Journal of Autism and Developmental Disorders

https://doi.org/10.1007/s10803-020-04426-2

1
ORIGINAL PAPER

2 Teaching Initiated Question Asking to Children with Autism Spectrum

3 Disorder Through a Short‑Term Parent‑Mediated Program
4 Svetlana C. Popovic1   · Elizabeth M. Starr1 · Lynn K. Koegel2

5
6 © Springer Science+Business Media, LLC, part of Springer Nature 2020

7 Abstract

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8 This study investigated whether a brief parent-mediated intervention would increase the frequency of question asking in
9 children with ASD. Mothers participated in a 3-week training consisting of 2-h sessions twice weekly. Data were collected

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10 in the context of concurrent multiple baseline design. Results demonstrate all three children increased frequency of question
11 asking with two children maintaining gains. All three children demonstrated generalization of question asking to novel items,

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12 family members, and/or settings. Affect improved for two of the three children. Overall, mothers were able to reach Fidelity
13 of Implementation during most sessions and rated the intervention as highly acceptable. Results are discussed in regard to the

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14 feasibility of providing a short-term parent-implemented intervention to increase social initiations through question asking.

15 Keywords  Autism spectrum disorder · Pivotal response treatment · Social initiations · Question asking · Parent training
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16 A hallmark of autism spectrum disorder (ASD) is a qualita- initiated questions tends to follow a predictable path in 31
17 tive impairment in social communication and social inter- typical language learners and begin to be produced within a 32
18 action (American Psychiatric Association 2013; [APA]). child’s first lexicon, shortly after 12 months of age. In con- 33
19 Very few studies have focused on explicit teaching to expand trast, children with ASD primarily use language for request-
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34
20 linguistic functions, such as asking questions, that are an ing objects/actions, and protesting (Wetherby and Prutting 35
21 important part of socialization (Plavnick and Dueñas 2018; 1984) and rarely, or never, engage in question asking as a 36
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22 Raulston et al. 2013). Children with ASD tend to use com- method of instigating social interactions or for the purpose 37
23 munication exclusively for requests and protests, and those of seeking information (Koegel et al. 2014). 38
24 who are taught to verbally initiate by asking questions dur- There are a few prompting techniques that exist when 39
25 ing social interactions receive much higher ratings on prag- it comes to teaching question asking. These include vocal 40
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26 matic scales and have more favorable long-term outcomes modelling, echoic prompts (e.g., “Say, ‘What’s that?’”), or 41
27 (Koegel et al. 1999). textual prompts (e.g., child is shown card with the ques- 42
28 Early in development, typical language learners demon- tion written on it as reminder of what to say) (Raulston 43
29 strate a variety of linguistic functions of communication, et al. 2013). Often times, these prompts are faded using 44
30 including question asking. The development of socially time delays (i.e., expectantly waiting to signal to the child 45
that something is required of them) in the natural environ- 46
ment (Raulston et al. 2013). In a review of the literature 47
A1 * Svetlana C. Popovic
A2 popovic1@uwindsor.ca with ASD, Raulston et al. (2013) noted that roughly 95% 48
of the 21 studies reviewed used echoic prompts to teach 49
A3 Elizabeth M. Starr
A4 estarr@uwindsor.ca question asking. When specifically looking at procedures 50
used to teach the query, “What’s that?” 10 studies were 51
A5 Lynn K. Koegel
A6 lynnk@stanford.edu cited. Eight of these studies used echoic prompting tech- 52
niques (Esbenshade and Rosales-Ruiz 2001; Hung 1977; 53
1
A7 Faculty of Education, University of Windsor, 401 Sunset Koegel et al. 1998; Marion et al. 2011; Roy-Wsiaki et al. 54
A8 Avenue, Windsor, ON N9B 3P4, Canada 2010; Taylor and Harris 1995; Williams et al. 2000) and 55
2
A9 Psychiatry and Behavioral Sciences ‑ Child and Adolescent two studies used textual prompts with a picture exchange 56
A10 Psychiatry and Child Development, Stanford University, 410 system (Ostryn and Wolfe 2011). Furthermore, the authors 57
A11 Quarry Road, Stanford, CA 94305, USA

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 Journal of Autism and Developmental Disorders

58 cited the importance of incorporating motivational compo- Another important item to consider in studies with child 111
59 nents as a key factor in successful studies. That is, many of participants is the affect of the child during intervention pro- 112
60 the interventions focused on using preferred items that the cedures. For example, Koegel et al. (1988) monitored affect 113
61 child is interested in or a certain environment/time of the levels of four children with severe communication delays 114
62 day (e.g., if the child is hungry, the opportunities would while comparing two reinforcer conditions (i.e., reinforc- 115
63 be presented in an area where there is access to food) to ing attempts for children’s responses compared to standard 116
64 evoke question asking, particularly during initial sessions. shaping protocol). The treatment condition in which chil- 117
65 As motivation increases, so does the rate of question ask- dren were reinforced for their attempts at language yielded 118
66 ing and the preferred items are gradually faded so that the higher interest and happiness scores. In this case, monitoring 119
67 children use the query for social learning, rather than as a affect helped to identify whether the child was motivated 120
68 mand (Swerdan and Rosales 2017). (i.e., level of interest and happiness) when comparing inter- 121
69 For example, Koegel et al. (1998) incorporated the moti- vention procedures. This practice of observing child affect 122
70 vational procedures of pivotal response treatment (PRT) to during intervention is also useful in determining if a child’s 123
71 teach “What’s that?” to children with ASD and results of the mood may have affected the data collection on a particular 124
study demonstrated that all of the children made significant day or how affect may evolve over the course of a particular

