NLP. During these breaks,

CH would continue to tantrum; however, aggressive behaviors were mitigated.

Upon redirecting CH back to DTT treatment, he exhibited more escalated

behaviors compared to those observed during breaks. It was apparent that DTT

treatment was aversive to CH and he protested during the duration of the treatment

sessions.

NLP Treatment Results for Participant IC

During the first treatment session for NLP, IC demonstrated an interest in

the treatment targets (castle, bubbles, plane, ball, fish) and was eager to engage in

activity. He was able to correctly produce 4% of the treatment trials; however, IC

exhibited difficulty and frustration with understanding the procedures that NLP

entailed and wanted to play with the objects rather than produce a mand for the

object. When the clinician withheld a desirable item from IC, he demonstrated

aggressive behaviors characterized by screaming, crying, hitting his head with his

hand, and throwing items on the floor. The clinician counteracted these behaviors

by redirecting IC to pick up the objects he threw on the floor. Majority of the first

NLP treatment session was directed at controlling IC's undesirable behaviors and

acclimating him to the routine of NLP.

After the first treatment session, IC no longer demonstrated aggressive

behaviors and was eager to participate in treatment. During the second NLP

treatment session, IC was able to produce 28% of the treatment trials correctly and

began to mimic phrases uttered by the clinician in response to activities the

clinician and IC were engaged in. By the third and fourth treatment session, IC

was able to correctly mand 71% and 88% of the treatment trials, respectively. He

began to use spontaneous three-word phrases in conjunction with the target items.

During the fifth treatment session, IC's accuracy of correct production decreased

to 59%; however, it was observed that IC just woke up from a nap immediately

before treatment and was still tired. A steady progression in the accuracy of

verbalizing the treatment targets was noticed and by the eighth NLP treatment

session, IC was able to answer 91% of the treatment trials correctly. The ninth

treatment session resulted in an accuracy rate of 95% for treatment trials. In

addition to the ability to mand for the treatment targets, IC was able to verbalize

colors of specific objects, numbers of objects from 1 to 15, verbs, adjectives, and

nouns associated with the treatment targets. By the final NLP treatment session, IC

was able to mand 97% of the treatment trials correctly and was able to

communicate his needs through phrases such as "My turn" and "Ian, all done."

Figure 3 shows IC's performance in the 10 NLP treatment sessions.

Figure 3. Baselines and NLP treatment accuracy for participant IC

NLP Treatment Results for Participant CH

During the first treatment session CH was able to answer 66% of the

treatment trails correctly. For the majority of the session, CH only attended to one

item and interacted with the item and clinician. He demonstrated a lack of interest

in the items that were chosen based upon the reinforcement sampling conducted

during the assessment. CH was able to correctly answer treatment trials with 55%

accuracy during the second NLP treatment session and engaged in activities that

provided sensory integration (bouncing and jumping on a therapy ball). For the

remaining sessions, CH's parents brought in reinforcing items that he was unable

to mand for from home and those were used as treatment targets. Resistant

behaviors began to arise during the third NLP treatment session and were

characterized by crying and whining. CH would pace up and down the treatment

room while engaging in repetitive flapping of the hands and vocalizations. A

decrease in accuracy of treatment trials occurred during the third and fourth

treatment sessions, which may have been related to the amount and severity of

undesirable behaviors present during those sessions. It was observed that CH cried

and whined for a majority of the third and fourth sessions while verbalizations

were at 43% and 46% for the third and fourth treatment sessions, respectively. An

increase in accuracy of treatment trials occurred on the fifth treatment session in

which CH was able to answer 67%) of the trials correctly.

A progression in accuracy continued in the following treatment sessions;

however, crying and whining behaviors were still observed. By the end of the

sixth session, CH was able to answer 83%) of the trials correctly and manded

mostly for edible items throughout the treatment session. During the seventh

session, CH was able to answer 62% of the trials correctly. It was noted that he

demonstrated resistant behaviors upon entering the clinic room and gesturally

manded for the clinician to open the door to cease treatment. At the end of the

eighth and ninth treatment sessions, CH was able to correctly verbalize 84% and

80% of the treatment trials, respectively. By the end of the eighth session, CH was

able to produce three-word phrases and descriptors of the items he manded for. At

the end of the final treatment session, CH produced 88% of the treatment trials

correctly. Despite the presence of undesirable behaviors, CH was able to verbalize

directives such as "Come here," "Open door," and "Help please." Data for the 10

NLP treatment sessions are shown in Figure 4.

