Augmentative and Alternative Communication, June 2003 VOL. 19 (2), pp.

86–103

The Use of Visual Supports in Teaching Young

Children With Autism Spectrum Disorder to Initiate
Interactions
SUSAN JOHNSTONa*, CATHERINE NELSONa, JOANNE EVANSa and KRISTIE PALAZOLOb

a
Department of Special Education, University of Utah, Salt Lake City, UT 84112, USA;
b
Child Behavior Therapy Unit, Salt Lake City, Utah, USA

Three preschool-aged children with autism spectrum disorder (ASD) were taught to utilize a
visual support (a graphic symbol representing ‘Can I Play?’) to request entrance into play
activities. Acquisition of graphic symbol use resulted from the implementation of a
naturalistic intervention strategy that included creating communicative opportunities,
providing a model of the desired behavior, prompting the participant to engage in the
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desired behavior (via a least-to-most prompting hierarchy and time delay), and providing
access to natural consequences for appropriate participant responses. Intervention occurred
in the context of ongoing play activities in the classroom. Results showed that the
intervention strategy was effective in teaching participants to request entrance into play
activities for all three participants. The collateral impact of the graphic symbol use on the
participant’s ‘off-task’ behavior and use of verbal language, and survey data on the
acceptability of the intervention to preschool staff are also discussed.

Keywords: Autism Spectrum Disorder; Single Subject Design; Intervention; Instructional

Techniques; Graphic Symbols; Augmentative and Alternative Communication (AAC); Social
Validation
For personal use only.

INTRODUCTION children with ASD (Hagiwara & Myles, 1999;

Hodgdon, 1995; Swaggart & Gagnon, 1995); (e)
Aided modes of augmentative and alternative increase the comprehension of linguistic concepts
communication (AAC) that provide visual in children with autism (Quill, 1997); and (f)
supports (e.g., tangible symbols, objects, line facilitate social initiation and communicative
drawings, written words) have assumed an intent with both children with severe disabilities
increasingly important role in a variety of and children with ASD (Bondy & Frost, 1994;
interventions with young children with severe Jolly, Test, & Spooner, 1993; Krantz & McClan-
disabilities, including autism spectrum disorders nahan, 1993; Mirenda & Santogrossi, 1985;
(ASD; Cafiero, 1998; Marcus, Garfinkle, & Schwartz, Garfinkle, & Bauer, 1998; Zanolli,
Wolery, 2001; Mirenda & Ericson, 2000; Quill, Daggett, & Adams, 1996).
1997; Rowland & Schweigart, 2000; Schlopler,
Mesibov, Shigley, & Hearsey, 1995). Visual
Visual Supports for Individuals with Autism
supports can enhance both receptive and expres-
Spectrum Disorder
sive communication (Hodgdon, 2000). They have
been used to (a) prompt joint attention in children Disorders that occur along the autism spectrum are
with autism (Quill, 1998); (b) establish conversa- described collectively as Autism Spectrum Disor-
tional referents with children with severe and der (ASD). Such disorders include Childhood
multiple disabilities, including children who are Autism, Pervasive Developmental Disorder Not
deafblind (Hunt, Alwell, Goetz, & Sailor, 1990; Otherwise Specified (PDD-NOS), Rett’s Disorder,
van Dijk, 1966; van Dijk & Nelson, 1998); (c) Childhood Disintegrative Disorder, and Asper-
promote memory recall in children with ASD ger’s Disorder (DSM-IV, American Psychiatric
(Quill, 1995b, 2000); (d) enhance attention to, and Association, 1994). Children with ASD exhibit
understanding of, social messages and behavior in diverse and complex social and communication

*Corresponding author. Tel: 801-581-5187. Fax: 801-585-6476. E-mail: [email protected]

ISSN 0743-4618 print/ISSN 1477-3848 online # 2003 Taylor & Francis Ltd
DOI: 10.1080/0743461031000112016
 VISUAL SUPPORTS AND AUTISM SPECTRUM DISORDER 87

