Journal of Behavioral Education

https://doi.org/10.1007/s10864-019-09340-x

ORIGINAL PAPER

A Structured Intervention to Increase Response Allocation

to Instructional Settings for Children with Autism Spectrum
Disorder

Tom Cariveau1,2   · M. Alice Shillingsburg3 · Arwa Alamoudi4 ·

Taylor Thompson5 · Brittany Bartlett6 · Scott Gillespie6,7 · Lawrence Scahill6,7

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Abstract
Access to early intensive behavioral intervention for children with autism spec-
trum disorder is commonly recommended. Intervention programs may include high
rates of instructional trials, which may evoke escape-maintained problem behavior.
Recent research on “pairing” or “rapport-building” interventions have sought to
reduce the likelihood that problem behavior occurs during instruction using ante-
cedent manipulations. The current study evaluated a structured intervention that
included differential reinforcement and demand fading to increase participants’
response allocation to instructional settings without the use of physical guidance.
Nine minimally verbal girls under the age of 6 years with autism spectrum disorder
enrolled in the study. The protocol was effective for seven of the nine participants.
One participant did not complete the protocol due to competing behavior and an
additional participant did not require the intervention. Our findings suggest that the
structured intervention was effective in increasing appropriate behavioral repertoires
that are necessary for children with autism spectrum disorder to effectively benefit
from early educational programs.

Keywords  Autism · Differential reinforcement · Demand fading · Pairing · Rapport-

building

Introduction

The benefits of early intensive behavioral intervention (EIBI) for children with
autism spectrum disorder (ASD) have consistently been demonstrated over the
last 30  years (Lovaas 1987; Reichow 2011; Remington et  al. 2007; Smith et  al.
2000). Available evidence has shown that EIBI produces better outcomes when the

* Tom Cariveau
cariveaut@uncw.edu
Extended author information available on the last page of the article

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 Journal of Behavioral Education

intervention begins at an early age (Harris and Handleman 2000; Itzchak and Zachor
2011), is 25  h per week or more National Research Council 2001), and is based
on the principles of applied behavior analysis (Peters-Scheffer et al. 2011; Reichow
2011; Warren et al. 2011).
In line with this body of evidence, very young children with ASD are often
exposed to a considerable number of hours of intensive intervention. Discrete Trial
Teaching (DTT) is one instructional procedure used in these interventions for chil-
dren with developmental disabilities and was used in the earliest described EIBI
program (Lovaas 1987). This approach typically includes therapist-driven instruc-
tion and provides numerous opportunities for the child to practice a skill during a
single instructional period (Smith 2001). A discrete trial includes five components:
(a) the presentation of a discriminative stimulus (e.g., the therapist saying “point
to the dog”), (b) the presentation of a prompt to evoke a correct response (e.g., the
therapist gesturing to the picture of the dog), (c) the response (e.g., the child point-
ing to the dog), (d) a consequence (e.g., praise and access to some preferred toy),
and (e) the intertrial interval (e.g., the duration between the removal of the preferred
toy and the presentation of the next discriminative stimulus).
The rate or number of instructional trials in DTT may strengthen motivating
operations (MOs) for behavior that is maintained by negative reinforcement (i.e.,
escape) such as attempting to leave the table, crying, or disrupting the instruc-
tional environment (e.g., pushing away instructional materials). MOs are defined
as stimulus conditions that momentarily alter the effectiveness of some reinforcer
and the likelihood that behaviors will occur that have produced the reinforcer in the
past (Michael 1993). When a stimulus is consistently associated with the worsen-
ing of conditions, this stimulus may eventually function as a reflexive conditioned
MO (CMO-R; Michael 1993). Some researchers have argued that the high rate of
instructional demands during DTT may function as a CMO-R (Carbone et al. 2010;
McGill 1999; Shillingsburg et  al. 2014). That is, the presentation of instructional
demands may come to indicate the worsening of conditions. Because noncompli-
ant behavior can impede skill acquisition, developing interventions that weaken
this CMO-R, promote competing reinforcement, or both would be advantageous for
early intervention. To reduce the likelihood that noncompliant behavior will occur
during intervention, several researchers recommend antecedent manipulations such
as pairing (Kelly et  al. 2015; Shillingsburg et  al. 2014; Shillingsburg et  al. 2018),
rapport-building (McLaughlin and Carr 2005; Shireman et  al. 2016; Weiss 2005),
and relationship-building interventions (Parsons et  al. 2016). Although the terms
used to describe them differ, these interventions largely adhere to the recommenda-
tions of Sundberg and Partington (1999). Specifically, when a child is not engaging
in a reinforcing activity, the therapist then presents some reinforcer and participates
in the consumption of the reinforcer with the child. As an example, this may include
a child sitting at the table, the therapist delivering a puzzle to the child, and then
handing the child puzzle pieces while delivering vocal and physical attention.
Kelly et al. (2015) examined the effects of presession pairing intervention on lev-
els of problem behavior (e.g., disruptive behavior or trying to escape) and academic
responding for three children with ASD between the ages of 9 and 11  years old
using a multiple baseline design across participants. During baseline, the participant