100 so •

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10 •

Baseline

•

Treatment

a-""""- *--_

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1

i BL BL 1 2 3 4 5 6 7 8 9 10 1 - Sessions

- • -NLP

Figure 4. Baselines and NLP treatment accuracy for participant CH

47

Both DTT and NLP have shown to increase expressive language abilities in

both participants. Both IC and CH had greater outcomes with NLP. Data for DTT

and NLP are shown in Figure 5 and Figure 6 for each participant.

120 Baselines Treatment

too

so

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40

20

* i m . a .

z £± / \

z / "7" I—V

~T"

7 £ -/

T 1 1 1 1 1 1 1 1 1 1 1 r 1 1 1 1 1 1

BLBLBLBLl 2 3 4 5 © 7 8 9 10 11 12 13 14 15 15 17 IS 1920 1 2 3 4 Sessions

-•"NLP "•~ DTT

Figure 5. Baselines, DTT, and NLP treatment data for participant IC

130

90 •

XS 80 "

E 70-8 so-1 • • p 40 • 1 30-l 2 0 -

10 •

Baseline

•

• *

Treatment

+r^~~ 1-^ j

/ A • ^ s» \ \

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~ " Sessions -•-DTT -•-NLP

Figure 6. Baselines, DTT, and NLP treatment data for participant CH

Reliability

To ensure that the study was reliable, a second measure of the treatment

sessions was scored by an outside investigator. Twenty-five percent of the

treatment sessions were selected at random and were evaluated by the second

investigator. The second investigator charted separate data while observing the

treatment sessions. After a series of trials were conducted, the outside investigator

conferred with the clinician to determine reliability of charting procedures. Data

were accepted if the clinician and outside investigator established an accuracy of

at least 90% on a point-by-point agreement. Accuracy was measured at 96% and

94% for DTT and NLP, respectively. Reliability was established by having an

accurate second measure of the data by an outside investigator.

Chapter 4

DISCUSSION

In this study the effectiveness of DTT and NLP for treating children with

autism with limited expressive language abilities was compared. The study

consisted of 2 participants who were diagnosed ASD. Both DTT and NLP were

proven to be effective in increasing expressive language acquisition in both

participants; however, more significant results were noticed in terms of rate of

acquisition, generalization, and behavioral responses with NLP treatment.

Each participant's baseline and treatment data are reviewed in this chapter

to compare the effectiveness of both DTT and NLP. The procedural aspects of

each treatment will be reviewed to determine how the procedures affected the

results of the treatments. Discussion on the clinical implications, limitations, and

additional research also are included in the chapter.

Methodology

To conduct the study, a single subject alternating treatment designed was

used to determine if DDT treatment or NLP treatment is more effective in treating

children with autism with limited verbal skills. This particular comparison

between DTT and NLP was conducted previously by Koegel et al. (1987) utilizing

a multiple baseline design and by Koegel et al. (1998). Although the two previous

studies conducted differed in research design, setting, and duration, both studies

resulted in outcomes similar to that of this study.

In the study conducted by Koegel et al. (1987), the 2 participants received

DTT treatment for a number of sessions and then received NLP treatment for a

number of sessions. However, the number of treatments sessions were not

equivalent to the type of treatment or the participant. To identify the more

effective treatment, the number of utterances produced per trial were recorded.

Verbalizations produced during DTT and NLP treatment were recorded, as well as

utterances produced during break time. Two independent observers calculated the

number of verbalizations produced by the 2 participants and phonetically

transcribed the utterances (Koegel et al., 1987).

In the study conducted by Koegel et al. (1998), an ABA across subjects

research design was used to improve speech intelligibility in children with autism.

DTT and NLP treatment occurred at the word level. NLP involved contingent

recast, or correct verbalization of the target stimuli by the clinician immediately

following an incorrect verbalization produced by the participant. To determine

effectiveness, a 6-point Likert scale was used to rate the participant's productions

(Koegel et al., 1998).

In the present study, DTT and NLP treatments were conducted in separate

rooms. Both participants received 10 DTT treatment sessions and 10 NLP

treatment sessions for a duration of 50 minutes per session. Data were collected

through confrontational naming and spontaneous utterances produced in response

to treatment stimuli. Both utterances produced during treatment sessions and break

times were recorded.

Overview of Results

The findings in this study resembled those of the previous studies

conducted by Koegel et al. (1987) and Koegel et al. (1998). While DTT and NLP

have been both evaluated individually by a variety of researchers, the two

aforementioned studies compared the effectives of both methods in treating

51

children with autism with limited verbal skills. The purpose of this study was to

evaluate the effectiveness of DTT and NLP treatments utilizing an alternating-

treatment design to determine rates of language acquisition, accuracy of language

usage, and generalization.

