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Journal of Positive Behavior Interventions

The Differential Effect of Three

13(2) 109­–118
© Hammill Institute on Disabilities 2011
Reprints and permission: http://www.
Naturalistic Language Interventions on sagepub.com/journalsPermissions.nav
DOI: 10.1177/1098300710384507

Language Use in Children With Autism http://jpbi.sagepub.com

Brooke Ingersoll1

Abstract
Naturalistic interventions show promise for improving language in children with autism. Specific interventions differ in direct
elicitation of child language and indirect language stimulation, and thus may produce different language outcomes. This study
compared the effects of responsive interaction, milieu teaching, and a combined intervention on the type and communica-
tive function of expressive language in two preschoolers with autism using a randomized alternating treatments design.
Milieu teaching led to more overall language, prompted language, and requests than responsive interaction. Responsive
interaction led to more comments than milieu teaching. The combined intervention was similar to milieu teaching for
prompted language and requests and responsive interaction for child comments. Implications for treatment of language
deficits in autism are discussed.

Keywords
autism, language, intervention, natural environment

Children with autism spectrum disorders (ASD) exhibit
significant difficulties with the acquisition of spoken language.
A number of intervention approaches have been developed
for teaching language skills to young children with autism
and other language delays. One class of interventions, natu-
ralistic language interventions, has been shown to be particu-
larly effective for promoting functional language skills that
generalize to the natural environment (Prizant, Wetherby, &
Rydell, 2000). These interventions teach language skills in
informal settings not primarily designed for language instruc-
tion, address topics of interests to the child, include linguistic
input appropriate for the child’s level of language develop-
ment, and provide natural reinforcement for the child’s com-
munication (Carrow-Woolfolk, 1988).
Within the class of naturalistic language interventions are
specific strategies that have emerged from two different
theoretical perspectives: the behavioral perspective and the
social interactionist perspective (Yoder et al., 1995). Natural-
istic interventions stemming from a behavioral perspective,
such as milieu teaching (Alpert & Kaiser, 1992), incidental
teaching (Hart & Risley, 1968; McGee, Krantz, Mason, &
McClannahan, 1983), and pivotal response training (PRT;
Koegel, O’Dell, & Koegel, 1987), promote language use via
direct prompting and reinforcement. There are a number of
studies that support the effectiveness of naturalistic behavioral
interventions for increasing language skills in children with
language disorders, including ASD (see Goldstein, 2002;
Kaiser, Yoder, & Keetz, 1992, for reviews). Those interven-
tions stemming from a social interactionist perspective, such
as responsive interaction (Weiss, 1981), the Ecological Com-
munication Organization (ECO) model (MacDonald, 1989),
transactional intervention (Mahoney & Powell, 1988), interac-
tive focused stimulation (Girolametto, Greenberg, & Manolson,
1986; Girolametto, Pearce, & Weitzman, 1996) and the Hanen
Centre’s More Than Words program (Sussman, 1999), are based
on descriptions of interactions between language-learning
children and their caregivers (Hoff-Ginsberg & Shatz,
1982). These interventions are focused on increasing the
adult’s responsiveness to the child and establishing balanced
turns between the child and the adult. These interventions do
not emphasize child production of specific language targets;
rather, they focus on providing models of developmentally
appropriate language around the child’s focus of interest and
expanding on the child’s utterances (Hemmeter & Kaiser,
1994; Kaiser et al., 1996). Research on this approach has
shown it to be effective for increasing expressive language
1
Michigan State University, East Lansing, MI, USA
Corresponding Author:
Brooke Ingersoll, Michigan State University, 105B Psychology Building,
East Lansing, MI 48824
Email: ingers19@msu.edu
Action Editor: Debra Kamps
110 Journal of Positive Behavior Interventions 13(2)
in children with language delay (Girolametto et al., 1996;
Kaiser et al., 1996). However, the evidence base for this
approach for children with ASD is very limited to date (Ingersoll,
Dvortcsak, Whalen, & Sikora, 2005).
The primary difference between these two naturalistic
intervention approaches is the degree to which the therapist
directly elicits child production of language targets and pro-
vides appropriate language models and expansion of the child’s
utterances (Yoder et al., 1995). Based on the differences in the
two approaches, it might be expected that they would have
different effects on child language behavior (Hemmeter &
Kaiser, 1994; Yoder et al., 1995), both in terms of the type of
language used (prompted or spontaneous) and its communica-
tive function (requesting or commenting). For example, milieu
teaching, with its focus on direct elicitation of language around
desired items, might be expected to produce prompted language
that is predominated by requests. In contrast, responsive inter-
action, with its focus on language modeling and expansions,