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received 5 min of tabletop instruction using DTT. In the subsequent phase, preses-
sion pairing was introduced and included the therapist asked what toy would the
participant like to play with or what the participant would like to discuss. The thera-
pist then presented the selected toy or discussed this topic for 2 to 4  min, before
starting the usual 5-min DTT session. Compared to the baseline condition without
presession pairing, the sessions with presession pairing significantly reduced rates
of problem behavior in all three participants.
More recently, Shillingsburg et al. (2018) evaluated a rapport-building interven-
tion with four boys with ASD between the ages of 3 and 4 years. The authors exam-
ined the effects of an 8-step rapport-building protocol, which included differential
reinforcement and demand fading components. During the intervention, reinforce-
ment was delivered based on the rate of problem behavior, duration of negative
vocalizations, and child’s proximity to the therapist. Instructional demands were
gradually introduced and the number of instructional demands increased from about
one demand every minute, to an average of three demands every 15 s. The authors
evaluated the effects of this intervention using a nonconcurrent multiple baseline
design across participants. High rates of close proximity to the therapist and low
rates of crying and problem behavior were observed for all participants following
this intervention. This study provides a more systematic intervention than prior
studies and the authors suggest that this procedure may effectively address problem
behaviors during DTT without requiring more intrusive procedures such as escape
extinction and/or physical guidance.
Kelly et  al. (2015) and Shillingsburg et  al. (2018) demonstrated the potential
benefits of two distinct pairing interventions. Important considerations include the
age and behavioral repertoires of the participants. For example, the participants
in the study by Kelly et al. (2015) were school-aged children with ASD and fairly
extensive verbal repertoires. In contrast, Shillingsburg et  al. (2018) included four
young boys with lower levels of functional communication. Additional research
is warranted to evaluate similar interventions with young children with ASD and
under-developed verbal repertoires. Indeed, young children with ASD and mod-
erate to severe language delay are likely early intervention participants. The cur-
rent study extends these previous studies in a sample of girls with ASD below age
5 years without functional vocal repertoires (i.e., minimally verbal). We evaluated a
structured protocol similar to Shillingsburg et al. (2018), designed to increase par-
ticipants’ response allocation to instructional environments and decrease problem
behavior. Moreover, we reported on all participants who were enrolled in the study,
including any participants who did not respond to, or need, the intervention.

Methods

Participants and Setting

Nine female participants with a mean age of 34.8 months (range, 26.8–52.1 months)

diagnosed with ASD were recruited through a large clinical program in the southeast
United States included in a pilot randomized control trial. In the randomized trial,

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participants were randomly assigned to 4 weeks of intervention or waitlist. If partic-

ipants were assigned to the waitlist condition, when the waitlist period had elapsed,
these participants were offered the same 4-week intervention. This report combines the
findings for all participants who completed the intervention including those initially
assigned to the waitlist condition. Prior to study enrollment, each child was diagnosed
with ASD by an experienced clinical team at the same center using standard assess-
ments. Based on caregiver report on the MacArthur-Bates Communicative Develop-
ment Inventories—Words and Gestures (CDI; Fenson et al. 2007), parent interviews,
and direct assessments, all participants had fewer than five vocal words. Participant
characteristics and inclusion criteria are included in another manuscript reporting the
feasibility of this randomized trial (see Cariveau et al. 2019).
An experimenter conducted all sessions within a private session room at the clini-
cal program three to 4 days per week. The room contained a table, chairs, and various
tangible items. A video camera mounted on a tripod was used to record each session
for data collection and review. In addition, at least one independent observer, seated
directly behind the child, was present for all sessions and recorded data throughout the
study.