Both participants presented with severe delays in expressive language

based upon the results of the REEL-3 (Bzoch et al., 2003) and observations made

during assessment. In addition, baseline data conducted over three sessions

determined that the gains made in expressive language were due to the

effectiveness of the two treatment methods.

Data collected during the treatment sessions provided information on the

rate of language acquisition, types of reinforcers that were more effective, and

effects of treatment on behaviors. In addition, data collected during break times

provided information on generalization and spontaneous use of language skills

acquired during treatment sessions.

Analysis of DTT and NLP

The following section consists of a discussion on the positive and negative

aspects of DTT and NLP, with respect to both participants. Clinical implications

for both treatments also are included.

DTT Analysis

DTT is a treatment that has been proven to be effective in treating the

expressive language deficits in children with autism. Both IC and CH were able to

make gains in their ability to produce verbalizations during DTT treatment

sessions. Treatment sessions were held for a duration of 50-minutes for each

participant. During DTT treatment, both participants exhibited difficulty engaging

in treatment for the duration of the 50-minute sessions. CH exhibited more

resistant behaviors to the treatment throughout the duration of the sessions. IC was

more receptive to the visual schedule provided during treatment, which aided in

his ability to tolerate treatment. While both participants were able to acquire

expressive language through DTT treatment, both participants found the treatment

to be aversive and both demonstrated avoidance behaviors.

In the initial stages of treatment, both participants progressed at a slow pace

and made moderate gains due to competing unfavorable behaviors. IC struggled

with producing verbalizations in response to the treatment stimuli. Vocalizations

were made but were not considered to be verbal approximations of the treatment

target. CH was able to attend during the first DTT treatment session and produced

verbal approximations and responded correctly to a few treatment stimuli.

However, by the second treatment session, CH demonstrated extreme resistance to

the treatment and exhibited resistant behaviors that perpetuated throughout the

remaining treatment sessions. Although behaviors occurred, CH was receptive to

treatment for the first 10 to 15 minutes of the session in which he would accurately

respond to the treatment trials. After the initial duration of the treatment session,

CH's behaviors would occur, and the remainder of the session would be focused

on reducing the undesirable behaviors and redirecting him to the treatment tasks.

During the middle stages of treatment, the treatment stimuli for IC were

switched to pictures of common objects in his environment such as edibles and

toys to mitigate behaviors that were occurring due to his lack of interest in the

treatment. At this point, IC was able to attend and maintain focus to the treatment

tasks. Significant gains in expressive language skills were made and IC

demonstrated an interest in learning to verbalize other objects in addition to the

treatment stimuli. IC would repeat the clinician's utterance when she verbalized

the colors he selected on the visual schedule. By the sixth treatment session, IC

was able to spontaneously verbalize the colors and mand for objects he desired

during break time. CH was able to make gains in the early stages of treatment;

however, during the middle stages of treatment, his aggressive behaviors and

resistance to treatment heightened. His accuracy with producing treatment trials

decreased significantly during the fifth treatment session and remained stagnant

for the remainder of the sixth and seventh sessions.

The final stages of treatment resulted in mixed outcomes for the

participants. IC demonstrated a 37% decrease in accurate productions by the

seventh session. His accuracy remained unchanged for the remainder of the

treatment sessions. His attention became more focused on manding for objects

used during break time, similar to procedures used in NLP. CH's accuracy became

dependent on behaviors that occurred during the treatment session. During the

seventh and eighth treatment sessions, CH's resistant behaviors emerged in the

observatory room prior to entering the DTT clinic room. He sat for a duration of 5

to 6 minutes before trying to escape the clinic room. During these sessions, his

verbalizations focused on requesting to exit the clinic room. CH demonstrated

severe aggressive behaviors during the remainder of the DTT treatment sessions,

characterized by pulling the clinician's hair and hitting himself and the clinician.

He had difficulty attending to the treatment tasks as soon as the session began,

resulting in a decrease in accurate productions.

Neither participant found DTT to be the favored treatment between DTT

and NLP. Both participants exhibited undesirable behaviors in response to the

treatment procedures. IC and CH both demonstrated an unwillingness to comply

during the treatment sessions by demonstrating resistance upon entering the clinic

room. An increase in interest was observed when the treatment stimuli for IC were

altered to stimuli that consisted of pictures of edibles and toys; however, his

accurate productions did not increase after the novelty of the stimulus items

subsided. A decrease in unfavorable behaviors may have occurred if the allotted

treatment time per session was reduced. To properly compare the effects of DTT

and NLP treatments, the frequency and duration of both treatment sessions were

the same for both participants.