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72 125
73 gains in question asking with the appropriate use of the tar- study (Baker et al. 1998). 126

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74 geted question generalizing to new, unfamiliar stimuli and Similarly, when training parents how to engage in specific 127
75 settings. Further research has targeted other areas in ques- intervention procedures, monitoring social validity become 128
tion asking, such as grammatical morphemes (Koegel et al. crucial. Social validity measures may help examine the

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76 129
77 2003), further wh-questions (“Where is it?”) (Koegel et al. social goals of the treatment from a parental perspective, 130
2010), and targeting all four common wh-questions: “What the social appropriateness of the procedures in the treat-

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78 131
79 is it?” “Where is it?” “Who is it?” and “What happened?” ment and to understand the social importance of the effects 132
80 (Koegel et al. 2014). a treatment may have (Carter 2010). In their systematic 133
81 In regard to implementation, including parents in the review on PRT literature, Vershuur et al. (2014) noted that 134
82 habilitation process and providing them with opportunities social validity was measured in only 10 out of the 39 stud- 135
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83 to learn specific techniques can result in the intervention ies included in the review. According to Carter (2010), the 136
84 being continued beyond the treatment setting (Patterson consideration of social validity in a study is important for 137
85 et al. 2012). Such involvement can be achieved in a variety two reasons: it allows for an understanding of which proce- 138
86 of ways, including “parent support interventions” where dures are liked and disliked (i.e., high social acceptance or 139
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87 the parent receives information regarding techniques and low social acceptance, respectively), and it allows for inno- 140
88 “parent-implemented interventions” where the parent is vation in the field surrounding the intervention practices. 141
89 taught target skill techniques (Bearss et al. 2015). Parent- Gaining insight into parent training procedures offers useful 142
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90 implemented models of intervention can expand the parents’ information regarding training protocol along with helping 143
91 understanding of the intervention being used and nurture to potentially determine the amount of training hours that a 144
92 their ability to support communication and social develop- parent may require. 145
ment in their children with ASD (Patterson et al. 2012). As suggested in the literature, PRT can be helpful in
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93 146
94 Parent-mediated interventions are an important adjunct to improving various skills in children with ASD, and par- 147
95 therapist implemented early intervention, as parents of chil- ents can be taught to implement the specific strategies with 148
96 dren with ASD in the USA report limited access to services, Fidelity of Implementation (FoI) given considerable training 149
97 trouble obtaining funding, and high costs associated with hours. To date, very few studies have evaluated short-term 150
98 intervention (Koegel and Koegel 2006, 2018). Similar issues trainings in PRT and no studies to date address social ini- 151
99 exist in Canada (Csanady 2015; Gordon 2015; Jones 2019). tiation through question asking using a short-term training 152
100 Given the large numbers of children being diagnosed with model. The current study contributes to the literature con- 153
101 ASD and the shortage of trained clinicians, many programs cerning short-term trainings models, achieving experimental 154
102 are assessing the feasibility of short-term parent-mediated control through replication across individuals, conducting 155
103 interventions with success (Coolican et al. 2010; Gengoux FoI on parent interventionists, and documenting social valid- 156
104 et al. 2015). A number of studies have shown that parents ity. Further, no studies to date have targeted question asking 157
105 can effectively improve their child with ASD’s communica- in the context of a parent-mediated intervention. 158
106 tion if working collaboratively with a professional (Brad- To our knowledge, no studies have addressed question 159
107 shaw et al. 2017; Coolican et al. 2010; Gengoux et al. 2015). asking using a short-term parent-mediated training model 160
108 The time spent training parents is a crucial variable and the thus providing the purpose of this study. Therefore, this 161
109 appropriate use of intervention procedures may be linked to study asked: (1) Will a short-term parent-mediated PRT 162
110 the amount of training a parent receives. intervention lead to an increase in the frequency of asking, 163

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164 “What’s that?” by children with ASD, will question asking member (e.g., father, relative, or sibling) and environment 186
165 generalize to novel items, another family member, and/or (e.g., grocery store or backyard) for data collection during 187
166 environments beyond intervention setting, and will gains the generalization phase. Ultimately, three boys and their 188
167 maintain over time; (2) Will parents be able to implement biological mothers participated in the study. Individual child 189
168 the short term intervention with Fidelity of Implementation characteristics were as follows: 190
169 (FoI); (3) Will child affect in regard to interest and happiness
170 be affected during intervention; and (4) How will parents
Child 1 191
171 rate the intervention?
Liam was 4 years and 2 months at the start of the study (see 192
Table 1). He is a white male diagnosed with ASD requiring
172 Method 193
support to requiring substantial support using the ADOS-2 194
(Lord et al. 2012) at the age of 3 years and 1 month. Liam’s 195
173 Participants
mother, Hanna, is a Caucasian female between 35 and 196
44 years of age and she has a 2-year community college 197
To recruit the participants, flyers were distributed through

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174
degree. The demographic characteristics of Hanna and the 198
175 various early intervention centers for ASD. To be included
other mothers are shown in Table 1. 199
in the study, children were required to have: (1) a docu-

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176
177 mented ASD diagnosis by an outside agency; (2) no co-
morbid neurological or sensory disability; (3) a minimum Child 2

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178 200
179 of 50 functional expressive words and two-word combina-
tions as determined by the Communication Development Jackson was 4 years and 8 months at the start of the study.