Dependent Variables and Response Measurement

Observers recorded data on four dependent variables: problem behavior, compliance,

proximity, and negative vocalizations. Problem behavior consisted of elopement,
disruption, and aggression, all of which were measured using frequency recording.
Elopement included any instance in which the participant’s hand made contact with
the doorknob of the session room. Disruption included any instance in which the par-
ticipant, threw, tore, or swiped materials from the table and any instance in which the
participant’s hand or foot made contact with a surface at a distance of 0.33 m or more.
Aggression included any instance in which the participant grabbed, hit, bit, or kicked
the therapist. Compliance was defined as any instance in which the participant emitted
the target response either independently or following a prompt. Compliance was not
scored if the participant resisted a physical prompt (i.e., moved in the opposite direc-
tion of the prompt). Data collectors also recorded the number of demands placed by
the experimenter. Percentage of demands with compliance was calculated by taking
the number of demands with compliance, divided by the number of demands placed
and multiplying by 100. Proximity was defined as any instance in which the participant
was within 0.66 m of the therapist, which was measured using a continuous recording
procedure. Finally, negative vocalizations were defined as any instance in which the
participant engaged in a vocalization above conversational level. Duration of negative
vocalizations was measured using a continuous recording procedure that included a 3-s
onset and offset criteria.

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Journal of Behavioral Education

Experimental Design

We examined the effect of the treatment package on the problem behavior, com-
pliance, proximity, and negative vocalizations using a nonconcurrent multiple
baseline design across participants (Harvey et al. (2004) with Kennedy 2005).

General Procedure

A variety of tangible and edible items were arranged at the table before each ses-
sion. No toys were present in other areas of the room. Sessions lasted 10  min
in duration. Physical guidance was not used during the study and the participant
was allowed to move about the room freely. If the participant approached a data
collector, no attention was delivered and attempts to manipulate materials (e.g.,
moving the camera or touching data sheets) were blocked with minimal attention.
Similarly, if at any point the participant was not in proximity to the experimenter,
minimal attention was delivered by the experimenter. Demands were included at
various stages in the protocol and were selected based on parent-reported skill
repertoires and previously observed responses. For all participants, a combination
of mastered and unmastered targets were identified and included motor imitation,
imitation with objects, matching, and listener response targets. Target tasks were
identified through caregiver interview prior to the beginning of the study and
direct assessments during sessions.

Baseline

All participants were exposed to a baseline condition, which was intended to rep-
licate DTT procedures used in early intervention settings. The therapist presented
demands using a short intertrial interval (i.e., less than 3  s; see Cariveau et  al.
2016) and compliance produced 15  s of access to preferred tangible and edible
items on a variable ratio 3 (VR 3) schedule. Instructional demands were presented
once the child engaged in reaching, pointing, or touching a preferred item, which
was presumed to indicate that a relevant establishing operation was present (see
Drasgow et al. 1996). A least-to-most prompting hierarchy was used in this phase
and included independent, model, and physical prompts. The therapist delivered
praise if the participant engaged in the correct response at any point during the
prompting hierarchy. If the child did not comply with a demand, the therapist
removed the demand and said “ok, you don’t have to.” When the child engaged
in a response indicating the presence of an establishing operation, the therapist
placed the same demand. Following the completion of all demands according to
the VR 3 schedule and the participant remaining in proximity to the therapist, the
therapist delivered praise and access to a preferred item. These baseline proce-
dures continued until a decrement in responding was observed in one or more of
the dependent variables.

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Treatment

All participants progressed through a standard sequence of stages during interven-

tion. A criterion for advancing through the stages of the protocol was set prior to
the study. This criterion was based on the rate of problem behavior (stages 1–3) or
the rate of problem behavior and duration of session in proximity (stages 4–8). For
stages 1–3, three consecutive sessions without any instances of problem behavior
were required to move to the subsequent stage. For stages 4–8, three consecutive
sessions without problem behavior and greater than 80% compliance were required
before the next stage was introduced.