needs and strengths that are particularly well-suited 1994; Jolly et al., 1993; Kranz & McClannahan,
to the use of visual supports (Cafiero, 1998; Quill, 1993; Schwartz et al., 1998; Wolfbert & Schuler,
1997, 1998; Schuler, Prizant, & Wetherby, 1997). 1993; Zanolli et al., 1996). The following
On standardized measures of intelligence, children instructional strategies have been found to result
with ASD have relatively high scores on perfor- in increases in the initiations of children who
mance scales. They demonstrate few deficits in previously had very low initiation rates: (a)
visual-spatial and perceptual organizational skills priming before activities (i.e., presenting a low
and appear to have intact sensorimotor abilities demand, high reinforcement activity prior to a
(Siegel, Minshew, & Goldstein, 1996; Sigman, regularly scheduled activity; Zanolli et al., 1996);
Dissanayake, Arbelle, & Ruskin, 1997). Their (b) the use of a least-to-most prompting hierarchy
performance on tasks that are externally cued, such and role playing (Jolly et al., 1993); (c) pre-
as those requiring rote memory, cued recall, and teaching written scripts and prompting within
associative learning have been found to be superior activities (Krantz & McClannahan, 1993); (d) the
to those requiring free recall, thereby indicating use of environmental arrangement and scaffold-
that memory for nonverbal material is less impaired ing or the gradual fading of adult support
than is memory for verbal material (Prior & Chin, (Wofberg & Schuler, 1993); and (e) errorless
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1976; Quill, 1997, 1998; Sigman et al., 1997). learning involving systematic distancing and
Based upon theoretical perspectives as well as fading of prompts (Bondy & Frost, 1994;
observation, Prizant (1982) argued that indivi- Schwartz et al., 1998).
duals with ASD process and learn language in a Embedded instruction has also been found to
‘gestalt form’ (Wetherby, Prizant, & Schuler, be effective in providing opportunities for skill
2000, p. 113) as opposed to an analytic one. acquisition and practice within routine preschool
According to Wetherby et al. (2000), when using a activities, while capitalizing on the interactions of
gestalt strategy, individual words and their children (Bricker, Pretti-Frontczak, & McComas,
components are not analyzed separately but 1998; Pretti-Frontczak & Bricker, 2001). It is
rather are learned by imitating unanalyzed similar to activity-based instruction in that typical
For personal use only.

chunks of speech and only later breaking them activities are used as the context for intervention.
down into meaningful units. Such a language Embedded instruction specifically involves the
learning style may then be expressed through the expansion, modification, or adaptation of activ-
use of delayed or immediate echolalia (Prizant, ities so as to maximize opportunities for the child
1982; Wetherby, Schuler, & Prizant, 1997). to practice individual goals (Bricker et al., 1998)
Stereotypic speech patterns, insistence on specific and the systematic yet naturalistic use of instruc-
verbal routines, and pronoun reversals, as seen in tional strategies (Sandall et al., 2002). It has been
children with ASD, may also be reflective of the widely touted as a preferred method of instruc-
imitation of chunks of unanalyzed information. tion in early childhood special education
Difficulties in the processing of transient signals (Hemmeter, 2000), but the research base on its
may lead children with ASD to use this gestalt effectiveness is limited (Daugherty, Grisham-
learning pattern; however, the pattern can be Brown, & Hemmeter, 2001).
counterproductive to the interpretation and
decoding of language and its social nuances
Collateral Impact of Visual Supports
(Weatherby et al., 1997). Visual supports, with
their nontransient attributes, may allow children Recent research has shown that the use of visual
with ASD to use their relative visual-spatial communication supports such as the Picture
strengths while providing support to compensate Exchange Communication System (PECS; Bondy
for weakness in the processing of more ephemeral & Frost, 1994), does not adversely affect the
information. Visual supports such as graphic subsequent use of verbal communication and may
symbols are, by nature, gestalt, because they actually promote the use of speech by some
represent chunks of information that children children (Bondy & Frost, 1994; Schwartz et al.,
may take as long as they wish to encode. 1998). Furthermore, research has indicated that
visual supports can be used successfully as
communicative replacements to challenging beha-
Visual Supports for Teaching Initiation
viors if the visual support is functionally
Children with ASD may demonstrate extreme equivalent to the challenging behavior (e.g.,
difficulty in initiating conversations and interac- Horner & Day, 1991; Carr & Durand, 1985;
tions (Layton & Watson, 1995; Quill, 1995a). Few Durand & Crimmins, 1987). Further investiga-
studies have been conducted in which visual tions are needed, however, in order to more
supports have been used to facilitate initiation clearly establish the connection between visual
in young children with autism (Bondy & Frost, supports and verbal language and/or challenging
 88 S. JOHNSTON et al.

behaviors. It is important to examine how support (graphic symbol representing ‘Can I

children with ASD’s use of symbolic communica- Play?’) to request entrance into play activities?
tion (verbal and/or graphic modes) changes (b) Does the use of the visual support have any
contingent on instruction in the use of a visual collateral impact on the participant’s off-task
support, for example. Furthermore, it is impor- behaviors and/or use of verbal language? (c) How
tant to examine whether a visual support that was do preschool staff rate the acceptability and
not specifically designed as a functionally equiva- perceived effectiveness of the use of the interven-
lent communicative replacement to competing tion strategy and the participants’ use of the
behaviors has an impact on the frequency of those graphic symbol?
behaviors.