might be expected to facilitate spontaneous language that is
predominated by comments. Some researchers have proposed
combining important components of the two (namely prompt-
ing and modeling/expansion) to create language interventions
that are more powerful. The resulting interventions, enhanced
milieu teaching (EMT; Hancock & Kaiser, 2002; Kaiser &
Trent, 2007) and responsive education and prelinguistic milieu
teaching (RMPT; Yoder & Warren, 2002), have been shown
to be effective for increasing verbal and preverbal language
in children with developmental disabilities, including autism.
However, combined interventions have not been compared
to either milieu teaching or responsive interaction imple-
mented individually. Furthermore, direct comparisons between
milieu teaching and responsive interaction have been very
limited. Thus, little is known regarding the relative effects
of the three types of naturalistic interventions on language
use in children with ASD.
The little research that has compared different interventions
indicates that they may indeed teach different language skills.
For example, in one study, Yoder et al. (1995) used a group
design to compare the effect of classroom-based responsive
interaction and milieu teaching on receptive and expressive
language development in children with developmental delays.
Although children in both groups showed treatment-related
improvements on measures of receptive and expressive lan-
guage, there were no group differences at posttest. Regression
analyses indicated that children with lower pretreatment lan-
guage skills benefited more from milieu teaching, whereas
children with higher pretreatment language skills benefited
more from responsive interaction. The authors suggested that
this finding might be due to differential effects of the two
interventions on the type of language being taught. For exam-
ple, milieu teaching might be better for teaching vocabulary,
which was the primary goal for the early language learners,
and responsive teaching might be better for teaching syntactic
relationships, which was the primary goal for the later language
learners. However, in this study, the children’s language level
and language targets were confounded. Also, the authors did
not examine the effects of the interventions on the commu-
nicative functions of the children’s language.
In a second study, Salmon, Rowan, and Mitchell (1998)
used an alternating treatments design to compare the effects
of a minimal prompt (responsive interaction) and an explicit
prompt (milieu teaching) intervention on intentional com-
munication in three nonverbal preschoolers with develop-
mental delay. Their results indicated that the explicit prompt
condition produced a higher overall rate of intentional com-
munication, with a much higher rate of requests and responses.
The minimal prompt condition led to a more balanced distri-
bution of communicative functions (comments and requests)
and discourse functions (initiations and responses), with com-
ments and initiations making up a greater proportion of total
communicative acts than in the explicit prompt condition.
The authors concluded that although milieu teaching may be
effective for increasing the frequency of a child’s communi-
cation, responsive interaction is more successful at promoting
commenting and initiations. However, only the proportion
of requests to comments and responses to initiations was
examined, rather than the overall rate of each behavior. Thus,
it is possible that the explicit prompt condition produced a
higher rate of all communication behaviors (commenting and
initiating as well), but was most effective at increasing com-
municative responses that served a requesting function. If this
were the case, it would significantly temper the authors’ con-
clusions regarding the potential benefit of responsive interac-
tion techniques.
The goal of this study was to compare the effect of three
naturalistic language teaching approaches (responsive inter-
action, milieu teaching, and a combined intervention) on the
expressive language behavior of two young children with
ASD. It was hypothesized that the milieu teaching condition,
with its use of prompting and reinforcement, would produce
more overall language, prompted language, and requests than
the responsive interaction condition. Second, it was hypoth-
esized that the responsive interaction condition, with its use
of modeling and expanding language, would produce more
spontaneous language and comments than the milieu teach-
ing condition. Furthermore, it was hypothesized that the
combined condition would produce a similar rate of prompted
language and requests as the milieu teaching condition and
a similar rate of spontaneous language and comments as the
responsive interaction condition, leading to a higher rate of
total language than the other two conditions.
Method
Participants
Two young children with autism participated in this study.
Diagnoses were provided by an outside professional with
Ingersoll 111
expertise in autism and were confirmed by the author using
Diagnostic and Statistical Manual of Mental Disorders–
Fourth Edition criteria (American Psychiatric Association,
2000). The Bayley Scales of Infant Development, 2nd Ed.
(Bayley, 1993) or Mullen Scales of Early Learning (Mullen,
1995) were administered to determine the children’s nonver-
bal and verbal mental age at intake. In addition, the children’s
