1

Using an Antecedent Prompting Method to Teach an Extended Communication

Sequence to Children with Autism Using a Speech Generating Device

by

Anastasia Sawchak, MS, BCBA

A thesis

submitted to Victoria University of Wellington in fulfillment of the requirements for the

degree of Doctor of Philosophy

Victoria University

2022
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ABSTRACT

Children with autism spectrum disorder often have severely limited speech and language

development and these children might therefore benefit from alternative and augmentative

communication (AAC) intervention. While there is an extensive literature demonstrating

effective procedures for teaching children with developmental disabilities and severe

communication to use AAC, studies in this area have mainly focused on teaching relatively

short and single-function communicative exchanges, such as teaching the person to request

access to a preferred object by producing one communication act, such as by selecting a

single symbol on a speech-generating device. While requesting access to a preferred object is

useful, it would also seem important for children to be able to engage in more extended and

multi-functional communication exchanges. However, there is little research into the

development and evaluation of procedures for teaching more extended, multi-function

communication sequences, such as teaching the child to (a) first greet his or her listener, (b)

then make a request for a general object (“I want a snack.”), (c) then make a request for a

specific object (“I want popcorn.”), and (d) then thank the listener for providing the

requesting item. Furthermore, there is no published literature teaching communicative

behaviours on a speech-generating device using the antecedent prompting procedure. The

aim of this research is to determine whether children with developmental disabilities and

severe communication impairment can learn to produce such extended and multi-functional

communication sequences by systematically implementing the antecedent prompting

procedure with an iPad-based speech-generating device.

Study 1 used a multiple baseline design to evaluate the effectiveness of the antecedent

prompt to teach a 4-step communicative exchange on an iPad®-based speech-generating

device set with a progressive display. Participants were required to discriminate between two

icons at a time, and the progressive display guided them through four screens, or the four
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steps, of the communicative exchange. All five participants (4 boys, 1 girl, aged 6 to 10

years) who participated in this study mastered the 4-step communicative exchange in four

sessions on average. Study 2 was identical to Study 1, except the iPad®-based speech-

generating device was set with a static screen. Participants (4 boys, aged 6 to 10 years) were

required to discriminate between 12 icons simultaneously and select the appropriate icon for

each step of the exchange. Of the participants, three were performing the sequence correctly

after one session on average, one student did not reach mastery criteria but the average

number of his communicative exchanges per interaction increased. Considering the positive

outcomes and rapid rate of acquisition from both studies, future research should consider

implementing the antecedent prompt when teaching communication interventions to

minimally verbal children with autism on a speech-generating device.

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ACKNOWLEDGEMENTS

I would like to thank my primary advisor Jeff Sigafoos, for his support, and patience

throughout the completion of this project. I would also like to thank my secondary supervisor,

Hannah Waddington, who has been a friend, then mentor.

Most importantly, thanks to my family. To my husband, Jonny, thank you for your

unconditional love and unwavering support throughout this entire process. Thanks to my

beautiful girls, Annabel, and Emily, who brighten my day with their smiles. To my loving

grandparents, you are greatly missed. And to my dear friends Jessica, Tegan, Sarah, Sian,

Caroline, and Hannah, thank you for always being there for me with a smile on your face. I

would especially like to thank the children and their families who participated in this

research, it was a pleasure working with you.

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DECLARATION BY THE AUTHOR

The present thesis is my original work conducted for a PhD under the supervision of Victoria

University of Wellington. No part of this thesis has been previously submitted for a degree or

diploma. Work by other authors has been referenced in text. Studies presented in this thesis

were designed and conducted by me with ongoing consultation from my primary supervisor,

Dr. Jeff Sigafoos, and secondary supervisor, Dr. Hannah Waddington throughout the

development, data-collection, and writing of this thesis. I report no conflicts of interest and

take sole responsibility for the content of writing.

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TABLE OF CONTENTS

ABSTRACT ............................................................................................................................... 3
ACKNOWLEDGEMENTS ....................................................................................................... 5
DECLARATION BY THE AUTHOR ...................................................................................... 6
LIST OF FIGURES ................................................................................................................. 11
LIST OF TABLES ................................................................................................................... 12
CHAPTER 1 ............................................................................................................................ 13
An Introduction to Autism, AAC, and the Proposed Research ............................................... 13
Original Descriptions of Autism .......................................................................................... 13
Contemporary Descriptions of ASD .................................................................................... 14
Prevalence ............................................................................................................................ 19
Aetiology .............................................................................................................................. 20
Behaviours and Symptoms ................................................................................................... 22
Social Impairments ........................................................................................................... 22
Communication Impairment ............................................................................................. 23
Repetitive and Ritualistic Behaviour ................................................................................ 24
Diagnosis and Assessment ................................................................................................... 25
Typical Language Development .......................................................................................... 29
Verbal Behaviour ................................................................................................................. 29
Augmentative and Alternative Communication (AAC)....................................................... 30
Characteristics of a Speech Generating Device ................................................................... 33
Types of speech output ..................................................................................................... 33
Icon design ........................................................................................................................ 33
Display types .................................................................................................................... 34
Past and Current Perceptions of AAC .................................................................................. 35
Neurodiversity ...................................................................................................................... 36
Brief Explanation of Research ............................................................................................. 37
Extended communication sequence ..................................................................................... 38
Summary .............................................................................................................................. 39
CHAPTER 2 ............................................................................................................................ 40
Literature Review..................................................................................................................... 40
Introduction .......................................................................................................................... 40
Methods ................................................................................................................................ 43
Search Strategy ................................................................................................................. 43
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Inclusion and Exclusion Criteria ...................................................................................... 44

Data Extraction ................................................................................................................. 45
Inter-rater Agreement ....................................................................................................... 46
Results .................................................................................................................................. 46
Participants ....................................................................................................................... 46
Device Type, Characteristics and Applications ................................................................ 49
Experimental Design ........................................................................................................ 53
Interventionists ................................................................................................................. 53
Settings ............................................................................................................................. 53
Dependent Variables......................................................................................................... 54
Independent Variables ...................................................................................................... 55
Preference Assessments .................................................................................................... 58
Generalization and Maintenance ...................................................................................... 58
Inter-observer Agreement and Procedural Fidelity .......................................................... 59
Quality Ratings ................................................................................................................. 61
Outcomes .......................................................................................................................... 62
Discussion ............................................................................................................................ 63
Limitations ........................................................................................................................... 68
Research Questions .............................................................................................................. 68
CHAPTER 3 ............................................................................................................................ 70
Study 1: Teaching an Extended Communication Sequence Using an Antecedent Prompting
Procedure with a Progressive Display on an iPad-based SGD ................................................ 70
Abstract ................................................................................................................................ 70
Ethical Considerations.......................................................................................................... 75
Methods ................................................................................................................................ 76
Participants ........................................................................................................................... 76
Setting and Intervention Context ......................................................................................... 79
Preferred Stimuli .................................................................................................................. 80
Speech-generating Device .................................................................................................... 81
Response Definitions and Measurement .............................................................................. 83
Experimental Design ............................................................................................................ 85
Session Schedule .................................................................................................................. 86
Procedures ............................................................................................................................ 86
Procedural Integrity .............................................................................................................. 90
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Results .................................................................................................................................. 90
Discussion ............................................................................................................................ 95
Limitations and Future Research.......................................................................................... 98
Conclusion............................................................................................................................ 99
CHAPTER 4 .......................................................................................................................... 100
Study 2: Teaching an Extended Communication Sequence Using an Antecedent Prompting
Procedure and a Static Display on an iPad-based SGD ......................................................... 100
Method ............................................................................................................................... 104
Participants ......................................................................................................................... 104
Setting and Intervention Context ....................................................................................... 105
Preferred Stimuli ................................................................................................................ 105
Speech-generating Device .................................................................................................. 106
Response Definitions and Measurement ............................................................................ 107
Experimental Design .......................................................................................................... 108
Session Schedule ................................................................................................................ 108
Procedures .......................................................................................................................... 108
Inter-Observer Agreement.................................................................................................. 112
Procedural Integrity ............................................................................................................ 113
Social Validity .................................................................................................................... 114
Results ................................................................................................................................ 114
Social Validity .................................................................................................................... 118
Discussion .......................................................................................................................... 120
Limitations and Future Research........................................................................................ 122
Conclusion.......................................................................................................................... 123
CHAPTER 5 ......................................................................................................................... 125
General Discussion ................................................................................................................ 125
Main Findings .................................................................................................................... 125
Limitations ......................................................................................................................... 128
Summary and Conclusion .................................................................................................. 132
REFERENCES ...................................................................................................................... 134
APPENDIX A ........................................................................................................................ 176
APPENDIX B ........................................................................................................................ 177
APPENDIX C ........................................................................................................................ 183
APPENDIX D ........................................................................................................................ 186
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APPENDIX E ........................................................................................................................ 192

APPENDIX F......................................................................................................................... 195
APPENDIX G ........................................................................................................................ 201
APPENDIX H ........................................................................................................................ 204
APPENDIX I ......................................................................................................................... 205
APPENDIX J ......................................................................................................................... 208
APPENDIX K ........................................................................................................................ 209
APPENDIX L ........................................................................................................................ 210
APPENDIX M ....................................................................................................................... 211
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LIST OF FIGURES

Figure 1.1 Hypothetical Trajectories for a Child Who Receives Intervention at the Age of

One (Child A) Compared to the Age of Four (Child B; Waddington, 2018). ……..………..26

Figure 2.1 Adapted PRISMA Flow Diagram for Article Inclusion. ..………….…………...43

Figure 3.1 Progressive Display Screen Configuration Programmed onto Each Participants

SGD.…...………………………………………………………………………………...…...81

Figure 3.2 Example of the Visual Display for Each Step on Andy’s SGD. ..….…………....83

Figure 3.3 Percentage of Trials in Which Participants Performed the 4-step Sequence

Correctly During Probe Trials, Across Sessions, for Each Phase of the Study. ..…..…….....92

Figure 4.1 Example of Andy’s SGD Set with a Static Display Containing a Request for a

Twister in the Message Window. ..……………………………..…………………………...105

Figure 4.2 Percentage of Trials in Which Sean, Chris, Victor, & Andy Performed the 4-step

Sequence Correctly Across Sessions and for Each Phase of the Study. ..…………………..117

Figure 4.3 Icons Activated Per Trial During Andy’s Procedural Modification 1, 2, and

Follow-up Phase. …...………………………………………………………………………118

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LIST OF TABLES

Table 1.1 DSM-V Diagnostic Criteria for Autism Spectrum Disorder …………...………...16

Table 1.2 Severity of Levels for Autism Spectrum Disorder …………………………...…....18

Table 2.1 Participant Demographics and Assessment Information ………………………...47

Table 2.2 ACC Technologies and Characteristics ………………………………...………..51

Table 2.3 Experimental Design Components ………………………………………...……..56

Table 2.4 Methodological Components …………………………………………………..…59

Table 2.5 Quality and Outcome Ratings ……………………………………...…………….60

Table 3.1 Child Demographic Characteristics, Vineland-III Age Equivalencies, and ACC

History ………………………………………………………………………………………75

Table 3.2 Preferred Stimuli for Each Participant ………………………………………….79

Table 3.3 Examples of Natural Consequences for Each Step of the Communication Sequence

……………………………………………………………………………………………….86

Table 4.1 Child Demographic Characteristics, Vineland-III Age Equivalencies, and ACC

History …………………………………………………………………………………...…102

Table 4.2 Preferred Stimuli for Each Participant ………………………………………....104

Table 4.3 Examples of Natural Consequences for Each Step of the Communication Sequence

………………………………………………………………………………………………108
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CHAPTER 1

An Introduction to Autism, AAC, and the Proposed Research

Original Descriptions of Autism

The term “autism” appears to date back to at least 1908 when it was used by

psychiatrist Eugen Bleuler during a lecture at the German Psychiatric Association in Berlin

(Ashok et al., 2012). The term is derived from the Greek word “autos”, which means self. In

Bleuler’s time, the term was used to describe a type of schizophrenia in which the person was

said to be exiled into a world of their own (Isler, 2018). Thus, initially the term autism

appears to have been used to describe self-isolating behaviour associated with a major mental

disorder (Isler, 2018). Thirty-five years after Bleuler’s lecture, the term autism was used by

Kanner (1943) and Asperger (1944) to describe what was later recognized to be a new

syndrome (Cohmer, 1943).

Kanner’s (1943) seminal paper reports on his observations of 11 children (8 boys and

3 girls), who were all described as showing stereotyped mannerisms, a tendency towards self-

isolation, and an obsessive insistence on the maintenance of sameness. They also showed

marked communication and social skills deficits. Additionally, the children were reported to

show a seeming inability to relate to people, inability to tolerate changes in routine, and

echolalia (that is repeating or parroting the speech of others). Kanner referred to this cluster

of symptoms using the term “infantile autism” and he suggested the condition was probably

biological in origin.

Independently of Kanner, Asperger (1944) described four children with similar

characteristics. However, these children were reported to have relatively more advanced

communication skills compared to the children described by Kanner. Asperger referred to

these children as his “little professors” because they could speak in detail about topics of

interest to them. Like Kanner, however, Asperger’s description included reference to the
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children’s social impairments and their tendency to insist on sameness, have a narrow range

of interests, and show repetitive behaviour. These two reports by Kanner (1943) and

Apserger (1944) had a major influence in shaping current clinical identification and diagnosis

of autism spectrum disorder (ASD) and have remained characteristic features of the condition

to this day (Reynolds & Kamphaus, 2013).

Contemporary Descriptions of ASD

ASD is currently considered a neurodevelopmental disorder with a biomedical/genetic

origin, although its exact cause or causes remain unknown (Geschwind, 2009; McPartland et

al., 2012). Evidence suggests symptoms of ASD can be explained by neuroanatomical

abnormalities, but a diagnosis of ASD is based on clinical observations of behaviour as there

are currently no definitive biochemical markers, laboratory tests or imaging scans available

(Geschwind, 2009; Xiao et al., 2014).

Brain imaging scans have provided evidence of atypical brain development amongst

individuals diagnosed with ASD compared to typically developing peers. Specifically,

research has presented observations of varying abnormalities in individuals diagnosed with

ASD with respect to (a) the volume of grey and white matter in the frontal, temporal, and

occipital lobes; (b) over or under connectivity in the structural networks; and (c) smaller

structures such as the hippocampus and amygdala (Courchesne et al., 2001; Fang et al,

2020a; Fu et al., 2020; Han, 2021; Li et al., 2021; Minshew & Williams, 2007; Ulay &

Ertugal, 2009; Xiao et al., 2014). As more data are gathered from brain imaging scans,

neurobiological markers may one day be identified (Jacobs, et al., 2021; Koyama et al.,

2016).

As a result of the nature, presentation, and current abilities to diagnose ASD,

development of reliable diagnostic instruments has been an important area of research (Lord,

et al., 2014). In this thesis, the diagnostic criteria and defining characteristics of ASD used is
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outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V;

American Psychiatric Association, 2013). The DSM- V is the current gold standard in the

field. The diagnostic criteria delineated in the DSM-V are listed in Table 1.1 (American

Psychiatric Association, 2013).

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Table 1.1

DSM-V Diagnostic Criteria for Autism Spectrum Disorder

Autism Spectrum Disorder

Diagnostic Criteria
A. Persistent deficits in social communication and social interaction across multiple
contexts, as manifested by the following, currently or by history (examples are
illustrative, not exhaustive; see text):
1. Deficits in social-emotional reciprocity, ranging, for example, from
abnormal social approach and failure of normal back-and-forth
conversation; to reduced sharing of interests, emotions, or affect; to failure
to initiate or respond to social interactions.
2. Deficits in nonverbal communicative behaviours used for social interaction,
ranging, for example, from poorly integrated verbal and nonverbal
communication; to abnormalities in eye contact and body language or
deficits in understanding and use of gestures; to a total lack of facial
expressions and nonverbal communication.
3. Deficits in developing, maintaining, and understanding relationships,
ranging, for example, from difficulties adjusting behaviour to suit various
social contexts; to difficulties in sharing imaginative play or in making
friends; to absence of interest in peers.
B. Restricted, repetitive patterns of behaviour, interests, or activities, as manifested by
at least two of the following, currently or by history (examples are illustrative, not
exhaustive; see text):
1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g.,
simple motor stereotypes, lining up toys or flipping objects, echolalia,
idiosyncratic phrases).
2. Insistence on sameness, inflexible adherence to routines, or ritualized
patterns of verbal or nonverbal behaviour (e.g., extreme distress at small
changes, difficulties with transitions, rigid thinking patterns, greeting rituals,
need to take same route or eat same food every day).
3. Highly restricted, fixated interests that are abnormal in intensity or focus
(e.g., strong attachment to or preoccupation with unusual objects,
excessively circumscribed or perseverative interests).
4. Hyper- or hypo-reactivity to sensory input or unusual interest in sensory
aspects of the environment (e.g., apparent indifference to pain/temperature,
adverse response to specific sounds or textures, excessive smelling or
touching of objects, visual fascination with lights or movement).
C. Symptoms must be present in the early developmental period (but may not become
fully manifest until social demands exceed limited capacities or may be masked by
learned strategies in later life).
D. Symptoms cause clinically significant impairment in social, occupational, or other
important areas of current functioning.
E. These disturbances are not better explained by intellectual disability (intellectual
developmental disorder) or global developmental delay. Intellectual disability and
autism spectrum disorder frequently co-occur; to make comorbid diagnoses of
autism spectrum disorder and intellectual disability, social communication should
be below that expected for general developmental level.
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The severity of ASD symptoms is classifiable into three levels as summarized in

Table 1.2 (American Psychiatric Association, 2013). Level 1 is labelled as mild severity,

“requiring support”. As an example, this could refer to a person who can speak in full

sentences, but who is typically unsuccessful in making friends, and has difficulty

transitioning between activities. Level 2 is labelled as moderate severity, “requiring

substantial support”. This could refer to an individual who speaks a few sentences and who

has a narrow range of interests and displays obvious stress with respect to changes in routine.

Level 3 is labelled as severe, “requiring very substantial support”. This severe category

includes individuals who have little or no intelligible speech and who show extreme

inflexibility of behaviour and extreme difficulty coping with change.

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Table 1.2

Severity Levels for Autism Spectrum Disorder

Severity Level Social Communication
Level 1, Mild Without supports in place,
“Requiring support” deficits in social
communication cause
noticeable impairments. Has
difficulty initiating social
interactions and
demonstrates clear examples
of atypical or unsuccessful
responses to social overtures
of others. May appear to
have decreased interest in
social interactions
Restrictive, repetitive
behaviours
Rituals and repetitive
behaviours [RRBs] cause
significant interference with
functioning in one or more
contexts. Resists attempts by
others to interrupt RRBs or
to be redirected from fixated
interest

Level 2, Moderate Marked deficits in verbal RRBs and/or preoccupations

“Requiring substantial
support”
and nonverbal social
communication skills; social
impairments apparent even
with supports in place;
limited initiation of social
interactions and reduced or
abnormal response to social
overtures from others
and/or fixated interests
appear frequently enough to
be obvious to the casual
observer and interfere with
functioning in a variety of
contexts. Distress or
frustration is apparent when
RRBs are interrupted;
difficult to redirect from
fixated interest.

Level 3, Severe Severe deficits in verbal and Preoccupations, fixed rituals

“Requiring very substantial
support”
nonverbal social
communication skills cause
severe impairments in
functioning; very limited
initiation of social
interactions and minimal
response to social overtures
from others.
and/or repetitive behaviours
markedly interfere with
functioning in all spheres.
Marked distress when rituals
or routines are interrupted;
very difficult to redirect
from fixated interest or
returns to it quickly.
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Prevalence

International figures suggest that ASD affects approximately 1 in every 160 children

(Elsabbagh et al., 2012; Mayada et al., 2012). However, many countries have reported much

higher figures. In the United States, for example, the prevalence has been estimated at

approximately 1 in 54 individuals (Centers for Disease Control and Prevention [CDC], 2016).

In Canada, from the year 2003 to 2015, prevalence of ASD increased from an average of 15.2

per 1,000 children to 17.6 per 1,000 (The Public Health Agency of Canada [PHAC], 2018).

Australia reported a 25.1% increase in the prevalence of autism from 2015 to 2018

(Australian Bureau of Statistics, 2019). In New Zealand according to the disability survey of

2006, 5% of children under 15 years of age were reported to have special needs, including

ASD and other DD (Statistics New Zealand, 2007). The next survey will be conducted in

2023 and will hopefully provide greater insight into current rates, as ASD is thought to

currently affect 1 in 100 New Zealanders (Ministry of Health, 2020).

Current prevalence estimates could be growing because of increased awareness and a

broader definition of ASD (Braun et al., 2015; Rice et al., 2013). A 10-year study in Sweden

compared the annual prevalence of the autism symptom phenotype (symptoms upon which

the diagnostic criteria are based) to the prevalence of reported diagnosis of ASD in the

national patient register and found that the prevalence of the autism symptom phenotype

remained stable while the number of individuals clinically diagnosed increased substantially

(Lundstrom et al., 2015). This suggests the increased diagnosis of ASD does not necessarily

reflect an increase of the phenotype in the population, but perhaps merely an increase in

diagnosis. More research from varying populations is needed before definitive conclusions

can be drawn.

Individuals diagnosed with ASD often meet criteria for a least one non-ASD

psychiatric diagnosis (Brookman-Frazee et al., 2018). These comorbid diagnoses include but
 20

are not limited to seizures, attention deficit hyperactivity disorder (ADHD), oppositional

defiance disorder (ODD), anxiety, depression, sleep disorders, motor impairment, an

intellectual disability, or a learning disability (Bhat, 2020; Espadas et al., 2020; Ivanovic,

2021; Reaven et al., 2012). Comorbidity diagnoses vary widely according to population size,

demographics, socioeconomic factors, ethnicity, and available specialized consultative care,

making it difficult to draw definitive conclusions regarding the expression of comorbidities

(Casanova et al., 2020)

Aetiology

The exact aetiology of ASD is unclear, but genetic components, varying

environmental risks, maternal infections, and post-natal factors have all been implicated as

potential causes (Hall et al., 2020; Pugsly et al., 2021; Rutter, 2005; Xaio et al., 2021). It is

likely there are a combination of genetic and pre-natal environmental factors that cause ASD

in utero (Amaral, 2017). But whatever these contributing factors are, it is important to

understand that it appears that individuals are born with ASD. That is, it does not appear

develop postnatally, although some children with ASD do often show periods of

developmental regression (Amaral, 2017).

In the largest study to date, researchers analysed multiple generations from over two

million families located in Denmark, Finland, Sweden, Israel, and Western Australia, and

found the occurrence of ASD could mainly be attributed to genetic factors, that is about 80%

of the time (Bai et al., 2019). There are currently no definitive genetic markers identified, but

the online human gene database, GeneCards, lists 7,211 genes potentially related to ASD

(GeneCards, 2021; Lin et al., 2021). The most frequent mutation associated with the

neuropathology of ASD involves a mutation in the SHANK3 protein that encodes for

signalling molecules present in postsynaptic receptors (Jaramillo et al., 2020). A mutation of

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this protein inhibits proper signalling between neurons, leading to atypical structural

development and functioning of neurons (Amaral, 2017; Lin et al., 2021; Lutz et al., 2020).

Environmental risk factors that have been researched as suspected contributors to the

occurrence of ASD include higher maternal or paternal age as well as taking Valproate or

selective serotonin reuptake inhibitors (SSRIs) during pregnancy. Higher maternal or paternal

age were found to be independently associated with increased risk for ASD and doubly

compounded if both parents are older (Mandy & Lai, 2016). Women with epilepsy who use

Valproate during pregnancy have an increased risk of ASD (4.4% versus 1.5% in the general

population). This medication appears to impact the development of the central nervous

system in utero (Christenson et al., 2013). SSRIs were examined as they cross the placental

barrier and are often used to treat depression in pregnant women, but research has yet to

provide conclusive evidence that taking them is a causal risk factor (Mandy & Lai, 2016).

Contracting rubella during pregnancy significantly increases the likelihood of having

a child with ASD (Chess, 1971). In a survey of women infected with measles from 1963-

1965 the prevalence of ASD was 740 per 10,000 (a 7% chance), compared to the general

population at the time which was 2-3 per 10,000 (a .03% chance; Chess, 1971; Chess, 1977).

A measles, mumps, and rubella (MMR) vaccine became available in 1969 and outbreaks of

these childhood diseases are now uncommon, at least in countries with high vaccination rates

(Dusczak, 2009).

At one point it was thought contracting influenza increased the risk of ASD, until

Zerbo et al. (2017) analysed the effects of 196,929 children born between 2000 and 2010 and

found that neither maternal influenza nor receiving the influenza vaccine was associated with

an increased risk of ASD. Furthermore, there appears to be no causal association between

parenting styles (Mandy & Lai, 2016; Silberman, 2015) or MMR vaccination (Amaral, 2017;

Demicheli et al., 2012; Hviid et al., 2019; Jain et al., 2015; Taylor et al., 1999). Inconsistent
 22

findings have been published regarding the causality between prenatal maternal infections

and increased risk of ASD, warranting more research (Atladóttir et al., 2010; Atladóttir et al.,

2012; Tioleco et al., 2021).

Interestingly, institution-reared children that suffered profound social isolation and

severe neglect in Romania were reported to display many of the behavioural traits that are

characteristic of ASD. But these children showed marked improvement once they were

placed in nurturing/stimulating environments suggesting there may be considerable value in

exposing children with ASD-like characteristics to more stimulating and structured

communication learning environments (Nelson et al., 2014).

Behaviours and Symptoms

Based on the DSM-V, there are three distinct clusters of behaviours that characterise

ASD: (a) qualitative impairments in social interactions, (b) qualitative impairments in

communication, (c) restricted repetitive and stereotyped patterns of behaviour, interests, and

activities (American Psychiatric Association, 2013).

Social Impairments

Social behaviour is the ability of an individual to relate to others in a mutually

reinforcing and reciprocal fashion and to adapt social skills to the varying demands of

interpersonal contexts (Howlin, 1986). Early in development children with ASD engage in

social behaviours (i.e., eye contact, greetings, communication attempts, peer-to-peer play)

much less than their typically developing peers’ (Ozonoff et al., 2010; Tager-Flusberg, 1999).

This in turn could lead to a failure to develop age-appropriate social competences as they

grow that includes: (a) paying attention to non-verbal and verbal social cues; (b) interpreting

those cues; (c) determining wants from an interaction and being able communicate those

wants; (d) the ability to compare experiences from previous situations and recall them; (e)
 23

having a repertoire of possible responses; and (f) act and evaluate the success of interactions

(Rose-Krasnor, 1997; Semrud-Clikeman, 2007).