METHOD
Social Validity
Participants
Social validation is the process of assessing the
social significance of goals, methods, and Three preschool-aged children (Brad, Alex, and
outcomes (Kazdin, 1977). Social validation Billy) participated in this investigation. Brad was
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demonstrates the degree to which an intervention a 4 year 3 month (51 month) old boy with autism,
strategy achieves goals and uses procedures that cognitive delays, and dysmorphic features.
are perceived as critical to key stakeholders. Results from the Early Learning Accomplishment
Although not limited solely to visual supports, Profile (Early LAP; Glover, Preminger &
Schlosser (1999) conducted a content analysis of Sanford, 1988) indicated that Brad’s gross motor,
AAC intervention studies using experimental self-help, and social/emotional development was
single-subject designs that were published in the at the 32 month level, fine motor development
journal Augmentative and Alternative Communi- was at the 30 month level, cognitive development
cation from 1985 to 1997. He found that only was at the 16 month level, and language
12.5% of the surveyed studies included social development was at the 22 month level. Observa-
For personal use only.

validation procedures. Thus, although there is a tion of Brad in the classroom environment
body of research documenting the effectiveness of revealed that although he showed interest in the
AAC intervention strategies, only a small portion activities of others, he often observed activities
of that research provides information regarding from the periphery or engaged in solitary play.
the extent to which the strategies and outcomes Brad occasionally used simple one to two word
are socially valid. utterances that were intelligible to familiar
communication partners. He did not use symbolic
communication to initiate interactions with peers
Purpose
or adults during child-selected activities.
In summary, ASD is a multifaceted and perplex- Alex was a 5 year 3 month (63 month) old boy
ing disability, of which communication difficulties with pervasive developmental disorder (PDD)
are an important component. Socially valid, and cognitive delays. Results from the Learning
effective intervention strategies that utilize visual Accomplishment Profile (LAP; Sanford &
supports may address some of the communication Zelman, 1981) indicated that Alex’s language
difficulties experienced by individuals with ASD. and cognitive development were at the 40 month
The purpose of this study was to examine the developmental level, personal/social development
effectiveness of an intervention strategy in was at the 46 month developmental level, gross
teaching preschool children with ASD to use a motor development was at the 48 month level,
visual support (a line-drawn, graphic symbol adaptive/self help was at the 49 month level, and
representing ‘Can I Play’) to request entrance fine motor was at the 52 month level. Observa-
into play activities. In this study, we also assessed tion of Alex in the classroom environment
the extent to which the visual support influenced revealed that he occasionally initiated play
the participants’ engagement in ‘‘off-task’’ beha- activities with others in the classroom, but more
viors and use of verbal language, and the frequently engaged in solitary play activities and/
perceived acceptability of the intervention to or observed others as they engaged in play
classroom teachers. activities. Alex occasionally communicated verb-
The study was designed to answer the following ally using four to six word utterances that were
questions: (a) Is the intervention strategy intelligible to familiar and unfamiliar commu-
comprised of creating communicative opportu- nication partners. His functional use of verbal
nities, modeling, prompting, and providing language to initiate interactions with peers or
natural consequences, effective in teaching adults during child-selected activities was infre-
preschool children with ASD to use a visual quent.
 VISUAL SUPPORTS AND AUTISM SPECTRUM DISORDER 89