Stage 1 The experimenter did not place any demands and the participant was
given free access to all tangible and edible items. The participant was allowed to
freely move around the room with tangible items.
Stage 2 No demands were presented and the participant had access to all tangible
and edible items as long as she was in proximity to the therapist. If the partici-
pant attempted to take an item out of proximity of the experimenter, the item was
removed and placed back on the table.
Stage 3 This stage was identical to the previous one with a single exception: if the
participant stood near the table for 20 s or more, the experimenter would guide
the participant into the child-sized chair at the table. If the participant resisted
this guidance at any point, the experimenter removed the prompt and the partici-
pant was allowed to stand.
Stage 4 The experimenter presented a single demand and immediately presented
a controlling prompt. If the participant did not resist the prompt, a 1-min rein-
forcement interval was presented. The participant had access to preferred tangi-
ble and edible items if she was in proximity to the therapist and complied with
instructional demands.
Stages 5–8 In subsequent stages, additional demands were introduced or the rein-
forcement interval was reduced. In stage 5, a single demand was presented with
a 30-s reinforcement interval. Stage 6 included two demands with a 30-s rein-
forcement interval. In stage 7, the experimenter presented two demands with a
15-s reinforcement interval. Finally, in stage 8, the experimenter presented three
demands with a 15-s reinforcement interval. After stage 8, baseline procedures
were again introduced for the remainder of the study as these procedures were
considered to be consistent with typical instructional procedures in EIBI pro-
grams.

Effect Size

Nonoverlap of all pairs (NAP) is an effect size calculation that measures the degree
of overlap between two phases in single-case research designs (Parker and Vannest
2009). Overlap is a commonly used component of visual analysis (see Horner et al.
2005) and NAP calculations include the number of data points that overlap between
two phases. The NAP score can range from 0.00 to 1.00. A score of 0.50 indicates

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Journal of Behavioral Education

that 50% of data points during the final phase overlap with data points during the
initial phase. A NAP score of 1.00 indicates no overlap between baseline and the
final intervention phase. NAP scores from 0 to 0.65 are classified as small effect
size, 0.66 to 0.92 are considered moderate, 0.93 to 1.0 are considered large (Parker
and Vannest 2009; Petersen-Brown et al. 2012). We chose to calculate NAP scores
as they have been shown to have high reliability with other effect size calculations
in single-case designs (Parker et al. 2011) with some evidence suggesting that this
index is superior to other effect size calculations (Parker and Vannest 2009).

Interobserver Agreement and Procedural Fidelity

A second observer was present for an average of 33.65% (range, 30.00–43.75%) of

all sessions across participants. Total count interobserver agreement was calculated
for each dependent variable by taking the lowest frequency or duration recorded by
an observer, dividing by the highest frequency or duration, and multiplying by 100.
For elopement, average agreement was 99.63% (range, 50.0–100%). Reliability was
below 100% during one session, in which one observer recorded two instances of
elopement and the other recorded a single instance. All other sessions across partici-
pants had 100% agreement. Average agreement for disruptions was 96.35% (range,
0–100%). Instances with 0% reliability occurred in a single session for 4 participants
when one observer recorded a single instance and the other observer did not record
any instances. Average agreement for aggression was 98.99% (range, 0–100%). In
one session one observer recorded a single instance of aggression and the other
observer recorded none. For duration of proximity, average agreement was 99.11%
(range, 68.9–100%). A single session was below 80% agreement. Average agree-
ment for duration of negative vocalizations was 97.41% (range, 62.0–100%), with
a single session at 62.0% when one observer recorded 5 s of negative vocalizations
and the other recorded 8 s. Finally, average agreement for number of demands with
compliance was 96.9% (range, 81.25–100%) and average agreement for number of
demands was 97.25% (range, 81.25–100%).
Fidelity of implementation was assessed by an independent observer using a
7-item checklist. Each item was scored as completed, not completed, or not possible
based on the stage of the protocol. A list of randomly selected sessions was gener-
ated for each participant prior to beginning the study with fidelity assessed during an
average of 14.06% sessions (range, 8.75–22.92%) across all participants. Mean level
of fidelity was 97.63% of components (range, 75.00–100%).