Failure to develop social behaviours can negatively impact academic achievement, the

ability to form relationships, behaviour, mental health, and adult life outcome (Dewey, 1938;

Mead, 1934). Because ASD is a disability associated with the functioning of the neurological

system and the brain, it has been hypothesized that children with ASD might engage in less

social behaviour because they lack the intrinsic motivation to interact with other people due

to altered brain development, such as a thicker frontal cortex, improper neuron connectivity

and atypical brain volumes (Chevallier et al., 2013; Silveira-Zaldivara, et al., 2021). The lack

of social engagement could also, however, stem from failure to acquire effective social skills

due perhaps to learning difficulties or lack of exposure to effective social skills learning

environments.

Because social impairment is a core challenge for individuals with ASD, developing

interventions that target social development are paramount to their success (Kasari-Patterson,

2012; Silveira-Zaldivar, et al., 2021). Artificially creating social experiences to be rewarding

and pleasurable is important to help children with ASD develop appropriate social skill and

engage with their environment (Vernon et al., 2012).

Communication Impairment

Communication involves a give-and-take between people, an exhibition of social

reciprocity which can occur only within social contexts, and entails a goal directed transfer of

information determined by the needs of the participant (Bransford & Nitsch, 1978; Bruner,

1975; Garfin & Lord, 1986). Current statistics suggest 25 to 30% of individuals with ASD

have severe communication impairment or complex communication needs in that they do not

develop sufficient speech and language to meet their everyday communication needs

(American Psychiatric Association, 2013; Hattier et al., 2011; Tager-Flusberg & Kasari,
 24

2013). Approximately 50% of children with ASD display typical development or only mild

delays in language until about 15 to 24 months of age, after which there can be a regression

or total loss of communication skills (Landa et al., 2007; Mayo et al., 2013).

Individuals with a severe communication impairment are often referred to as non-

verbal or minimally verbal (Charlop & Haymes, 1994; Tager-Flusberg & Kasari, 2013).

There is no consistent definition of what is means to be minimally verbal (Kasari,et al.,

2013), but it is considered to mean that the person has less than 10 spoken words or fixed

phrases that are used communicatively. Initially it was suggested that if a child did not

acquire very much spoken language by the age of five years, it was unlikely they would ever

develop natural speech (Tager-Flusberg et al., 2005). However, Pickett et al. (2009)

reviewed literature in relation to later speech development and found the majority of 167

children with ASD began speaking between five and seven years of age. A more recent

analysis of 535 children with ASD who were non-verbal at the age of four found that by the

age of eight, 70% attained phrased speech and 40% attained fluid speech (Wodka, 2013).

Non-verbal cognitive skills and social responsiveness (i.e., joint attention) are more

predictive of language acquisition than age (Anderson et al., 2018; Bruinsma et al., 2004;

Wetherby et al., 2006). Therefore, interventions that promote language attainment, include

social skills, and encourage engagement, would help ameliorate communication deficits

associated with ASD (Rhea, 2008).

Repetitive and Ritualistic Behaviour

The tendency to engage in frequent repetitive and restrictive patterns of behaviour is

another defining characteristic of ASD (American Psychiatric Association, 2013). These two

characteristics may manifest as repetitive actions (i.e., hand flapping, body rocking, or toe

walking), an insistence on sameness (i.e., rigid routines), fixated interests (i.e., trains), and

atypical object exploration (i.e., focusing on the spinning wheels of train instead of rolling it;
 25

Braddock & Brady, 2016; Williams et al., 1999). The repetitive and ritualistic behaviours

appear to be driven in part by having limited interests, preference for familiarity, and limited

development or learning of alternative adaptive skills, such as leisure skills and social skills

(Jones et al., 2014). Such behaviours may interfere with opportunities to engage in functional

social behaviours, like turn taking, eye contact, and gesturing, often seen in the play routines

of typically developing children (Adamson et al., 2010; Ross et al., 1982; Stone & Greca,

1986). To promote social development, it is important to develop communication-based

interventions that incorporate skills like reciprocity and turn-taking and teach alternative

functional behaviours that encourage interactions with the environment, and which will

replace inappropriate use and engagement with inanimate objects (Charlop et al., 2018).

Diagnosis and Assessment

Early interventions in children with ASD reduce negative symptoms that hinder

development, therefore early diagnosis, and assessment to initiate treatment is crucial (Elder

et al., 2017; Manohar et al., 2019). The average age of first recognizable symptoms of ASD is

22 (± 9) months, the average age of first consultations is 27 (± 10) months, the average age

for receiving a diagnosis of ASD is 32 (±10) months, and the average age children begin

receiving ASD-specific interventions in 36 (±10) months (Harris et al., 2014; Manohar et al.,

2019; Rogers & Vismara, 2008). Rounded out, this means there is often at least a 5-month

delay to receiving a consultation after first noticing symptoms, another 5-month delay before

receiving a diagnosis, and an 18-month delay to receiving intervention.

This delay to intervention may permanently hinder the child’s developmental

trajectory. The earlier an intervention occurs, the more likely the child’s developmental

trajectory will return to the zone of normal development as seen in Figure 1.1 (Eikeseth et al.,

2017; Klintwall et al., 2015; Waddington, 2018). Figure 1.1 (Waddington, 2018) portrays a

theoretical example of the effects of early intervention. In this instance, Child A and Child B
 26

both have learning rates of 0.5, which increases to 1.25 after receiving early behavioural

intervention. However, Child A receives intervention at age one, and has caught up to his

peers in two years. Child B receives intervention at age four and is significantly behind his

peers at age six.

Figure 1.1

Hypothetical Trajectories for a Child Who Receives Intervention at the Age of One (Child A)

Compared to the Age of Four (Child B) (Waddington, 2018)

The American Academy of Paediatrics recommends children be screened for

developmental delays at 9, 18, and 30-months; and specifically, for ASD at 18 and 30-months

(CDC, 2020). Screening and diagnostic tools have been developed to assist in with the early

identification of ASD so that treatment may begin as soon as possible. The evidence-based

tools that have been developed provide a reliable source about children’s development. If a

screening result is positive, it should be followed up with a diagnostic assessment (CDC,

2020).
 27

Screening tools do not provide conclusive evidence or result in a diagnosis, but they

may help to identify atypical development that may lead to an earlier diagnosis and treatment

of ASD (CDC, 2020). Two examples of widely used screening tools for ASD are: (a)

Childhood Autism Rating Scale (CARS) for individuals aged two and older (Schopler et al.,

2010), and (b) the Gilliam Autism Rating Scale – Third Edition (GARS-3) for individuals

ranging from 2-22 years (Gilliam, 2014; Robinson, 2013).

First reported in 1980, the CARS screening is a brief questionnaire that serves to

differentiate children with ASD from other developmental disabilities and quantify severity

of the condition (Breidbord & Croudace, 2013). There are 15 items that address social,

communication, and behavioural flexibility, that are scored on a continuum from ‘non-

autistic’ to ‘mild to moderate’ to ‘severe autism’ (Ministry of Health, 2011). It takes 5-10

minutes to complete via parent/caregiver interview and is recommended for ages two and up

(Schopler et al., 2010). This tool requires minimum training and can be used by a variety of

professionals.

GARS-2 is an observational instrument that can identify children with ASD compared

to other developmental disabilities and determine symptoms severity (Ministry of Health,

2011). Stereotypic behaviours, communication behaviours, and social behaviours are scored.

Percentiles of the scores are provided which indicate the likelihood an individual has autism.

The assessment can be completed in five to ten minutes.

The most widely used diagnostic tools are: (a) the Autism Diagnosis Interview –

Revised (ADI-R) for children and adults with a mental age above 2-years (Kim et al., 2013;

Tadevosyan-Leyfer et al., 2003), (b) Autism Diagnostic Observation Schedule – Generic

(ADOS-G) for individuals aged 12 months through adulthood (Carr, 2013; Lord et al., 2000).

The diagnostic tools generally rely on information gathered from parents and caregivers

about their child’s development, but also often solicit professional observations of a child’s
 28

behaviour. The child’s behaviours and development can then be compared against

standardized developmental criteria to aid in the diagnostic process.

After receiving a diagnosis, ongoing assessments and evaluations are used to set

treatment targets. These allow professionals (e.g., speech, occupational, and behavioural

therapists) to develop intervention to address the child; needs (American Psychiatric

Association, 2013). Varying assessments have been developed to assess adaptive behaviour

functioning to inform clinical decisions (Reschly et al., 2002).

Adaptive behaviours include conceptual skills (i.e., expressive/receptive language,

reading, writing, handling money), social skills (i.e., interacting with peers, social

comprehension, etc.), and practical skills (i.e., dressing, bathing, preparing food, taking

medicine, using a phone, etc.) needed to independently navigate daily life (Reschly et al.,

2002). There is a negative association between age and adaptive skills amongst individuals

with ASD and statistics report adults with ASD are 87.1% more likely to continue living with

a guardian after leaving high school (Anderson et al., 2014; Ashwood et al., 2015). Validated

assessments that identify deficits in adaptive behaviours are crucial for promoting

independent living and enhancing the quality of life (Kanne et al., 2010; Klin et al., 2006).

The Vineland Adaptive Behavior Scales, third edition (Vineland-3; Sparrow et al.,

2016), is widely used to assess adaptive behaviour functioning and inform clinical decisions.

Communication, daily living skills, socialization, and motor skills are assessed through parent

and caregiver interviews, then age equivalent scores are provided for each domain (Perry et

al., 2009). The Verbal Behavior Milestones Assessment and Placement Program (VB-MAPP;

Sundberg, 2008) could also be seen as a type of adaptive behavioural assessment, albeit one

that specifically focuses only on communication skills. Similarly, the Assessment of Basic

Language and Learning Skills-Revised (ABLLS-R; Partington, 2006) focuses on language

and critical thinking skills. The Assessment of Functional Living Skills (AFLS; Partington &
 29

Mueller, 2012) focuses on basic living skills for the home, community, and classroom. These

assessments are conducted in a similar fashion to diagnostic assessments, through parent

interviews and direct observations of behaviour.

Typical Language Development

The fact that just under a third of children with ASD remain minimally verbal

presents a stark contrast to typical language development. On average, the typically

developing child has a repertoire of 50 words by two years of age. By 18 months, most

typically developing children will learn approximately 50 words, after which a spurt of

language development occurs (O’Grady, 2005). From 18 months the average child will learn

approximately 10 new words a day, averaging 14,000 words by six years of age. From six

years of age, they will learn approximately 20 new words a day, averaging 60,000 words by

18 years of age.

Verbal Behaviour

According to Skinner (1957), language in learned behaviour under the functional

control of environmental contingencies. Sounds, words, phrases, and sentences are all units of

verbal behaviour. Verbal behaviour consists of 4 verbal operants: (a) the request, asking for

reinforcers; (b) the tact, naming objects, actions, or events; (c) the echoic, repeating what is

heard; and (d) the intraverbal, answering questions or having a conversation. Requesting,

tacting, and interverbals are all part of expressive language. The request is controlled by

motivation for the reinforcer. The tact is controlled by a stimulus in the environment. The

intraverbal is controlled by verbal exchanges with another person. The echoic is similar to an

echo of a written text or sound, but not expressive in nature. When language development is

defective, each functional unit of verbal behaviour can be analysed as a starting point for an

intervention program, and each verbal operant can then be taught using operant conditioning

(Sunberg & Michael, 2001).

 30

Operant conditioning is a learning process that involves learning by consequences. If

a behaviour is followed by reinforcing consequences, a behaviour is more likely to occur

again (Skinner, 1938). Requesting is a behaviour that immediately reinforced by the listener,

and why it is usually the first verbal operant to develop in children. Other operants are

important but do not provide the same benefit (Sundburg & Michael, 2001). As it applies to

language interventions, teaching requesting consists largely in presenting an object that is

assumed effective as a reinforcer and asking, “What do you want?” The “correct” answer to

the question can be considered part tact, part intraverbal and part request. Teaching

requesting facilitates the development of all other verbal operants, and starting with a request

facilitates willingness to participate in training sessions (Sundburg & Michael, 2001).

Augmentative and Alternative Communication (AAC)

AAC is a means of communication that does not require talking (American Speech

and Language Association, 2021). For the 25-30% of children with ASD that are likely to

remain minimally verbal, AAC intervention is indicated to help them communicate more

effectively because it provides a clear and consistent method for the user to relay information

to a listener (Flaubert et al., 2017; Hodge, 2007).

There are three main types of AAC modalities: (a) unaided, (b) aided, and (c) multi-

modal (Beukelman & Mirenda, 2005; Sigafoos & Lacono, 1993; van der Meer et al., 2011).

Unaided AAC refers to a method that does not require any external aid or device, such as the

use of gestures or manual signs (van der Meer et al., 2012; Wendt, 2009). Aided AAC refers

to using a device external to the body that may be a picture exchange-based communication

system or use of a computer-based speech generating device (SGD; Bondy & Frost, 2001;

Sigafoos & Drasgow, 2001). Multimodal refers to using a combination of aided and unaided

systems (Hidecker, 2010).

 31

Unaided AAC in the form of manual signing was first used with children with ASD in

the 1970s (Carr et al., 1978; Schlosser & Wendt, 2008). The rationale for introducing manual

sign was based on four assumptions: (a) it would be easier for the learner to imitate motor

movements, (b) if the learner could not imitate motor movements, it would be easier to

prompt motor imitation, (c) it may be less demanding of memory and abstract understanding,

and (c) it may help overcome a negative emotional history with speech (Fulwiler & Fouts,

1976; Sundberg & Partington, 1998; Wendt, 2007). Research suggests teaching manual

signing or gestures to individuals with ASD is an effective communication option, but it

requires the listener to be knowledgeable in the language (Wendt, 2009). Unfortunately, New

Zealand Sign Language (NZSL) only became a recognised language in 2006, and since then

the New Zealand census data have reported a steady decline in its use, which could make it

more difficult to find communication partners (McKee, 2017). Additionally, evidence

suggests ASD, and motor coordination problems co-occur (Bonvillian & Blackburn, 1991;

Jones & Prior, 1985; Mirenda, 2003; National Research Council, 2001). Children with poor

fine motor skills may develop idiosyncratic/inarticulate signs or be limited to using just a few

simple signs (i.e., more, stop, yes, and no), this limits vocabulary size so as language

develops an aided AAC device may be required (Mirenda, 2003; Mirenda & Iacomo, 2009).

The second category of AAC, aided devices, are broken down into two categories: (a)

low-tech, and (b) high-tech. A low-tech device does not include any computer software or

voice output features. The most referenced low-tech devices are communication boards, pen

and paper, and the picture exchange communication system (PECS; Mirenda & Iacono, 1988;

Wendt, 2008; Bondy & Frost, 2009). A high-tech AAC device is any computer-based

technology with voice output features (Van der Meer et al., 2012).

The first known use of an aided, low-tech, AAC device, was in the 1920’s when the F.

Hall Roe communication board was developed to aid individuals with severe disabilities
 32

(Vanderheiden, 2003; Copeland, 1974). Like modern day communication boards, it

consisted of letters and words printed on Masonite and was attached to the user’s wheelchair.

Currently, a communication board refers to a laminated board containing 20-40 messages that

the user can gesture, point, or blink at (Shane et al., 2012). The downfall of communication

boards is users may lack precision to point accurately, they may cover multiple images with

their hand leaving the user to interpret imprecise messages, it requires a listener to be near

enough to observe and interpret the user’s gesture and teaching the user to point or respond to

a point does not necessarily teach them to make a communicative exchange with a partner

(Bondy & Frost, 2001).

Pen and paper are self-explanatory, however for some individuals with limited

cognitive or motor deficits this may be beyond their scope of abilities (Mirenda, 2001;

Moorcraft et al., 2019). The PECS method involves exchanging picture cards or photographs

with a listener to communicate and has been shown to enhance communication amongst

individuals with ASD (Bondy & Frost, 1998; Charlop-Christy et al., 2002). First reported in

1985, the PECS system is highly effective but may be cumbersome when a large vocabulary

is acquired as it means the person must carry around a correspondingly large number of

pictures or photographs (Charlop-Christy et al., 2002; Preston & Carter, 2009). Once a user

has mastered PECS and their vocabulary expands, a transition to a high-tech device that can

display a larger selection of messages is recommended (Frost & McGowan, 2011).

High tech AAC devices include a wide range of devices from a microswitch that

produces a single message, to a complex computer-based operating system (i.e., a tablet,

smartphone, or computer) that can produce an infinite number of utterances. A voice output

communication aid (VOCA), or a speech generating device (SGD), refers to a category of

AAC that uses a talking word processor to provide auditory stimuli via speech output

(Schlosser et al., 2009). Reports indicate high-tech AAC was first used in 1970s, but it
 33

wasn’t until the 1990’s and computer tablets became commercially available, affordable, and

portable, that reports of their use to improve communication amongst individuals with ASD

dramatically increased (Gilroy et al., 2017; Kagohara et al., 2013; Nepo et al., 2015).

Characteristics of a Speech Generating Device

An SGD is a portable, electronic device with a talking word processor that provides

auditory stimuli for the listener via speech output (Schlosser et al., 2009). These portable

devices display a variety of graphic symbols called icons, each icon represents a message and

can be activated to produce voice output (van der Meer & Rispoli, 2010). Depending on

communication goals, speech output, icon design, and display format of SGDs can be

customized to best suit the user.

Types of speech output

Current SGDs allow individuals to use digitized or synthesized speech (Schlosser &

Koul, 2014). Digitized speech is produced by recording a sample of speech in analogue form

and quantizing it into numbers (Schlosser et al., 2009). Programmes with digitized speech

produce sound that is more naturalistic than synthesized speech but require a large amount of

computer memory and voice output is limited to prestored messages (Drager et al., 2006;

Schlosser et al., 2009). Synthesized speech is produced by converting typed words into

speech waveforms using speech coding techniques (Schlosser et al., 2009; Venkatagiri &

Ramabadran, 1995). Programmes with synthesized speech do not require as much computer

memory, have unlimited voice output options, and have sound output that is as intelligible as

natural speech (Duff & Pisoni, 1992; Koul, 2003; Koul & Allen, 1993; Koul & Hester, 2006;

Mirenda & Beukelman, 1987; Schlosser et al., 2009).

Icon design

Determining the size and arrangement of icons plays a vital role in the communicative

success of SGD users (Dukhovny & Zhou, 2016). Initially, it is common practice for
 34

clinicians to use a fewer number of larger, icons; then as vocabulary increases icons are

placed in a grid-like fashion (Dukhovney & Zhou, 2016). A visual search on an SGD grid to

locate and activate an icon is a significant cognitive load for some users, therefore it is

important to arrange and design icons with optimal graphic representation (Dukhovny &

Zhou, 2016).

Features of graphic representation within icons to consider are the use of colour, as

well as including a picture and/or text only (Dukhovny & Zhou, 2016). Colour and contrast

of images can impact the user’s ability to discriminate with speed and accuracy (Alant et al.,

2010; Hetzroni & Ne’eman, 2013; Wilkinson et al., 2008). Colour matching the natural

occurrence of an object leads to an increased discrimination rates amongst users (Stephenson,

2009; Thistle & Wilkinson, 2015; Wilkinson et al., 2008).

It is important to consider the aim of intervention when choosing picture and/or text

only icons (Erickson et al., 2010). Picture supported text icons describes pairing labels with

picture symbols; text only options refer to icons containing a word or letters in a keyboard

display (Downing, 2005; Erickson et al., 2010). Evidence suggests if literacy is the goal of

intervention, then pairing pictures with text makes it more difficult to learn to read the words;

however, if the goal is only to provide access to content it is reasonable to expect pictures

will increase access to that content (Erickson et al., 2010).

Display types

A display refers to the way icons are presented on an AAC system (American Speech-

Language-Hearing Association, 2021). The display affects the user’s ability to communicate

and must be modified over time to suit individual needs (Beukelman & Mirenda, 2013).

Displays can be (a) static in which the symbols remain in a fixed location on one page and

there is a finite number of messages, or (b) progressive in which the activation of an icon

automatically takes the user to a consecutive screen (Waddington et al., 2015). A learner’s
 35

cognitive ability, vocabulary size, and learning history should be considered when making

format designs about the characteristics of their SGD.

Past and Current Perceptions of AAC

Prior to the 1970s, it was thought providing an alternative method of communication

would inhibit or deter natural speech production and was therefore not a widely accepted

intervention method (Bates, 1976; Schlosser & Wendt, 2008). However, it has been found in

many cases the use of AAC does not deter but might rather be moderately facilitative of

natural speech production (Blischak et al., 2003; Bondy & Frost, 2001; Schlosser & Wendt,

2008; Sundberg et al., 1996).

Recent studies have described varying opinions regarding older versus newer versions

of AAC. In the 1950s and 1960s low-tech and no-tech modes of AAC were developed to

promote functional communication skills for individuals lacking natural speech but in more

recent studies where non-users of AAC were surveyed, no-tech devices were viewed as less

helpful unless the user was fluent in sign and low-tech devices generated negative attitudes

about the user, described as unattractive or cumbersome (Alexander, 2008; Hourcade et al.,

2004). Currently, high-tech devices have been reported to generate positive attitudes about

the user, are the easiest to learn, and appear to be more intelligible to unfamiliar listeners

(Achmadi et al., 2012; van der Meer & Rispoli, 2010). Additionally, their portability,

customizable screen, and range of voice options promotes greater community inclusion

compared to other modes (Schafer et al., 2016). The rapid development of new technologies

warrants an analysis of existing experimental designs targeted at enhancing and elongating

communication skills.

In the 1980s, the American Speech-Language-Hearing Association (ASHA) formed

the Committee on Communication Processes and Nonspeaking Persons that began outlining

the groundwork for AAC interventions today. That, along with the development of miniature
 36

portable computer systems that can be used as communication aids, AAC has become a more

widely accepted method of alternative communication, providing an effective form of

communication that enhances opportunities in education, employment, and community living

outcomes for minimally and non-verbal individuals diagnosed with ASD (American Speech-

Language-Hearing Association, 2021; Mirenda, 2001). There is a growing body of evidence

suggesting high-tech AAC devices positively enhance communication skills amongst

individuals with ASD by supplementing and replacing natural speech (Alzrayer et al., 2014;

Beukelman & Mirenda, 2013).

Guidelines to determine the best suited AAC system or device for any given

individual often involves identifying individual vocabulary requirements, motor skills,

financial limitations (high tech vs. low tech), symbol options (photograph vs. line drawing),

message representation, output options (visual display vs. natural speech), expandability, and

portability (Mirenda, 2003; Reichle, 1997; Schlosser & Blischak, 2001; Sigafoos & Iacono,

1993; van der Meer et al., 2011). Because an AAC device is used to augment or replace

natural speech, use of the device should result in generalised, functional communication that

is sustainable over time (Mirenda, 2003). There is currently no complete formal assessment

tool used to determine best AAC options for users, individual clinicians must evaluate which

mode would best suit the user in their environment, communication needs and goals,

strengths and abilities, and potential barriers (American Speech-Language-Hearing

Association, 2021).

Neurodiversity

Interventions based around the use of an AAC device respectfully encourage the

inclusion of neurodiverse individuals in society. Neurodiversity, or differences in brain

function and behavioural traits, is a normal variation in the human population and is a term

that has been especially used in the context of individuals with ASD (Armstrong, 2011;
 37

Oliver, 1983). The neurodiversity movement celebrates autism as an inseparable aspect of

identity, challenging the medical model’s causation and cure attitude towards disorders (Kapp

et al., 2013). In respecting differences, it is important to center interventions around

evidence-based practices that respect sociality and self-expression, as well as create

environmental arrangements that promote communicative competence for children with

autism (Nelson, 2020; Thorne & Searsmith, 2021).

While it is important to promote societal education and acceptance of differences, it

is equally important to develop interventions to accommodate neurodivergent individuals,

especially when communicative behaviours fail to develop naturally (Schuck, et al., 2021).

Furthermore, we must focus on what changes we can make to the environment to

accommodate individuals who are neurodivergent to promote positive educational outcomes,

because everyone deserves the right to an equal standard of education, dignity, and humanity

(Whaley, 2021). A novel teaching strategy and an AAC device could greatly enhance the

quality of life for a non-speaking individual. It is my hope that this research provides

information to aide in the development and implementation of interventions that promote

inclusion and equality to anyone who is minimally verbal.

Brief Explanation of Research

Considering the current perceptions of AAC, the present research involved the

development and evaluation of communication interventions for minimally verbal children

with ASD. The interventions used a portable, high-tech device. Icons on the device were

displayed in a grid-like format with first a progressive, then a static screen. The goal of the

research was to provide evidence that minimally verbal children with ASD can: (a) first be

successfully taught to engage in a conversational exchange using an SGD that was reflective

of typical conversation, and (b) demonstrate the effectiveness of implementing an antecedent

 38

prompting strategy to teach the communicative exchange. A definition of the target behaviour

is highlighted below.

Extended communication sequence

The aim of the presented research is to teach minimally verbal children with ASD to

participate in an extended or multi-step communication sequence, henceforth referred to as an

ECS. For the purposes of this research, I define an ECS as the occurrence of consecutive

behaviours in which the speaker uses their SGD to address the listener in a manner that

requires a verbal response from the listener in more than one communicative exchange. To

be considered an ECS, the exchange must include a minimum of two verbal exchanges

between the speaker and the listener within a 1-min period, one of which must be a request.

The request was selected as the target verbal operant because it is positively reinforced in a

naturalistic way when the requester gains access to the desired object, it is the most essential

and first type of verbal behaviour learned in development and because it increases motivation

to participate and learn as it allows the inclusion of individualized reinforcers in interventions

(Bondy & Frost, 1998; Skinner, 1957; van der Meer et al., 2012). Including a request allows

interventionist to maximise motivation by including highly desired items, tailor regimented

protocols, and incorporate everyday activities or routines as a basis for teaching a broader

spectrum of communicative functions (Michael, 1982; van der Meer & Rispoli, 2010). This

enhances the likelihood an individual will learn a new behaviour (Michael, 1982). The

overall purpose of the designed interventions was to expand the student’s communicative

repertoire on their SGD by increasing the number of interactions between the speaker and the

listener. The ECS was chosen as the focus of these interventions to promote social

development and teach children to participate in an interaction reflective of typical

conversation.
 39

Summary

To ameliorate the social deficits and communication difficulties associated with ASD,

it is important to develop interventions that allow minimally verbal individuals to engage in

socially appropriate communication exchanges with others. The following chapter will

provide an in-depth analysis of current research related to teaching an extended

communication sequence. Chapter 3 will present the results of an initial Study 1, in which

five learners were taught to engage in a 4-step communicative sequence using an SGD

configured with a progressive screen display and implementation of an errorless learning

technique called the antecedent prompting procedure. Chapter 4 will describe Study 2, in

which four learners were taught to engage in a 4-step communicative sequence using an SGD

configured with a static screen display and implementation of the same errorless learning,

antecedent prompting procedure. Lastly, Chapter 5 will provide a general discussion based on

the findings of these two intervention studies.