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180 201
181 Inventory (Fenson et al. 2000); and (4) no prior intervention He is a white male diagnosed with ASD requiring substan- 202
182 for question asking or applied behavioural analysis. Each tial support using the ADOS-2 at the age of 4 years and 203
183 mother was required to: (1) speak English at home; (2) be 3 months. Jackson’s mother, Marie, is a Caucasian female 204
184 available daily to engage in data collection during the inter- between 35 and 44 years of age and has a 4-year university 205
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185 vention phase; and (3) have access to an additional family undergraduate degree. 206

Table 1  Mother and child characteristics

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Children Liam Jackson Eli

Chronological ­age1 4:2 4:8 3:9

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Age at diagnosis 3:1 4:3 3:8

ADOS-22 score –3 16 19
VABS-II4 communication score
 Listening/understanding 1:0 1:0 1:2
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 Talking 0:9 2:6 2:3

 Early reading/writing 1:10 3:1 4:3
VABS-II ABC score 1st percentile 0.2 percentile 3rd percentile
CDI5
 Has the child more than 50 words? Yes Yes Yes
 Does the child speak in two-word phrases? Yes Yes Yes
Mothers Hanna Marie Sarah

Gender Female Female Female

Age range 35–44 35–44 45–54
Relationship to child Birth mother Birth mother Birth mother
Race/ethnicity White White White
1
 Year: month
2
 ADOS-2 = Autism Diagnostic Observation Schedule, Second Edition—Module 1
3
 Score not provided
4
 VABS-II = Vineland Adaptive Behavior Scales II: Parent/Caregiver Rating Form
5
 CDI = MacArthur Bates Communication Development Inventory Level II A

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207 Child 3 teaching of initiations (Koegel 2014b). The mothers were 253
asked to read the manual prior to the start of week two, 254
208 Eli was 3 years and 9 months at the start of the study. He and verbally acknowledged that they had done so. The 255
209 is a white male diagnosed with ASD requiring very sub- second week of training focused on teaching the mothers 256
210 stantial support using the ADOS-2 at the age of 3 years to implement procedures for asking, “What is it?” Mothers 257
211 and 8 months. Eli’s mother, Sarah, is a Caucasian female were taught the following procedure: 258
212 between 45 and 54 years of age and has a 2-year community
213 college diploma. 1. Twenty items that the child could not label were identi- 259
fied. To do this, the caregiver presented common items 260
214 Research Design and Procedure found around the home and asked the child “What is 261
this?” If the child did not label the item, it was desig- 262
215 Pretreatment measures were collected prior to the start of the nated as an unknown vocabulary label. 263
216 study to assure that the child did not ask questions using the 2. Ten child-preferred items were placed in an opaque bag. 264
217 MacArthur Bates Communication Development Inventory Parents selected favorite snacks and items that their child 265
(CDI) Level II A (Fenson et al. 2000). In addition, a 10-min- frequently requested to place in the opaque bag. This

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218 266
219 ute video interaction was recorded of each mother and child step was done as an initial motivational step to encour- 267
participating in the child’s preferred activity. Mothers were age the child to ask the wh-question.

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220 268
221 asked to try and get the child to ask questions during these 3. The child was verbally prompted to ask, “What’s that?” 269
communication samples. The CDI and the parent–child com- in response to the opaque bag containing the neutral and

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222 270
223 munication sample were scored for the number of times the preferred items. After the child repeated the question, 271
child asked, “What’s that?” in the 10-minute video probe. the mother initially took a preferred item out of the bag,

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224 272
225 No participants demonstrated the use of questions and all labeled the item, and gave it to the child as a natural 273
226 parents reported that they had not heard their child ask a reward for asking the question. In this step, the child is 274
227 question. Baseline measures were then collected. being functionally taught to ask, “What’s that?” when an 275
item is hidden, and they are unaware of what the object 276
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228 Baseline is. The label is also provided to model the function of 277
the question (i.e., seeking information). 278
229 During each baseline session, 10-minute communication 4. Once the child was consistently asking, “What’s that?” 279
230 samples were recorded of the child with ASD and the car- the verbal prompt was faded, and the mother provided 280
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231 egiver engaging in a play routine that is typical for the fam- a time delay to provide an opportunity for the child to 281
232 ily (e.g., playing with toys after snack time, etc.) in various spontaneously ask “What’s that” Once the child asked, 282
233 rooms in their home while the mother was trying to elicit “What’s that?” independently with 80% accuracy across 283
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234 question asking. Communication samples were collected one three consecutive sessions, the mothers began inter- 284
235 to three times per week. In accordance with the multiple spersing the ten preferred items with the neutral items 285
236 baselines design, the introduction of the caregiver training beginning every fourth trial, then third, and so on, until 286
was staggered for each participant dyad. all preferred items were faded and the child was asking
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237 287
“What’s that?” about items to which he didn’t produce 288
238 Treatment the label. 289
5. Next, the bag was faded to provide opportunities for the 290
239 After baseline measures were collected, each mother was children to ask, “What’s that?” for neutral items that they 291
240 given two training manuals, the first an introduction to could not label for the purpose of seeking information 292
241 PRT (Koegel 2014c), and the second focusing on motiva- regarding unknown items (Koegel 2014b). After asking 293
242 tion as a pivotal response (Koegel 2014a) and was asked to “What’s that?” the parent labeled the item, had the child 294
243 read them prior to the first parent training session. These repeat the label, and gave the item to the child. 295
244 focused on the motivational components (child choice,
245 natural rewards, rewarding attempts, etc.) that would be The first two weeks of training included only the mothers 296
246 incorporated into the intervention. Next, parent training in order to avoid diffusion of treatment effects (O’Neill et al. 297
247 was provided for 3 weeks. Parent training sessions were 2011). In the third week the child was included so that the 298
248 conducted twice weekly in various rooms of the family mothers could practice teaching the question to their child. 299
249 home for 2 h, for a total of 12 h. Week one of training Mothers were provided with feedback and had the opportu- 300
250 focused on discussion of PRT and the motivational com- nity to ask questions. Mothers were also taught how to col- 301
251 ponents of PRT. At the end of the first week of training, lect data on question asking during the third week of training 302
252 the mothers were given a third manual focusing on the using a pre-printed data sheet to record the frequency of 303