Results

The effect of the treatment package on problem behavior, compliance, proximity and
negative vocalizations are shown in Figs. 1, 2 and 3. Eight of nine participants dem-
onstrated some aberrant responding during the baseline phase. Seven of the eight
completed all stages of the treatment. Before introducing the treatment, a primary
dependent variable was identified for each participant using visual analysis out of

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 Journal of Behavioral Education

Participant #5
Stage
BL 1 2 3 4 3 4 5 6 7
3 100

75
2

50
Proximity
1

Percent of Demands with Compliance/Percentage of session with Close

25

0 0

Stage Participant #4
Baseline 1 2 3 4 5 6 7 8 Baseline

Proximity or Negative Vocalizations

3 100
Rate of Problem Behavior

75
2
Compliance
50

1 Problem
Behavior 25

0 0

Participant #9

Stage
Baseline 1 2 3 4 5 6 7 8 BL
3 100

75
2

50

1
Negative 25
Vocalizations

0 0
5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85
Session

Fig. 1  Findings for participants #5 (top panel), #4 (middle panel), and #3 (bottom panel). Rate of prob-
lem behavior is shown on the primary y-axis and represented by the closed diamonds. Percentage of
session with proximity (closed squares), percentage of demands with compliance (open triangles), and
percentage of session with negative vocalizations (open circles) are shown on the secondary y-axis

the four dependent variables included in the study. We identified a primary depend-
ent variable because multiple topographies of escape-maintained behavior likely
belonged to the same response class; however, we expected that a single topography
would be emitted more frequently than others and this may vary across participant.
For some participants, rates of compliance and proximity were similar during the
baseline phase. If this was the case, we calculated the mean level for each dependent

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Journal of Behavioral Education

Stage Participant #8
BL 1 2 3 4 5 6 7 8 Baseline
3 100

75
2

50
Problem
1 Behavior
25

0 0

Percentage of Session with Close Proximity or Demands with Compliance

Participant #7
Stage
BL 1 2 3 4 5 6 7 8 Baseline
3 100

75
2

50

1
Rate of Problem Behavior

25

0 0

Participant #2
Stage
Baseline 1 2 3 4 5 6 7 8 Baseline
3 100

75
2 Compliance
50

1
25

0 0

Stage
Baseline 1 2 3 4 5 6 7 8 Baseline Participant #3
3 100

75
2 Proximity

50

1
25

0 0
5 10 15 20 25 30 35 40 45 50 55 60
Session

Fig. 2  Findings for participants #8 (top panel), #7 (second panel), #2 (third panel), and #3 (bottom
panel). Rate of problem behavior is shown on the primary y-axis and represented by the closed dia-
monds. Percentage of session with proximity (closed squares) and percentage of demands with compli-
ance (open triangles) are shown on the secondary y-axis

variable during the initial baseline phase and selected the dependent variable with
the lowest mean level. For three participants (#5, #4, and #9) the primary dependent
variable was proximity (Fig. 1). The primary dependent variable was compliance for

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Stage Participant #6
BL 1 2 3 4 5 6 7 8 Baseline
3 100

Percent of Demands with Compliance/Percentage of session with Close Proximity

Compliance
75
2

50

1
25
Behavior
Problem
Rate of Problem Behavior

or Negative Vocalizations
0 0

Participant #1
Baseline
3 100

75
2

50

1
Negative Proximity 25
Vocalizations

0 0
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85
Session

Fig. 3  Findings for participants #6 (top panel) and #1 (bottom panel). Rate of problem behavior is shown
on the primary y-axis and represented by the closed diamonds. Percentage of session with proximity
(closed squares), percentage of demands with compliance (open triangles), and percentage of session
with negative vocalizations (open circles) are shown on the secondary y-axis

four participants (#8, #7, #2, and #3; Fig. 2). Figure 3 includes the results for partici-
pant #6, which was the only participant with negative vocalizations as the primary
dependent variable (top panel). Finally, participant #1 is shown in Fig.  3 (bottom
panel). This participant did not progress from the baseline condition as no aberrant
responding was observed during the study.
Figure 1 shows the findings for three participants. For participant #5 (top panel), a
decreasing trend was observed in proximity during the baseline phase with relatively
high percentage of demands with compliance. An initial increase was observed in
proximity during stage 1, although variable levels were observed through stage 4.
We observed highly variable rates of compliance in stage 4 and reintroduced stage
3 procedures at session 21. Following 12 sessions in the second stage 3, high rates
of compliance were observed during all subsequent stages; however, proximity
remained highly variable. The protocol was terminated prior to stage 8. Anecdotally,