 40

CHAPTER 2

Literature Review

Introduction

This chapter is a systematic review of studies that have aimed to teach extended or

multi-step communication exchanges with aided augmentative and alternative

communication devices (AAC), specifically speech-generating devices (SGDs). The primary

goal of this review is to examine what specific communication skills and sequences have

been taught and what instructional strategies and evidence-based practices (EBPs) have been

applied to successfully teach SGD-based multi-step communication to individuals with

developmental disabilities, mainly autism spectrum disorder (ASD), while also identifying

potential gaps in current literature for future application.

Aggression, tantrums, and self-injury are types of challenging behaviours specifically

linked to communication deficits, and often observed in minimally verbal children with ASD

(Alzrayer et al., 2014; Bott et al.,2007; Chiang, 2008; Jang et al., 2011; Matson & LoVullo,

2008; Tager-Flusberg & Kasari, 2013; Waddington et al., 2014). It is important to identify

effective and functional communication interventions because once implemented, they might

not only enable the child to communicate better and thus better achieve successful social

interactions, but might also help to reduce the occurrence of challenging behaviour and help

individuals gain independence and succeed in educational and social domains (Alzrayer et al.,

2014; Baxter et al., 2012; Chiang, 2008; Ganz et al., 2011; Sennott & Bowker, 2009; Walker

& Snell, 2013; White et al., 2021). Several literature reviews have found AAC interventions

targeting communication skills produce positive behavioural outcomes when various

systematic instructional procedures based on the principles of Applied Behaviour Analysis

(ABA) are used (ABA; Alzrayer et al., 2014; Gilroy et al., 2017; Holyfield et al., 2017;

Logan et al., 2016; van der Meer & Rispoli, 2010).

 41

Alzrayer et al. (2014) conducted a meta-analysis of communication interventions

using iOS devices (i.e., iPad® and iPad Touch®) and identified successful teaching

techniques that have been used to successfully teach single-step exchanges. Fifteen studies

were identified with interventions that targeted varying types of verbal behaviour (i.e.,

requesting, labelling, and answering questions), and effectiveness of intervention was

calculated and found to be effective for 41 of the 46 participants. This article lists several

EBPs successfully implemented to children with ASD such as differential reinforcement,

time-delay, prompting, and discrete-trial-training (DTT). The least used intervention

techniques were error correction and backward chaining, each mentioned once.

Holyfield et al. (2017) conducted a review analysing AAC interventions amongst

individuals with ASD. Eighteen studies taught 19 participants to engage in requesting,

labelling, and creating multi-phrased messages using varying types of high and low-tech

AAC devices. A breakdown of instructional strategies described 14 studies that implemented

a prompting technique, three implemented a partner instruction (peer or professional)

method, and one used video modelling. Of the 14 studies which implemented prompting

techniques, results of seven studies were designated as inconclusive due to design flaws. A

multi-step request was the focus of intervention for three studies, but there was no elaboration

as to the type of prompt used in any of the studies included in this review (Achmadi et al.,

2012; Strasberger & Ferreri, 2013; van der Meer et al., 2012).

Mouharib and Alzrayer (2018) evaluated single-case studies that utilised high-tech

SGDs with children with ASD between 0-8 years of age. The review included 20 studies,

totalling 54 participants, and suggested high-tech SGDs are a viable option for minimally

verbal children with ASD. Systematic instruction was implemented in a DTT format for 17

studies and natural environment teaching (NET) in three studies. Two studies included taught

a multi-step request (Flores et al., 2012; Waddington et al., 2014). Intervention components
 42

such as least-to-most prompting, differential reinforcement, or time-delay were not

considered, therefore a future analysis taking them into account would help broaden

identification of practices that are EBPs regarding teaching an ECS on an SGD.

Al-Rashaida et al. (2021) conducted a review of studies on tablets, iPods®, and

smartphones, and reported successful outcomes when children were taught to request, label,

engage in social interactions, and participate in educational activities using their SGD. This

review included 24 studies with outcomes reported for 60 participants whose ages ranged

from 2 - 5 yrs. In this review, only one study taught participants a multi-step request and

specific intervention components were not described (Genc-Tosun & Kurt, 2017).

These reviews highlight the positive outcomes reported that can accrue when using an

SGD to teach communication but failed to highlight effectiveness of specific instructional

techniques regarding an ECS. Replicating tried and true teaching strategies is beneficial to

broadening the body of evidence supporting the efficacy of SGD interventions, but it is also

important to highlight novel instructional techniques to continue moving the field forward.

To date there have been no reviews specifically analysing studies that have aimed to teach

extended or multi-step communication sequences with SGDs.

Evaluating instructional procedures for teaching extended communication sequences

to children with developmental disabilities who are minimally verbal and therefore require

AAC is a benchmark target for language intervention programmes (Rice et al., 2010; Rice et

al., 2013; Yoder et al., 1995; Yosick et al., 2015). The present review aimed to identify

studies that aimed to teach multi-step requesting and extended communication sequences to

learners with ASD or other developmental disabilities who were minimally verbal and who

were being taught to use SGDs.

 43

Methods

Search Strategy

Five databases were searched: Cumulative Index for Allied Health Literature

(CINAHL), Education Resources Information Center (ERIC), MEDLINE, Psychology and

Behavioral Sciences Collection, and PsycINFO. The Boolean search terms used were:

"mand*" OR "extend* mand* sequence*" OR "request*" OR "ask*", "speech generating

device" OR "SGD" OR "VOCA" OR "voice output communication aid*" OR "AAC" OR

"augmentative and alternative communication*", AND "developmental disability" OR

"auti*" or "ASD" OR "intellectual disability" in October and November of 2020. The initial

search returned 275 articles; 104 duplicates were removed leaving 171 articles for review.

Titles and abstracts were then scanned to determine if the studies were related to AAC

research, teaching multi-step requesting and/or extended communication sequences to

learners with ASD who were minimally verbal and who were being taught to use SGDs,

excluding 154 articles. The remaining 17 articles were analysed including, what specific

communicative exchange that was taught, participant demographics, AAC characteristics and

what experimental design components were used to determine if the articles met inclusion

criteria. Nine articles were left that met inclusion parameters and their reference lists were

searched for potential additional articles.

A second search was conducted in October 2021, using the same search parameters

and databases. This search generated 24 articles, five were duplicates, and remaining articles

were read and determined not to meet inclusion criteria. In total, nine articles met inclusion

criteria from the database searches. One article was found from a search alert established

from the original saved searches across all databases, leaving a total of 10 articles were

included in this review (See Figure 2.1).

 44

Figure 2.1

Adapted PRISMA Flow Diagram for Article Inclusion

Identification of studies via databases

Records removed before

Identification

Records identified from: screening:

Databases (n = 5) Duplicate records removed
2020 search (n = 275) 2020 search (n = 104)
2021 search (n = 24) 2021 search (n = 5)

Records screened Records excluded

2020 search (n =171) 2020 search (n =154)
2021 search (n = 19)

Reports sought for retrieval Reports not retrieved

2020 search (n = 17) 2020 search (n = 0)
Screening

2021 search (n = 19) 2021 search (n = 0)

Reports assessed for eligibility Reports excluded

2020 search (n =17) 2020 search (n = 8)
2021 search (n = 19) 2021 search (n = 19)

Studies included in review

Included

2020 search (n = 9)
2021 search (n = 0)
Table of contents alert (n = 1)

Inclusion and Exclusion Criteria

To be included, articles needed to evaluate the efficacy of an intervention for teaching

a multi-step exchange, with one component being a request using a SGD, and needed to
 45

include at least one participant with ASD. Additionally, the interventions had to be evaluated

using an experimental design – either a single case design or group design. Evaluate the

efficacy of outcomes relation to communication with an SGD-based AAC device and engage

in a minimum two-step communicative interaction that could include a request in addition to

commenting, greeting, or answering a question. For this study, articles were excluded if they

only included one participant, did not include a participant with ASD, or did not include a

request in the communicative sequence. Ten articles met this criteria.

Data Extraction

Data were extracted from the included articles by the author (Sawchak) on the

following variables: (a) participant demographics; (b) SGD device (application, screen, and

icon characteristics); (c) experimental design; (d) interventionist; (e) setting; (f) dependent

variable; (g) independent variable; (h) preference assessments; (i) generalization; (j)

maintenance; (k) inter-observer agreement; (l) procedural fidelity; (m) social validity; (n)

quality ratings, and (o) outcomes.

Quality ratings were conducted to evaluate the rigor of each publication. This

included an evaluation of primary indicators (participant characteristics, independent

variables, dependent variables, baseline condition, visual analysis, and experimental control)

that were graded on trichotomous scale of high (H), acceptable (A), and unacceptable (U)

quality. Secondary quality indicators (IOA, Kappa, blind raters, generalization or

maintenance, and social validity) were scored on a dichotomous scale, meaning the research

did (yes) or did not (no) contain the evidence of each indicator. After scoring primary and

secondary quality indicators according to the single subject experimental design guidelines, a

quality rating was given to each study (Reichow, 2011).

 46

Inter-rater Agreement

To assess inter-rater agreement a second university colleague, acting independently,

conducted identical searches. Inter-observer agreement was 92% for CINAHL, 95% for

ERIC, 100% for Medline, 100% for Psych & Beh Sci, 97% for PsychINFO. From the 2020

search, of the 17 articles fully assessed for inclusion, there were 10 agreements and 7

disagreements. To resolve the disagreements, a third university colleague was recruited to

review the papers and decide whether these papers did or did not meet the inclusion criteria.

In the second article search that was conducted in 2021, there was 100% IOA between raters.

Furthermore, a university colleague was recruited to conduct IOA on 30% of the

included literature to ensure it met inclusion criteria and the primary authors analysis of were

correct. There was 100% agreement during this process.

Results

Tables 2.1, 2.2, 2.3, 2.4, and 2.5 provide a summary of each included study. In each

table, the studies are listed in alphabetical order.

Participants

As indicated in Table 2.1, a total of 30 participants (5 females, 25 males) were

involved in the nine included studies. Their ages ranged from 3 to 17 years with a mean age

of 9 years. Twenty-seven participants had a primary diagnosis of ASD (5 females, 22 males).

The other 3 participants’ diagnoses included Down syndrome (DS), brain injury (BI), and

developmental delay (DD). The average study sample size was three. No study exceeded

four or included less than two participants.

The Vineland Adaptive Behavior Scales, second edition (Vineland-II) was the most

frequently used assessment tool, utilised in five studies (Achmadi et al., 2012; Alzrayer et al.,

2017; Alzrayer et al., 2019; Sparrow et al., 2005; van der Meer et al., 2013; Waddington et

al., 2014). Other standardised assessments used to determine communicative abilities

 47

amongst participants were (a) The Adaptive Behavior Assessment System (ABAS; Choi et

al., 2010), (b) the Functional Communication Profile – Revised (FCP-R; Alzrayer et al.,

2019), the Preschool Language Scale–Fifth Edition (PLS-5; Alzrayer et al., 2019), (c) the

Receptive Expressive Emergent Language Scale REEL-2 (Brady, 2000) and (d) the Verbal

Behavior Milestones Assessment and Placement Program (VB-MAPP; Bzoch & League,

1991; Harrison & Oakland, 2003; Santos et al., 2012; Shillinsburg et al., 2019; Sundberg,

2008; Zimmerman et al., 2011). Chavers et al. (2021), conducted three assessments: the (a)

Childhood Autism Rating Scales-second edition (CARS-2; Schopler et al., 2010), (b) the Test

for Nonverbal Intelligence, fourth edition (TONI-4; Brown et al., 2010); and (c) the

Receptive One Word Picture Vocabulary Test, fourth edition (ROWPVT-4; Martin &

Brownell, 2011).

Seven studies made no mention of challenging behaviours present amongst

participants (Achmadi et al., 2012; Brady, 2000; Choi et al., 2010; Shillinsburg et al., 2019;

Strasberger & Ferrari, 2013; van der Meer et al., 2013; Waddington et al., 2014). Three

studies mentioned the presence of various forms of aggression, self-injury, and tantrums

(Alzrayer et al., 2017; Alzrayer et al., 2019; Chavers et al., 2021).

Fifteen participants had history using a portable SGD prior to intervention (Achmadi

et al., 2012; Alzrayer et al., 2017; Chavers et al., 2021; Choi et al., 2010; Shillingsburg et al.,

2019; van der Meer et al., 2013; Waddington et al., 2014). Seven participants were reported

as having no experience with any form of AAC device prior to intervention (Alzrayer et al.,

2019; Chavers et al., 2021; Strasberger & Ferreri, 2013). The remaining six participants had

experience with manual signs (MS) or a picture exchange system (PECS; Alzrayer et al.,

2017; Brady, 2000 Strasberger & Ferreri, 2013)

 48

Table 2.1

Participant Demographics and Assessment Information

Participant Demographics
Age(yrs)/
Study Communicative AAC
Gender/ Assessment
Abilities History
Diagnosis
Achmadi et al. 13/M/ASD < 2 years* Vineland-II SGD
(2012) 17/M/ASD < 2 years* Vineland-II SGD

8/M/ASD 6 V-scale score* Vineland-II MS/PE/SGD

Alzrayer et al., 9/M/ASD 8 V-scale score* Vineland-II PE
(2017) 10/M/DS 6 V-scale score* Vineland-II PE
10/F/ASD 5 V-scale score* Vineland-II MS/PE

7/M/ASD < 1 year FCP-R None

Alzrayer et al.,
9/M/ASD < 1 year Vineland-II None
(2019)
10/M/ASD Below average PLS-5 None

5/F/ASD <20 months* REEL-2 PECS

Brady (2000)
5/M/BI <20 months* REEL-2 PECS

CARS-2/TONI-
4/ROWVT-4
9/M/ASD 69/37/<1 None
Chavers et al., CARS-2/TONI-
9/F/ASD 86/5/<1 None
(2021) 4/ROWVT-4
7/M/ASD 42/68/<1 SGD
CARS-2/TONI-
4/ROWVT-4

6/M/ASD “Extremely low” ABAS PE

7/M/ASD “Extremely low” ABAS SGD
Choi et al., (2010) 8/M/ASD “Extremely low” ABAS SGD
9/M/DD “Extremely low” ABAS SGD

6/M/ASD 30-48 months VB-MAPP SGD

Shillinsburg et al.,
7/F/ASD 30-48 months VB-MAPP SGD
(2019)
3/M/ASD 18-30 months VB-MAPP SGD

5/M/ASD No/limited VB Educational diagnosis MS

Strasberger & 8/M/ASD No/limited VB Educational label PECS
Ferreri (2013) 9/M/ASD No/limited VB Educational label None
12/M/ASD No/limited VB Educational label PECS

van der Meer et al. 10/M/ASD < 2.5 years Vineland-II SGD/PE/MS
(2013) 11/F/ASD < 2.5 years Vineland-II SGD/PE/MS

7/M/ASD <2.5 years Vineland-II SGD

Waddington et al.
8/M/ASD <2.5 years Vineland-II SGD
(2014)
10/M/ASD <2.5 years Vineland-II SGD
 49

Note. ABAS = Adaptive Behavior Assessment System; CARS-2 = Childhood Autism Rating

Scales, 2nd ed; FCP-R = Age equivalence on the Functional Communication Profile-Revised;

PLS-5 = Preschool Language Scale–5th ed.; REEL-2 = Receptive Expressive Emergent

Language Scale; ROWPVT-4 = Receptive One Word Picture Vocabulary Test, 4th ed.;

TONI-4 = Test of Nonverbal Intelligence, 4th ed.; VB = verbal behaviour; VB-MAPP =

Verbal Behavior Milestones Assessment and Placement; Vineland-II = Vineland Adaptive

Behavior Scales, second edition; * = specific to the expressive language scoring section of

the assessment

Device Type, Characteristics and Applications

Table 2.2 summarizes the AAC devices, and the speech-generating software or

applications used in each of the ten included studies. A high tech AAC device, generally a

portable computer with a speech output component, was the most widely used technology

used in these studies. Apple devices (e.g., iPads® and iPods®) were used in six studies, and

all utilised Proloquo2Go™ software onto a portable tablet (Achmadi et al., 2012; Alzrayer et

al., 2017; Alzrayer et al., 2019; Strasberger & Ferrari, 2013; van der Meer et al., 2013;

Waddington et al., 2014). Participants in Chavers et al (2021) used an Indi 7 Communication

tablet with Snap + Core First (Tobii Dynavox, 2019) and Picture Communication Symbols

(PCS; Mayer-Johnson Company, 1994). Once downloaded on a device, the Snap + Core

First and Proloquo2Go™ AAC applications allow the user to customise the screen settings to

meet the needs of individuals with various skill levels and disabilities. Participants’ in Choi et

al. (2010) each used their own devices which included: (a) Vantage (Prentke Romich

Company), (b) Tech Speak device (Advanced Multimedia Devices, Inc.), and (c) Springboard

(Prentke Romich Company). Vantage, Tech Speak, and Springboard devices were portable,

computer-based tablets, which contained a smart screen with icons that generated synthetic
 50

speech output when activated. Devices used in the Shillingsburg et al. (2019) study were

unspecified tablets loaded with Touch Chat and Proloqu2Go™ software. One study

employed a low-tech microswitch-based SGD with picture symbols of preferred items affixed

to the switch (Brady, 2000).

Nine studies included at least one participant who used a device with a progressive

screen, whereby once an icon is activated the software automatically progresses to the next

screen leading the participant through the conversational exchange (Achmadi et al., 2012;

Alzrayer et al., 2017; Alzrayer et al., 2019; Chavers et al., 2021; Choi et al., 2010;

Shillinsburg et a., 2019; Strasberger & Ferrari, 2013; van der Meer et al., 2013; Waddington

et al., 2014). Three studies included a participant who used a device with a static display, in

which all icons used to engage in the extended request sequence were located on the same

page (Choi et al., 2010; van der Meer et al., 2013; Waddington et al., 2014). With Vantage,

Springboard, and Teck Speak SGD devices, as well as with the Sonoflex software, it was not

possible to personalize the user interface and the size and quantity of icons per page was

fixed by the manufacturer (Choi et al., 2010) In all high-tech devices, the icons were arranged

in a grid-like framework. Icons per page ranged from one (Alzrayer et al., 2017; Waddington

et al., 2015) to 45 (Choi et al., 2010). But generally, screens were programmed to have five

icons or fewer per page, and in all these instances Proloquo2Go™ or Snap + First software

was used (Achmadi et al., 2012; Alzrayer, et al., 2017; Alzrayer et al., 2019; Chavers et al.,

2021; Strasberger & Ferrari, 2013; Waddington et al., 2014). Van der Meer et al. (2013) set

up participant SGDs to have selection of 15 icons on one page.

Icon designs consisted of a generalised graphic symbol (e.g., “toys”) with a describing

word; or a photograph and describing word. A general trend among researchers was to use a

photograph and corresponding word for the participants highly preferred items (e.g.,

“bubbles”), and a graphic symbol with a corresponding word or phrase for generalised
 51

requests and statements (e.g., “I want a toy”, “Thank you”). Please see Table 2.2 for a

complete breakdown of AAC characteristics for each study

 52

Table 2.2

AAC Technologies and Characteristics

Icon Features
Arrangement
Studies SGD Screen Software
/Num. Per Design
Page
Achmadi et iPod® Progressive Proloquo2go™ Grid/2-3 SymbolStix™
al., 2012

Alzrayer et iPad® Progressive Proloquo2go™ Grid/1-5 SymbolStix™

al., 2017 & Photographs

Alzrayer et iPad® Progressive Proloquo2go™ Grid/3-8 SymbolStix™

al., 2019

Brady, 2000 VOCA n/a n/a Single photo Boardmaker™

on button graphic
symbols

Chavers et Tablet Progressive Snap + Core Grid/4-5 Picture

al., 2021 First Communication
Symbols from
Dynavox

Choi et al., Vantage Progressive Preprogramed Grid/45 Graphic

2010 Springboard Progressive device Grid/45 symbols &
Teck Speak Static Grid/ 32 words

Shillinsburg, Tablet Progressive Touch Chat Grid Graphic

et al., 2019 Proloquo2go™ symbols, word
icons, & typing

Strasberger iPod® Progressive Proloquo2go™ Grid/4 Graphic

& Ferreri, symbols &
2013 words

van der iPad® Static Proloquo2go™ Grid/15 Graphic

Meer et al., symbols, words
2013 & photographs

Waddington iPad® Static & Proloquo2go™ Grid/1-4 SymbolStix™,

et al., 2014 Progressive photographs, &
words
 53

Experimental Design

All the studies used single-case research designs. Specifically, six studies utilised a

multiple baseline across participants design (Achmadi et al., 2012; Alzrayer et al., 2017;

Chavers et al., 2021; Choi et al., 2010; Strasberger & Ferreri, 2013; Waddington et al., 2014).

One study used a non-concurrent multiple baseline across behaviours (the requesting, social

greeting, and answering questions of each participant was observed by Alzrayer et al., 2019),

across activities (tape playing and snack preparation by Brady, 2000), across conditions

(“who” and “which” conditions by Shillinsburg et al, 2019), and lastly one study used an

alternating treatments design to compare acquisition rates when using different AAC devices

(van der Meer et al., 2013).

Interventionists

In seven studies, the sole individual implementing intervention was a graduate student

(Achmadi et al., 2012; Alzrayer et al., 2017; Alzrayer et al., 2019; Brady, 2000; Chavers et

al., 2021; Choi et al., 2010; Waddington et al., 2014). Chavers et al. (2021) did design the

intervention to include a functional communication partner (FCP; i.e., parent, teacher, or

therapist), who was present during intervention and conducted generalisation probes. The

two participants from van der Meer et al. (2013) received intervention from a parent or

graduate student. Shillingsburg et al (2019) had a trained therapist implement their

intervention, whereas Strasberger and Ferrari (2013) taught students to communicate with

similar aged school peers who prompted SGD use in varied school settings. In total 22

participants received intervention from an educated professional (non-family member), four

were taught by a peer, and one person was taught by their mother.

Settings

Seven studies were conducted on the participants’ school campuses, either a

classroom or a resource room on school grounds (Achmadi et al, 2012; Alzrayer et al., 2017;
 54

Alzrayer et al., 2019; Brady, 2000; Choi et al., 2010; Shillingsburg et al., 2019; Strasberger &

Ferreri, 2014). In the case of Strasberger and Ferreri (2013), intervention took place at school

but on the playground during recess to encourage applicable peer engagement. Strasberger

and Ferreri (2014) was the only study to utilise naturalistic milieu teaching strategy at school.

Participants from the Chavers et al (2021) and van der Meer et al. (2013) received

intervention at different locations (school, home, or clinic), but their environmental

arrangement was similar in that both participants worked exclusively 1:1 at the table, making

the location difference inconsequential. Only one study took place in a university-based

clinic (Waddington et al., 2014) where the three participants visited once a week to receive

therapy. All training sessions varied from one to five days a week, with sessions lasting from

5 to 30 min.

Dependent Variables

Behaviours targeted for change included variations of using an SGD in a multi-step

interaction, one of which was a request. Nine of the studies taught a scripted conversation

(Achmadi et al., 2012; Alzrayer et al., 2017; Alzrayer et al., 2019; Brady 2000; Chavers et al.,

2021; Choi et al., 2010; Shillingsburg et al., 2019; van der Meer et al., 2013; Waddington et

al., 2014). Achmadi et al. (2012), taught students to turn on, unlock device, ask for a general

snack or toy, then a specific snack or toy. Alzrayer et al. (2017) taught participants to

navigate through one, 3-step request. Alzrayer et al. (2019) taught students to request an

item, say thank you, and answer social questions (i.e., what is your mom’s name?). Brady

(2000) taught students to request three missing items in an activity sequence. Chavers et al.

(2021) targeted requesting referred activities or snacks (i.e., “what would you like to do?”)

and engaging in generic small talk (i.e., “How are you doing?”. Choi et al. (2010) set up a

play scenario with missing items, when the student requested the item, they were given the

wrong item and taught to re-request the correct one. Shillingsburg et al. (2019) taught
 55

participants to request in two different conditions. In one condition a preferred item was

placed under one of nine different coloured cups and the participant was taught to ask a

therapist “which cup?” the item was under. In the other condition the participant was taught

to ask a therapist “who has it?”, then take their SGD to the person, name them, and ask for

the item again. van der Meer (2013) taught an extended sequence that included, saying hello,

a generalised request, specific request, yes/no, thank you and goodbye. Waddington et al.

(2014) included a generalised request, specific request, thank you. Overall, the components

of scripted conversations included a generalised request, a specific request, and a social

comment such as hello/goodbye, please/thank you or a response to an intraverbal (e.g.,

answering the question “What is your name”?). Strasberger & Ferreri, 2010 did not teach a

scripted conversation, but collected participant data on independent requests and responses

using their SGDs to engage with peers during recess.

Independent Variables

All the studies implemented systematic instructional packages that included multiple

instructional procedures as indicated in Table 2.3. Two studies implemented one to two

instructional techniques (Choi et al., 2010; van der Meer et al., 2013). Eight studies

implemented three to five instructional techniques (Achamdi et al., 2012; Alzrayer et al.,

2017; Alzrayer et al., 2019; Brady, 2000; Chavers et al., 2021; Shillingsburg et al., 2019;

Strasberger & Ferreri, 2013; Waddington et al., 2014). A form of prompting was included in

all ten studies, five specifically utilizing least-to-most prompting (Achmadi et al., 2012;

Alzrayer et al., 2017; Chavers et al., 2021; van der Meer et al., 2013; Waddington et al.,

2014).

Time delay was a popular method utilised by eight studies (Achmadi et al, 2012;

Alzrayer et al., 2017; Alzrayer, et al., 2019; Chavers et al., 2021; Choi et al., 2010;

Shillinsburg et al., 2019; Strasberger & Ferreri, 2013; Waddington et al., 2015). Differential
 56

reinforcement was specified in two studies (Achmadi et al., 2012; Alzrayer et al., 2017).

Backward chaining (Achmadi et al., 2012), error correction (Brady, 2000; Chavers et al.,

2021), peer assisted communication training (PACT; Strasberger & Ferreri, 2013) and

practice trials (Waddington et al., 2015) were each listed as an intervention component once.