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304 question asking and the type of prompt that was needed (if (2) Parent FoI; and (3) child affect. Data for these measures 351
305 any) (e.g., full verbal prompt, partial verbal prompt, etc.). were collected during 10-minute probes video recorded on 352
306 Following the three-week training, each mother was an iPad by the researcher who did not interact with the child 353
307 asked to implement the intervention with her respective during the probes. The recorded probes were scored by the 354
308 child at least three times a day for 10-minute sessions in researcher after each daily session. 355
309 various rooms in their home. During teaching sessions, the
310 mothers were asked to record each time their child asked, Frequency of “What’s That?” 356
311 “What’s that?” and the type of prompt that was used or if the
312 child did not respond. The third daily session was recorded. The number of times the target question (i.e., “What’s that?”) 357
313 In these 10-minute probes, the number of times the targeted was emitted and whether the question was asked following a 358
314 question was asked during each minute was recorded using prompt (e.g., “[Child’s name], can you ask mama, ‘What’s 359
315 a frequency count. Questions were scored as prompted when that?’”) was totaled for each 10-minute probe collected dur- 360
316 the mother used the entire question in her previous utterance ing baseline, intervention, and follow-up. Additionally, to 361
317 (e.g., “Can you ask me ‘What’s that’”?) or a partial utterance measure generalization of question asking, the mothers were 362
(e.g., “What’s…?”). Spontaneous utterances were recorded asked to collect data daily for five days after intervention was

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318 363
319 when the child asked “What’s that” without prompting. completed using a frequency count for targeted initiation 364
Each day the parent-educator provided the mother with (i.e., “What’s that?”) in response to novel items, and/or with

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320 365
321 3–5  minutes of feedback regarding the previous day’s other family members, and in non-treatment settings. Each 366
intervention. parent tallied how many questions her child asked across the

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322 367
day (see above). Once these five days were complete, the 368
Generalization researcher collected the forms and a treatment acceptability

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323 369
measure was administered to each parent at the end of the 370
324 Once the intervention was completely faded, generalization study (see below). 371
325 probes were collected in an additional environment (i.e.,
326 park, daycare, garage, etc.) where treatment had not been Fidelity of Implementation (FoI) 372
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327 provided and with a member of the family who did not pro-
328 vide intervention (e.g., father, sibling, grandparent, etc.). FoI was scored during the 10-minute probes using a pre- 373
329 The mothers recorded data for these generalization probes printed FoI scoring sheet. Each mother was scored on how 374
330 every day for one week (i.e., 5 data points) using a frequency accurately she adhered to the following aspects: incorpo- 375
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331 count in the natural environment. To measure generalization rating child choice during the initial steps, securing child 376
332 of question asking, the mother tallied the total number of attention, prompting a clear opportunity, ensuring the label/ 377
333 targeted initiations (i.e., “What is it?”) in response to novel response was given by the child, providing a natural reward 378
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334 items, and/or other family members, and settings. These after the child’s question, providing the reward immediately 379
335 were recorded on a frequency sheet. and contingently after the child’s the response, and whether 380
the attempts were reinforced. In order to meet the FoI 381
Follow‑Up requirements for the 10-minute probe, the mothers needed
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336 382
to implement the intervention procedures correctly during 383
337 Follow-up data were gathered one month after generalization at least 80% of the intervals. 384
338 probes were completed. Mothers were instructed to continue
339 providing opportunities for question asking between gener- Child Affect 385
340 alization and follow-up in various environments. Follow-
341 up data were collected twice in the home environment and The Rating Scale for Child Affect (Baker et al. 1998) was 386
342 twice in a different environment (e.g., grocery store, park, used to score measures of happiness and interest. The scale 387
343 etc.) in the span of a week. Follow-up data were analyzed uses a six-point affect scale to identify if the child is moti- 388
344 from a 10-minute probe of the mother–child interaction vated during the interaction. On the “Interest” scale, a score 389
345 similar to intervention procedures. of “0” or “1” indicates a disinterested child (e.g., child looks 390
uninvolved). A score of “2” or “3” indicates a neutral interest 391
346 Dependent Measures displayed by the child (e.g., child is inactively accepting the 392
situation). Lastly, a score of “4” or “5” indicates an inter- 393
347 Data were collected on three dependent measures throughout ested child (e.g., child is attending). On the “Happiness” 394
348 the study: (1) The number of (“What’s that?”) questions each scale, a score of “0” or “1” indicates an unhappy child (e.g., 395
349 child asked during intervention and in response to untrained tantrums, crying, or avoiding task). A score of “2” or “3” 396
350 items, to new people, and/or in new settings (generalization); indicates a neutral child (e.g., child is neither smiling nor 397