NLP Analysis

NLP has been used as an effective means of treating children with autism

with various expressive language deficits. Treatments sessions involving NLP

occurred for a duration of 50 minutes each session for a total of 10 sessions. Both

participants found NLP to be less aversive and more willingly engaged in

treatment. Undesirable behaviors exhibited by both participants were kept to a

minimum due to the less stressful nature of the treatment method. Since NLP is a

child-directed treatment, the participants were able to choose the treatment target

they desired to engage with and were motivated to produce verbalizations. As

stated in chapter 1, the use of natural settings, child-directed procedures, and direct

reinforcers increases the motivation to participate in treatment, increasing the

likelihood that the participant will attempt to produce a verbalization to request a

desirable object (Gillett & LeBlanc, 2006).

In the initial stages of treatment, both participants conveyed their means of

communicating for objects they desired. IC would point to an object he wanted to

engage in and CH would pull the clinician to an object of his choice. Both

participants used gestures and attempted to communicate verbally. In order to

increase the participants' joint referencing abilities, the clinician would hold an

object that the participant desired out of reach (by the clinician's face) to increase

the likelihood of establishing and maintaining eye contact. For the participant to

55

obtain the object, he would have to attend to both the object and the clinician, and

attempt a verbalization. A discrepancy in the second baseline data for CH occurred

due to his manding for one object rather than attending to various objects in the

room. An increase his accuracy production derived from his desire to attend to the

only object he could verbalize during this baseline phase.

During the treatment sessions, the clinician commented on various

attributes of the object, otherwise known as tacting, as well as expanding on

comments made by the participants in relation to the treatment target. As the NLP

treatment sessions progressed, the participants began to spontaneously produce

comments made by the clinician in previous treatment sessions. Their ability to

mand and tact for objects generalized to the DTT treatment sessions held in

another clinic room and were also observed in the home setting by their parents.

While both participants made substantial gains with NLP treatment, this treatment

method was significantly effective for IC. He was highly receptive to treatment

and readily entered the NLP treatment room. IC attended to every treatment target

in the clinic room and engaged in imaginative play with the objects. His

imaginative play consisted of acting out scenarios with action figures and

transportation toys. During the treatment sessions, IC developed an ability to

comment on conditions of an inanimate object during a play scenario, such as

saying "ouch, stuck" if an action figure was stuck in a toy castle. CH was also

receptive to the treatment method and found it to be more enjoyable than DTT. He

would attend to edible objects and sensory activities, such as jumping on a therapy

ball or playing with objects that spun. Treatment targets were limited to such

objects since CH did not find many of the toys used in treatment reinforcing,

which may be due to the lack of sensory input they provided. CH developed an

ability to comment on attributes of objects such as "red car" or "big ball."

Although CH demonstrated some resistance to NLP treatment, his behaviors were

reduced compared to those exhibited during DTT.

Verbalizations produced during NLP treatment sessions generalized to the

DTT treatment room for both participants. IC and CH were able to spontaneously

request desirable objects during break times held during DTT. Their tacting

abilities also generalized to the DTT treatment room as well as the home setting.

IC's mother documented a list of his spontaneous words and phrases produced in

the home setting while the study was being conducted. Verbalizations produced in

the clinic setting were consistent were those produced in the home setting. In

addition, the rates of language acquisition for both participants were significantly

higher compared to DTT, which may be attributed to the participants' motivation

levels. NLP was effective in reducing undesirable behaviors and increasing

language acquisition in both participants.

Clinical Implication

DTT and NLP are two treatments that have been proven to be effective in

treating the expressive language deficits in children with autism. DTT has been

used to teach social skills and self-help, as well as language skills in children with

autism. NLP has been proven effective in treating a wide range of language

deficits, including language acquisition and intelligibility.

The results of this study showed that NLP is more effective in producing

significant gain in expressive language compared to DTT. When children have an

increased motivation level and are engaged in activities, their likelihood of making

greater efforts during treatment increases. The naturalistic aspects of NLP

treatment, such as letting the participants engage in play with the objects of their

choice compared to the structured procedures of DTT reduced the anxiety and

stress exhibited by both participants. The rate of language acquisition exhibited by

both participants in response to NLP treatment was significantly higher compared

to that observed in DTT. Their ability to generalize their verbalizations produced

in the NLP treatment room to various settings was also observed, while

productions made during DTT sessions were not generalized. The results of this

study have proven NLP to be effective in increasing language acquisition,

reducing undesirable behaviors, and promoting generalization in children with

autism.