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Journal of Behavioral Education

this participant emitted high rates of motor stereotypy that occurred away from the
table.
Results for participant #4 are shown in the middle panel of Fig.  1. Baseline
levels of compliance and proximity were variable and on a decreasing trend. We
observed an immediate increase in proximity with a decreasing trend during stage 1.
Nevertheless, high levels of proximity were observed during stages 2 and 3. When
demands were introduced in stage 4, an immediate reduction in proximity during the
first session followed by high levels observed for the remainder of the intervention.
High levels of demands with compliance continued, including during the reversal to
baseline procedures.
Results from participant #9 are shown in the bottom panel of Fig. 1. For this par-
ticipant, proximity and percent compliance remained high during the initial base-
line phase until a decreasing trend was observed in both percent compliance and
percent proximity after 20 sessions. When stage 1 was introduced, we observed an
immediate reduction in proximity. However, increased levels were observed for the
remainder of the protocol albeit with some variability during stages 7 and 8. We also
observed increased levels of elopement in which the participant would pull down on
the door handle multiple times within a few seconds without opening the door. This
was scored as separate occurrences of problem behavior. For participant #9, the final
baseline phase was only conducted for a single session due to time constraints of the
study. Percentage of demands with compliance and proximity were both 100% dur-
ing this session with no problem behavior or negative vocalizations.
Figure 2 shows all participants with compliance as the primary dependent vari-
able. The percentage of sessions with negative vocalizations is excluded from this
figure as none of these participants engaged in negative vocalizations during the
study. For participant #8 (top panel), responding during baseline was on a decreas-
ing trend for compliance and proximity. During the initial stages of intervention,
variable levels of proximity were observed until the final three sessions of stage 5.
Levels of proximity and percentage of demands with compliance remained high for
the remainder of the intervention. Compliance and proximity for seven out of eight
sessions were 100% during the final baseline phase.
The results for participant #7 are shown in the second panel of Fig. 2. For this
participant, low levels of compliance were observed during baseline. When demands
were reintroduced in stage 4, the overall high levels of demands with compliance
were observed for the remainder of the protocol. During the reversal to baseline pro-
cedures, demands with compliance remained above 80%, with no problem behavior
and high levels of proximity.
The findings for participant #2 are shown in Fig.  2 (third panel). Compliance
was highly variable during the baseline phase with a decreasing trend in proximity
throughout the phase. Once the treatment was introduced, an immediate increase
with slightly variable levels of proximity was observed, until the end of stage 3.
Demands were reintroduced during stage 4, with variable levels of responding,
and high levels in stage 5 and the first three sessions of stage 6. During stage 6,
we observed a decreasing trend in compliance; however, due to an error, the
experimenter advanced to stage 7. Responding for the first two sessions of stage 7
were similar to the final three sessions of stage 6; however, responding increased

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throughout this stage and remained high through the final baseline phase. Similar
to participant #8, low levels of problem behavior were observed at various points
during the study, although problem behavior only occurred during the intervention
stages for this participant.
Participant #3 was the final participant with compliance as the primary depend-
ent variable (Fig. 2, bottom panel). A decreasing trend with low levels of demands
with compliance was observed during the initial baseline phase. Proximity remained
fairly stable at around 80%. The participant would leave proximity when demands
were placed and would quickly move back into proximity until another demand was
presented. When treatment was introduced, we observed an immediate increase in
proximity. Proximity remained above 85% of the session for the remainder of the
study. Similarly, when demands were again introduced in stage 4, 100% compliance
was observed during all sessions until study endpoint. To note, levels of problem
behavior were observed throughout each phase. All problem behaviors were coded
as disruptions; however, they were due to a motor skill deficit. Specifically, disrup-
tions occurred after demands were completed and reinforcers were being delivered
(e.g., attempting to grab a bag of edibles and pulling them toward her, but land-
ing on the floor). Although this topography met our definition for disruptions and
was recorded as such, problem behavior was not included in the criteria to advance
through the protocol for this participant.
Figure  3 shows the results for participants #6 and #1. For participant #6 (top
panel), the primary dependent variable was negative vocalizations, which occurred
for more than 50% of the session during three of the four baseline sessions. An
immediate decrease in negative vocalizations was observed when the intervention
was introduced and low rates continued until stage 6, during which, variable levels
of negative vocalizations were observed. Throughout the intervention stages, com-
pliance and proximity remained high with significant reductions in negative vocali-
zations observed during the final baseline phase.
Finally, a total of 80 sessions of the baseline phase were conducted for participant
#1 with high levels of proximity and compliance and low levels of problem behavior
and negative vocalizations throughout the phase. As a result, the intervention was
not introduced before the study was terminated.
An effect size was calculated from the primary dependent variable for each par-
ticipant (see Table  1). Moderate to large effect sizes were observed for all partic-
ipants. No overlap between the initial and final baseline phases was observed for
three of the seven participants, yielding a NAP score of 1.00.