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398 upset). Lastly, a score of “4” or “5” indicates a happy child calculated for the Child Affect scores. Inter-rater reliability 446
399 (e.g., child is smiling or seems to be enjoying interaction). was 100% for Liam and Eli, and 83% for Jackson. 447
400 After reviewing each video, an overall Child Affect score
401 was calculated by adding the score for interest and the score
402 for happiness. A rating of 0 to 1.7 indicates negative affect Results 448
403 (i.e., disinterested/unhappy), rating of 1.71 to 3.29 indicates
404 neutral affect (i.e., neither disinterested or interested/neither The first research question asked was whether a short-term 449
405 happy nor unhappy), and rating of 3.3 to 5 indicates positive parent-mediated PRT intervention would lead to an increase 450
406 affect (interested/happy). in the frequency of asking, “What’s that?” by children with 451
ASD. The results of the intervention videos are shown in 452
Fig. 1. Frequency of “What’s that?” during Baseline, Inter- 453
407 Social Validity
vention and Follow-up. Parent report of generalization 454
probes are shown in Table 2. The results demonstrated that 455
408 To measure the social validity of the intervention proce-
the short-term parent-mediated PRT led to an increase in the 456
409 dures, the TARF-R (Carter 2010) was administered at the
frequency of asking the social initiation question, “What’s

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457
410 end of the study. The TARF-R is a 20-item questionnaire
that?” with all three children reaching mastery criterion. 458
411 with a six-point Likert scale that asks the caregiver to rate
That is, all three children correctly asked, “What’s that?”

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459
412 the practicality of continuing the intervention, willingness
with 80% accuracy across three consecutive sessions. Liam 460
413 to implement, and cost/time associated. Each participant’s
met criterion in 17 days, Jackson met criterion in 8 days, and

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414 answers are summed, with higher numbers indicating greater
Eli met criterion in 7 days. 462
415 acceptability of the treatment (Carter 2010). The total pos-
Specifically, Liam did not ask, “What’s that?” when

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463
416 sible score is 120. According to Carter (2010), the TARF-R
engaging in play interactions with his mother when pre- 464
417 has an internal consistency of 0.92, displaying high reliabil-
sented with unknown objects on any probe during baseline. 465
418 ity. With respect to the question asking intervention, parental
During the parent-implemented home intervention sessions, 466
419 insights were sought using the TARF-R to determine the
the frequency of Liam asking, “What’s that?” increased to 467
significance of the intervention along with whether the func-
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420
a mean of 6.6 occurrences (range 1 to 11) per session, with 468
421 tion of the question was achieved.
an improving trend as intervention progressed. He reached 469
criterion on days 37 through 39. The percentage of non- 470
422 Interobserver Agreement overlapping data points (PND) was evaluated to determine if 471
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the dependent variable (i.e., the frequency of “What’s that?”) 472

423 For each child, 30% of the data across all phases of the study increased as a result of the intervention. As seen in Fig. 1, 473
424 were randomly selected to determine interrater reliability no data points overlap between baseline and intervention. 474
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425 (O’Neill et al. 2011). Random selection consisted of print- Thus, the PND was 100%. 475
426 ing and cutting each session day for each phase on its’ own As can be seen on Jackson’s baseline, he asked, “What’s 476
427 piece of paper. The papers were then put in a bag according that?” on two occasions during baseline (i.e., day 9 and day 477
to the phase and randomly selected until 30% of sessions for 16) when engaging in a play interaction with his mother
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428 478
429 each phase were chosen. This process was repeated for each following her verbal model prompt. During intervention, 479
430 child. Two staff from an external agency, blind to the experi- Jackson’s frequency of asking, “What’s that?” increased to 480
431 mental phases, scored: (1) the frequency of “What’s that?” a mean of 13.7 (range 11 to 18). He reached criterion on 481
432 (2) parent’s FoI of the PRT procedures for teaching question days 40 through 42 of intervention. PND between baseline 482
433 asking; and (3) child affect. The percentage for interrater and intervention for Jackson was 100%. 483
434 reliability was calculated by dividing the number of agree- Eli did not spontaneously ask, “What’s that?” during 484
435 ments by the total number of agreements plus disagreements any of the nine baseline probes. During intervention, Eli’s 485
436 and multiplied by 100 to obtain a percentage. “What’s that?” question asking increased to a mean of 20.7 486
437 Interrater reliability was completed for the frequency of occurrences (range 16 to 28). He reached criterion on days 487
438 “What’s that?” question asking, the FoI, and for child affect. 46 through 48 of intervention. Similar to the other partici- 488
439 In total, 20 video probes (i.e., eight videos for Liam, six pants, PND between baseline and intervention for Jackson 489
440 videos for Jackson, and six videos for Eli) yielded a 100% was 100%. 490
441 agreement on the occurrence of “What’s that?” using a fre- In regard to generalization, Table 2 shows that all three 491
442 quency count for each minute. In terms of scoring FoI, the participants demonstrated generalized improvements in the 492
443 observers also had a high level of agreement. For all three spontaneous use of the question as reported in the parent 493
444 mothers, a score of 100% agreement was calculated for data. During the generalization phase, the number of times 494
445 PRT fidelity procedures. Lastly, inter-rater reliability was Liam spontaneously and appropriately asked, “What’s that?” 495

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Fig. 1  Frequency of “what’s that?” during baseline, intervention, and follow-up