primary caregivers completed the MacArthur-Bates Com-
municative Development Inventory (CDI; Fenson et al., 1993)
to measure the children’s expressive vocabulary.
Leon was 42 months at intake. Leon was in the moderate
range of autistic symptomology and met full criteria for a
diagnosis of autism. His nonverbal mental age was 28 months
and his verbal mental age was 21 months on the Bayley. On
the CDI, his expressive vocabulary was 56 words, which is
equivalent to about 17 months expressive language age. His
spontaneous language consisted primarily of word approxima-
tions and single words. Leon mainly communicated for the
purpose of requesting and protesting. Leon’s language targets
for this study consisted of single words.
Griffon was 40 months at intake. Griffon was in the mild
range of autistic symptomology and met full criteria for a
diagnosis of autism. His nonverbal mental age was 29 months
and his verbal mental age was 34 months on the Mullen. On
the CDI, Griffon’s expressive vocabulary was 579 words,
which is equivalent to about 30 months expressive language
age. His spontaneous language consisted mainly of single
words and simple phrase speech. He used a variety of com-
municative functions, including requesting, commenting/
sharing, protesting, greeting, and gaining attention and infor-
mation. Griffon’s language targets for this study consisted of
noun–verb and noun–adjective combinations.
Setting and Materials
All sessions were conducted in a small treatment room at an
intervention center specializing in communication disorders.
A number of motivating toys were made available during treat-
ment. Although toys were varied each day, they were the same
for all conditions occurring on the same day.
Procedure
A single-subject, randomized alternating treatments design
was used with both participants (Hersen & Barlow, 1976).
The order of conditions was assigned using a random number
generator with the restriction that each condition must occur
the same number of times for each participant. Participants
attended the intervention center 2 days per week for approxi-
mately 1 month. At each visit, three to four 10-min treatment
sessions were conducted, totaling seven to eight implementa-
tions of each condition for each child. Condition length and
overall length of treatment were kept short in an attempt to
control for treatment carryover due to learning and changes
due to overall maturation. Ten-minute sessions provided for
an adequate sample of behavior, while also allowing data
collection to be completed in a relatively short amount of
time. Neutralizing sessions (i.e., sessions in which each child
engaged in a nonstudy activity) were not used between treat-
ment sessions.
Treatments
All treatment was provided by a doctoral-level clinical psy-
chologist with extensive experience implementing a range of
naturalistic interventions with young children with autism.
Responsive interaction condition. The responsive interaction
condition consisted exclusively of language modeling and
expansions emphasizing the children’s language targets. The
therapist sat next to the child and narrated, labeled, and
described the child’s play using simplified language, with a
goal of one language model every 10 to 15 s. For example, if
the child was rolling a car back and forth, the therapist might
model, “Car” (for Leon) or “Roll car” (for Griffon). This rate
was used to provide enriched language input, while still allow-
ing the child an opportunity to respond. In addition, the thera-
pist expanded on the child’s communication. For example,
if the child said, “Car,” the therapist might respond by saying
“Drive car.” The therapist responded to all child commu-
nication in a contextually appropriate manner (see Note 1);
however, she did not attempt to directly elicit language during
the session.
Milieu teaching condition. The milieu teaching condition
consisted exclusively of direct elicitation of the children’s
language targets using milieu language teaching (Kaiser
et al., 1992), with a goal of one elicitation every 20 to 30 s.
For example, if the child was rolling a car back and forth,
the therapist might gain access to the car by taking a turn or
interrupting the child’s play and prompt the child to say,
“Car” (for Leon) or “Red car” (for Griffon). Four types of
milieu language prompts were used: Model (“Car”; “Drive
car”), mand (“Say, ‘Car’”; “Tell me what you want”), ques-
tions (“What do you want?”; “What color car?”), and time
delay (restricting access with an expectant look). A general
prompt hierarchy was used such that novel labels were elicited
using a model, and labels that were known to the children
were targeted first with time delay, followed by a question
or mand if the child did not respond appropriately. Once the
child used the language target or made a clear attempt, the
therapist would reinforce the child’s language behavior with
access to the desired materials. The therapist used minimal
other language during the session. Given the focus of milieu
teaching, directly elicited language served a requesting func-
tion, although the children could use other language functions
during the session.
Combined condition. The combined condition consisted of
both responsive interaction and milieu teaching strategies to
address the children’s language targets.
112 Journal of Positive Behavior Interventions 13(2)