Discussion

The current study was designed to evaluate a method for arranging instructional
environments to reduce problem behavior and increase appropriate alternative
responses for nine minimally verbal girls with ASD. For one participant, no inter-
vention was required as compliance and proximity was high during the initial base-
line phase, with low occurrences of problem behavior or negative vocalizations.
For an additional participant, high levels of stereotypy, which included physical

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Table 1  Effect size calculation NAP score Effect size

of primary dependent variable
from initial and final baseline Proximity
phases across participants
Participant #5 1.00 Large
Participant #4 0.84 Moderate
Participant #9 0.85 Moderate
Compliance
Participant #8 0.92 Moderate
Participant #7 1.00 Large
Participant #2 1.00 Large
Participant #3 0.92 Moderate
Negative vocalizations
Participant #6 1.00 Large
None
Participant #1 N/A N/A

NAP nonoverlap of all pairs. Effect size calculations are based on

Parker and Vannest (2009). NAP scores correspond with small
(0–0.65), moderate (0.66–0.92), and large (0.93–1.00) effect sizes

posturing on the floor, impeded her completion of the protocol in its entirety. For
the remaining seven participants, although the primary dependent variable differed,
the intervention, which included differential reinforcement and demand fading was
effective and produced moderate to large effect sizes. Notably, this intervention did
not include physical guidance to the instructional setting or other escape extinction
procedures (e.g., three-step prompting). These intrusive procedures are commonly
used in early intervention programs to teach the child to sit at a table or to reduce
the child’s noncompliant behavior during intervention sessions. The current study
suggests that more intrusive procedures are not necessary to increase the amount of
time that participants remain in the instructional setting and comply with demands.
For the eight participants who exhibited low levels of compliance, proximity, or
high levels of negative vocalizations during baseline, the primary dependent vari-
able differed. Compliance was the primary dependent variable for three partici-
pants, proximity for four participants, and negative vocalizations for one participant.
Although these topographies were identified as the primary dependent variable,
based on the mean level during the baseline phase, variability in other depend-
ent variables was also observed for all but two of the participants (participants #6
and #7). This suggests that early intervention providers may observe a variety of
topographies of challenging behaviors beyond typically regarded problem behaviors
(e.g., aggression, disruption) ranging from moving away from the therapist to resist-
ing prompts. Regardless of this topography, the current protocol was effective in
increasing appropriate responding for the majority of the participants.
The procedures in this study systematically arranged a concurrent schedule
of reinforcement, such that remaining in proximity to the therapist and comply-
ing with demands produced access to preferred items and attention. In addition,
potential escape-maintained behaviors, such as problem behavior, being more

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than 0.66 m from the therapist, or resisting prompts during instruction produced
escape from instructional demands. This arrangement is an example of methods
to increase meaningful repertoires for individuals with developmental disabili-
ties by arranging compound schedules of reinforcement. This may be particularly
meaningful as extinction-based procedures may produce undesirable side effects
(see Lerman and Iwata 1996) or may be problematic when implemented with low
levels of integrity (Smith et al. 1999).
Prior research (i.e., Kelly et al. 2015) has evaluated the use of presession pair-
ing on levels of problem behavior and academic responding during subsequent
periods of instruction using DTT. Previous findings showed that a brief (i.e., 2-
to 4-min) period of interaction between the therapist and participant produced
greater levels of compliance and reductions in problem behavior for three par-
ticipants with ASD (Kelly et al. 2015). In their study, one participant had limited
vocal verbal behavior (i.e., Ariel), although her receptive language was reported
as a strength. Furthermore, tasks were more advanced academic skills (e.g., spell-
ing words, completing math problems, etc.). Our study included participants
under the age of 6  years old with fewer than five vocal words and targets were
preacademic instructional tasks, which primarily included matching and imitation
targets. The characteristics of the participants and targeted skills in the current
study may be more similar to the clientele typically referred to EIBI programs.
There are a number of limitations of the current study that should be men-
tioned. First, we did not conduct a functional analysis to determine the main-
taining variables of participants’ problem behavior, proximity, or compliance.
Because our baseline procedures included high rates of demands, it was likely
that challenging behaviors, including problem behavior, lack of proximity, or lack
of compliance were maintained by escape from the task as this was the only con-
sequence available following these responses during the baseline condition. Nev-
ertheless, future research should consider whether functional analyses are critical
to their research question. We were interested in demonstrating the meaningful
arrangement of the instructional environment to facilitate appropriate responding
similar to the study by Lalli et al. (1999) and extended to early intervention set-
tings. As a result, we were less interested in the function of these responses, and
instead hoped to apply a standardized protocol to promote higher levels of appro-
priate behavior. Also, the brief duration of the initial or final baseline phases for
some participants may reduce our confidence that steady-state responding was
being measured (see Sidman 1960). It may be ideal that these phases are con-
ducted for more extended periods to ensure steady-state responding is observed,
although this has been noted as a limitation more generally in applied work
(Schmitt 1984). Nevertheless, the duration of our initial baseline phase was con-
sistent with past research on similar methods (e.g., Kelly et  al. 2015; Shillings-
burg et  al. 2018). Additionally, the variability in responding observed for some
participants may suggest that the progression through the intervention stages was
completed too quickly. This limitation should be considered for both its experi-
mental and applied implications as it is ideal to demonstrate steady-state respond-
ing, while also progressing through protocols efficiently to promote timely gains
in clinical programs.