The important features to take away from the intervention packages is that teaching generally

occurred in a 1:1 scenario, targeted behaviour was systematically prompted, prompts were

faded, and correct behaviours were always reinforced.

 57

Table 2.3
Experimental Design Components

Study Design IV Components Interventionist Setting

Achmadi et al. Multiple baseline Least-to-most Graduate School
(2012) across participants prompting, time student
delay, backward
chaining,
differential
reinforcement
Alzrayer et al., Multiple probe across Least-to-most Graduate School
(2017) participants prompting, time student
delay,
differential
reinforcement
Alzrayer et al., Nonconcurrent Least-to-most Graduate School
(2019) multiple baseline prompting, time student
across behaviours delay, error
correction,
reinforcement
Brady (2000) Multiple baseline Error correction, Graduate School
across activities physical Student
prompting,
reinforcement
Chavers et al., Multiple baseline Least-to-most Graduate Home,
(2021) across participants prompting, Student School &
constant time Clinic
delay, error
correction,
systematic
instruction
Choi et al., Multiple probe across Progressive time Graduate School
(2010) participants delay, gestural Student
prompt
Shillinsburg et Nonconcurrent Constant time Therapist School
al., (2019) multiple baseline delay prompt,
across conditions gestural and
physical prompts
Strasberger & Multiple baseline Graduated Peer School
Ferreri (2013) across participants guidance, time
delay, prompting
van der Meer et Alternating treatment Least-to-most Parent, Home &
al. (2013) design prompting, Graduate school
reinforcement Student
Waddington et Multiple baseline Least-to-most Graduate University
al. (2014) across participants prompting, time student clinic
delay, error
correction,
practice trials,
reinforcement
 58

Note. IV = Independent variable

Preference Assessments

Ten studies performed preference assessments to identify stimuli that would function

as reinforcers for the participants requesting responses (Achmadi et al., 2012, Alzrayer et al.,

2017; Alzrayer et al., 2019; Brady, 2000; Chavers et al., 2021; Choi et al., 2010;

Shillingsburg et al., 2019; Strasberger & Ferreri, 2013; van der Meer et al., 2013;

Waddington et al., 2014). Initially, researchers requested a list of potential reinforcers from

participant’s family and teachers, items from these lists were then used in varying types of

brief stimulus presentations to determine which items would be most likely to motivate

behaviour change. Achmadi et al. (2012) offered items individually and the most selected

items were used in research. Alzrayer et al. (2017) as well as Chavers et al. (2021) used a free

operant procedure, where the items most frequently selected during free play were used

(Roane et al., 1998). Alzrayer et al. (2019) and Shillingsburg et al. (2019) presented a

multiple stimulus without replacement preference assessment, ranking items from most to

least preferred (DeLeon & Iwata, 1996). Brady (2000) offered an item on multiple occasions

and if the child consumed the edible or engaged with the activity and showed positive affect,

the item was considered a reinforcer. Choi et al. (2010) used a single stimulus presentation

assessment (Pace et al., 1985). Strasberger and Ferrer (2014) paired each potential stimulus

once with every other stimulus and the most highly selected items were considered

reinforcers (Piazza et al., 1996). Van der Meer et al. (2013) and Waddington et al. (2014),

simultaneously presented multiple items without replacement and items were then listed from

most to least preferred (DeLeon & Iwata, 1996; Duker et al., 2004).

Generalization and Maintenance

As listed in Table 2.4, four of the studies did not test for any type of generalization

(Achmadi et al., 2012; Brady, 2000; Shillingsburg et al., 2019; van der Meer et al., 2013).
 59

Four studies tested for generalization in one of the following areas: across items (Alrayer et

al., 2017), across activities (Choi et al., 2010), across settings (Strasberger & Ferreri, 2013),

and across people (Waddington et al., 2014). Two studies tested for generalisation in two

forms, Alzrayer et al. (2019) tested for novel items and questions, Chavers et al. (2021) tested

novel reinforcers and people. Seven studies included maintenance in their experimental

designs ranging from one to six weeks post intervention (Achmadi et al., 2012; Alzrayer et

al., 2019; Chavers et al., 2021; Choi et al., 2010; Strasberger & Ferreri, 2013; van der Meer et

al., 2013; Waddington et al., 2014). Three studies did not include any follow-up (Alzrayer et

al., 2017; Brady, 2000; Shillingsburg et al., 2019).

Inter-observer Agreement and Procedural Fidelity

Ten studies included measurements for inter-observer agreement (IOA), averages

ranged from 91 to 100% (Achmadi et al., 2012, Alzrayer et al., 2017; Alzrayer et al., 2019;

Brady, 2000; Chavers et al., 2021; Choi et al., 2010; Shillingsburg et al., 2019; Strasberger &

Ferreri, 2013; van der Meer et al., 2013; Waddington et al., 2014). This high degree of

agreement between all observers in the studies increases confidence in the consistency of

reported measurements. Total procedural fidelity averages ranged from 87 to 100% amongst

all phases and participants in the included literature (See Table 2.4).
 60

Table 2.4

Methodological Components

Procedural Social
Studies Generalization Maintenance IOA*
Fidelity* Validity
Achmadi et al., No 1 week 92-100% 87-100% No
2012

Alzrayer et al., Yes, items No 91-100% 96-98% No

2017

Alzrayer et al., Yes, items & 2 weeks 90.5- 94-99% Yes, +

2019 questions 100%

Brady, 2000 No No 97-100% 97.5% No

Chavers et al., Yes, people & Yes, 1 week 100% 100% No

2021 activities/snacks

Choi et al., 2010 Yes, activities 2-5 weeks 95-99% 99% No

Shillingsburg et No No 92-100% 92-100% No

al., 2019

Strasberger & Yes, setting 4 weeks 95% 97% Yes, +

Ferreri, 2013

van der Meer et No 3-6 weeks 97-100% 97-100% No

al., 2013

Waddington et Yes, person 3-6 weeks 95% 90-100% No

al., 2014

Note. + = positive findings reported, * = percentages represent range of averages

Social Validity

Two studies included social validity assessments (Alzrayer et al., 2019; Strasberger &

Ferreri, 2013), in which teachers and peers reported the interventions as acceptable and

effective (See Table 2.4).

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Quality Ratings

As all studies implemented a single subject experimental design, the quality rating

scale developed by Reichow (2011), was used to analyse the methodological quality of each

study. The results of this analysis are shown in Table 2.5.

Table 2.5

Quality and Outcome Ratings

Research Article Quality Rating Outcomes

Achmadi et al. (2012) Strong Positive

Alzrayer et al. (2017) Strong Positive

Alzrayer, et al. (2019) Strong Positive

Brady (2000) Weak Positive

Chavers et al., (2021) Strong Positive

Choi et al., (2010) Strong Positive

Shillingsburg, et al. (2019) Adequate Positive

Strasberger & Ferreri (2013) Adequate Positive

van der Meer et al. (2013) Strong Positive*

Waddington et al. (2014) Strong Positive*

Note. * = All participants showed improvement, but 1 participant did not exceed 75% correct

opportunities during intervention.

Seven articles were high-integrity experiments with sound experimental designs as

they received strong quality ratings of primary and secondary indicators (Achmadi et al.,

2012; Alzrayer et al., 2017; Alzrayer et al., 2019; Chavers et al., 2021; Choi et al., 2010; van

der Meer et al., 2013; Waddington et al., 2014). Brady (2000) was the only study to receive a

weak quality rating due to the lack of a baseline condition, resulting in an unacceptable

quality score amongst primary indicators. Shillingsburg et al. (2019) received an adequate
 62

rating because of their failure to implement generalisation, maintenance, or social validity.

Strasberger and Ferreri (2013) received an adequate quality rating because of an increasing

trend observed in baseline data for two participants.

Outcomes

Each intervention focused on increasing the length of participants’ communicative

interactions with peers, teaching staff, or the interventionist by elongating a simple request.

Achmadi et al. (2012) successfully taught two participants to turn on their SGD, unlock it,

and navigate through screens to make a multi-step request. Four participants from Alzrayer

et al. (2017) were effectively taught to navigate through three progressive screens to request

preferred items or activities. Alzrayer et al. (2019) taught a generalised request, then a

specific request, followed by personal questions (i.e., “what is your mom’s phone number?”

or “what is your address?”). Brady (2000) successfully taught two children to request three

items during a joint activity routine (i.e., tape player, earphones, and a cassette tape during a

listening to music routine). Chavers et al. (2021) taught three participants to engaged in a 4-

step ECS that included questions such as “how are you going?”, “what would you like to

do?”, and “do you like this toy/snack?” Procedures used in Choi et al. (2010), successfully

taught four participants to request, reject, and re-request items. Shillinsburg et al. (2019)

taught children to ask for information regarding a missing preferred item (i.e., “who has it”

and “which cup?”). Strasberger and Fererri (2013) taught four participants to answer the

question “What is your name?” and request an item. Van der Meer et al. (2013) taught one

participant to engage in an extended communication sequence, which consisted of two

greetings, and two requests. The second participant never reached criterion (80% or higher

over three consecutive sessions) even with modifications, but he did show an increase in

communication using the SGD. Waddington et al. (2014) taught participants a 3-step
 63

sequence, one participant required a modification from a static to progressive screen and one

participant did not meet mastery criteria.

Based on the review by van der Meer and Rispoli (2010), research outcomes for each

study were classified and ranked into one of three categories: (a) positive outcomes in which

target communication skill(s) improved for all participants, (b) negative outcomes in which

none of the participants improved in the target communication skill(s) and, (c) mixed

outcomes in which improvement was evident for some, but not all participants in the study or

in which some target skills improved and others did not (see Table 2.5). All participant data

included for this review displayed an increasing trend, indicating an increase in multi-step

requesting behaviour amongst participants. In total 30 students engaged with a partner in a

multi-step communicative exchange. Two participants, or 6% of the total population,

displayed an increase in requesting during intervention, but did not meet mastery criteria (van

der Meer et al., 2013; Waddington et al., 2014). As such, all research met the criteria to be

categorized as producing positive outcomes.

Discussion

The purpose of this review was to identify and summarize studies that aimed to teach

children with DD including ASD, who were minimally verbal to use SGDs for multi-step

requesting and/or extended communication sequences. A systematic search identified 10

studies specifically aiming to teach participants with DD/ASD to engage in an extended

communicative exchange. The targeted sequences required participants to partake in more

than one communicative response before gaining access to a requested item. Overall, the

research presented positive findings, and the interventions enhanced participant’s

communicative repertoires. Researchers were able to successfully arrange environmental

conditions in a manner to develop children’s verbal behaviour. Analysing participants’

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communicative attempts under controlled contingencies, allowed researchers to determine

whether individuals could learn an extended communication sequence.

Participants consisted of school aged children with speech capabilities of three years

or younger as assessed from a standardized assessment tool, most predominantly the

Vineland-II (Sparrow, et al., 2005). Five participants had no previous experience using an

AAC device, but this did not appear to have any effects on their learning outcomes as they

reached mastery criteria (Alzrayer et al., 2019; Strasberger & Ferreri, 2013). Researchers

consistently utilised high-tech devices, except for the study by Brady (2000), which was

conducted prior to the development of the portable tablet computer (Elsahar et al., 2019).

ProloQuo2Go™ was the most widely used application, perhaps because it allows for

easily programmable screen, icons design, and extensive real voice output options. Icon

trends included using minimal words, clear symbols, and photographs when possible. Icons

were always kept in the same position and organized in a grid-like pattern. Researchers

consistently stuck to 15 icons per page or fewer when programming options were available.

Setting up SGDs with a progressive screen, consistently generated positive results. If

participants failed to master a multi-step communicative exchanges on a static screen,

switching to a progressive screen aided in learning.

In this body of literature, one-to-one teaching formats appeared to have been effective

when implemented by a range of personnel, such as peers, teachers, graduate students, or

parents. As participants were school-aged children, research was generally conducted at

individual school campuses. However, students learning at home or in a clinic also exhibited

success at mastering an extended communicative exchange. As such, it can be inferred the

important setting characteristics were instructing participants in a 1:1 manner to ensure

attention to the task at hand, being near to allow for quick prompting, and reducing

environmental distractions as much as possible.

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Changes in behaviour as a function of intervention were evaluated using single-case

experimental designs (e.g., multiple baseline designs). Three intervention components

present in all ten research articles were using a consistent instructional package, controlling

access to preferred items, and limiting intervention times to 30 mins or less. While the least-

to-most prompting technique was the most widely used prompt, the important factor to note

is researchers consistently applied the same prompting method for the duration of the

intervention.

Preference assessments were performed prior to intervention when possible, ensuring

motivation was present for the learner to engage in the targeted communication sequence

(Koul et al., 2001; Sigafoos & Mirenda, 2002; van der Meer & Rispoli, 2010). Individual

motivating operations (MO) control requesting behaviour, therefore determining what items

create MOs for participants is an essential part of the intervention package (Sundberg, 2004).

In the case of the two participants who did not learn the sequence, it can be deduced that the

antecedent stimuli in their environment did not connect to the prevailing contingencies of

reinforcement (Skinner, 1957).

All studies included checks for IOA and procedural fidelity (Achmadi et al., 2012;

Alzrayer et al., 2017; Alzrayer et al., 2019; Brady, 2000; Chavers et al., 2021; Choi et al.,

2010; Shillingsburg et al., 2019; Strasberger & Ferreri 2013; van der Meer et al., 2013;

Waddington et al., 2014). It is the usual convention to achieve an average of 80% or higher

when observing a new behaviour (Cooper et al., 2014). Regarding included literature, IOA

averages ranged from 92 to100%, and procedural fidelity averages ranged from 87 to 100%,

indicating an acceptable level trustworthiness in the implementation of intervention and data

collection. One can believe protocol implementation and data collection practices were

performed according to the researchers’ published guidelines.

 66

Key secondary quality indicators generalization, maintenance and social validity were

missing from several of the research articles. Forty percent of studies (including nine

participants) did not test for generalisation. Twenty percent of studies did not include any

form of maintenance or follow-up (including nine participants), and social validity

assessments were not included in 80% of studies (including 23 participants). Failure to

conduct secondary quality checks in research is a significant limitation effecting the

application and interpretation of data. Lasting effects and social significance are important

aspects of a behaviour change program, failure to include them weakens the overall value of

this body of literature. The positive outcomes of the included research are tainted by the lack

of generalization probes, maintenance, and inclusion of social validity measures.

Asking caregivers, teaching staff and other related individuals about the goals,

outcomes and methods of interventions can provide insight as to the acceptability of the

intervention procedures as well as the value of the behaviour change. Because seven out of

nine studies include no measures of social validity, it is impossible to assess the social

significance of the target behaviour, the appropriateness of the procedures and the social

importance of the results (Cooper et al., 2014).

Clinical implications taken away from this body of research provide insight on how to

elongate communicative exchanges on an SGD. The SGD should be set up with a progressive

screen if possible. Recommended screen layout would involve 15 icons or less, in a grid-like

fashion. Icons should be easily interpretable photographs or pictures with few words and

always remain in the same place on the screen. Therapists or interventionists should

rigorously adhere to a predetermined instructional package that is implemented in a 1:1

teaching style. Sessions should not exceed 30 mins and take place at least twice a week.

Limitations to this research lie within the small participant pool and the repeated

failures to implement secondary methodological components such as maintenance,

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generalisation, and social validity. The lack of generalisation, maintenance, and social

validity data means that it is not currently clear whether lengthening communicative

interactions enhances quality of life, maintains over time, or generalises. Inferences on the

reduction of challenging behaviours cannot be made as data was not collected on challenging

behaviours from any individuals in the participant pool.

This review of literature indicates most-to-least prompting, time delay and

reinforcement can be considered EBPs when used in combination to teach an ECS on an

SGD to minimally verbal children with ASD. While backwards chaining, error correction,

and practice trials did present positive findings, there was not enough evidence available to

consider them EBPs. Results highlight the lack of novel interventions tested in current

literature. The antecedent prompting procedure was not implemented in the included

research.

Expressing a want or need is an imperative life skill that can enhance quality of life.

Much of a neurotypical child’s first language is requesting unconditioned reinforcers,

therefore it is legitimate to begin a language program with this type of request (Hart &

Risley, 1999). Pairing social interactions with a request for a highly desired item, can

facilitate the transfer of stimulus control so that a learner ultimately learns to independently

engage in a conversation (Cooper et al., 2014). Although the motivating operation in these

experiments is the non-verbal stimuli (i.e., popcorn, bubbles), increasing children’s verbal

repertoires so that interactions become increasingly varied, complex, and naturalistic is a

positive step towards more age-appropriate communication.

The included interventions lengthened participants verbal interactions by pairing

social interactions with gaining access to a reinforcer. Researchers artificially created MOs

for participants to engage in previously un-attempted conversational interactions. The strong

quality ratings and positive outcomes in this body of research allows one to conclude that
 68

greetings, answering personal questions, rejecting, and participating in a joint activity were

all effectively taught when paired with a request.

Limitations

This literature review identified two major limitations in the current body of literature

related to teaching an ECS on an SGD. First, there were repeated flaws in experimental

design. The body of literature included nine published articles, and of those eight did not

measure for generalisation, maintenance, or social validity. The presented research will

ameliorate flaws in methodological design of the current body of research by including data

related to generalisation, maintenance and social validity.

The second major limitation this review brought to light was the stagnation in the use

of novel instructional strategies to teach an ECS on an SGD. Clinicians and researchers have

not attempted to find new, potentially more efficient ways to teach this communication skill.

It is important to keep the field moving forward and to try and always find new and better

ways to teach. To address this limitation, a novel intervention that has never been used to

teach an ECS on an EGD (the antecedent prompting procedure) will be implemented in the

hopes of providing positive evidence of an effective alternative teaching strategy.

This research project was designed to answer the following questions as they apply to

Studies 1, 2, or both.

Research Questions

Study 1:

1. Can minimally verbal children with ASD learn to participate in a 4-step ECS,

including 2 social responses, using their iPad®-based SGD configured with a

progressive screen display and with the implementation of a novel antecedent

prompting procedure?

Study 2:
 69

2. Can minimally verbal children with ASD learn to participate in the same 4-step ECS

using their iPad®-based SGD configured with a static display screen and with

implementation of a novel antecedent prompting procedure.

3. If configuration of the SGD display is changed to a static display, will participants

continue to engage in the 4-step ECS?

4. Do parents, teachers, and teacher-aids find the intervention socially valid?

The following questions relate to Studies 1 & 2:

1. Is the antecedent prompting procedure an effective method to teach the targeted ECS

on an iPad-based SGD?

2. Do the newly acquired communication skills generalise to novel people and do the

skills maintain for three weeks after intervention is completed?

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CHAPTER 3

Study 1: Teaching an Extended Communication Sequence Using an Antecedent

Prompting Procedure with a Progressive Display on an iPad-based SGD

Abstract

This quantitative study was designed to evaluate a style of intervention specifically

focused on alleviating problems associated with language deficits amongst minimally verbal

individuals with ASD. The hope was to apply behaviour analytic principles to create

environmental change to evoke an elongated interaction between the learner and the listener,

counteracting the anti-social traits associated with the condition.

When a behaviour produces consequences that strengthen that behaviour in the future,

it is called positive reinforcement. Skinner (1948) first described this stimulus-response

relationship in which a stimulus is added to the learner’s environment to increase the

probability (motivation) of that response in future. It is the foundation of ABA. This study

implemented systematic instructional techniques based on this relationship by arranging

positive reinforcement contingencies to teach communicative behaviour to minimally verbal

children with ASD.

In operant conditioning, an individual learns to engage in a behaviour following the

presentation of a discriminative stimulus to gain access to a specified reinforcer (Heweitt,

1965; Skinner, 1953). The presented research will apply the principles of operant

conditioning and use the learner’s motivation to gain access to highly preferred items, to

teach new communicative behaviours (Hall & Sunberg, 1987; Rheingold et al., 1959). The

request was specifically targeted for teaching because it is the verbal operant that is

controlled by a motivational variable and is usually the first operant to develop in children

(Michael, 1988; Skinner, 1953; Sundberg, 1993).

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A method used for teaching operantly learned behaviours is systematic instruction

(Katz, 1994). Systematic instruction, first presented in 1974, involves presenting material in

small steps, allowing the student to practice after each step, and providing a reinforcing

response for correct responses (Rosenshine, 2012). This method involves creating an

instructional objective, choose a teaching strategy, determining a data collection method, and

evaluating the results (Ascherman, 2017). Systematic instruction has been shown to address

deficiencies by utilising extrinsic motivation and allows instructors to direct work and specify

tasks (de Graaff et al., 2009; Katz, 1994). Teaching takes place in individual sessions,

sessions are composed of trials, and each trial is a learning opportunity (Collins, 2012). Each

session may be composed of as many trials as the instructor deems appropriate, based on the

learner’s ongoing responsiveness, and contains an antecedent, a behaviour, and a

consequence, which are referred to as the A-B-Cs of an instructional trial (Collins, 2012).

One specific way to implement systematic instruction is the DTT format. Lovaas

(1987) originally developed DTT for young children with autism and it is currently one of the

most widely researched behaviour analytic techniques specifically used to teach skills to

children with ASD (Smith, 2001; Stahmer et al., 2003; Tarbox & Najdowski, 2008). Like

systematic instruction, DTT takes a skill, breaks it down to components, each component is

trained individually through repeated instructional trials, and correct responses are positively

reinforced. Implemented in a one-to-one instructional format, DTT has been proven to be

effective at improving expressive and receptive language for children with ASD (Lerman et

al., 2016; Prelock et al., 2011; Tsiouri & Greer, 2003; Yoder & Layton, 1988).

Just like systematic instruction, every trial of DTT should have a clear beginning and

end, and each trial should consist of an antecedent, a response, and a consequence. But DTT

breaks down individual trials into five components: (a) an antecedent stimulus, which
 72

becomes the discriminative stimulus (𝑆 𝐷 ), (b) the prompt, (c) the response, (d) the

consequence, and (e) an the intertrial interval (Smith, 2001; Tarbox & Najdowski, 2008).

How quickly an operant behaviour is learned is dependent on an effective

reinforcement schedule, therefore it is important to maintain a consistently high behaviour to

reinforcement ratio during when teaching a new skill (Morse, 1966; Pierce & Chaney, 2008).

A consistently high schedule of reinforcement is called a continuous schedule, or a fixed ratio

of 1 (FR:1). In a FR:1, each occurrence of the behaviour results in a reinforcing

consequence. It is best to use this ratio when initially teaching new behaviours as it creates a

strong association between the behaviour and the consequence, increasing the likelihood the

behaviour will increase in frequency (Lerman et al., 2016; Thorndike, 1911).

In the present intervention, multiple communication opportunities were created in

each teaching session by providing communication opportunities that were configured to

have a clear beginning and end, with each opportunity consisting of an initial cue, a time

delay, a response expectation, and a consequence. The ultimate and final consequence being

access to a reinforcer. For all trials, reinforcer specificity was used exclusively, meaning “you

get what you name” (Reichle et al., 1986). This technique is advantageous for learners as it

generally requires fewer trials to criterion (Litt & Schreibman, 1981). It is a strategy in

which the reinforcer matches the referent requested. Consequences provided at each step of

the ECS matched the function of the communicative response provided by the participant,

and specific reinforcement for a specific request was delivered upon the completion of the

sequence.

The communication opportunities were systematically taught using a unique

prompting approach referred to as antecedent prompting. The antecedent prompt, sometimes

called a simultaneous prompt, minimizes errors by providing a controlling prompt that results

in the learner making a correct response 100% of the time and accessing high levels of
 73

reinforcement (Leaf et al., 2010). The learner is presented with the discriminative stimuli then

immediately prompted through the ECS, prior to the learner having an opportunity to

incorrectly engage in the sequence.

The antecedent prompting procedure could be seen as a type of errorless learning that

was chosen because it has been successfully used to teach chained tasks to individuals with

developmental disabilities (Ersoy et al., 2009; Matson et al.,1990; Singleton et al., 1999;

Wolery, 1986; Wolery et al., 1988). Errorless learning is not necessarily errorless, but error

reducing because it decreases the likeliness of incorrect responding and has been

demonstrated to be especially beneficial when the learner must choose an appropriate

response from multiple stimuli (Fillinghan et al., 2003; Mueller et al., 2007; Terrace, 1963a;

Terrace, 1963b).

The errorless learning technique is herein refer to as antecedent prompting consisted

of two stages: (a) First presenting prompted trials, that are conducted with a 0-s delayed

prompt, and (b) second, presenting the probe trials (i.e., unprompted trials) conducted after

the prompt trails to assess if any learning/acquisition had occurred (Ersoy et al., 2009). The

antecedent prompting procedure was specifically chosen for three reasons. First, errorless

learning has been proven to reduce learning time for many skills and many learners with

ASD; and has also been demonstrated to be an effective teaching method. Students were

prompted through a correct performance of the ECS and reinforced by being granted access

to the item they were prompted to request. Second, this approach stimulated success during

independent trials because the student had already performed the sequence correctly. It also

allowed the interactions during the probe trials to occur without the necessity of prompts or

disrupting the students attempts to communicate. Third, for data collection purposes, this

method provided an easily observed presentation of behaviour, the participant did or did not

independently engage in the behaviour. Students were guided through a correct request of
 74

their four reinforcers, granted access to the items after each request, then had four

independent opportunities to request any of the items without limit with complete

independence. Data was collected during the independent trials allowing for crystal clear

data collection of observable behaviour. To meet mastery criteria, students had to engage in

all four steps of the ECS independently, for four opportunities, across three sessions.

The aim of the present study was to evaluate an instructional program aimed at

teaching a ECS that involved four steps, inspired by previous studies including: (a) Alzrayer,

et al. (2017), (b) van der Meer et al. (2013), and (c) Waddington et al. (2014). There is a large

amount of literature on teaching AAC to children with ASD (Ganz et al., 2011; Kagohara et

al., 2013), however the focus of this research has predominately been on teaching a single-

step communicative exchange (Iacono et al., 2016). Whether teaching a request, an

intraverbal, comment, or labeling (i.e., tact) response, children with ASD have been

repeatedly taught to successfully engage in 1-step interaction using their SGD (Ganz et al.,

2011; Ganz et al., 2012; van der Meer & Rispoli, 2010).

Children have also been successfully taught to engage multi-step requests that

involved navigating through multiple screens and activating multiple icons (Gervarter, et al.,

2018; Gen-Toun & Kurt, 2017). But the issue as to whether children with ASD can be taught

to use SGDs to engage in multi-step/multi-function ECS has not been extensively researched.