Table 1. Behavioral Definitions

Language type/
communicative
function Definition
Total language The child uses his language target for the purpose of communicating with the therapist. Language may be in response
to the therapist’s communication or spontaneously initiated. Language must be in context and meaningful.Total
language was then categorized according to type (prompted or spontaneous) and function (requests or comments).
Prompted The child uses his language target to maintain an interaction by responding within 3 s to the therapist’s prior verbal
language behavior.This includes verbal imitation of a model, answers to questions, compliance with directions, and topic
extension. Prompted language includes responses to therapist prompts as well as responses to therapist comments.
Spontaneous The child uses his language target to spontaneously initiate an interaction with the therapist. There must be at
language least 3 s between the therapist’s last utterance and the child’s production.
Requests The child uses his language target for the purpose of requesting a desired object or activity or to protest the
therapist’s behavior.
Comments The child uses his language target for the purpose of labeling or commenting on an object or activity for the
purposes of social interaction.

Dependent Measures engaged in each of the defined treatment components for

All sessions were videotaped and scored for child production
of language targets (i.e., single words for Leon and noun–verb
and noun–adjective combinations for Griffon) by trained under-
graduate research assistants blind to order of the conditions.
The primary rater scored all observations, and these data were
used in all analyses. The secondary rater scored every third
observation to ensure interrater reliability. Child language
behavior was scored for total appropriate language using
occurrence/nonoccurrence data in 10-s intervals. Total language
was further categorized by language type (prompted language
or spontaneous) and communicative function (requests or com-
ments) using occurrence/nonoccurrence in 10-s intervals (see
Table 1). Thus, all total language was also scored as either
prompted or spontaneous language. Instances of total language
that did not serve one of the two communicative functions of
interest (e.g., questions, greetings) were not scored for language
function. These instances were extremely rare.
Fidelity of Implementation
Two separate undergraduate research assistants were trained
to score fidelity of implementation by recording therapist
use of the two defined treatment components, modeling/
expanding language and prompting language, using occurrence/
nonoccurrence data in 10-s intervals (see Table 2). These thera-
pist behaviors were not mutually exclusive and, thus, could
both occur in the same interval. Again, the primary rater
scored all observations and these data were used in the analy-
ses, whereas the second rater scored every third session for
reliability. Raters were kept blind to the order of conditions.
Table 2 presents the average number of intervals and the
range of intervals across sessions in which the therapist
each condition.
Reliability
Reliability data were collected on every third observation
(36%) using Cohen’s Kappa, which corrects for chance
agreement. Cohen’s Kappa was calculated on the number
of agreements and disagreements per interval using the stan-
dard formula (Cohen, 1960). Kappa values between .61 and
.80 are considered to indicate substantial agreement, and
Kappa values between .81 and 1.0 are considered to represent
almost perfect agreement (Landis & Koch, 1977). Kappa
values were .82 for total language, .78 for prompted lan-
guage, .73 for spontaneous language, .78 for requests, .75
for comments, .65 for modeling & expanding language,
and .76 for prompting language, indicating good to very good
agreement.
Data Analysis
Data analysis was conducted using visual analysis. Random-
ization tests were used to verify observed differences in treat-
ment conditions (Good, 2000; Todman & Dugard, 2001). To
conduct this analysis, a computer program randomly selected
data points from the pooled data of the two conditions being
compared and placed them in two bins. The means of the
two bins were compared to see if they were equal to or greater
than the observed mean difference. This process was com-
pleted 1,000 times for each comparison. Differences in per-
formance between conditions were considered significant
if the calculated mean difference was less than the observed
mean difference on 95% or more of the simulations (Ingersoll
& Schreibman, 2006; see Table 3).
Ingersoll 113

Table 2. Percentage of Intervals in Which the Therapist Engaged in Each of the Defined Treatment Components for Each Treatment
Condition

Treatment condition, M (range)

Responsive Combined
Technique Behavioral definition interaction Milieu teaching intervention
Modeling & The therapist engages in descriptive and parallel 85.24% (69–100%) 17.31% (0–38%) 60.86% (50–82%)
expanding talk around child’s focus of attention or uses
language expansion by imitating the child’s language and
adding information. Language must be descriptive in
nature rather than in the form of a question and the
therapist must not require the child to imitate or
otherwise respond to her language.
Prompting The therapist uses a verbal instruction, question, 1.33% (0–7%) 40.19% (27–50%) 39.34% (23–55%)
language model, or nonverbal prompt (e.g., holding the bubbles,
blocking the child’s play with cars) to elicit a verbal
response from the child. The therapist must reinforce
the child by providing access to the desired materials
or activity contingent on the child’s language response
within 10 s of the response. If prompting occurred
across intervals, only the interval in which the
therapist delivered the reinforcer was recorded.