Comparison of DTT and NLP

DTT and NLP were effective in increasing the expressive language abilities

of each participant. Although both treatments resulted in gains, NLP proved to be

more efficient than DTT. Equivalent number of treatment sessions and the same

duration of time were allotted for both DTT and NLP; however, both participants

found DTT to be aversive, while acquiring significant gains in expressive

language as a result of NLP. As a result of this study, it is recommended that NLP

be utilized to treat expressive language skills in children with autism.

DTT treatment resulted in an increase in the participants' ability to produce

verbal productions, but often resulted in resistant and undesirable behaviors.

Arbitrary reinforcers did not seem to provide an increase in motivation, and the

participants manded for the reinforcers instead of verbalizing the treatment target

in order to receive the reinforcer. The structure and rigid practice of DTT is useful

in enhancing confrontational naming abilities. DTT would serve as an effective

method for teaching children with autism the functional skills needed for everyday

living.

NLP differed from DTT in the procedures used to evoke verbalizations.

NLP was more naturalistic and was child-directed. Treatment consisted of having

the child attend to highly reinforcing items and manding for a specific object to

play with. The use of direct reinforcers increased the motivation of the

participants. Both participants were able to increase their ability to not only

produce nouns, but also adjectives, verbs, and adverbs. NLP treatment also

promoted generalization of treatment targets to various settings. Although both

participants received equal amounts of DTT and NLP, more favorable and

efficient outcomes resulted from NLP.

Limitations and Future Research

The results of this study indicate that both DTT and NLP treatment

methods have the capability of producing positive results in improving expressive

language skills. NLP was more effective throughout the duration of the treatment

sessions and resulted in less resistant behaviors. To provide more efficacy, it is

recommended that this research study be replicated. This study was conducted

across 20 treatment sessions. For future studies, a more longitudinal study would

provide information on the maintenance of language acquired during the treatment

sessions. In addition, NLP was proven to be more effective in treating language

disorders in children with autism; therefore, treating other disorders to determine

which populations benefit from either DTT or NLP treatments would be possible

topics for future research.

Future studies should involve participants from various ethnicities, ages,

disorders, and should be collected from various geographic locations. Altering

treatment procedures such as visual schedules and other transitional cues to further

59

reduce unfavorable behaviors should also be applied to provide therapy that would

result in the best outcomes possible.

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APPENDICES

APPENDIX A

PARTICIPANT STIMULI LIST

Stimulus List for IC

Verbalizations Produced with at least 90% accuracy.

Discrete Trial Training Natural Language Paradigm

Trained Words: Hat Pants Jammies Color Cup Star Cheerios Carrot Pizza Banana Hamburger Pizza Butterfly Shoe

Trained Words: Ambulance Boat Helicopter Fire Truck Boat Horse Sheep Duck Girl Man Blocks Police car

Plane Cat Fish Green Blue Red Pink Yellow Orange Bubbles Castle Pin

Spontaneous Words and Phrases: All spontaneous verbalizations produced during DTT treatment sessions occurred during breaks and visual schedule transitions in the form of NLP treatment.

Spontaneous Words and Phrases: Ready, set, go Clean up My turn Stuck Crash On Close Peek-a-boo Come on Get out Help Up Down Knock, knock Bye-Bye Good 1-18

Words Produced Prior to Treatment: Doi Car Cookie Duck Apple Sun

Stimulus List for CH

Verbalizations Produced with at least 90% accuracy.

Discrete Trial Training Natural Language Paradigm

Trained Words: Ball Crayon Plane Spoon Cup Book Train

Trained Words: Bounce Jump Water Cereal bar Pillow I want pillow Bubbles French fries Castle Red car Big ball Car Frito Cereal Pole Inside Rice cake Spin Blue Farmer Ted

Spontaneous Words and Phrases: All spontaneous verbalizations produced during DTT treatment sessions occurred during breaks and visual schedule transitions in the form of NLP treatment.

Words Produced Prior to Treatment:

Spontaneous Words and Phrases: My turn Open More Carson Come here Go All done

Cow

APPENDIX B

TREATMENT DATA SHEET

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Discrete Trial Training and Natural Language Paradigm Data

Participant: Treatment:

Date: Session

Target Behavior

Spontaneous Words

Total Percentage Correct:

Behaviors:

Key: + = Correct

- = Incorrect

P = Prompted