There is a gap in high-tech AAC literature linking initial communication training (i.e., the

request) to more advanced and social forms of communication (Gilroy et al., 2017).

Interventions designed to address deficits in socialization should be a target when

working with children with ASD (Bondy & Frost, 2009; Gilroy et al., 2017; Lorah et al.,

2014). This is especially important when considering the social mannerisms required to

actively participate in New Zealand society. Adding social niceties to a request, such as

“Hello” and “Thank you” tend to make a positive impression and reflect good manners on the
 75

individual using them. This study was designed to fill in that gap in literature and evaluate a

novel antecedent prompting procedure, which involved implementing four fully prompted

practice trials, followed by four unprompted probe trials (to assess independence of

responding) to teach an extended communicative request. Using an antecedent prompting

procedure, five participants were taught to participate in a 4-step ECS that included (a) an

initial greeting, (b) a generalized request, (c) a specific request, and (d) a social response.

Specifically, the sequence required of the child was to first communicate “Hello”, then to

make a general request (e.g., “I want a toy”), then to make a specific request (“I want

bubbles”) and then after receiving the requested object to communicate, “Thank you”. The

specific research question was can antecedent prompting be used to teach five children with

ASD to engage in an extended and multifunctional communication sequence using an iPad®-

based SGD loaded Proloquo2go™ software set up with a 4-page progressive screen?

Ethical Considerations

Ethical approval for this study was granted by the Victoria University of Wellington

Human Ethics Committee (Reference Number 0000023430). Informed consent was obtained

by parents, teachers, teacher aides and school principles for Studies 1 and 2. Each study

complied with ethical standards of the American Psychological Association and the New

Zealand Psychological Society. In consideration of the special population of children

participating in the studies who are minimally verbal, assent to participate was assessed

regularly through their observable behaviour and willingness to participate in each session. If

a child displayed challenging behaviour indicating they wanted the session to be terminated

(crying, screaming, elopement, etc.) across multiple consecutive sessions, intervention would

discontinue.
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Methods

Participants

Five children were recruited who met the following criteria: (a) ASD diagnosis from a

paediatrician, (b) under 18 years of age, (c) adequate motor ability to use an iPad-based SGD

touch screen based on informal observation, and (d) severe communication impairment as

evidenced by scoring less than 3:0 (years:months) on the Expressive Communication sub-

domain of the third edition of the Vineland Adaptive Behavior Scales (Vineland-III, Sparrow,

et al., 2016). Participants included four males and one female; whose ages ranged from 6 to

10 years old. Four children were recruited from a university data bank in which their

caregivers registered interest to participate in research projects. One participant attended the

same special education classroom as a participant who was registered in the university data

bank and their teacher expressed interest in involving an additional student. Table 3.1

provides a summary of participants gender, age, ethnicity, diagnosis, Vineland-III scores and

AAC device history.

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Table 3.1

Child Demographic Characteristics, Vineland-III Age Equivalencies, and AAC History

Sean Chris Andy Victor Grace

Gender M M M M F
Age at start of
8 10 6 7 7
study (yrs)
Maori/NZ NZ
Ethnicity Russian Fijian/Indian Maori/British
European European
Diagnosis ASD ASD, ID ASD ASD ASD
Vineland-III
(Yrs: Months)
Receptive 1:2 1:7 0:8 0:11 0:0
Expressive 0:9 1:7 0:7 0:8 0:9
Written 3:6 4:4 3:0 3:5 3:3
MS, PE,
AAC History SGD PE SGD PE, SGD
SGD

Sean. Sean was an 8-year-old male of Russian decent with a diagnosis of ASD. He

lived with his mother, father, and sister. Sean attended school Monday through Friday where

he received learning assistance from a teacher aide. On the communication sub-domains of

the Vineland-III (Sparrow et al., 2016), Sean received age equivalencies of 1:2 (years:

months) for receptive communication, 0:9 for expressive communication, and 3:6 for written

communication. Sean used his iPad®-based SGD loaded with ProloQuo2Go™ software on a

regular basis at home to request items. Sean engaged in challenging behaviours in the form of

biting and elopement. During Sean’s generalization probes, the novel person used in this

study was his teacher aide, who was familiar to him. The teacher aide observed most sessions

conducted for this study upon the request of the teacher.

Chris. Chris was a 10-year-old male of Fijian Indian descent, diagnosed with ASD

and intellectual disability. He lived at home with his mother and attended school five days a

week and received assistance from a teaching aide. On the communication sub-domains of

the Vineland-III (Sparrow et al., 2016), Chris received age equivalencies of 1:7 (years:
 78

months) for receptive communication, 1:7 for expressive communication, and 4:4 for written

communication. Chris had no experience using an SGD. He would consistently try to

communicate with eye contact accompanied by gestures and vocalizations, but his

vocalizations were mostly unintelligible to the untrained listener. In the classroom Chris used

a visual schedule as well as a picture-exchange communication system with his teacher aide.

Because Chris had no experience using an SGD, prior to the implementation of baseline he

was taught to make a 1-step request using his SGD. Chris was a pleasant, mild-tempered boy

and challenging behaviour was not reported. During Chris’ generalization probes the novel

person used was his teacher aide. Chris’ aide spent most of the school day by his side and

observed most research sessions.

Andy was a 6-year-old boy of Māori and New Zealand European decent. He lived at

home with his mother, father, and sister. Attending school five days a week, he spent much

of his day in a special education unit. He received assistance from a teacher aide and

participated in school outings to swim and walk during the week. On the communication

sub-domains of the Vineland-III (Sparrow et al., 2016), Andy received age equivalencies of

0:8 (years: months) for receptive communication, 0:7 for expressive communication, and 3:0

for written communication. Andy had no spoken language and would communicate through

gestures and physically guiding adults to what he wanted. When Andy made vocalisations,

they were in the form of a humming sound with no consonant-vowel combinations. At home

and in school, Andy used his SGD to make 1-step requests. Andy did not exhibit violent

behaviour, but on occasion would throw tantrums. For generalization purposes, Andy’s

novel person was his teacher aide whom he was familiar with. Andy’s teacher aide assisted

with data collection and generalisation probes.

Victor was a 7-year-old male of New Zealand European decent. Victor lived at home

with his mother, father, and two siblings. He attended a special needs school with 2:1 student
 79

to teacher ratio and received 10 hours of behavioural therapy a week at home. On the

communication sub-domains of the Vineland-III (Sparrow et al., 2016), Victor received age

equivalencies of 0:11 (years: months) for receptive communication, 0:8 for expressive

communication, and 3:5 for written communication. Victor had experience using his SGD at

home. At school, a visual schedule and PECS was in place. Victor spoke a few words (i.e.,

“no”, “hello”, “okay” and “yes”), but he did not use speech to communicate independently or

on a regular basis. Prior to intervention, Victor would often leave the classroom without

permission and refused to sit at a table to work. Aggressive or violent challenging behaviours

were not reported by his parents or teachers. For generalization purposes, Victor’s novel

person was a graduate student. Victor only spent time with the novel person during research

sessions.

Grace was a 7-year-old female of Māori and British decent. Grace lived with her

mother and Father, attended school 5 days a week where she spent most of her time in a

special education unit and received 1:1 assistance from a teacher aide throughout the day. On

the communication sub-domains of the Vineland-III (Sparrow et al., 2016), Grace received

age equivalencies of 0:0 (years:months) for receptive communication, 0:9 for expressive

communication, and 3:3 for written communication. Grace is non-verbal and only used 1

manual sign (MS) for “more”. Grace had experience using her SGD at home and at school.

Grace also successfully used picture exchange cards to request snacks, toilet, television, and

other activities from a board located in the kitchen area of her home. For generalization

purposes Grace’s novel person was her teacher aide, who she was very familiar with as they

spent most of the school day together.

Setting and Intervention Context

All five participants received 1:1 intervention in a private room at their school.

Sessions were conducted while the child sat at a table or desk with the SGD and the trainer
 80

(Sawchak). Reinforcers were kept in a clear storage box on the floor behind the trainer’s

seat. A teacher, teacher’s aide, and/or graduate student was generally in the room during

intervention to collect inter-observer agreement data, treatment fidelity, and/or to perform

generalization probes. Some sessions were video recorded so that inter-observer agreement

data treatment fidelity data could be coded when a live observer was not available for this

purpose. To avoid distraction, the video camera was placed on a tripod in the corner of the

room when used.

Preferred Stimuli

Participants’ preferred snacks and toys to request during intervention are listed in

Table 3.2. Reinforcers were selected using a two-stage stimulus assessment process (Fisher et

al., 1996). Stage 1 involved asking parents and teachers to provide a list of snacks and toys

that the children seemed to enjoy. During Stage 2, four items from each list were used in a

paired stimulus preference assessment (Chazin et al., 2016). Paired items from each category

were presented and the child was asked to choose one item, creating a hierarchy of highest to

lowest preferred items. Every item was paired with every other item of the same category

(toys or snacks), and the process was repeated a minimum of four times. The two most

preferred snacks and toys were selected for intervention. This method produces a ranking of

preferences (Deleon & Iwata, 1996; Fisher et al., 1992; Piazza et al., 1996; Roane et al.,

1998).

Preferred stimuli for Sean included a puzzle, bubbles, mini-M&Ms, and chocolate

biscuits. Chris’s preferred stimuli were bubbles, a tennis ball, mini-M&Ms, and chips.

Reinforcers for Andy were bubbles, kinetic sand, Twisters, and potato crisps. Victor’s

reinforcers included a toy car, kinetic sand, mini-M&Ms, and chips. A preference assessment

for edible reinforcers was not conducted for Grace as she had a strict diet and several food

sensitivities, and thus the edible reinforcers used during the study with her were at the
 81

specific direction of her mother. Grace’s reinforcers were coconut crackers, macadamia nuts,

bubbles, and a ball. Only a bite size portion of edibles was given to participants when

conducting the preference assessments and during intervention. Toys could be manipulated

for 30-seconds or until the activity was complete (i.e., the puzzle).

Table 3.2

Preferred Stimuli for Each Participant

Participant Preferred Snacks Preferred Toys

Sean chocolate biscuit, mini-M&Ms puzzle, bubbles

Chris chips, mini-M&Ms tennis ball, bubbles

Andy red liquorice candy, potato crisps car, kinetic sand

Victor chips, mini-M&Ms car, bubbles

Grace coconut crackers, macadamia Nuts ball, bubbles

Speech-generating Device

Several studies have demonstrated the effectiveness of using a portable tablet, with a

touch screen and icons that produce synthetic speech output to enhance communication skills

of children with ASD and developmental disabilities (Achmadi et al., 2012; Alzrayer et al.,

2014; Kagohara et al., 2013; Lorah et al., 2014; van der Meer et al., 2011; van der Meer &

Rispoli, 2010; Waddington et al., 2014). Specifically, using Proloquo2Go™ downloaded

onto a portable Apple based operating system, such as an iPod® or iPad®, has been shown to

increase students’ communication abilities compared to other forms of AAC (Collette et al.,

2019; Flores et al., 2012; Kagohara et al, 2013).

Based on the successful outcomes of previous research, participants were taught the

extended communication sequence using an Apple iPad® loaded with Proloquo2Go™

software (Sennott & Bowker, 2009). Proloquo2Go™ is especially appropriate for individuals
 82

with ASD because it incorporates evidence-based practices by integrating symbols on icons

as visual supports, providing voice output with icon activation, and has a dynamic touch

screen display (Sennott & Bowker, 2009). More specifically, the user can customize the

screen display to contain anywhere from 1 to 256 icons per page. Furthermore, the

application can be designed to display all the user’s icons on one page in a static display, or

throughout multiple pages with a progressive display. A customisable voice output

application used in combination with a device that is portable has been repeatedly

demonstrated to create effective outcomes when used together (Sennott & Bowker, 2009). An

iPad®-based SGD, loaded with Proloquo2Go™ software, was used in the current research

because of the large body of empirical evidence supporting its effectiveness, specifically to

improve communication skills amongst minimally verbal individuals with ASD (Alzrayer et

al., 2014).

The iPad® was configured to have four screens, each screen containing two icons.

Figure 3.1 outlines the sequence of four conversational exchange options. The two icons on

Screen 1 were “Hello” and “Thank You”. Activating the “Hello” icon took participants to

Screen 2, activating the “Thank You” icon generated speech output, but did not progress to

the next screen. The two icons on Screen 2 were “I want a snack” and “I want a toy”. If

participants activated either icon, they would be taken to Screen 3. For instance, if Andy

activated the “I want a snack” icon, he was taken to his personalised Screen 3 which

contained photographed icons of his preferred snacks: “Crisps” and “Twisters”. Activating

the “I want a toy” icon on Screen 2, in contrast, led Andy to Screen 3 which contained icons

for a toy car and kinetic sand. An example of Andy requesting an edible reinforcer can be

seen in Figure 3.2. If any specific reinforcer icon was activated by the student on Screen 3,

they were taken to Screen 4. Screen 4 was looked identical to Screen 1, it contained a

“Hello” and “Thank You” icon. Activating either icon did not take the user to another screen
 83

but only generated speech output. The icons used on Screens 1, 2, and 4 were SymbolStix™

images taken from the ProloQuo2Go™ data bank and were identical on all five participants’

SGDs. The icons used for both snack and toy versions of Screen 3 were individualised for

each participant and contained icons with photographs of their reinforcers with the

corresponding word. Speech output was in an Australian accent with a child’s gender

matching voice.

Figure 3.1

Progressive Display Screen Configuration Programmed onto Each Participant’s

SGD

Response Definitions and Measurement

Correct responding was defined as independently activating (i.e., without prompting)

an icon during probe trials to generate speech output at each of the four steps in the

communication sequence. First, the student had to greet the researcher by selecting the

“Hello” icon within 10 s of being asked, “Hello, would you like a snack or a toy”? Second,

the student had to make a general request for a toy or a snack from the icons available on
 84

Screen 2, again within 10 s of that screen appearing on the SGD. Third, the participants had

to make a specific request for one of their two preferred snacks or toys from the icons

available on Screen 3 again within 10 s of that screen appearing. Lastly, the child had to say

“Thank you” upon receiving the item requested at Step 3 by selecting the “Thank you” icon

from Screen 4. Data at each step were collected on a trial-by-trial basis and recorded onto a

prepared data sheet via direct observation. An example of a correct request for an edible item

is pictured in Figure 3.2, images are taken from Andy’s SGD and display a correct extended

request for one of his edible reinforcers, a Twister. If students did not activate an icon on

their SGD within 15-sec it was considered non-responding and marked as an incorrect trial.

Trials were also marked as incorrect if the child activated the “Thank you” icon during the

first step of the sequence, at which point the trial was terminated. There was not an

opportunity for incorrect responding during the second or third steps of the sequence, if the

student engaged using their SGD any behaviour was reinforced with a social response.

During the last step of the sequence, if a student incorrectly selected the “Hello” icon, the

trial was marked an incorrect, but the interventionist prompted the correct activation of the

“Thank you” icon and granted the student access to the requested item.
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Figure 3.2

Example of the Visual Display for Each Step on Andy’s SGD

Screen 1 Screen 2

Screen 3 Screen 4

Experimental Design

A multiple baseline across participants design was implemented to evaluate the

effectiveness of the intervention (Kennedy, 2005). The design included the following

experimental phases: (a) baseline, (b) intervention, and (c) follow-up. Generalisation probes

involving a novel person were conducted during each phase of the study. Three

generalisation probes took place during intervention after mastery criteria had been met. One

generalisation probe during baseline and maintenance phases were performed singly for each
 86

participant. Once a trend in baseline was established, intervention was staggered across

participants.

Session Schedule

Sessions were scheduled to occur at the same time of the day for each participant, two

days per week (Tuesday and Thursday), barring absences and school holidays. These days

were selected to accommodate room availability at participating school campuses, as well as

children’s school schedules. Each baseline and follow-up session were approximately 15-

min in duration and consisted of four probe trials. Each intervention session consisted of

eight communication opportunities, comprised of four prompt trials and four probe trials.

Participant performance data was only collected during probe trials of independent activation

of their SGD.

Procedures

Baseline. During baseline, prior to student arrival, a camera was set up in the corner

of the room when sessions were recorded. The student and researcher were seated at a table.

The iPad was placed on the tabletop, directly in front of the student and within arm’s reach of

both individuals. The device was loaded with Proloquo2Go™ software open and on guided

access. The reinforcer box was on the floor next to the interventionist, out of sight from the

participant. A trial was cued when the interventionist said, “Hello, let me know if you want a

snack or a toy”, while placing the reinforcer box on the table. This statement and action by

the interventionist were the discriminative stimulus (𝑆 𝐷 ) that signalled the start of a

communication opportunity or discrete teaching trial. Data were collected over the following

15 s, if the student activated speech output on their SGD it was recorded. After 15 s, the box

of reinforcers was moved out of sight and data was scored on the participants behaviour. The

researcher repeated this process four times, waiting a minimum of 30 s between trials. Four
 87

opportunities were chosen because there were four reinforcers available to request, thereby

each student had one opportunity to request each item.

Intervention. During the intervention phase, the room was set up in an identical

fashion to baseline. However, four initial antecedent prompting trials occurred prior to

conducting the subsequent four probe trials. During each antecedent prompting trial, the

student was guided with a full physical prompt through the entire communication sequence

and for each reinforcer according to a randomly generated order (two trials for snacks and

two for toys). Once the researcher provided the 𝑆 𝐷 , “Hello, let me know if you want a snack

or a toy” while placing the box of reinforcers on the table, the learner was immediately

prompted to progress through the multi-step sequence (e.g., “Hello”, “I want a toy”, “I want

bubbles”, “Thank you”). After the child was prompted to press “Thank you”, they were given

access to the requested reinforcer for 30 s. A minimum 15 s pause occurred between trials.

Antecedent prompting trials ceased to occur after the participant correctly participated in the

extended communicative exchange for four probe trials with 100% accuracy for three

consecutive sessions.

Once the four antecedent prompting trials were completed at the start of each session,

the four probe trials (identical to those of baseline) were conducted. For these, the

interventionist provided the 𝑆 𝐷 and then waited 10 s for the student to independently activate

an icon. If a student did not independently activate an icon for 10 s, the trial was terminated,

and a “no response” was recorded. If a student selected an appropriate icon that corresponded

to the correct step of the request, their behaviour was met with a natural consequence as

described in Table 3.3. For example, if the participant activated the “Hello” icon, the

researcher would respond with a socially appropriate response such as “hi” or “hello”. At

screen 2, if the participant selected the icon for “I want a toy”, the research would say “a toy

sounds fun!” or “awesome, what would you like?”. Once the participant requested a specific
 88

toy the researcher would say “Good choice!”, and then say “You’re welcome!” while giving

them their requested reinforcer in response to the child activating the “Thank you” icon. A

trial was immediately terminated if the student activated the “Thank you” icon on the first

screen. If a participant arrived at Screen 4 did not independently activate the “Thank you”

icon, the researcher held the reinforcer that had been requested from Screen 3 in view and

physically prompted the participant to select the “Thank You” icon. Only after the participant

correctly engaged in all four steps of the sequence, where they were granted free access to the

reinforcer for approximately 30 s, time to consume the edible or play with the toy. The

prompt at Screen 4 was implemented to maintain a high level of reinforcement during

teaching and to ensure communicative attempts did not extinguish. During the inter-trial

break the interventionist and IOA data collector recorded data. Mastery criteria was

independently performing all four steps of the ECS, for four probes, across three sessions.

Table 3.3

Examples of Natural Consequences for each Step of the Communication Sequence

Participant Interventionist Response

“Hello” “Hi!”, “Hello!”, “Hiya!”
“I want a snack/toy” “Okay, a snack”; “A toy sounds fun!”
“I want a specific snack/toy” “Chips, good choice!”; “Bubbles are great!”
“Thank you” “You’re welcome!”; “My pleasure”

Discrimination tests. Discrimination trials were identical to intervention probe trials.

However, after the student completed the communication sequence, the researcher opened the

reinforcer box and allowed the student to freely select one of the preferred items. These trials

were run to determine if the student was appropriately discriminating between icons and

requesting the item they wanted to access or consume. These trials occurred after mastery

criteria had been met and before the intervention phase was terminated. A total of 10

discrimination trials were conducted for each participant. These trials occurred across three
 89

sessions, for 12 probe trials. Data were collected by recording the item requested and the

item selected for each trial.

Generalization probes. Once participants reached mastery criteria during the

intervention phase, three generalization probes were performed using a novel person. Except

for Andy, the same novel person performed generalisation probes during baseline and follow-

up. Andy’s teaching assistant and teacher left during the year, a graduate student Andy had

never interacted with before was recruited to assist with the generalisation probes. During

these probes environmental arrangements and reinforcers remained the same to intervention

probe trials. Requests were made to conduct generalisation probes in novel locations on each

school campus, but because of video recording requirements and the presence of additional

students who were not participating in the study, some school campuses requested

intervention only take place in a private room. Therefore, generalisation probes for location

were not conducted for any participants.

Follow-up sessions. Two follow-up sessions were conducted. One session was run

by the interventionist and the second by a novel person. Protocol during this phase was

identical to baseline. Follow-up sessions were scheduled to occur three weeks post

intervention for all students. Miscellaneous scheduling conflicts resulted in delayed probes

for some participants (i.e., school holidays, illness, field trips, etc). As a result, maintenance

was tested three to eight weeks post intervention.

Inter-Observer Agreement

Independent observers recorded participant responses during all phases of the study.

IOA checks occurred for a minimum of 20% of sessions conducted for each child per study

phase. Inter-observer agreements (IOA) were calculated using the formula: Agreements/

(Agreements + Disagreements) × 100. The primary author trained each independent observer

by performing practice trials, defining independent variables, and explaining the purpose of
 90

the study. If both observers marked a behaviour occurred, it was considered an agreement. If

only one observer marked a behaviour occurred, it was considered a disagreement. Mean

percentages of agreement were 99 (range 96-100) for Sean, 100 for Chris, 96 (range 91-100)

for Andy, 100 for Victor, and 97 (range 89-100) for Grace. Inter-observer agreement was

collected by each student’s teacher aide, except for Victor. All of Victor’s IOA checks were

collected by the same graduate student.

Procedural Integrity

Procedural integrity was assessed by an independent observer using a checklist to

determine if the intervention procedures had been implemented correctly. During all phases

of the study, data collectors checked that the SGD was on the table, Proloquo2Go™ software

was open and on guided access, and the reinforcer box was out of sight. It was noted if the

researcher properly cued the start of a trial by saying, “Hello, let me know if you want a

snack or a toy?” while placing the box of reinforcers on the table. Then data were collected

to ensure the correct prompting procedures were used during the antecedent prompting trials.

In the intervention phase, during the probe trials, observers marked the child’s behaviour at

each step of the sequence and if the interventionist was required to prompt the child to

activate the “Thank You” icon. The conclusion of a trial was noted if the researcher returned

the box of reinforcers out of sight and waited 15 s between trials. The observer was either a

teacher aide or graduate student. The same person that recorded IOA data, assessed whether

the researcher correctly implemented each step of the protocol. Checks occurred during 22 to

37% of sessions per participant, with a minimum of one observation for each phase of the

study. Resulting percentages of correct implementation were always 95% or above.

Results

Figure 3.3 shows displays percentages of correct responses from probe trials

conducted throughout baseline, intervention, and follow-up phases of the study. Data were
 91

collected in situ, graphed, and analysed to show the children’s performance in the 4-step

communicative exchange (i.e., “Hello”, “I want a toy”, “I want bubbles”, and “Thank You”).

Sean. Six sessions of baseline were conducted for Sean, one of which was a

generalisation probe. During Sean’s 3rd baseline session, he attempted to use his SGD and

activated icons that progressed him through the conversational exchange once but did not

attempt to use his SGD in any other instances. Once the intervention phase began, Sean met

mastery criteria in the 4th session, but was consistently performing the sequence correctly

after one intervention session. Sean did not independently activate the “Thank you” icon

during one probe trial in his 1st intervention session. But by session two, he consistently

performed the sequence accurately and continued to do so for the remainder of the study.

During follow-up Sean maintained proficiency and the skill generalized to a novel person in

both intervention and follow-up sessions. During Sean’s discrimination trials, he correctly

selected the corresponding item he requested using his SGD in 11 out of 12 opportunities.

Chris. Chris did not initiate any communication using his iPad-based SGD during

baseline. By the 4th intervention session Chris was performing the ECS with 100% accuracy

and met mastery criteria by the 6th intervention session. During the first three sessions of

intervention, Chris’s inaccurate responses were because he failed to activate the “Thank you”

icon. Chris continued to accurately engage in the ECS during the follow-up phase and for all

generalization sessions. In discrimination trials, Chris, accurately selected the item which

corresponded to his request for 12 out of 12 opportunities.

Andy. During baseline Andy showed no variability in his data as he did not

independently attempt to use his SGD to communicate, despite using it regularly throughout

the day for requesting purposes at home and at school. On his 9th intervention session, he

performed the ECS accurately and met mastery criteria by the 11th intervention session. Andy

continued to consistently execute the 4-step sequence for the remainder of the study. During
 92

the first eight intervention sessions, Andy received marks for an incorrect response for three

different reasons. Most commonly, Andy would remain seated at the table but not activate

any icons on his SGD. The second behaviour most observed was Andy engaging in first 2-

steps of the ECS, then he would sit silently until time ran out. The least common error was

Andy activating the “Thank you” icon during the first step of the ECS at which point the trial

was terminated. After Andy had been consistently performing the ECS at mastery level, there

were two dips in his performance during the 18th and 22nd session. During these two

sessions, Andy correctly performed the sequence for three out of four opportunities, but

failed to activate “Thank You” icon independently during one independent trial. Andy’s

participating in the ECS continued in the follow-up phase as well as during all generalization

probes. During Andy’s discrimination trials, he correctly selected the corresponding item

corresponding to his request for 12 out of 12 opportunities.

Victor. Victor made no attempts to communicate with the interventionist or novel

person during baseline. Victor was performing the sequence accurately by the 2nd

intervention session and reached mastery criterion by the 4th intervention session. During

Victor’s 1st, 6th, and 17th session of intervention Victor’s inaccurate responses were because

he did not independently activate the “Thank You” icon. Generalization of the skill occurred

to a novel person during intervention and follow-up phases. During Victor’s discrimination

trials he selected the item corresponding to his request in 11 out of 12 opportunities.