496 occurred at a mean of 4.8 (range 3 to 6). These questions Figure 1 shows maintenance data that were collected 511
497 occurred in the home with several novel items. Similarly, one month after the generalization probes. At follow-up, 512
498 during the generalization phase Jackson continued to spon- Liam continued to ask, “What’s that?” with a mean of 0.75 513
499 taneously ask, “What’s that?” with a mean of 11.8 (range (range 0 to 2) during the 10-min probes. For the second 514
500 6 to 21). Jackson’s data indicated that spontaneous use of participant, Jackson spontaneously asked “What’s that?” 515
501 the targeted question generalized to novel items at home, at a similar frequency (M = 9.5) as his treatment data with 516
502 several environments (e.g., grocery store, fast food restau- some variability during the 10-minute probes. Lastly, Eli 517
503 rant, electronics store, and car rides) and with another family spontaneously asked “What’s that?” at a higher frequency 518
504 member (e.g., sibling). During the generalization phase, Eli with a mean of 23 (range 12 to 33) during the 10-minute 519
505 continued to spontaneously ask the target question with a probes at follow-up. 520
506 mean of 6.6 (range 5 to 10). Eli generalized his spontaneous The second question asked in this study was whether 521
507 question asking to novel items at home, several environ- parents would meet FoI with this short-term intervention. 522
508 ments (e.g., backyard, car ride, cousin’s home, the garage, Probes to determine the FoI were conducted during each 523
509 and the grocery store) and with two family members (e.g., videotaped intervention probe and at follow-up. During 524
510 father and cousin). intervention, Liam’s mother Hanna achieved fidelity on 12 525

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 Journal of Autism and Developmental Disorders

Table 2  Parent report of Liam Jackson Eli (M = 3.2) with scores ranging from 1 to 5. During the fol- 541
frequency of “What’s that?” low-up, his average continued to improve, but still remained 542
during generalization Day 42 6 in the high neutral range (M = 3.0) with scores ranging from 543
Day 43 5 2 to 3.5. Jackson’s average affect was scored in the positive 544
Day 44 4 range in both baseline (M = 4.2) and intervention (M = 4.4) 545
Day 45 3 with scores ranging from 2 to 5 and 3 to 5, respectively. 546
Day 46 6 During the follow-up sessions, his average affect was in the 547
Day 47 13 high neutral level (M = 3.0) with scores ranging from 2 to 548
Day 48 21 5. Eli’s average affect during baseline was in the neutral 549
Day 49 10 range (M = 3.2) with scores ranging from 1.5 to 4.5. During 550
Day 50 9 intervention, Eli’s average affect improved to the positive 551
Day 51 6 range (M = 3.9) with scores ranging from 2 to 5. During 552
Day 53 10 the follow-up sessions, Eli continued to demonstrate higher 553
Day 54 5 positive affect (M = 4.0) with scores ranging from 3 to 5. 554
Day 55 6 In regard to social validity, the TARF-R (Carter 2010)

F
555
Day 56 6 was designed to measure a caregiver’s perceptions towards 556
Day 57 6 the acceptability of the intervention and the ease of imple-

O
557
mentation. Scores are summed, with higher scores indicating 558
greater treatment acceptability. Overall, all three mothers’

O
559
Table 3  Mean ratings and range of child interest and happiness for scores indicated a high level of acceptability of the short- 560
each phase for each child term PRT intervention. Hanna’s total score was 94 points,

PR
561
Baseline Intervention Follow-up Marie’s total score was 82 points, and Sarah’s total score 562
M M M was 94 points. 563

Liam
 Interest 2.4 2.9 2.7
ED
 Happiness 3.0 3.5 3.2
Discussion 564

 Composite score 2.7 3.2 3.0

Typical language developers begin using questions at a very 565
Jackson
young age and by the time they are in preschool they average 566
 Interest 4.2 4.4 3.0
IS

75 questions an hour when given a task to solve (Chouinard 567

 Happiness 4.2 4.4 3.0
et al. 2007). The information provided to children through 568
 Composite score 4.2 4.4 3.0
question asking provides a critical role in cognitive develop- 569
EV

Eli
 Interest 3.5 4.4 4.0
ment (Chouinard et al. 2007; Kurkul and Corriveau 2018). 570

 Happiness 2.8 2.5 4.0

In contrast, many children with ASD do not exhibit ques- 571

 Composite score 3.2 3.9 4.0

tion asking during their communication (Koegel and Koegel 572
2018). This study showed that a short-term parent-mediated
R

573
question asking intervention increased the frequency of 574
spontaneous question asking. 575
526 of the 17 days (or 71% of the intervention days). Jackson’s Although all three children increased their frequency of 576
527 mother Marie met the 80% minimum criteria for FoI during appropriately asking “What’s that?” when an unknown item 577
528 all 7 days (or 100%). Eli’s mother, Sarah, also achieved FoI was present, there were individual differences in how quickly 578
529 on all eight possible days of intervention (i.e., 100% of the they met criterion and in their overall frequency of question 579
530 total days). During the four follow-up sessions, Hanna and asking. One possible explanation for this may relate to the 580
531 Marie did not achieve fidelity on any of the four scheduled children’s affect. That is, their levels of question asking may 581
532 days (0%) while Sarah achieved fidelity on all 4 days (100%). have been affected by the child’s happiness and interest dur- 582
533 The third research question asked was whether the chil- ing intervention. The two children who achieved criterion 583
534 dren’s affect would be affected during intervention and more quickly (Jackson and Eli) were scored as higher on 584
535 follow-up. As seen in Table 3, all three children demon- affect during intervention. It should be noted that we did 585
536 strated considerable variability from session to session with not analyze repetitive and restricted behaviors (RRBs) nor 586
537 improved overall averages for two of the three children. Spe- ASD severity in this study, but anecdotally it was noted that 587
538 cifically, Liam’s average scores were in the neutral range when the children were not engaging, they tended to engage 588
539 during baseline (M = 2.7) with scores ranging from 1 to in RRBs (i.e., hand flapping, scripting songs, etc.). Thus, it 589
540 4.5. Similar neutral affect was shown during intervention may be that Jackson and Eli were more reinforced by social 590