Table 3. Means and Standard Deviations of Conditions for Each Participant

Responsive Milieu Combined

Participant interaction teaching intervention
Total language  
Leon 13.89 (8.28)a,b 55.13 (3.68) 48.29 (6.90)
Griffon 40.00 (13.50)a 55.75 (8.58) 54.86 (6.54)
Language type: prompted  
Leon 7.74 (4.74)a,b 38.39 (7.97) 31.97 (5.07)
Griffon 13.42 (5.70) 32.32 (4.05) 30.02 (7.44)
Language type: spontaneous  
Leon 6.53 (6.95)a,b 24.70 (7.11) 22.45 (9.57)
Griffon 28.47 (11.81) 28.60 (10.42) 29.91 (11.51)
Communicative function: request  
Leon 3.86 (3.72)a,b 51.00 (5.45) 44.29 (8.71)
Griffon 8.38 (7.33)a,b 42.63 (11.46) 35.00 (11.08)
Communicative function: comments  
Leon 10.57 (8.22)a 3.25 (2.38) 5.71 (5.31)
Griffon 25.25 (9.33)a 13.75 (6.82) 20.00 (10.17)
a. Significantly different from milieu teaching based on randomization test (p < .05).
b. Significantly different from combined intervention based on randomization test (p < .05).