Grace. Grace made no attempts to communicate using her SGD during the baseline

phase. During Grace’s first two intervention session, her incorrect performance was because

she activated the “Thank You” icon during the first step of the ECS or did not attempt to use

her SGD during the trial. Once intervention began, she was performing the ECS accurately by

the 3rd intervention session and met mastery criteria in the 5th intervention session. During

intervention Grace became ill and missed several weeks of school, as can be seen in her gap
 93

from sessions 46-53. Despite this large gap in treatment, Grace maintained the skill for the

remainder of intervention and follow-up phases. Additionally, her newly learned skills

generalized to a novel person. During discrimination trials, Grace selected the reinforcer

which corresponded to her request for 10 out of 12 opportunities.

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Baseline Intervention Follow-Up

100
Novel Person
75
Therapist
50

25
Sean
0
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65

100
75
50
Percentage of Correct Response

25
Chris
0
1 3 5 7 9 11131517192123252729313335373941434547495153555759616365

100
75
50
25
Andy
0
1 3 5 7 9 11131517192123252729313335373941434547495153555759616365

100
75
50
25
Victor
0
1 3 5 7 9 11131517192123252729313335373941434547495153555759616365

100
75
50
25
Grace
0
1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64
Sessions

Figure 3.3 Percentage of Trials in Which Participants Performed the 4-step Sequence
Correctly During Probe Trials, Across Sessions, for Each Phase of the Study
 95

Discussion

The results of this study suggest the intervention was successful in teaching an

extended multi-step and multi-function communication sequence to five children with ASD.

Indeed, all five participants learned the skill and showed maintenance of the acquired skill at

the post intervention follow-up sessions. After intervention, the children were able to

navigate through the 4-page display to engage in: (a) a social greeting (Step 1); (b) a

generalized request (Step 2); (c) a specific request (Step 3); and, to (d) execute an appropriate

social etiquette response (Step 4). The students’ successful performance suggests using the

antecedent prompting procedure, which included conducting four trials with prompting and

then conducting four probe trials without prompting, was a seemingly effective method of

teaching the extended communicative sequence. However, prompting was also occasionally

necessary to ensure a response at Step 4 during some of the intervention probe trials.

Furthermore, the skill generalized to novel people for all participants. Additionally, the

discrimination trials suggest that the children’s requests were functional, that is used to

request specific items and not just rote tapping responses to each new screen presentation.

These findings support results from previous studies suggesting that systematic instructional

procedures based on ABA principles can be successfully used in teaching multi-step

communication sequences via an iPad®-based SGD (Achmadi et al., 2012; Alzrayer et al.,

2017; Alzrayer et al., 2019; Strasberger & Ferreri, 2014; Waddington et al., 2014).

This study broadens iPad®-based SGD research by extending the length of the

sequence to four responses and by including multiple functions within the communication

sequence to an initial greeting, then a general and specific request, and finally a social

etiquette response. With this intervention, these five participants were successfully engaging

in what could be seen as an apparent dyadic social-communicative interaction.

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Because teaching a request is immediately beneficial to the learner while the other

communication functions are less so (Skinner, 1957), embedding social communicative

requirements into a requesting sequence could be seen as one way to promote the

development of multi-function communicative exchanges. It is possible that in this of the

multi-step, multi-function extended communication sequence was facilitated by linking social

communication requirements to a general and specific requesting paradigm. Taking into

consideration that while students were learning the ECS the most common error was not

saying “Thank you”, developing interventions that include polite, societal conventions, can

lengthen, and enhance the quality of social exchanges for the speaker.

Multiple sources of control can be seen within every verbal operant. This is especially

apparent in this ECS. The sequence could be part tact, in the fact that the items were on the

table in a clear box. Part intraverbal in that we were having a conversation, and there was a

dyadic exchange. And potentially part echoic, with the greeting “hello” said by both the

listener and speaker. Specifically addressing the “thank you” it could have been considered a

request, or an intraverbal in that it was part of an exchange. But the important thing to note is

that the entire ECS was a requesting frame, with multiple controls of all of the verbal

operants. The listener provided generalised conditioned reinforcement in between each step

of the exchange, but ultimately the motivating operation was for the reinforcer that was

provided at the end of the sequence which was validated by participants accurate responding

in the discrimination trials.

The five components of the DTT format as implemented in this study were: (a) the

antecedent stimulus presented to cue the start of a trial, “Hello, let me know if you want a

snack or a toy”; (b) the use of an antecedent prompt strategy; (c) the 4-step behavioural

requirements or response chain; (d) the consequence of positively reinforcing students for
 97

engaging in the ECS; and (e) the inter-trial interval of 15 seconds when data were recorded

(Smith, 2001; Tarbox & Najdowski, 2008).

The antecedent prompting procedure provided participants the opportunity to practice

the correct response and gain reinforcement for completing the 4-step sequence, which could

be seen as an error-less teaching strategy (Wolery, 1986). The outcomes of this research

support previous findings that in a 1:1 instructional arrangement, this antecedent prompting

procedure appeared to promote rapid acquisition of the correct responses as evidenced by

independent performance during the probe trials of the intervention phase (Morse & Shuster,

2004). However, it is important to note that even during the probe trials of the intervention

phase, students in the current study were also prompted to select Thank you” icon before

receiving full access to the reinforcer. This extra level of prompted was included based on

response to outcomes of research conducted by Waddington et al. (2014) and in anticipation

of the likelihood that there would be a lack of motivation to engage in a social exchange once

the student had been given the requested item. The single prompt in the last step of the

sequence potentially probably aided in the rapid acquisition of the communicative exchange

because it allowed the interventionist to maintain a FR:1 schedule of reinforcement.

Restricting sessions to four prompt trials and then four probe trials was seen as one

way to try reinforcer effectiveness as students demonstrated a willingness to participate in all

the trails in each session throughout the duration of the study and did not show any signs of

satiation with respect to the snacks or toys requesting (Downing et al., 2015). There may be

several additional factors that might account for the student’s rapid acquisition of the ECS.

Setting up the SGDs with a progressive screen could be one such factor. Reducing

discrimination requirements made the task easier to master, accommodating a wide array of

individual learner’s potentially limited cognitive and perceptual abilities. The high degree of

similarity between each reinforcer icon and its corresponding referent also potentially aided
 98

in the student’s rapid acquisition (Koul et al., 2001). There is some evidence that the students

were in fact using the icons functionally in that they correctly selected the corresponding item

during discrimination trials. That is, if the student requested a specific toy at Step 3, they then

correctly selected that toy when given the opportunity during discrimination trials. This

correspondence suggests that the students were making discriminated icon selections and not

just tapping any icon that was presented to them on the screen. However, it should be noted

that the reinforcer icons were photographs, whereas the social and general request icons were

SymbolStix™. Therefore, we cannot definitively ascertain if the students understood they

were participating in an ECS or had simply learned to select any icon that popped up on each

screen. All that we can argue for certain is students learned to activate four icons on their

SGD to receive reinforcement. One would have to present the same students with an SGD

with all icons located on a static screen, then observe if they continued to correctly engage in

the ECS to determine if they had learned to select icons in the correct sequence versus simply

selecting symbols that appeared on each newly presented screen.

Limitations and Future Research

Students were cued to initiate the request, denying participants the opportunity to

initiate a social exchange more spontaneously. Common with DTT format, the setting was a

private room, free of distraction, and children were not granted the opportunity to practice the

skill in their natural classroom or home environment. On top of this, further environmental

cues were implemented by requiring students to say “Hello” on their SGD, even though no

one had left or re-entered the room. Teaching a greeting in this somewhat contrived manner

may not be ideal for promoting appropriate use in day-to-day life. Expanding generalization

probes to include setting and time in addition to novel persons would have strengthened the

validity of the study.

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Although this study has more participants than other research of its kind, five is still a

relatively small population in comparison to the number of individuals who require

communication interventions. A larger scale study would provide valuable insight into the

acquisition of communication skills and validity of the prompting methodology.

The SGDs set with a progressive screen did not provide sufficient evidence to suggest

the students learned to communicate in a 4-step ECS but learned to request on their SGDs at

a FR:4. Meaning, students learned to activate four icons on their SGD to receive

reinforcement. The next step in expanding the findings of the current research would be to

increase the number of icons per page and set up the SGD with a static display screen as the

progression from one screen to the next might have come to represent a discriminative

stimulus for the students to make a response.

Conclusion

Communication skills are a vital necessity in day-to-day life. These skills become

increasingly difficult to master when a child is minimally verbal. The current study supports

the existing body of research suggesting an SGD loaded with Proloquo2Go™ software is an

effective alternative method of communication. Students learned to participate in a functional

communicative sequence that included two social interactions and two types of requests.

Specifically customizing an iPad-based SGD to have a progressive screen, minimal icons,

and using the antecedent prompting procedure, five participants were able to master a

complex exchange. Interventions focused on alleviating social and communication deficits

which define ASD is an applied and relevant area of future study.

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CHAPTER 4

Study 2: Teaching an Extended Communication Sequence Using an Antecedent

Prompting Procedure and a Static Display on an iPad-based SGD

This intervention study aimed to extend the findings from Study 1 by changing the

display of the SGD loaded with Proloquo2Go™ software from a progressive screen to a static

screen. Switching from a progressive to a static display is a way of testing if the children had

in fact learned to make four discriminated communication responses or had they perhaps only

learned to make a response when presented with each new screen to eventually gain the

reinforcer, that is perhaps they had merely learned to respond to an FR-4 schedule.

Progressive displays change automatically after an icon is activated, which may

reduce learning time (Mirenda & Iacono, 1999). Using a progressive display in Study 1

meant participants did not have to make decisions about what to do for the next step of the

ECS. In this study, we will utilise a static display that contains icons that do not change

automatically. Multiple icons are located on a single screen and the user must recall and

recognize symbols and words to make appropriate selections. As participants have mastered

the ECS using a progressive display, a reasonable next step in gradually increasing task

difficulty is increasing the discrimination requirement. Students will now be required to

select the correct icon in the sequence from an array of eight icons.

Reinforcing successive approximations of behaviour that approach a target goal is

referred to as response shaping (Foxx, 2008; Skinner, 1951). Shaping that involves gradually

increasing task difficulty is a various of this approach that could be referred to as stimulus

shaping (Cooper, et al., 2014). Participants who had already mastered the 4-step sequence

taught in Study 1, were then exposed to a static display as a way of trying to shape up the task

to require more discrimination, that is selecting the correct icon from an array of several

options for each step of the communication sequence. By first teaching students on a
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progressive display and then moving to a static display, the aim was to reduce learning time,

minimize errors, and prevent challenging behaviours that might have arisen by beginning the

intervention with the static display due the greater likelihood of errors that are possible with a

static versus progressive display.

Experimental research has demonstrated opportunities to make incorrect selections

during learning trials can result in negative side effects such as extinction induced aggression,

negative emotional responses, and stimulus over selectivity, that is attending to and

responding to irrelevant aspects of a stimulus (Azrin et al., 1966; Kelly & Hake, 1970;

Lerman et al., 2013; Lovaas et al., 1979; Mueller et al., 2007; Rilling & Caplan, 1973; Weeks

& Gaylord-Ross, 1981). It was initially thought learning required incorrect and correct

responses to occur so the learner could experience the consequence of each, that is known as

trial-and-error learning (Hull, 1950; Mueller et al., 2007; Spence, 1936). However, if

differential consequences are programmed for incorrect and correct responses, learning can

occur from either (Fazio et al., 2010). Performing the incorrect response would result in

extinction if the consequence were aversive; and performing the correct responses would

increase the behaviour if the consequence were reinforcing (Clo & Dounavi, 2020; Sigafoos

& Meikle, 2006). In the acquisition of new responses, any errors that occur during the

learning process tend to persist (Lovaas et al., 1979). Thus, any procedure or teaching

configuration that minimizes errors (such as the antecedent prompting procedure and the

progressive display used in Study 1) would reduce the persistence of errors that would

interfere with acquisition of correct response patterns in the current study. An important

question arising from Study 1 however, is whether that errorless approach did in fact teach

the children the discriminations amongst the icons and the function of each icon, for example,

that the “Hello” icon was used in response to the trainer’s greeting and that the “Thank you”
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icon was used at the end of the communication sequence after having requested a specific toy

or snack.

In summary, errorless learning refers to a technique that reduces incorrect responding

and promotes learning from making correct responses (Mueller et al., 2007). The antecedent

prompting procedure is a type of errorless learning that reduces the likelihood negative

behaviours associated with incorrect performance will arise. Gradually increasing task

difficulty and implementing an antecedent prompting procedure are programmed into this

intervention to strengthen and build communicative skills amongst four minimally verbal

children with ASD.

A lack of social reciprocity is a core deficit of ASD; therefore, it is important to create

interventions based on encouraging back-and-forth exchanges/turn-taking interactions that

are a hallmark of communication and social interaction (American Psychological

Association, 2013; Bourque & Goldstein, 2020; Snyder-McLean & McLean, 1978). Studies

have been conducted in which participants successfully learned to engage in multiple types of

communicative functions using an SGD set with a static display. However, the reported data

were not reported as to whether children learned an ECS containing more than one exchange,

or multiple varying types of single exchanges.

Along these lines, Xin and Leonard (2014) trained a classroom teacher and teaching

assistant to encourage naturalistic communications in the classroom and during recess

amongst three minimally verbal boys with ASD. Researchers evaluated participant expressive

communication using an SGD with a voice output app called SonoFlex, set with a static

screen that could contain up to 28 icons. Participants used their SGDs to engage in requests

(i.e., “I want cereal”); responses to questions (i.e., What is your name? “Eric”); and social

comments (i.e., “I like it!”), which varied in accordance with school activities. Findings

suggest SGD use increased amongst participants, but the study did not include any measure
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of generalisation, maintenance, IOA, procedural fidelity, or social validity, giving it a weak

strength rating. Additionally, it was not reported if exchanges required multiple interactions.

Bourque and Goldstein (2020) evaluated peer-to-peer interactions between six

children with ASD and 15 of their peers from the same school. The children with ASD used

an SGD with voice output software called TouchChat, set with static display of 48 icons to

communicate with their peers (Silver Kite, 2017). Peers were put into groups of 2-3, given

SGD ‘talk’ training, and assigned to one participant with ASD. Interactions were recorded

during 10-min sessions and as one of four possibilities: (a) requests for objects, (b) requests

for actions, (c) comments, and (d) requests for joint attention. This study had strong strength

ratings with positive outcomes for measures of generalization, maintenance, IOA, procedural

fidelity, and social validity findings. Children with ASD were successfully taught to use their

SGD with a static screen to engage in multiple and varying types of exchanges with their

peers. But specifically teaching an ECS that required two communicative exchanges, one of

which was a request, did not occur.

Bourque and Goldstein (2020) and Xin and Leonard (2014) both suggested that

minimally verbal children can successfully use their SGDs to communicate in varied

communicative functions and discriminate between multiple icons on an SGD set with a

static display in consecutive interactions. This second study aims to expand the current body

of literature by specifically reporting if participants could successfully be taught to engage in

a more complex multi-step and multi-function ECS. If so, this would extend the utility of the

antecedent prompting procedure as it would be shown to be effective for teaching children to

select the correct icons in the correct sequence from a static screen display.
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Method

Participants

Four children who participated in Study 1 were recruited to participate in Study 2.

Please refer to the Study 1 participant section for detailed inclusion criteria. Participants

included four males; whose ages ranged from 6–10 years old and had a diagnosis of ASD.

Unfortunately, the fifth participant from Study 1, Grace, was unable to participate in this

study due to an extended flu-like illness that caused her to miss an extended amount of

school. Grace was completing Study 1 at the time Study 2 concluded. Table 4.1 gives a

summary of participants gender, age, ethnicity, diagnosis, Vineland-III scores and AAC

device history.

Table 4.1

Child Demographic Characteristics, Vineland-III Age Equivalencies, and AAC History

Sean Chris Victor Andy

Gender M M M M
Age at start of 6
8 10 7
study (yrs)
Ethnicity Russian Fijian/Indian NZ European Maori/NZ
Diagnosis ASD ASD, ID ASD ASD
Vineland-III
(Yrs: Months)
Receptive 1:2 1:7 0:11 0:8
Expressive 0:9 1:7 0:8 0:7
Written 3:6 4:4 3:5 3:0
AAC History SGD PE, SGD PE, SGD SGD

Sean. Sean was an 8-year-old male of Russian decent with a diagnosis of ASD, please

refer to the Study 1 participant section for his detailed information. During Sean’s

generalisation probes the novel person used was his teacher aide. Sean’s aide spent most of

the day with him and observed most research sessions.

Chris. Chris was a 10-year-old male of Fijian Indian descent, diagnosed with ASD

and an intellectual disability by a developmental paediatrician, please refer to the Study 1

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participant section for his detailed information. During Chris’ generalization probes the

novel person used was his teacher aide. Chris’ aide spent most of the school day with him and

observed most research sessions.

Victor was a 7-year-old male of New Zealand European decent with a diagnosis of

ASD by a developmental paediatrician, please refer to the Study 1 participant section for his

detailed information. For generalization purposes, Victor’s novel person was a graduate

student. Victor only spent time with the novel person during research sessions for data

collection purposes.

Andy was a 6-year-old boy of Māori and New Zealand European decent, please refer

to the Study 1, participant section for his detailed information. For generalization purposes,

Andy’s novel person was his teacher aide, until she relocated during the intervention phase at

which point a graduate student, he was unfamiliar with assisted with data collection and

generalisation probes.

Setting and Intervention Context

The setting and intervention context were identical to Study 1.

Preferred Stimuli

Items used were identified in the preference assessment conducted for Study 1 using a

two-stage stimulus assessment (Fisher et al., 1992). Participants’ preferred snacks and toys to

request during intervention are listed in Table 4.2. Preferred stimuli for Sean included a

puzzle, bubbles, mini-M&Ms, and chocolate biscuits. Chris’s preferred stimuli were bubbles,

a tennis ball, mini-M&Ms, and chips. Victor’s reinforcers included a toy car, kinetic sand,

mini-M&Ms, and chips. Reinforcers for Andy were bubbles, kinetic sand, Twisters, and

potato crisps. Only a bite size portion of edibles was given to participants when conducting

the preference assessments and during intervention. Toys could be manipulated for 30-

seconds or until the activity was complete (i.e., the puzzle).

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Table 4.2

Preferred Stimuli for Each Participant

Participant Preferred Snacks Preferred Toys

Sean chocolate biscuit, mini-M&Ms puzzle, bubbles
Chris chips, mini-M&Ms tennis ball, bubbles
Victor chips, mini-M&Ms car, bubbles
Andy red liquorice candy, potato crisps car, kinetic sand

Speech-generating Device

Participants were taught the ECS using an Apple iPad® with Proloquo2Go™

software (Sennott & Bowker, 2009). The iPad® was configured to have one static screen,

containing eight icons. Figure 4.1 displays an example of the static screen configuration of

Andy’s iPad®. Each SGD was personalised for the individual and contained icons of their

two snacks, two toys, “Hello”, “Thank You”, “I want a toy”, and “I want a snack”.

Photographs were used for icons of each participant’s specific reinforcers, otherwise

SymbolStix™ images from the ProloQuo2Go™ data bank were used. Icons were arranged in

random order and located in different positions on the screen for each participant.
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Figure 4.1

Example of an SGD set with a Static Display Containing a Request for a Twister in the

Message Window

Response Definitions and Measurement

Correct responding was defined as independently activating (i.e., without prompting)

an icon to generate speech output at each of the 4-steps in the communication sequence. First

the student had to greet the researcher by selecting the “Hello” icon within 10 s of being told,

“Hello, would you like a snack or a toy”? Second, the student had to make a general request

for a toy or a snack. Third, the participants had to make a specific request for one of their two

preferred snacks or toys. Lastly, the child had to say “Thank you” upon receiving the item

requested in Step 3. Data at each step was collected on a trial-by-trial basis and recorded onto
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a prepared data sheet via direct observation. An example of a correct request for an edible

item is pictured in message window of Figure 4.1.

Experimental Design

As in Study 1, the aim was to demonstrate the extent to which there was experimental

control using a multiple baseline across participants design (Kennedy, 2005). The design

included the following phases: (a) baseline, (b) intervention, (c) modification 1 (Andy only),

(d) modification 2 (Andy only) and (d) follow-up. Generalisation probes involving a novel

person were conducted during each phase of the study. Three generalisation probes took

place during intervention after mastery criteria had been met. One generalisation probe

during baseline and maintenance phases were performed singly for each participant. Once a

trend in baseline was established, intervention was introduced in a staggered manner across

participants.

Session Schedule

Identical to Study 1, sessions were scheduled to occur at the same time for each

participant two days per week (Tuesday and Thursday). Each session was 15 min in duration

and consisted of four prompted trials (with no data collection) and four probe trials (with data

collection).

Procedures

Baseline During baseline, prior to student arrival, a camera was set up in the corner of

the room if sessions were being recorded. The student and researcher were seated at a table.

The iPad was placed on the tabletop, directly in front of the student and within arm’s reach of

both student and interventionist. The device was loaded with Proloquo2Go™ software open

and on guided access. The clear box of reinforcers was on the floor next to the interventionist

(behind the chair), out of sight from the participant. The discriminative stimulus cueing the

start of a trial was the interventionist saying, “Hello, let me know if you want a snack or a
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toy”, while placing the reinforcer box on the table. Data was collected over the behaviours

that occurred in the following 15 s. After 15 s the box of reinforcers was returned out of sight

and data was scored on the participants behaviour. The researcher repeated this process four

times, waiting a minimum of 15 s between trials. Data was collected on each participants

behaviour, specifically related to activation of their SGD.

Intervention During the intervention phase, the room was set up in an identical

fashion to baseline. Four prompt trials took place before probe trials were conducted. Just as

in Study 1, each participant was prompted through the 4-step sequence of requesting a

reinforcer one time according to a randomly generated list. A full physical prompt was used

to direct participants to activate the correct icon through the 4-step sequence. Once the

researcher provided the 𝑆 𝐷 , “Hello, let me know if you want a snack or a toy” while placing

the box of reinforcers on the table, they physically prompted the child through one of their

four conversational sequence options (i.e., “Hello”, “I want a snack”, “I want a twister”, and

“Thank you”). After the participant said “Thank you” they were given their requested

reinforcer. If the participant activated the wrong icon at any stage in the sequence the trial

was terminated. For example, if after the interventionist initiated the start of a trial and the

learner said, “I want a snack/toy”, or “I want M&Ms”, at step one of the extended

communication exchanges instead of the correct response “Hello”, the trial was immediately

terminated before a second icon could be activated. If the participant performed three steps

of the sequence correctly, “Hello”, “I want a toy”, “I want ball”, but did not activate the

“Thank you” icon, the interventionist would take out the requested reinforcer and hold onto it

with one hand, while prompting the learner to say, “Thank you”. At each step of the

exchange the interventionist responded with a varied naturalistic response, examples of

natural responses for each step of the conversation can be seen in Table 4.3. In response to

step-1 the interventionist would say “Hello” or “Hi” back to the student. In response to step
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2, the general request, the interventionist would say “okay, a snack” or “a toy sounds fun”.

After the student made a specific request, the researcher would respond with, “good choice”

or “sounds great”. In response to the last step of the exchange, “thank you”, the

interventionist would say “you’re welcome” or “my pleasure”.

Table 4.3

Examples of Potential Natural Consequences for each Step of the Communication Sequence

Participant Interventionist Response

“Hello” “Hi!”, “Hello!”, “Hiya!”

“I want a snack/toy” “Okay, a snack”; “A toy sounds fun!”

“I want a specific snack/toy” “Chips, good choice!”; “Bubbles are great!”

“Thank you” “You’re welcome!”; “My pleasure”

Generalisation Once participants reached mastery criteria for the independent

variable during intervention phase, three generalization probes were performed using a novel

person. The same novel person performed generalisation probes during baseline and follow-

up, apart from Andy. During generalisation probes the child only received the item if they

independently completed the entire sequence. During these probes environmental

arrangements and reinforcers remained the same to intervention. Requests were made to

conduct generalisation probes in novel locations on the school campuses, but because of

video recording requirements researchers were asked to solely conduct intervention sessions

in a private room.

Follow-up Two follow-up sessions were conducted per participant. One session was

run by the primary author (Sawchak) and the second by a novel person (teacher aide or

graduate student). Protocol during this phase was identical to generalization probes. Follow-

up sessions were scheduled to occur 3 weeks post intervention for all participants.
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Miscellaneous scheduling conflicts resulted in delayed probes for some participants (i.e.,

school holidays, illness, field trips, etc.). As a result, maintenance was tested three to ten

weeks post intervention.

Procedural Modification 1 Because Andy was not responsive to the antecedent

prompting procedure, two separate modifications were implemented. The first modification

involved adding an error correction procedure during probe trials. The antecedent prompting

procedure remained in place, then if Andy did not complete all four of the steps in the

sequence during his probe trials (i.e., only activated one of the specific reinforcer icons) the

researcher used a full physical prompt to guide him through the sequence. In this phase

Andy’s SGD was on the table in front of him, the researcher cued the start of a trial by saying

“Hello, let me know if you want a snack or a toy?” and waited for Andy’s response. If Andy

requested an item but incorrectly (i.e., only pressed “hello” and “twister”), the researcher

would say “Good try, but this is how we ask for twister” and use a full physical prompt to

correctly guide him through the 4-step request for the same item. If Andy did not activate his

SGD during a probe trial the trial within 15-sec it was terminated. This modification was put

in place for 24 trials, meaning six sessions over three weeks.

Procedural Modification 2 When Andy did not show improvement after three weeks

a second modification was attempted. This involved removing the antecedent prompting

procedure and implementing a backward chaining procedure. During this modification, the

researcher would say, “Hello, let me know if you want a snack or a toy” while placing the

box of reinforcers on the table. If Andy used his SGD to request but did not engage in the

complete 4-step sequence, the researcher responded with “nice try, but this is how we ask for

twister” and then applied a backward chaining and prompt fading procedure. In backwards

chaining the last step of the task analysis is taught first, moving backwards through the

behaviour chain until all the steps in the task analysis are mastered. The behaviours in the
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task analysis for the backward chain included independently activating an icon on his SGD to

say, (1) “Hello”, (2) “I want a snack/toy”, (3) “I want a specific snack/toy”, and (4) “Thank

you”. Once Andy successfully performed the last step independently for three consecutive

trials, the prompt was faded (full physical > gestural > none) until Andy performed the step

independently for 3 consecutive trials. Backwards chaining was specifically chosen because

Andy was consistently requesting “I want a twister”, during probe trials, and when he did

activate a second icon it was regularly “Thank you”.