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 Journal of Autism and Developmental Disorders

591 interaction than Liam. Positive affect has been one variable demonstrated gains during follow up. Additional partici- 644
592 that researchers suggest may be predictive of improved treat- pants may help tease out mediators and moderators that 645
593 ment outcomes (Fossum et al. 2018). Future research in this may differentially affect the children’s outcomes. Second, 646
594 area may be fruitful. issues surrounding the treatment fidelity and accuracy of 647
595 When examining the frequency of question asking during caregiver recording are another potential limitation. Par- 648
596 follow-up, the three children displayed varied results which ent fidelity of recording during the generalization probes 649
597 may have been related to the parent implementation of the was not monitored and this may cause issues with the 650
598 procedures. For example, Liam’s mother had the most dif- accuracy in the recording of generalization. For example, 651
599 ficulty reaching FoI, and Liam emitted the fewest number of Liam’s mother, Hanna, reported that the instances of ques- 652
600 questions during intervention, generalization, and follow-up. tion asking occurred only with her in the home with novel 653
601 In particular, Liam’s mother had difficulties with providing items. However, Liam was observed to appropriately ask, 654
602 prompting clear opportunities, making it difficult for him to “What’s that?” to his father outside of the data collection 655
603 understand what was required of him. Additionally, she also sessions. Therefore, the parent report during generaliza- 656
604 had difficulty fading in the neutral items that he was not able tion may have underestimated the child’s behavior. Given 657
to label. She incorporated the neutral items very quickly, and this, visual analysis techniques and the interrater reliability

F
605 658
606 thus the intervention may have been less motivating for him. procedures helped to assess potential inconsistencies in 659
Again, future studies understanding the relationship between data collection procedures and increase the certainty of

O
607 660
608 parental FoI and child performance are warranted. the operational definition of the target behavior (O’Neill 661
In regard to the parent-mediated procedures used in this et al. 2011).

O
609 662
610 study, there are several advantages associated with using The mothers’ FoI was consistently documented during 663
parents as agents of intervention. Research shows that par- intervention (O’Neill et al. 2011). However, more research is

PR
611 664
612 ents have the capability to implement an evidence-based needed in the area of short-term training for parents. Future 665
613 intervention with fidelity (Patterson et al. 2012). Moreover, studies can investigate how many hours may be ideal for 666
614 many parents report that services are more beneficial to their parents to reach FoI when using a short-term training model 667
615 child when parent education is included (Hume et al. 2005). and whether booster courses may be helpful or necessary. 668
ED
616 By using the mother as the primary change agent during Additionally, parent affect was not monitored in the cur- 669
617 intervention when teaching question asking, the intervention rent study. An interesting question would be whether a rela- 670
618 was time-efficient. Further, the parents may have served as tionship exists between FoI, child acquisition of targeted 671
619 a stimulus for question asking, thereby increasing the likeli- behaviors and variations in parental affect, particularly in 672
IS

620 hood that generalization would occur. light of research suggesting that child behaviors may impact 673
621 The three mothers’ high ratings on the TARF-R (Carter parent affect (Solomon et al. 2008). It may also be interest- 674
622 2010) suggested they were satisfied with the intervention, ing to look into whether a relationship exists between parent 675
EV

623 found the intervention to be acceptable in addressing ques- FoI, parent affect, and parent report of social validity when 676
624 tion asking, and saw themselves using the procedures. The looking to their child’s rate of learning toward the target 677
625 mothers also indicated that the intervention might be able to behavior. Having a child with ASD can be very stressful 678
help make long-term improvements and indicated that their (McConachie et al. 2018), and although the parents reported
R

626 679
627 children’s problem behaviors (e.g., yelling) were lower dur- satisfaction with the intervention, it did add an extra respon- 680
628 ing the sessions. When asked about the overall effectiveness sibility. Thus, it may be important to assess any potential 681
629 of the intervention, all three mothers perceived the interven- relationships between parent affect FoI, the child’s affect, 682
630 tion as effective in relation to the goal as well as effective learning curves, and other variables. 683
631 specifically for their own child. In addition, all three mothers Although multicultural issues are present in the field 684
632 liked the procedures used in the intervention and they were of autism research, it is an under-researched area. Dyches 685
633 very willing to regularly incorporate the interventions during et al. (2004) note that ASD occurs equally across people of 686
634 natural play opportunities. Although Liam’s mother Hanna varying race, socioeconomic status, families, lifestyle, and/ 687
635 had difficulty with attaining FoI and implementing the inter- or educational level. The current study did not address cul- 688
636 vention, she still scored the intervention as socially valid. tural differences, thus limiting generalization of the results in 689
637 This could be attributed to her observing a behaviour change this respect. Future research could investigate how question 690
638 in her child and viewing the treatment as socially appropriate asking may differ across cultures in terms of the methods 691
639 for her family context regardless of the challenges she may involved in teaching question asking, the cultural appropri- 692
640 have experienced during the training. ateness of asking questions, and whether the parents’ culture 693
641 There are several limitations to the current study. influences how they learn the procedures for implementing 694
642 First, a small sample size was used, and some variability an intervention. Also, it would be interesting to investigate 695
643 in outcomes was noted. Only two of the three children the role of a father in parent-mediated interventions and 696

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 Journal of Autism and Developmental Disorders