Results the responsive interaction condition. Visual analysis suggests

Total Language
Leon exhibited a substantial difference in his use of total
language between treatment conditions that maintained
throughout treatment (see Figure 1). Both visual analysis and
randomization tests indicate that Leon used more total lan-
guage in the milieu teaching and combined conditions that in
that Leon used slightly more language in the milieu teaching
than the combined condition; however, these differences were
not significant when analyzed using a randomization test.
There was an initial difference in total language between
the three conditions for Griffon, with the milieu teaching and
combined conditions producing substantially more total lan-
guage than the responsive interaction condition. However,
114 Journal of Positive Behavior Interventions 13(2)
100
Percent of Intervals
80
60
40
20
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
Session
100
Percent of Intervals
80
60
40
20
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Session
Figure 1. Total language for each child in each condition
visual analysis indicates that Griffon’s use of total language
in the responsive interaction condition increased over the
course of the study such that it was no longer different from
the other conditions by the end (see Figure 1). The random-
ization tests indicate that the combined condition was not
significantly different from the responsive interaction condi-
tion; however, the milieu teaching condition was significantly
different from the responsive interaction condition. The milieu
teaching and combined condition did not differ significantly
from each other.
Language Type
Prompted language. Both Leon and Griffon used signifi-
cantly more prompted language in the milieu teaching and
combined conditions than in the responsive teaching condi-
tion, although Griffon’s use of prompted language in the
responsive interaction condition increased toward the end of
the study period (see Figure 2). Randomization tests con-
firmed these differences. Although visual analysis suggests
that the milieu teaching condition may have produced slightly
more prompted language than the combined condition for
both children, these differences were not significant.
Spontaneous language. As depicted in Figure 2, Leon used
significantly more spontaneous language in the milieu teach-
ing and combined conditions than in the responsive interaction
condition, but his spontaneous language did not differ between
Responsive Interaction
Milieu Teaching
Combined
Leon
Griffon
the milieu teaching and combined conditions. At the begin-
ning of the study, Griffon used slightly more spontaneous
language in the milieu teaching and combined teaching con-
ditions than the responsive interaction condition. However,
the amount of spontaneous language he used in the responsive
interaction condition increased over the course of the study,
such that the conditions did not differ by the end. Random-
ization tests confirm that none of the conditions differed in
spontaneous language use for Griffon.
Communicative Function
Requests. Both Leon and Griffon used significantly higher
rates of requests in the milieu teaching and combined condi-
tions than the responsive teaching condition (see Figure 3).
Although visual analysis suggests that both children used
slightly more requests in the milieu teaching than the com-
bined teaching conditions, randomization tests did not con-
firm this difference.
Comments. Visual analysis indicates that both children
produced slightly more comments in the responsive interac-
tion than the milieu teaching condition (see Figure 3). Ran-
domization tests indicated that these differences were
significant. Visual analysis suggests that both children’s rates
of comments in the combined condition were similar to their
rates in the other two conditions. Randomization tests con-
firmed that the rate of comments in the combined condition
Ingersoll 115
Figure 2. Type of language used by each child in each condition
was not significantly different from the responsive interaction
or milieu teaching conditions.
Fidelity of Implementation
The fidelity of implementation data indicated that the amount
of prompting was implemented at a very low rate in the respon-
sive interaction condition (1.33%) and at a moderate rate in
the milieu teaching (40.19%) and combined (39.34%) condi-
tions. Modeling and expanding language was used at a high
rate in the responsive interaction condition (85.24%), a moder-
ate to high rate in the combined condition (60.86%), and a
low rate in the milieu teaching (17.31%) condition. These
data indicate that the conditions were implemented as intended
and differed on the key intervention components.
Discussion
The three treatment conditions led to different patterns of
language use. Consistent with the first hypothesis, the milieu
teaching condition produced significantly more total language
than the responsive interaction condition. This difference
was due mainly to an increase in the rate of prompted lan-
guage and requests in the milieu teaching condition, but also
to an increase in spontaneous language for Leon. This finding
indicates that direct elicitation of language leads to higher
rates of language behavior than indirect language stimulation.
This is particularly the case for prompted language and lan-
guage that serves a requesting function. It is interesting to
note that the benefit of milieu teaching for increasing overall
language was much greater for Leon, the child with lower
pretreatment language ability. Griffon, who had more complex
language, showed a strong initial benefit of milieu teaching,
but began to increase his overall language in the responsive
teaching condition over time. This finding is partially consis-
tent with Yoder et al.’s (1995) finding that children who began
treatment with lower language abilities benefited more from
milieu teaching, whereas children with higher pretreatment
language abilities benefited more from responsive interaction.
However, it is also possible that Griffon’s increase in language
in the responsive interaction condition over time was due to a
carryover effect from the other conditions. Additional research
116 Journal of Positive Behavior Interventions 13(2)
Figure 3. Communicative function of language used by each child in each condition
on this possibility is needed to extend these findings to chil-
dren with ASD.
Consistent with the second hypothesis, the responsive inter-
action condition led to a small, but consistently higher, rate of
commenting than the milieu teaching condition. Although all
conditions included some modeling and expansion as indi-
cated by the fidelity data, the responsive interaction condition
included a far greater rate of these therapist behaviors (85%
of intervals) than the milieu teaching condition (17% of inter-
vals). This finding indicates that the intensive use of modeling
and expanding language techniques used in responsive interac-
tion may directly promote the use of commenting, and in fact,
may lead to more commenting than prompting and reinforce-
ment techniques used in milieu teaching.
Contrary to expectations, neither child used more spon-
taneous language in the responsive interaction than the milieu
teaching condition. In fact, the trend was in the opposite direc-
tion. Leon used more spontaneous language in the milieu teach-
ing than responsive interaction conditions throughout the
study. Griffon used more spontaneous language in the milieu
teaching and combined condition initially; however, his rate
of spontaneous language in the responsive interaction condi-