Discrimination Trials Discrimination trials were conducted in a manner identical to

intervention phases; however, after the student completed the communication sequence the

researcher opened the box containing their four reinforcers and allowed the student to freely

select an item. This was to ensure the student was appropriately discriminating between

icons and correctly requesting the item they wanted to access. That is, would the participants

select the item from the box that corresponded to their prior specific request. This could be

seen as a check on the correspondence between the form of the request and the reinforcer

selected. A high level of correspondence would suggest the requesting responses made by the

participants were functional and discriminated. For Sean, Chris, and Vincent, these trials

occurred after mastery criteria had been met but before the intervention phase was

terminated. For Andy, these trials took place during his second procedural modification in the

intervention phase and before follow-up. During discrimination trials, all participants

independently selected the corresponding item they requested from the box of reinforcers for

100% of opportunities.

Inter-Observer Agreement.

Independent observers recorded participant responses for a minimum of 20% of

sessions for each phase of the study. Inter-observer agreements (IOA) were calculated using

the formula: Agreements/ (Agreements + Disagreements) × 100. Mean percentages of

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agreement were 100% for Sean, 100% for Chris, 100% for Victor, and 94% (80-100%) for

Andy. Inter-observer agreement was collected by each student’s teacher aide, except for

Victor and Andy. All of Victor’s IOA and approximately half of Andy’s IOA was collected

by the same graduate student. The primary author trained each independent observer by

verbally explaining the procedures and having the observers practice with feedback. If both

observers marked a behaviour occurred, it was considered an agreement. If only one

observer marked a behaviour occurred, it was considered a disagreement.

Procedural Integrity

Procedural integrity was assessed by an independent observer using a checklist to

determine if intervention procedures were implemented correctly. The observer was either a

teacher aide or graduate student. The same person that recorded IOA data, assessed whether

the researcher correctly implemented each step of the protocol. Checks occurred during 20-

45% of sessions per participant, with a minimum of one observation during each phase of the

study. Resulting percentages were all 95% or above.

During teaching trials, the primary author and teacher aide or graduate student

checked that the SGD was on the table, Proloquo2Go™ software was open and on guided

access, while the reinforcer box was out of sight. It was noted if the researcher properly cued

the start of a trial by saying, “Hello, let me know if you want a snack or a toy?” while placing

the box of reinforcers on the table. Then data was collected to ensure the correct prompting

procedures were used during the practice trials. In the intervention phase, primary author and

teaching aides or graduate student marked the child’s behaviour at each step of the sequence

and if the interventionist was required to prompt the child to activate the “Thank you” icon.

The conclusion of a trial was noted if the interventionist returned the box of reinforcers out of

sight and waited 10 s between trials.

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Social Validity

Social validity was assessed through a questionnaire because it is highly

comprehensive and common practice (Schwartz & Baer, 1991). Requests to complete the

survey were given to the teacher, teacher aide, and parents of each participant. The

questionnaire consisted of six questions with the rating scale: strongly agree, agree, neutral,

disagree and strongly disagree. The questions were as follows: 1) I feel the intervention was

effective, 2) I feel the participating in this study was helpful the my child/student, 3) I am

satisfied with the results of this intervention, 4) I found the assessment and intervention

procedures acceptable, 5) I noticed an increase in the amount of requests made by my

child/student in the classroom or at home, 6) I noticed an increase in the amount of

approaches my child/student made to other individuals, 7) Please provide any additional

comments you would like to share regarding positive or negative outcomes regarding the

child’s response to intervention. At the conclusion of the study, ten social validity

questionnaires were left at each participant’s school in a plain white envelope. Each teacher

was asked to hand out the questionnaires to family and staff and notify the primary researcher

(Sawchak) when to pick them up from the office.

Results

Figure 4.2 displays the percentage of trials in each session that Sean, Chris, Victor,

and Andy correctly performed the 4-step sequence. The full 4-step sequence involved (a)

making a social greeting, (b) making a generalised request for a snack or toy, (c) making a

specific request for a snack or toy, and (d) saying thank you upon receiving the item. Sean,

Chris, and Victor mastered the 4-step sequence on their SGD after three sessions of

intervention procedures. However, even with two procedural modifications Andy did not

master the skill of participating in an extended communication exchange. Figure 4.3 displays

the number of icons activated per trial during both of Andy’s procedural modifications.
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Sean During baseline, Sean had 0% correct responses. During baseline trials Sean

consistently participated in two-steps of the ECS by activating an icon to make a specific

request (i.e., “I want M&M’s”) and “Thank You”. During intervention, Sean correctly

executed the sequence after one session once the antecedent prompting trials were in place

and reached mastery criteria after three sessions. Sean displayed continued success

throughout intervention with momentary dips in performance at data points 10, 11, and 17.

The lapses in performance were momentary and Sean resumed an accurate performance

within one to three sessions. During Sean’s discrimination probes he correctly selected the

corresponding reinforcer he requested during his 4-step conversational exchange for 10 out of

10 opportunities.

Chris During baseline Chris did not engage in the 4-step ECS but consistently used

his SGD to say “hello” and make a generalised request (i.e., “I want a toy”). During the first

session upon which the antecedent prompting trials were implemented, Chris’s performance

improved 100%. By the third session of intervention Chris met mastery criteria and was

correctly executing the 4-step sequence. Throughout the intervention and follow-up phase

his mastery of the skill remained unaltered and he consistently engaged in the 4-step

sequence for 100% of opportunities. Inter-observer agreement and treatment fidelity were

collected for 76% of Chris’s total sessions by his TA, with a minimum of 20% of sessions per

phase. During discrimination probes for Chris, he correctly selected the corresponding

reinforcer he requested during his 4-step conversational exchange for 10 out of 10

opportunities.

Victor In baseline, Victor’s interactions were usually a 1-step specific requests (i.e.,

“I want chips”) or he did not activate any icons using his SGD, with one exception of one

time where he correctly performed the 4-step ECS. During intervention he positively

responded to the antecedent prompting trials and immediately began performing the 4-step
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sequence with 100% accuracy during his second intervention session. During the

intervention phase he successfully maintained the skill as well as in follow-up sessions.

Inter-observer agreement and treatment fidelity were collected for 40% of Victor’s total

sessions by a graduate student, with a minimum of 20% of sessions per phase. Throughout

Victor’s discrimination probes he correctly selected the corresponding reinforcer he requested

during his 4-step conversational exchange for 10 out of 10 opportunities. Before the

experiment was concluded, Victor began naturally speaking the steps of the exchange in

addition to activating his SGD. One year after the conclusion of this study, Victor’s parents

reported he no longer used his SGD and was speaking independently.

Andy Throughout baseline, Andy did not perform the 4-step ECS, and this trend

continued throughout intervention, two treatment modifications, and follow-up. In baseline,

Andy had 0% correct responses over four sessions. Intervention was then implemented for 8

sessions, 4 weeks, or 32 trials. During this time Andy had 0% correct responses and

consistently made a 1-step request for one of his specified snack reinforcers omitting all

social comments as well as a generalised request. Because there was no improvement in his

performance, a procedural modification was put in place that involved adding an error

correction procedure during probe trials. In this modification, the antecedent prompting trials

remained in place, but if the 4-step sequence was incorrectly performed during probe trials

the researcher (Sawchak) would physically prompt Andy through the correct sequence, then

provide access to the requested reinforcer. This phase was implemented for three weeks,

sessions, or 24 trials. During this modification Andy used his SGD to make a 1-step request

for 17 opportunities, a generalised request with a specific request twice, a specific request and

a social response two times, and did not activate his SGD for three opportunities. Andy still

had 0% correct responses during modification one, and breakdown of his trial-by-trial

performance portrayed a steady trend that stagnated at a 1-step request.

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The antecedent prompting procedure and error correction procedure were removed, as

these strategies appeared to be ineffective at teaching Andy to engage in the 4-step ECS.

Modification 2 was implemented at the 15th intervention session and involved using a

backwards chaining procedure during probe trials. In the backwards chaining procedure, the

participant was prompted through all the steps of the sequence, except for the final step

(Cooper et al., 2014). Once Andy independently and correctly performed the last step of the

sequence, the prompt was removed proceding backwards.

During modification 2, Andy had 0% correct responses, but his trial-by-trial data

indicated an upwards trend after 3 weeks, or 24 sessions where he had increased his

performance from making a 1-step request to a 2-step request. This procedural modification

remained in place for the duration of the experiment, or 21 sessions (including follow-up), or

84 trials. Andy’s performance continued to improve and eventually 26 trials occurred where

Andy activated his icon to make a social greeting, a generalized request, a specific request,

and say thank you, however never in the correct order.

Throughout the course of the intervention phase, Andy’s teacher and teacher aid

relocated. Research continued and Andy’s new teacher, and a graduate student were asked to

assist with IOA and treatment fidelity. Inter-observer agreement and treatment fidelity were

collected for 21% of Andy’s total sessions, with a minimum of 20% of sessions per phase.

During Andy’s discrimination probes, which were conducted during his second procedural

modification, he correctly selected the corresponding reinforcer he had requested during the

probe trial for 10 out of 10 opportunities. This indicates that while Andy may not have

learned to engage in the 4-step sequence, a motivation to gain access to his reinforcers was in

place.
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Social Validity

Sean and Chris attended the same school, and three questionnaires were filled out and

returned from their school. Two questionnaires were returned in Victor’s envelope, and three

were in Andy’s envelope. In total, eight surveys were returned, however as they are

anonymous, it cannot be specified if caregivers or school staff filled them out. Social validity

measures indicated that six out of seven respondents, who could have been the children’s

teachers, teacher aides, and and/or parents, found the intervention to be effective and helpful.

One person slightly disagreed with the effectiveness of the intervention but failed to

elaborate. The other comments suggested involving classroom staff and parents in teaching

sessions. As well as probing for additional types of setting/situation generalization (e.g.,

classroom, restaurant, home), to provide the children the opportunity to use their new skills in

multiple settings. There was also an anecdotal report from a parent that their participating

child increased his attempts at spoken language during and after the study. Another

participant was reported to have overall increased use of their SGD and one person reported

their child began typing 2-step messages at home which they previously had not done before.
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Baseline Intervention Follow-up

100

75

50

25
Sean
0
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57

100

75

50

25
Chris
0
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57

100

75

50

25
Victor
0
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57

Mod. 1 Mod. 2 Follow-up

100

75

50

25
Andy
0
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57
Sessions

Figure 4.2 Percentage of Trials in which Sean, Chris, Victor and Andy Performed the 4-step
Sequence Correctly Across Sessions and for each Phase of the Study
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Figure 4.3 Icons Activated Per Trial During Andy’s Procedural Modifications 1, 2, and

Follow-up Phases

Discussion

The four participating children with ASD were minimally verbal and therefore

candidates for AAC intervention. The aim of this intervention was to teach children to

engage in a 4-step extended communication sequence using their iPad®-based SGD loaded

with ProloQuo2Go™ software set with a static screen of eight icons by implementing an

antecedent prompting procedure. The components of the extended communication sequence

were: (a) making a social greeting (Step 1), (b) making a general request for one of two types

of reinforcers (Step 2), (c) making a specific request for a reinforcer (Step 3), and (d)

thanking the listener for providing the reinforcer (Step 4). The results were generally positive

and consistent with the results of previous studies suggesting that systematic instructional

procedures derived from ABA can be successful in teaching an extended communicative

exchange (Alzrayer et al., 2017; Alzrayer et al., 2019; van der Meer et al., 2013, Waddington

et al., 2014). This study also supports the current body of research validating the use of iOS-

based SGDs loaded with ProloQuo2Go™ software when used to extend communicative

interactions for individuals with ASD who are minimally verbal (Alzrayer, et al., 2014;

Kagohara et al., 2013).

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For three children, the antecedent prompting procedure was an effective teaching

method, and they mastered the skill quickly. As with previous findings, this data also

suggests the antecedent prompting procedure may be effective for some learners, as it may

promote rapid acquisition and few errors (Day, 1987; Singleton et al., 1999). For one child,

the antecedent prompting procedure appeared to be ineffective, and extending his

communicative repertoire using a static screen on his SGD only occurred after a backwards

chaining procedure was implemented. Although Andy did not reach mastery criteria, results

support findings of previous studies that backward chaining is a potentially effective

instructional tactic for teaching SDG-based communication skills (Achmadi et al., 2012;

Muharib et al., 2019).

The failure of one participant to master the extended communication exchange is

perhaps reflective of the communication deficit characteristic of ASD. Potentially more time

or additional modifications would have given Andy the opportunity to master the skill.

However, this could not be done due to time constraints from the researcher (Sawchak)

needing to conclude sessions by the end of the school year.

It could be postulated that Sean, Chris, and Victor had a larger verbal repertoire than

Andy. In future, conducting additional types of language assessments prior to the start of

intervention could offer further insight into individual capabilities and research outcomes

(Grondhuis et al., 2018; Joseph & Fein, 2011). It could also be hypothesized that Andy had a

deficient tact repertoire and his motivation to gain access to the item was greater than his

desire to engage in the social parts of the ECS, thereby inhibiting his overall performance. An

additional and more complex discussion point is that individuals tend to take the shortest

route to the reinforcer. Andy’s responses were not inappropriate or conversationally incorrect

as the icons he activated together were, “I want a twister” and “Thank you”. His use of
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pictoral communication was correct and did include a social component, although it was not

the total exchange aimed to be taught in this study.

The DDT and antecedent prompting procedure appeared to have some positive

qualities, such as enabling instruction to occur in a way that did not interfere with the

children’s performance during probe trials. This approach also enabled a relatively rapid pace

of instruction and minimized opportunities for errors, which may have facilitated acquisition.

The consistent performance of all learners during their discrimination trials indicates

icon discrimination occurred and the participants were in fact using the icons for functional

communication. Three participants continued to engage in the social steps of the exchange

even when access to the reinforcer icons were available. This could indicate that these

participants were motivated to engage in the social components of the exchange, perhaps

because these responses were part of a chain that terminated in receiving a

preferred/reinforcing stimulus (Giannini, 2009; Prelock et al., 2011).

Limitations and Future Research

One limitation of this research are the relatively small sample size which limits

external validity (Birnbrauer, 1981; Faber & Fonseca, 2014). The study might also have been

improved by undertaking some cognitive testing of the participants. Without the testing prior

to intervention, it cannot be concluded if participating in the 4-step exchange was related to

significant cognitive ability/learning difficulties or whether this reflects ineffective

instruction. Conducting sessions in one location with the same reinforcers limits conclusions

of generalization. Limitations associated with the DTT format apply in this scenario as

teaching occurred in a highly characteristic environment, with the same materials and people,

and a consistently high rate of reinforcement.

Future research should focus on varying locations, items, and communication partners

as it would have added to the proof of generalization and social validity of the study.
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Involving teachers, peers, and parents to conduct sessions would benefit the participants and

likely lead to increased use outside the research environment and provide the user real-world

application. With the positive outcomes presented in these findings using the antecedent

prompting teaching procedure, applying it to teach other behaviours should be examined. For

example, using the antecedent prompting procedure to teach other behaviours or additional

forms of conversational exchanges (i.e., “How are you today?”, “What’s your name?”) could

potentially expand participants communicative repertoire and enhance their social skills,

which would be beneficial to the learner in compensating for the communicative deficits of

ASD.

As some learners mastered the skill under the current contingencies, the next step

would be thinning the reinforcement schedule, removing the request, or increasing socially

communicative interactions required before providing the opportunity to request. Thinning

reinforcement, promoting generalisation, and including natural contingencies in research

designs would improve the body of evidence regarding SGD use for advanced forms of

communication and strengthen evidence regarding the effectiveness of the antecedent

prompting procedure (Yamamoto & Isawa, 2020).

Conclusion

Expanding the verbal repertoire of individuals who are minimally verbal has the

potential to greatly enhance their quality of life by providing a means to access reinforcement

and engage socially. The current study provides support for further use of the antecedent

prompting procedure to teach an extended communicative exchange to individuals with

developmental disabilities, specifically ASD. This experiment also supports existing

literature that suggests an SGD loaded with Proloquo2Go™ software is a viable alternative

method of communication for minimally verbal children with ASD. Three participants

successfully learned to participate in a functional communicative sequence that included 2-

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social interactions and a 2-step request on an SGD with a static screen display of eight icons.

In these instances, one could hypothesize that the social components of the exchange taught

because they were embedded into a communicative requesting scenario and thus the social

responses became part of a change that ended with access to preferred stimuli/reinforcement.

One student failed to meet mastery criterion but did increase the length of his overall

communicative exchange from a one exchange using his SGD to three exchanges once a

modification to the intervention, involving the implementation of a backwards chaining

procedure, was implemented. Backwards chaining was chosen because this method has been

successfully used to teach a series of responses in AAC based communication interventions

(Achmadi et al., 2012; Bondy & Frost, 2001; King et al., 2014; Muharib et al., 2019).

Interventions such as this one, which focus on novel teaching strategies that elongate

communicative interactions would be a positive and beneficial area of future study.

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CHAPTER 5

General Discussion

Main Findings

The present series of two intervention studies focused on teaching a multi-step and

multi-function extended communication sequence to children with ASD. Because the

children had limited expressive speech (ability to convey a message to a listener),

intervention focuses on teaching them to use an iPad-based® SGD as an alternative mode of

communication. In Study 1, the iPad® was configured with a progressive display, meaning

their SGD progressed them through the 4-steps of the exchange minimizing discrimination

requirements. In Study 2, the SGD was configured with a static display meaning all icons

were located on a single page, increasing their discrimination requirements.

The shift from a progressive to a static display was arranged to promote errorless

learning and shape the final desired performance of completing the 4-step communication

sequence. First, children had to select the symbol functioning as a greeting (“Hello”) in the

response to the 𝑆 𝐷 , “Hello, let me know if you want a snack or a toy.” said with the

presentation of reinforcers. Second, they had to select the symbol functioning as a

generalised request (“I want a snack/toy”). Then they had to select the symbol functioning as

a specific request (“I want bubbles”) in the presence of the 𝑆 𝐷 , “a toy is a great choice!”.

Finally, select the symbol functioning as a socially appropriate nicety, “Thank you.” in

presence of the 𝑆 𝐷 of the interventionist taking the requested item out of the box and handing

it to them. A novel antecedent prompting procedure was applied to teach the children to

engage in this 4-step sequence. The antecedent prompting procedure was intended to be an

errorless learning strategy used to prime correct responses, which would continue

independently and be reinforced during subsequent probe trials with the interventionist

(Sawchak).
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In Study 1, the children did not correctly perform the ECS in baseline. When the

intervention phase began the children showed increases in correct responding and eventually

reached 100% rate of correct responses, which generalised to a novel person and maintained

in follow-up. In Study 2, with the static display children did not engage in correct ECS in

baseline. When intervention began, all four participants showed increases in responding and

three reached 100% rate of correct responses, which generalised to a novel person and

maintained in follow-up. One student did not master the 4-step ECS, but they did show

improved performance on a static screen after a backwards chaining procedure was

implemented, consistently participating in three steps of the communicative exchange. Social

validity findings suggested that overall parents, teachers, and teacher-aides found the

intervention effective and helpful. By first teaching participants the ECS on a progressive

display in Study 1, then a static display in Study 2, one could suggest this method minimized

errors and prevented the development of challenging behaviours by gradually increasing task

difficulty.

The results of Study 1 suggest that the instructional procedures were effective in

teaching the children to perform the multi-step communication sequence on the iPad® with a

progressive display. Study 2 results suggest that the children were able to perform the ECS

correctly when iPad® screen was shifted to a static display. The antecedent prompting

procedure appeared to be effective in that once it was implemented three times on average in

Study 1 for all participants, and two times on average in Study 2 for Sean, Chris, and Victor,

the participant’s number of correctly sequenced communicative exchanges using their SGD

increased. The experimental design suggests that it was in fact the intervention procedures

that were responsible for the children’s improved performance. Also, it is likely that

reinforcement was a critical component of skill acquisition. Anecdotal evidence the children
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were functionally communicating is evident in their corresponding selection of reinforcing

items during discrimination trials.

In Studies 1 and 2, it could be argued that the following behaviour analytic principles

were what made the intervention successful: (a) utilising access to a highly preferred tangible

items to positively reinforce communicative behaviour, (b) implementing the antecedent

prompting procedure, (c) programming SGDs with icons/symbols that were judged to be

highly iconic, (d) limiting session times to avoid satiation, (e) gradually increasing

discrimination requirements (stimulus shaping), and (f) implementing a DTT format during

data collection trials. Additionally, reinforcement was maintained at a consistently high

schedule, and a motivational operation was in place that increased the likelihood a request

would occur due to the selection of effective reinforcers by conducting a preference

assessment prior to the start of intervention (Fisher et al., 1996; Skinner, 1957).

Because social and communication impairments are core deficits associated with

ASD, it is imperative to include social requirements in a requesting scenario. The 4-step ECS

taught in Study 1, and 2, could be seen as a behavioural chain, wherein within the chain each

response provided the 𝑆 𝐷 for the next response. Both studies were taught using a total task

chaining approach, in that each step of the ECS was taught together. Research has

demonstrated total task chaining may provide higher rates of learning (greater behaviour

change per units of time) compared to other chaining methods, because it allows a

relationship between steps to be established as they are presented in a naturally occurring

sequence and learners do not get stuck performing a single step repeatedly (Jameson et al.,

2012; Spooner, 1981; Spooner & Spooner, 1984).

Designing SGDs to have a progressive screen in Study 1 lightened the cognitive load

required to complete the ECS and could be seen as a prompt that cued each child to make the

next step in a behaviour chain. Once Study 2 began, the participants were using their SGD
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with the same level of competency and had mastered performing the 4-step sequence.

Switching from a progressive to a static screen was arguably the next step towards increasing

task difficulty. It removed the prompt, increased the cognitive load required to complete the

ECS and the learners could potentially select incorrect responses at every step of the

sequence, instead of just the first (“Hello”) and last (“Thank you”).

The successful presentation of a novel teaching strategy, the antecedent prompt, to

teach an ECS on an SGD makes the findings presented in these studies unique and supports

the trend of using tablet-based SGD device (Bailey et al., 2006). When work for this thesis

originally began in 2015 there were six articles published teaching an ECS, and none that

implemented an antecedent prompting procedure. As of October 2021, there are at least 10

published articles that specifically address teaching an ECS to children with developmental

disabilities, such as ASD, and still, none that reference the use of an antecedent prompting

procedure.

The presented studies support Skinner’s (1957) account of verbal behaviour. The

primary verbal operant, the request, was elongated amongst the participating children by

providing generalised conditioned reinforcement after each exchange, and a reinforcer upon

completion of the sequence. Basing a communicative exchange around a request that

included two social exchanges promoted the development of other verbal operants and the

exchange became part request, part intraverbal, and part tact. These studies further illustrate

Skinner’s emphasis that most verbal operants are under the control of multiple variables.

Limitations

There were several limitations that applied to both Study 1 and 2 which limit the

external validity and generalisability of the findings. The limitations also suggest the data

collected supporting the outcomes of the antecedent prompting procedure should be

interpreted with caution. The presented research does provide evidence supporting the
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efficacy of teaching an ECS on an SGD using the antecedent prompting procedure, however

studies designed to replicate or expand findings presented in the current research would

broaden the existing evidence base.

A major limitation is the small sample size of participants. Both interventions were

implemented on five participants, a population size from which no definitive conclusions can

be made. Recent statistics report ASD affects males and females in a 4:1 ratio; Study 1

included five participants (four males and one female) which is reflective of ASD in the

population, but Study 2 included a total four participants (all male), failing to appropriately

reflect the population of affected individuals (CDC, 2020). Future research should include a

larger participant pool, specifically including a representative number of female participants.

There was also little variety amongst the participants. Implementing the same

instructional approach on a wider range of participants with other developmental disabilities,

ability levels, and ages would provide more information as to the efficacy of the intervention

package. It would be helpful to determine if the antecedent prompting procedure is an

effective teaching strategy for an array of ages and disabilities, or specific to young children

with ASD.

Evaluating the modifications to the student who did not master the skill is also a

potential area of future study. Gradually increasing task difficulty from a progressive to a

static screen was potentially unnecessary for the three learners in Study 2 that quickly

mastered the exchange. But for the fourth learner, Andy, that did not master the ECS on a

static screen in Study 2, it could be hypothesized that transitioning his screen display from

two icons across four pages, to eight icons on one page was too large a step. In retrospect

more analysis of Andy’s verbal behaviour prior to the start of research may have shed light

on his failure to acquire the ECS. He may had a deficient tact repertoire and benefited from

breaking down the task even further. For instance, setting up his SGD with four icons per
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page, across two pages. Then once he mastered the 4-step sequence using two screens, he

could have been transitioned to one static screen. Further analysis as to how to appropriately

increase task difficulty for individual learners should be examined.

Studies were implemented by an interventionist (Sawchak), a Board-Certified

Behaviour Analyst (BCBA). It is unknown if implementing the antecedent prompting

procedure would generate the same results if teaching were led by a parent, teacher, or less

experienced individual. Future studies should include training parents, school staff, and other

therapists to provide the intervention package.

Access to the requested item was a natural maintaining contingency, but it might have

been better to conduct the intervention in a more naturalistic setting such as at school during

morning tea or playtime (Wong, et al., 2015). According to the New Zealand ASD guidelines

(Ministries of Health and Education, 2008) and the United Nations Convention on the rights

of persons with disabilities (United Nations General Assembly, 2007) children should be

taught in their home environment. Teaching an ECS was designed with the aim to promote

socialisation, but the intervention failed to establish if the behaviours would occur outside the

room where teaching took place and in a natural context.

Another limitation was the conversation was not typical of a natural conversation, in

that an individual does not repeatedly say “Hello” to a person who has not left the room. This

feature also would have been addressed had the intervention been conducted in a more

naturalistic setting. Cueing participants to initiate a greeting denied them the opportunity to

do so of their own volition, making the interaction contrived. Research in future could design

an instructional technique that taught an ECS in a realistic manner such as when a child

arrives to school in the morning or upon returning to the classroom. This feature was

discussed prior to implementation of the intervention, however including a social greeting,

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and completing a 4-step sequence was the primary goal and the “Hello” was necessary to

signal the beginning of each trial.

In the same way “Hello” was contrived, so was “Thank you”. It cannot be proven that

children were genuinely grateful for access to their requested reinforcer, only that they

learned to activate an additional icon after their request before gaining access to the item. The

participants learned to engage in an additional conversational exchange as part of a request.

This is a classic example of the impurity of verbal operants present in real life situations,

because multiple sources of control are present in every conversational exchange. Future

studies should establish a method to teach “thank you” across events including using the term

in a situation that does not specifically result in access to reinforcer. This would be beneficial

to the learner because it is a social convention that provides the user with an enhanced social

image. Engaging in social niceties could improve others’ perceptions of the child, which

could have a positive impact on how others respond in a positive way and reduce the

occurrence of unwanted negative stigmatisation. These studies presented the first step in

demonstrating participants can master the skill of multi-step exchanges, but future studies

should consider the social nicety as a behaviour controlled by multiple stimuli.