Billy was a 5 year 1 month (61 month) old boy throughout the classroom and included areas for
with autism, cognitive delays, Klinefelter blocks/construction, housekeeping, sand/water,
Syndrome, and Pierre Robin Syndrome. Results and movement. Materials and options for activ-
from the Early LAP (Glover et al., 1988) ities were selected by the teacher and were
indicated that Billy’s language and social devel- developmentally appropriate. Children in the
opment was at the 21 month level, self-help skills classroom were encouraged to select from the
were at the 23 month level, cognitive development options for activities during the time allocated to
was at the 25 month level, gross motor develop- the centers for these activities. The classroom was
ment was at the 28 month level, and fine motor comprised of 12 children with ASD and was
was at the 29 month level. Observation of Billy in staffed by five adults. One adult had a master’s
the classroom environment revealed that he degree and a teaching license in early childhood
typically engaged in solitary activities and special education, one adult had a bachelor’s
occasionally showed interest in the activities of degree in psychology, one adult had an associate’s
others. Billy’s verbal language was comprised degree in early childhood, and two adults had
primarily of infrequent jargon-speech. He did not high school diplomas. In addition to these five
initiate interactions with peers or adults using adults, a speech-language-pathologist, occupa-
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symbolic communication during child selected tional therapist, and a psychiatrist served as
activities. classroom consultants.
Based upon these observations and interactions As discussed previously, the intervention plan
with members of Brad’s, Alex’s, and Billy’s team, specified that, within child-selected activities, the
an intervention strategy involving the use of participants would request entrance into
visual supports was developed. This intervention playgroups by using symbolic communication (a
specified that, within child-selected activities, graphic symbol and/or verbal language). The
when the participants indicated interest via eye- graphic mode of communication in this investiga-
gaze, the participants would request entrance into tion consisted of a colored line drawing represent-
play groups by using symbolic communication ing ‘Can I play?’ from The Picture
For personal use only.

(e.g., a graphic symbol and/or verbal language). Communication Symbols Collection (Johnson,
1994). The same colored line-drawn symbol was
chosen for all three participants, based on
Experimental Design
anecdotal information about their matching
A multiple probe design across participants was proficiencies provided by the participants’ class-
used to assess the effects of the intervention room teacher. The symbol was glued to a 5 6 5
strategy on teaching preschool children with ASD in. piece of green construction paper cut into the
to use symbolic communication (graphic symbol shape of a key and then laminated. To increase
and/or verbal language) to initiate entrance into the relative efficiency of using the ‘key’ to enter
play activities. Prior to the introduction of the playgroups, a hole was punched into the top of
intervention, interspersed baseline probes were the key so that it could be worn as a necklace or
used to demonstrate stability across participants. on a key ring attached to a child’s belt loop/
Daily intervention probes were used to document pocket. In order to allow for peer and adult
the impact of the intervention. All training modeling of the use of the graphic symbol to enter
opportunities were included in the daily interven- playgroups, a sufficient number of keys were
tion probes. Intermittent probes of post interven- made for all of the children and adults in the
tion behavior served as a maintenance check to preschool classroom.
determine if experimental effects were durable
over time, and as a generalization check to
determine if experimental effects generalized to Procedures
other activities.
Goal individualization
Prior to baseline, research staff met with class-
Setting and Materials
room staff to identify activities during which the
The participants attended a full-day preschool participants could engage in the target behavior.
program for children with ASD located in a For all participants, existing curriculum and
metropolitan area of Utah, for 4 days per week. materials were utilized to the maximum extent
The program incorporated a combination of possible. The only additional materials that were
discrete trial intervention strategies and center- introduced into the activities were the graphic
based activities. All intervention sessions for this mode of communication (i.e., Keys) and, when
study occurred during free-choice, center-based necessary, materials that would increase commu-
activities. These activities were organized nicative opportunities.
 90 S. JOHNSTON et al.

wanted. If peer modeling did not occur

Baseline without keys
contingent on the participants’ use of eye-
Baseline observations occurred during free-choice gaze, the interventionist provided a model.
time in the preschool classroom. All physical and Step 3:
social variables were held equivalent between the Specific guidance was provided in order to
baseline and intervention conditions. The Keys teach the participant to engage in the desired
were not available during this baseline phase. behavior. Guidance was provided via a least-
During this baseline condition, classroom to-most prompting hierarchy that progressed
teachers were asked to engage in routine interac- from an indirect verbal/gestural prompt, to a
tions with the participants. To increase the direct verbal/gestural prompt, to a partial
similarity to intervention conditions, the inter- physical prompt, and finally to a full physical
ventionist for the study joined the ongoing prompt (Johnston, McDonnell, Nelson, &
activities and maintained close proximity to the Magnavito, 2003; Jolly et al., 1993).
participants but did not provide instructional Step 4:
support. The interventionist provided natural conse-
quences (e.g., facilitating access to the play
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activity and/or social interactions with peers/

Baseline with keys
adults) contingent on the emission of the target
During the Baseline with Keys phase of the response.
investigation, all physical and social variables
were the same as for the first baseline condition. The 4-step intervention strategy was delivered in
In addition, the Keys were given to the two stages. During the first stage, immediately
participants, but no instruction on their use was following an opportunity, the interventionist
provided. As was the case during the first provided the model and the least-to-most
baseline, classroom teachers were asked to engage prompt hierarchy with no delay following the
in routine interactions with the participants, and model or between each prompt in the hierarchy.
For personal use only.