tion increased over the course of the study, such that it was
not significantly different between conditions by the end.
Salmon et al. (1998) reported that their minimal prompt condi-
tion produced a greater proportion of initiations (spontaneous
language in this study) than their explicit prompt condition.
The current results suggest that although responsive interac-
tion increased the proportion of spontaneous to prompted
language, it did not produce a higher rate of spontaneous
language than milieu teaching; in fact, for Leon, it produced
less spontaneous language. It is likely that the higher rate
of spontaneous language in the milieu teaching condition for
Leon was due to the use of a time delay to illicit child language.
Indeed, when the spontaneous language data were reanalyzed
without including language produced in response to a time
delay, there was no longer a difference in the amount of spon-
taneous language used in any of the conditions for either child.
Consistent with the third hypothesis, the combined condi-
tion was similar to the milieu teaching condition in terms of
the rate of prompted language and requests and was similar
to the responsive interaction condition in terms of the rate of
child comments. However, the combined condition did not
lead to more overall language than the other two conditions.
Rather, it produced language that fell in between the other
two, leading to an overall language rate slightly below but
not significantly different from the milieu teaching condition.
This finding suggests that at least for these two participants,
Ingersoll 117
prompting was the most powerful treatment strategy for pro-
ducing child language. Perhaps if the combined condition had
used a lower rate of prompting, there would have been more
opportunity for commenting. This potential outcome is pos-
sible given the higher rate of commenting in the responsive
interaction than the milieu teaching condition. Responsive
interaction interventions often include other treatment strate-
gies, such as imitating the child’s nonverbal behavior and turn-
taking (e.g., Mahoney & Powell, 1988), which may increase
their effectiveness in isolation or in combination with prompt-
ing techniques. Thus, the added benefit of combined interven-
tions should be examined in future research.
In this study, the treatments were short in duration and low
in intensity, and baseline data were not collected. Thus, this
study cannot evaluate the degree to which these interventions
improve overall language ability, nor the long-term effects
of the interventions when implemented at a higher degree of
intensity (e.g., more than about 20 min per week). However,
previous research has found these interventions to be effective
for promoting language skills in young children with ASD
and language delay.
Given that the goal was to compare the patterns of language
use produced by the three treatments, this study used a rapidly
alternating treatments design. This design can demonstrate
that within an individual, different types of language and com-
municative functions rapidly shift in step with changes in the
interventions. The findings indicate that both participants
exhibited similar patterns of responding to the three conditions
despite having different language abilities, suggesting that
these interventions differentially impact language skills. How-
ever, alternating treatment designs can be susceptible to car-
ryover effects, in which gains in one condition generalize to
the other conditions. Although we used a randomized design
and kept session lengths short in an attempt to avoid this pos-
sibility, it is still possible that child gains in one condition (e.g.,
milieu teaching) may have led to improvements in another
condition (e.g., responsive interaction). This possibility seems
more likely for Griffon, who showed improvements in lan-
guage use over time during responsive interaction sessions.
Although the differences in patterns of language use across
conditions were statistically significant, for behaviors such
as commenting, these differences were small. Thus, one might
question the clinical significance of these results. However,
the fact that differences were evident at such low intensities
suggests the need for additional research in this area, as it
might have important implications for the selection of inter-
vention strategies for young children with ASD.
Future research should investigate interventions imple-
mented at a greater intensity over a longer period of time. With
more intensive treatments, the differences between interventions
observed in this study might become greater and, thus, more
clinically significant. Alternatively, the observed differences
might diminish over time, especially if the different intervention
strategies have their impact on language skills on a different
time course or require different intensities to achieve maximal
benefit. For example, milieu teaching, with its use of direct
elicitation, may immediately increase target production, even
when implemented at a low intensity, whereas responsive inter-
action may require more time or intensity to increase production
of target utterances. This possibility is consistent with the fact
that Griffon, the child with better initial language skills,
increased his use of language targets over time in the responsive
interaction condition and is underscored by research that finds
parent responsiveness to be associated with long-term positive
language outcomes (Mahoney & Perales, 2005). Future research
is needed to determine the rate of change of different language
behaviors in response to various naturalistic language interven-
tions, as well as whether the interventions differ in their ability
to promote generalization of skills to other environments.
A few additional limitations of this study affect its inter-
pretation, including the use of only two participants with
differing language abilities and the small number of treatment
sessions per condition. Thus, future research studies that
include a larger number of children with a wider range of
language abilities, as well as group design studies that avoid
the possibility of carryover effects, are necessary.
In sum, the results indicate that these naturalistic interven-
tions produce immediate differences in patterns of language
use. This suggests that intervention providers should consider
the specific language goals of the child when selecting a
naturalistic language intervention. Future research that can
examine the long-term effects of these interventions on lan-
guage use in children with a wider range of language abili-
ties is necessary to determine whether these patterns persist
over time.
Declaration of Conflicting Interests
The author declared no conflicts of interests with respect to the
authorship and/or publication of this article.
Funding
The author disclosed receipt of the following financial support for
the research and/or authorship of this article:
This work was supported by Autism Speaks (Grant 5020).
Note
1. By responding to the child’s communication in a contextually
appropriate manner, the therapist consequated child language
behavior by providing natural social (e.g., expanded com-
ments) and nonsocial (e.g., requested items/activities) rein-
forcement. Given that the child had free access to the materials
during the responsive interaction condition, requests were rela-
tively rare.
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About the Author
Brooke Ingersoll, PhD, is an assistant professor of psychology at
Michigan State University. Her current interests include autism, early
intervention, and social-communication development.