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Journal of Behavioral Education

A strength of the current study is the inclusion of all participants enrolled in this
study. This study demonstrates the evaluation of a structured intervention across
nine participants regardless of outcome. As a result, we presented instances when
participants may not have required the protocol (i.e., participant #1) or when the
protocol was not sufficient (i.e., participant #5). This is noteworthy as our partici-
pants were identified from a very homogenous group (i.e., minimally verbal girls
with ASD under the age of 6 years). Nevertheless, repertoires beyond age, sex, and
vocal verbal behavior likely influence the effectiveness of certain procedures and
should be considered in future studies.
The current study demonstrates the effectiveness of a structured intervention to
increase appropriate behavior during instructional arrangements that may be typical
in early intervention settings. This protocol includes the systematic arrangement of
contingencies that did not necessitate the use of extinction, effectively contributing
to the body of research on nonextinction-based procedures (Gardner et  al. 2009).
Although the protocol required a mean of 390  min for participants to progress
through the intervention stages, because instructional demands were included in the
intervention, the current protocol can be implemented while still targeting habili-
tative goals. This arrangement will hopefully serve as a demonstration of methods
that early interventionists may use during early programming to increase appropriate
responding for children with ASD.

Funding  This study was funded by the Autism Science Foundation (Grant Number 16-002) and the Mar-
cus Foundation.

Compliance with Ethical Standards 

Conflict of interest  Tom Cariveau declares that he has no conflict of interest. Alice Shillingsburg declares
that she has no conflict of interest. Arwa Alamoudi declares that she has no conflict of interest. Taylor
Thompson declares that she has no conflict of interest. Brittany Bartlett declares that she has no conflict of
interest. Scott Gillespie declares that he has no conflict of interest. Larry Scahill has served as a consultant
for Roche, CB Partners, Shire, Supernus, Neurocrine, and the Tourrette Association of America. Larry
Scahill also receives royalties from Guilford and Oxford Press.

Ethical Approval  All procedures performed in studies involving human participants were in accordance
with the ethical standards of the institutional and/or national research committee and with the 1964 Hel-
sinki Declaration and its later amendments or comparable ethical standards.

Informed Consent  Informed consent was obtained from all individual participants included in the study.

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Affiliations

Tom Cariveau1,2   · M. Alice Shillingsburg3 · Arwa Alamoudi4 ·

Taylor Thompson5 · Brittany Bartlett6 · Scott Gillespie6,7 · Lawrence Scahill6,7
1
Department of Psychology, University of North Carolina Wilmington, 601 S. College Rd,
Wilmington, NC 28403, USA
2
Center for Pediatric Behavioral Health, Wilmington, NC, USA
3
The May Institute, Randolph, MA, USA
4
Department of Communication Sciences and Special Education, University of Georgia, Athens,
GA, USA
5
College of Education and Human Development, Georgia State University, Atlanta, GA, USA

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6
Marcus Autism Center, Atlanta, GA, USA
7
Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA

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