Even though each step of the sequence was under control of multiple verbal operants,

the discrimination trials provided solid evidence the participants were in fact, engaging in a

functional request. When each participant was allowed to independently select a reinforcer

from the box after completing the ECS they repeatedly and accurately selected the reinforcer

that corresponded to their request, then consumed or played with the item. Additionally, the

participants demonstrated their motivation for the reinforcer by continuing to repeatedly

request the items for the duration of both studies. Had the participants not selected the

corresponding item they requested, or if they stopped engaging with their reinforcers, than it
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could be argued only intraverbals or tacts were taught, but results from the discrimination

trials indicate this is not the case.

In hindsight, family, parents, caregivers, and primary educators should have been

involved in the teaching process. There is no benefit to the learner, if a skill is only used in

one context, with one person, that is temporarily involved in the child’s life. Although

participants were taught a valuable conversation skill, their main caregivers and teachers

were not included. As a result, once research concluded participants returned to their previous

habits surrounding SGD use. Future studies should teach varied types of ECSs, include

varied etiquette exchanges, and continue to test the benefits of novel teaching strategies while

making a broader effort to include carers in the intervention.

Summary and Conclusion

Two interventions were designed in a manner that allowed social reinforcement

appropriate to task difficulty, emphasised choice making, implemented skill building

strategies, varied the task by providing a variety of items to request, and used a novel

teaching procedure to do so (Foxx, 2008). These studies could be the first to provide

empirical evidence for the use of the antecedent prompting procedure to promote advanced

communication skills using and SGD amongst minimally verbal children with ASD. This is

important because it is paramount to find effective and timely interventions to improve the

quality of life of individuals whose natural speech has failed to develop (Yamamoto & Isawa,

2020).

Implications of the results for the presented research suggest the antecedent

prompting methodology should be further examined in when teaching new communicative

behaviours on an SGD. Increasing the length of communicative exchanges emitted by

children with ASD is a vital step for improving functional communication skills. Making a

single-step request on an SGD is monumental for a child with ASD who could previously not
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communicate, but multiword exchanges allow them the opportunity to convey more complex

information, be more socially accepted, and clarify their intent (Yosick et al., 2015).

There is evidence to suggest minimally verbal children with ASD can be successfully

taught to communicate using an SGD. This research supports the existing body of literature

regarding SGD use and provides additional evidence the antecedent prompting procedure is a

promising technique. Studies 1 and 2 evaluated the antecedent prompting method using a

static and progressive screen. Specifically, Study 1 evaluated the effectiveness of the

antecedent prompting procedure when teaching a 4-step ECS on a progressive screen to five

children with ASD. The results of this study suggest that all five participants mastered the 4-

step ECS on a progressive screen. Study 2 evaluated the effectiveness of the antecedent

prompting procedure when teaching the same 4-step ECS on a static screen to four children

with ASD. The results of this study suggest three of the four participants learned the ECS on

a static screen. One participant increased their communicative exchanges only after a

backwards chaining procedure was implemented. Future research should focus on using the

antecedent prompting procedure to teach a wider array of skills on an SGD or replicate

current findings with a parent or peer as the interventionist. More research addressing

language deficits amongst minimally verbal children with ASD to engage in an ECS as well

as research regarding the validity of the antecedent prompting procedure is needed.

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APPENDIX A

Ethics Approval
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APPENDIX B

Parent Information Sheet

TITLE OF RESEARCH PROJECT: Teaching Extended Communication Sequences to

Children with Developmental Disabilities

INFORMATION SHEET FOR PARENTS

This research has been approved by the Victoria University of Wellington Human Ethics

Committee (Reference Number: 0000023430).

Thank you for your interest in this project. Please read this information sheet before deciding

whether or not to you would allow your school to participate in this research project. If you

decide to participate, thank you. If you decide not to, then I thank you for considering my

request.

Who am I?

My name is Anastasia Sawchak, and I am a Doctoral student in the School of Education at

Victoria University of Wellington. This research project is part of my PhD Thesis research.

What is the aim of the project?

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I will be aiming to teach children with disabilities to use an iPad as a tool for communication.

The communication skill that I will be aiming to teach involves teaching the child to tap

pictures on the iPad screen that will communicate the following sequence of exchanges with

me (a) a greeting (“Hi. How are you?”), (b) a general request for a preferred object (“I want a

snack.”, “I want a toy.”), (c) a specific request for a preferred object (“I want popcorn.”, “I

want the puzzle.”), and then (d) a final communication response in which the child would

thank the listener for providing the requested item.

At the start of this research project, an assessment will be done to determine the participating

children’s skill levels. For this I will be using the Vineland Adaptive Behaviour Scales

(Vineland-II). I will complete the assessment by observing each child in the classroom and

interviewing his or her teacher. After this, in order to identify preferred items for each child,

I will ask the parents and teachers to identify five snacks and five toys that each child enjoys.

Prior to the start of each teaching session, two items from each category (i.e., two toys or two

snacks) will placed in front of the child and they will be asked to choose one. Snacks and toys

will be provided by myself and will be based on of the list provided. Only snacks and toys

that parents have approved will be offered to the children.

I will be teaching 3 extended communication exchanges in order to improve the children’s

communication skills and quality of life. The first exchange, will be taught during term 1 of

the school year. The second exchange will be an extension of the first, and taught during

term 2. The third exchange will be taught during term 3 and will also build upon the skills

the children have been taught in terms 1 and 2. It is anticipated the length of a school term

should allow for enough time for each child to successfully learn each exchange. Children

who participate in this intervention, will receive a 20 minute 1:1 teaching session with myself
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at the school in a private room pre-approved by the staff. Sessions will take place 2 to 5

times per week depending on what individual schedules will allow. The more opportunities

each child has to learn, the better, so I would like to be able to set up as many sessions per

week as possible. These teaching sessions will be video recorded for data collection purposes

and will be viewed by researchers directly involved with the study for data collection

purposes. Parents of children who participate and teachers involved in the study, who have

signed consent forms, may view these recordings privately upon request.

During teaching sessions, each child will receive training on each step of the extended

communication sequence. If at any step, a child is unable to perform a step of the sequence

independently, I will provide cues and some physical assistance to help the child select the

right symbol from the iPad screen. Upon completion of the study, teachers and parents will

be asked to fill out a questionnaire to determine the benefits of learning the communication

sequence. It will consist of 7 questions and take approximately 5 to 15 minutes to answer.

Six questions will ask classroom staff and parents to rate aspects and outcomes of the

intervention on a scale followed by one short answer question.

If you agree to allow your school to take part in this research project, I will be doing the

teaching in a classroom at your school with students from the special education unit. I will be

the main person providing the teaching, although sometimes one of my peers (Alicia Bravo)

will be helping me. Alicia is also a PhD student at Victoria University of Wellington.

Confidentiality

The results of this project will form the basis for my PhD thesis and the results might also be

presented in written and verbal reports, but in any such reports, I will not use information that
 180

could potentially identify the participants. Instead we will use made-up names. I will not

include any personal information that would enable anyone to identify children, staff or

family members.

Voluntary Consent and the Right to Withdraw

You do not have to allow your school to participate in this study. Your decision about

whether or not you want to give consent for me to invite participants to take part in the

research from your school will not affect any future relationship you have with Victoria

University of Wellington.

If you decide to give consent for research to occur at your school, you have the right to

withdraw your consent up to 4 weeks after the research start date. Your decision to withdraw

your consent will not affect your present or future relationship with Victoria University of

Wellington.

Ethics

This research has been assessed and approved by Victoria University of Wellington Human

Ethics Committee (Reference Number: 0000023430). If at any time you have any questions

or concerns about the treatment of research participants in this study, contact Dr. Susan

Corbett Associate Professor, School of Accounting and Commercial Law, Victoria University

of Wellington, Chair of the Victoria University of Wellington Human Ethics Committee

(telephone: 04 463 5480; E-mail: susan.corbett@vuw.ac.nz).

Data Storage and Deletion

All data will be stored in a locked filing cabinet/password protected computer in a locked

office at Victoria University of Wellington. Only members of the research team will have
 181

access to this data. The data will be stored for 5 years after publication and then shredded and

thrown away after the 5-year storage period.

If you accept this invitation and give your consent, you have the right to:

• choose not to answer any questions;

• withdraw from the study up to 4 weeks after the start date;

• ask any questions about the study at any time;

• receive a copy of any information that we collect about any participant from your

school;

• be able to read any reports of this research by emailing the researcher to request a copy.

If you have any questions or problems, whom can you contact?

If you have any questions, either now or in the future, please feel free to contact either:

Students: Supervisor:

Name: Anastasia Sawchak Name: Professor Jeff Sigafoos

Email Address: Role: Supervisor

anastasia.sawchak@vuw.ac.nz School Address: Room 808, Murphy

anastasia_sawchak@hotmail.com Building, Kelburn Parade, Kelburn Campus

School Address: School of Education

15C Waiteata Road Telephone: 04 463 9772

Kelburn, Wellington E-mail: jeff.sigafoos@vuw.ac.nz

New Zealand, 6145

 182

Name: Alicia M. Bravo

Email Address:

Alicia.bravo@vuw.ac.nz

School Address:

15C Waiteata Road

Kelburn, Wellington

New Zealand, 6145

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APPENDIX C

Parent Consent Form

TITLE OF RESEARCH PROJECT: Teaching Extended Communication Sequences to

Children with Developmental Disabilities

This research has been approved by the Victoria University of Wellington Human Ethics

Committee [Reference Number: 0000023430].

CONSENT FROM PARENT(S) OR LEGAL GUARDIAN(S) FOR CHILD’S

PARTICIPATION

This consent form will be held for 5 years.

Researcher: Anastasia Sawchak, School of Education, Victoria University of Wellington.

• I have read the Information Sheet and my questions have been answered to my

satisfaction. I understand that I can ask further questions at any time.

• I agree to allow my child to participate in this research project.

I understand that:
 184

• I may withdraw my child from this study up to 4 weeks after the research start date and

any information that has been collected on my child will be returned to me or destroyed

at my request.

• The information collected on my child will be destroyed 5 years after the research is

finished.

• Any information collected about my child in relation to this study will be kept

confidential. I understand that the results will be used for a PhD thesis and a summary

of the results may be used for publications in academic journals and for presentation at

academic conferences.

• My name and the name of my child will not be used in reports, nor will any information

that would identify my child or me be disclosed.

• I understand the teaching sessions (research) may be recorded and can only be viewed

by parents, and researchers or school staff directly involved in the study.

Name of parent or legal guardian: ________________________ Date:

______

Signature of parent or legal guardian: ________________________

 185

Child’s Name: _____________________________________________________

Contact details: _____________________________________________________________

_________________________________________________________________________
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APPENDIX D

School Staff Information Sheet

TITLE OF RESEARCH PROJECT: Teaching Extended Communication Sequences to

Children with Developmental Disabilities

INFORMATION SHEET FOR TEACHERS

This research has been approved by the Victoria University of Wellington Human Ethics

Committee (Reference Number: 0000023430).

Thank you for your interest in this project. Please read this information sheet before deciding

whether to you would like to participate in this research project. If you decide to participate,

thank you. If you decide not to, then I thank you for considering my request.

Who am I?

My name is Anastasia Sawchak, and I am a Doctoral student in the School of Education at

Victoria University of Wellington. This research project is part of my PhD Thesis research.

What is the aim of the project?

I will be aiming to teach children with disabilities to use an iPad as a tool for communication.

The communication skill that I will be aiming to teach involves teaching the child to tap
 187

pictures on the iPad screen that will communicate the following sequence of exchanges with

me (a) a greeting (“Hi. How are you?”), (b) a general request for a preferred object (“I want a

snack.”, “I want a toy.”), (c) a specific request for a preferred object (“I want popcorn.”, “I

want the puzzle.”), and then (d) a final communication response in which the child would

thank the listener for providing the requested item.

At the start of this research project, an assessment will be done to determine each child’s skill

level. For this I will be using the Vineland Adaptive Behaviour Scales (Vineland-II). I will

complete the assessment by observing each child in the classroom and interviewing his or her

teachers. After this, in order to identify preferred items for each child, I will ask you and

their parents to identify five snacks and five toys each child enjoys. Prior to the start of each

teaching session, two items from each category (i.e., two toys or two snacks) will placed in

front of the children and they will be asked to choose one. Snacks and toys will be provided

by myself and will be based on of the lists provided by you and parents. Only snacks and

toys that parents or legal guardians have approved will be offered to your students.

I will be teaching 3 extended communication exchanges in order to improve the children’s

communication skills and quality of life. The first exchange, will be taught during term 1 of

the school year. The second exchange will be an extension of the first, and taught during

term 2. The third exchange will be taught during term 3 and will also build upon the skills

the children have been taught in terms 1 and 2. It is anticipated the length of a school term

should allow for enough time for each child to successfully learn each exchange. Children

who participate in this intervention, will receive a 20 minute 1:1 teaching session with myself

at the school in a private room pre-approved by the staff. Sessions will take place 2 to 5

times per week depending on what individual schedules will allow. The more opportunities
 188

each child has to learn, the better, so I would like to be able to set up as many sessions per

week as possible. These teaching sessions will be video recorded for data collection purposes

and will be viewed by researchers directly involved with the study for data collection

purposes. Parents of children who participate and teachers involved in the study, who have

signed consent forms, may view these recordings privately upon request.

During teaching sessions, each child will receive training on each step of the extended

communication sequence. If at any step, a child is unable to perform a step of the sequence

independently, I will provide cues and some physical assistance to help each child select the

right symbol from the iPad screen. Upon completion of the study, you will be asked to fill out

a questionnaire to determine the benefits of learning the communication sequence. It will

consist of 7 questions and take approximately 5 to 15 minutes to answer. Six questions will

ask you to rate aspects and outcomes of the intervention on a scale followed by one short

answer question.

If you agree to allow your child to take part in this research project, I will be doing the

teaching in a private classroom at your child’s school. I will be the main person providing the

teaching, although sometimes one of my peers (Alicia Bravo) will be helping me. Alicia is

also a PhD student at Victoria University of Wellington.

Confidentiality

The results of this project will form the basis for my PhD thesis and the results might also be

presented in written and verbal reports, but in any such reports, I will not use information that

could potentially identify the participants. Instead we will use made-up names. I will not
 189

include any personal information that would enable anyone to identify anyone that took part

in the study.

Voluntary Consent and the Right to Withdraw

You do not have to participate in this study. Your decision about whether or not you want to

give consent for me to invite your students to take part in the research from your school will

not affect any future relationship you have with Victoria University of Wellington.

If you decide to give consent for research to occur, you have the right to withdraw your

consent up to 4 weeks after the research start date. Your decision to withdraw your consent

will not affect your present or future relationship with Victoria University of Wellington.

Ethics

This research has been assessed and approved by Victoria University of Wellington Human

Ethics Committee (Reference Number: 0000023430). If at any time you have any questions

or concerns about the treatment of research participants in this study, contact Dr. Susan

Corbett Associate Professor, School of Accounting and Commercial Law, Victoria University

of Wellington, Chair of the Victoria University of Wellington Human Ethics Committee

(telephone: 04 463 5480; E-mail: susan.corbett@vuw.ac.nz).

Data Storage and Deletion

All data will be stored in a locked filing cabinet/password protected computer in a locked

office at Victoria University of Wellington. Only members of the research team will have

access to this data. The data will be stored for 5 years after publication and then shredded and

thrown away after the 5-year storage period.

 190

If you accept this invitation and give your consent, you have the right to:

• choose not to answer any questions;

• withdraw from the study up to 4 weeks after the start of research;

• ask any questions about the study at any time;

• receive a copy of any information that we collect about any of your students.

• be able to read any reports of this research by emailing the researcher to request a copy.

If you have any questions or problems, whom can you contact?

If you have any questions, either now or in the future, please feel free to contact either:

Students: Supervisor:

Name: Anastasia Sawchak Name: Professor Jeff Sigafoos

Email Address: Role: Supervisor

anastasia.sawchak@vuw.ac.nz School Address: Room 808, Murphy

anastasia_sawchak@hotmail.com Building, Kelburn Parade, Kelburn Campus

School Address: School of Education

15C Waiteata Road Telephone: 04 463 9772

Kelburn, Wellington E-mail: jeff.sigafoos@vuw.ac.nz

New Zealand, 6145

Name: Alicia M. Bravo

Email Address:

Alicia.bravo@vuw.ac.nz

School Address:

15C Waiteata Road

 191

Kelburn, Wellington

New Zealand, 6145

 192

APPENDIX E

School Staff Consent Form

TITLE OF RESEARCH PROJECT: Teaching Extended Communication Sequences to

Children with Developmental Disabilities

This research has been approved by the Victoria University of Wellington Human Ethics

Committee [Reference Number: 0000023430].

CONSENT FROM TEACHER AND OTHER CLASSROOM STAFF

This consent form will be held for 5 years.

Researcher: Anastasia Sawchak, School of Education, Victoria University of Wellington.

• I have read the Information Sheet and my questions have been answered to my

satisfaction. I understand that I can ask further questions at any time.

• I agree to participate in this research project.

I understand that:
 193

• I may withdraw from participating in this study up to 4 weeks after the research start

date.

• The information collected from this research project will be destroyed 5 years after the

research is finished.

• Any information collected in relation to this study will be kept confidential. I

understand that the results will be used for a PhD thesis and a summary of the results

may be used for publications in academic journals and for presentation at academic

conferences.

• My name and the name of children in the class who participate in the research study

will not be used in reports, nor will any information that would identify me or the

participating children be disclosed.

• I understand the teaching sessions (research) may be recorded and can only be viewed

by parents, and researchers or school staff directly involved in the study.

Name of staff member: _____________________________________

Date: _____________________________________

Signature of staff member: _____________________________________

 194

Contact details: _____________________________________________________________

__________________________________________________________________________
 195

APPENDIX F

Principal Information Sheet

TITLE OF RESEARCH PROJECT: Teaching Extended Communication Sequences to

Children with Developmental Disabilities

INFORMATION SHEET FOR PRINCIPAL

This research has been approved by the Victoria University of Wellington Human Ethics

Committee (Reference Number: 0000023430).

Thank you for your interest in this project. Please read this information sheet before deciding

whether or not to you would allow your school to participate in this research project. If you

decide to participate, thank you. If you decide not to, then I thank you for considering my

request.

Who am I?

My name is Anastasia Sawchak, and I am a Doctoral student in the School of Education at

Victoria University of Wellington. This research project is part of my PhD Thesis research.

What is the aim of the project?

 196

I will be aiming to teach children with disabilities to use an iPad as a tool for communication.

The communication skill that I will be aiming to teach involves teaching the child to tap

pictures on the iPad screen that will communicate the following sequence of exchanges with

me (a) a greeting (“Hi. How are you?”), (b) a general request for a preferred object (“I want a

snack.”, “I want a toy.”), (c) a specific request for a preferred object (“I want popcorn.”, “I

want the puzzle.”), and then (d) a final communication response in which the child would

thank the listener for providing the requested item.

At the start of this research project, an assessment will be done to determine the participating

children’s skill levels. For this I will be using the Vineland Adaptive Behaviour Scales

(Vineland-II). I will complete the assessment by observing each child in the classroom and

interviewing his or her teacher. After this, in order to identify preferred items for each child,

I will ask the parents and teachers to identify five snacks and five toys that each child enjoys.

Prior to the start of each teaching session, two items from each category (i.e., two toys or two

snacks) will placed in front of the child and they will be asked to choose one. Snacks and toys

will be provided by myself and will be based on of the list provided. Only snacks and toys

that parents have approved will be offered to the children.

I will be teaching 3 extended communication exchanges in order to improve the children’s

communication skills and quality of life. The first exchange, will be taught during term 1 of

the school year. The second exchange will be an extension of the first, and taught during

term 2. The third exchange will be taught during term 3 and will also build upon the skills

the children have been taught in terms 1 and 2. It is anticipated the length of a school term

should allow for enough time for each child to successfully learn each exchange. Children

who participate in this intervention, will receive a 20 minute 1:1 teaching session with myself
 197

at the school in a private room pre-approved by the staff. Sessions will take place 2 to 5

times per week depending on what individual schedules will allow. The more opportunities

each child has to learn, the better, so I would like to be able to set up as many sessions per

week as possible. These teaching sessions will be video recorded for data collection purposes

and will be viewed by researchers directly involved with the study for data collection

purposes. Parents of children who participate and teachers involved in the study, who have

signed consent forms, may view these recordings privately upon request.

During teaching sessions, each child will receive training on each step of the extended

communication sequence. If at any step, a child is unable to perform a step of the sequence

independently, I will provide cues and some physical assistance to help the child select the

right symbol from the iPad screen. Upon completion of the study, teachers and parents will

be asked to fill out a questionnaire to determine the benefits of learning the communication

sequence. It will consist of 7 questions and take approximately 5 to 15 minutes to answer.

Six questions will ask classroom staff and parents to rate aspects and outcomes of the

intervention on a scale followed by one short answer question.

If you agree to allow your school to take part in this research project, I will be doing the

teaching in a classroom at your school with students from the special education unit. I will be

the main person providing the teaching, although sometimes one of my peers (Alicia Bravo)

will be helping me. Alicia is also a PhD student at Victoria University of Wellington.

Confidentiality

The results of this project will form the basis for my PhD thesis and the results might also be

presented in written and verbal reports, but in any such reports, I will not use information that
 198

could potentially identify the participants. Instead we will use made-up names. I will not

include any personal information that would enable anyone to identify children, staff or

family members.

Voluntary Consent and the Right to Withdraw

You do not have to allow your school participate in this study. Your decision about whether

or not you want to give consent for me to invite participants to take part in the research from

your school will not affect any future relationship you have with Victoria University of

Wellington.

If you decide to give consent for research to occur at your school, you have the right to

withdraw your consent up to 4 weeks after the research start date. Your decision to withdraw

your consent will not affect your present or future relationship with Victoria University of

Wellington.

Ethics

This research has been assessed and approved by Victoria University of Wellington Human

Ethics Committee (Reference Number: 0000023430). If at any time you have any questions

or concerns about the treatment of research participants in this study, contact Dr. Susan

Corbett Associate Professor, School of Accounting and Commercial Law, Victoria University

of Wellington, Chair of the Victoria University of Wellington Human Ethics Committee

(telephone: 04 463 5480; E-mail: susan.corbett@vuw.ac.nz).

Data Storage and Deletion

All data will be stored in a locked filing cabinet/password protected computer in a locked

office at Victoria University of Wellington. Only members of the research team will have
 199

access to this data. The data will be stored for 5 years after publication and then shredded and

thrown away after the 5-year storage period.

If you accept this invitation and give your consent, you have the right to:

• choose not to answer any questions;

• withdraw from the study up to 4 weeks after the start date;

• ask any questions about the study at any time;

• receive a copy of any information that we collect about any participant from your

school;

• be able to read any reports of this research by emailing the researcher to request a copy.

If you have any questions or problems, whom can you contact?

If you have any questions, either now or in the future, please feel free to contact either:

Students: Supervisor:

Name: Anastasia Sawchak Name: Professor Jeff Sigafoos

Email Address: Role: Supervisor

anastasia.sawchak@vuw.ac.nz School Address: Room 808, Murphy

anastasia_sawchak@hotmail.com Building, Kelburn Parade, Kelburn Campus

School Address: School of Education

15C Waiteata Road Telephone: 04 463 9772

Kelburn, Wellington E-mail: jeff.sigafoos@vuw.ac.nz

New Zealand, 6145

 200

Name: Alicia M. Bravo

Email Address:

Alicia.bravo@vuw.ac.nz

School Address:

15C Waiteata Road

Kelburn, Wellington

New Zealand, 6145

 201

APPENDIX G

Principal Consent Form

TITLE OF RESEARCH PROJECT: Teaching Extended Communication Sequences to

Children with Developmental Disabilities

This research has been approved by the Victoria University of Wellington Human Ethics

Committee [Reference Number: 0000023430].

CONSENT FROM SCHOOL PRINCIPAL

This consent form will be held for 5 years.

Researcher: Anastasia Sawchak, School of Education, Victoria University of Wellington.

• I have read the Information Sheet and the project has been explained to me. My

questions have been answered to my satisfaction. I understand that I can ask further

questions at any time.

• I agree to allow research to be performed at the school.

I understand that:
 202

• I may withdraw consent to perform research on this campus up to 4 weeks after the

research start date and any information that has been collected will be returned to

participants or destroyed at my request.

• The information collected at the school will be destroyed 5 years after the research is

finished.

• Any information collected from school staff and participants in relation to this study

will be kept confidential. I understand that the results will be used for a PhD thesis and

a summary of the results may be used for publications in academic journals and

conferences.

• My name and the names of those involved with research will not be used in reports, nor

will any information that would identify myself, participants, or other employees of the

school.

• I understand the teaching sessions (research) may be recorded and can only be viewed

by parents, and researchers or school staff directly involved in the study.

Signature of School Principal:

______________________________________________

Name and Date:

______________________________________________
 203

Name of School:

______________________________________________

Contact details:

______________________________________________
 204

APPENDIX H

Paired Stimulus Data Sheet

 205

APPENDIX I

Social Validity Questionnaire

Questionnaire

Please circle the most appropriate number of each statement which correspond most

closely to your desired response

1. I feel the intervention was effective.

1 2 3 4 5

Strongly Agree Neutral Disagree Strongly

Agree Disagree

2. I feel participating in this study was helpful to my child/student.

1 2 3 4 5

Strongly Agree Neutral Disagree Strongly

Agree Disagree

3. I am satisfied with the results of this intervention.

 206

1 2 3 4 5

Strongly Agree Neutral Disagree Strongly

Agree Disagree

4. I found the assessment and intervention procedures acceptable.

1 2 3 4 5

Strongly Agree Neutral Disagree Strongly

Agree Disagree

5. I noticed an increase in the amount of requests made by my child/student in the

classroom or at home.

1 2 3 4 5

Strongly Agree Neutral Disagree Strongly

Agree Disagree

6. I noticed an increase in the amount of approaches my child/student made to

other individuals.
 207

1 2 3 4 5

Strongly Agree Neutral Disagree Strongly

Agree Disagree

7. Please provide any additional comments you would like to share regarding

positive or negative outcomes regarding the participant’s response to

intervention.
 208

APPENDIX J

Study 1 Treatment Fidelity

 209

APPENDIX K

Study 2 Treatment Fidelity

 210

APPENDIX L

Study 1 Data Sheets

 211

APPENDIX M

Study 2 Data Sheets