697 whether this may produce any differences in the frequen- obsessive behaviors. Journal of the Association for Persons with 746
cies of question asking. Severe Handicaps, 23, 300–308. 747
698
Bearss, K., Burrell, L., Stewart, L., & Scahill, L. (2015). Parent train- 748
699 Similarly, it may be interesting to understand child char- ing in autism spectrum disorder: What’s in a Name? Clinical 749
700 acteristics (e.g., age of the child, the number of functional Child and Family Psychology Review, 18(2), 170–182. https​:// 750
701 words in the child’s repertoire, or ability to speak spontane- doi.org/10.1007/s1056​7-015-0179-5. 751
ously) that may be associated with best outcomes in terms of Bradshaw, J. L., Koegel, L. K., & Koegel, R. L. (2017). Improv- 752
702
ing functional language and social motivation with a parent- 753
703 frequency of initiations. Such factors may be related to the mediated intervention for toddlers with autism spectrum dis- 754
704 maintenance and generalization of question asking (Fossum order. Journal of Autism and Developmental Disorders, 47, 755
705 et al. 2018). Lastly, the present study did not assess gener- 2443–2458. 756
alization to peers. It may be interesting to assess whether Carter, S. L. (2010). The social validity manual. London: Elsevier. 757
706
Chouinard, M. M., Harris, P. L., & Maratsos, M. P. (2007). Chil- 758
707 question asking improves peer interactions, as ultimately this dren’s questions: A mechanism for cognitive development. 759
708 is an important end goal (Guivarch et al. 2017). Monographs of the Society for Research in Child Development, 760
709 In summary, the teaching of pivotal areas, such as ques- 72, 1–129. 761
tion asking, appears to be important for long-term develop- Coolican, J., Smith, I. M., & Bryson, S. E. (2010). Brief parent train- 762
710
ing in pivotal response treatment for preschoolers with autism. 763
ment (Koegel et al. 1999). Overall, the results of the study

F
711 Journal of Child Psychology and Psychiatry, 51(12), 1321–1330. 764
712 support the notion that a short-term parent training in PRT Csanady, A. (2015). Over 16,000 children on Ontario wait lists for 765
for social initiation through question asking can be help-

O
713 autism services: More kids are waiting than are getting support. 766
ful for producing an increase in the frequency of asking, National Post. Retrieved from https​://news.natio​nalpo​st.com/ 767
714
news/canad​a/canad​ian-polit​ics/over-16000​-child​ren-on-ontar​io- 768
“What’s that?” When parents are empowered and taught to

O
715 wait-lists​-for-autis​m-servi​ces-some-famil​ies-are-waiti​ng-years​ 769
716 effectively implement treatment procedures, parent–child -for-help. 770
intervention can be extended to multiple environments Dyches, T. T., Wilder, L. K., Sudweeks, R. R., Obiakor, F. E., &

PR
717 771
(McConachie and Diggle 2007). Algozzine, B. (2004). Multicultural issues in autism. Journal of 772
718
Autism and Developmental Disorders, 34(2), 211–222. 773
Esbenshade, P. H., & Rosales-Ruiz, J. (2001). Programming common 774
719 Acknowledgments  Lynn Koegel is a partner in the private company stimuli to promote generalized question-asking. Journal of Posi- 775
720 Koegel Autism Consultants, LLC. The first author would like to thank tive Behavior Interventions, 3, 199–210. 776
721 all of the families who participated in the research along with the Fenson, L., Pethick, S., Renda, C., Cox, J. L., Dale, P. S., & Reznick, S.
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777
722 Koegel Autism Consultants, LLC for their endless support during train- J. (2000). Short-form versions of the MacArthur communicative 778
723 ing. The authors do not list any other acknowledgments, have financial development inventories. Applied Psycholinguistics, 21, 95–116. 779
724 information to disclose, or author notes. Fossum, K. L., Williams, L., Garon, N., Bryson, S. E., & Smith, I. M. 780
(2018). Pivotal response treatment for preschoolers with autism 781
Author Contributions  SCP and EMS conceptualized the research
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725 spectrum disorder: Defining a predictor profile. Autism Research, 782

726 query. SCP wrote the initial manuscript draft, participated in the design 11(1), 153–165. 783
727 of the methodology as well as engaged in the analysis and discussion. Gengoux, G. W., Berquist, K. L., Salzman, E., Schapp, S., Phillips, J. 784
728 EMS verified the analysis, edited the manuscript, and participated in M., Frazier, T. W., et al. (2015). Pivotal response treatment parent
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785
729 writing portions of the discussion. LKK also edited the manuscript and training for autism: Findings from a 3-month follow-up evalua- 786
730 contributed to portions of the methodology and discussion. tion. Journal of Autism and Developmental Disorders. https:​ //doi. 787
org/10.1007/s1080​3-015-2452-3. 788
Compliance with Ethical Standards  Gordon, A. (2015). Chronic wait times persist for families coping with 789
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chron ​ i c-wait-times ​ - persi ​ s t-for-famil ​ i es-copin ​ g -with-autis​ 791
732 Informed Consent  Informed consent was obtained from all individual m.html?refer​rer=http%3A%2F%2Fm.faceb​ook.com. 792
733 participants included in the study as well as throughout the study. Guivarch, J., Murdymootoo, V., Elissalde, S. N., Salle-Collemiche, X., 793
Tardieu, S., Jouve, E., et al. (2017). Impact of an implicit social 794
734 Ethical Approval  In compliance with ethical standards, all procedures skills training group in children with autism spectrum disorder 795
735 performed in this study involving human subjects were accordance without intellectual disability: A before-and-after study. PLoS 796
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