the interventionist joined the ongoing activities No delay was used in this stage to facilitate
and maintained close proximity to the partici- high rates of correct responding. In the second
pants but did not provide instructional support. stage, the interventionist followed the same
procedure but inserted a 5 s response interval
following the opportunity, the model, and also
Intervention strategy
between each prompt in the hierarchy. If the
The intervention was implemented in the context child engaged in the target response indepen-
of a regularly scheduled, center-based free play dently within the 5 s response interval, the
activity in the preschool classroom. The interven- requested item or action was provided. If the
tion consisted of the following 4-step instructional child did not engage in the target response
strategy: within the 5 s response interval, the interven-
tionist provided the next higher level of
Step 1: assistance in the prompting hierarchy. This
Communicative opportunities were established second stage was designed to transfer stimulus
by arranging the environment and by control exhibited by the prompt to the naturally
establishing physical proximity. Based upon occurring communicative opportunity. In both
observations of the participants and discussions stages, natural consequences were delivered
with their early childhood special education contingent on the emission of the target
teacher, an opportunity to implement the response.
intervention was defined as those instances
when a participant would indicate interest in an
Interventionist
activity via eye gaze towards the activity but
would not independently initiate or engage in The fourth author, a licensed early childhood
the activity. special education teacher and the lead teacher
Step 2: in the preschool classroom, provided the inter-
A peer or teacher modeled the use of the vention for all three participants. The interven-
graphic symbol and verbal language to request tionist was trained in the use of the instruc-
entrance into playgroups. All peers in the tional strategy through a series of training
classroom received verbal instruction during a sessions that involved role-playing with the first
large group circle time activity on the use of the author. Criterion for training was set at a
visual support and were encouraged to use it to minimum of 90% accuracy on all components
request entrance into playgroups whenever they for three consecutive trials.
 VISUAL SUPPORTS AND AUTISM SPECTRUM DISORDER 91

routines, whether it would be difficult to use the

Maintenance and Generalization
strategy while still meeting the needs of the other
Follow-up maintenance and generalization children in the classroom). The survey was
probes began approximately 1 week after each completed by three of the preschool staff for each
of the participants met criterion for the target of the three participants during the final week of
behavior. Intermittent probes continued until the intervention.
end of the school year. Maintenance probes were
conducted in the context of the same activity and
Reliability
with the same materials that were used during the
intervention sessions. Generalization probes were The first author collected dependent and indepen-
conducted in the context of a different activity dent variable reliability data during at least 30% of
than was used during the intervention sessions all experimental conditions for each student. To
but which afforded opportunities for engagement compute dependent variable (percent correct use
in the target behavior. of symbolic communication) reliability, a point-
by-point method was used in which the number of
agreements was divided by the number of agree-
Data Collection
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ments plus disagreements and multiplied by 100.

Data to assess the effectiveness of the intervention Mean dependent reliability for Brad was 100%
strategy were collected by the interventionist during baseline and 100% during intervention/
during baseline, intervention, and follow-up maintenance. Mean dependent reliability for Alex
sessions. The interventionist utilized a coding was 100% during baseline and 98% (range = 90 –
sheet to collect data on the participants’ use of the 100%) during intervention/maintenance. Mean
graphic symbol and/or verbal language to request dependent variable reliability for Billy was 100%
entrance into play activities, and the interven- during baseline and 98% (range = 86 – 100%)
tionist’s prompts and consequences. during intervention/maintenance.
The second author used the Ecobehavioral Procedural reliability data were calculated by
For personal use only.

System for Complex Assessment of Preschool dividing the number of interventionist behaviors
Environments (ESCAPE) to assess the impact of exhibited by the number of planned interven-
the intervention procedures on a variety of class- tionist behaviors and multiplying by 100. Proce-
room ecological variables (Greenwood, Carta, dural reliability data included the measurement of
Kamps, & Delquadri; 1997). ESCAPE is a the following planned interventionist behaviors
computerized, 15-s momentary time-sampling when appropriate: (a) recognizing or creating an
system that provides comprehensive ecobehavioral opportunity; (b) providing an immediate model
information regarding an early childhood class- or waiting 5 s prior to delivery of the model,
room setting. Classroom events are sampled based depending on the stage of intervention; (c)
on a brief observation of their occurrence following implementing the prompt hierarchy with or
the presentation of timed data entry screens. without the 5 s delay, depending on the stage of
Observational variables are divided into three intervention; and (e) delivering the appropriate
categories: (a) ecological variables, such as the consequence. Reliability data indicated the inter-
physical placement of the target child, size and ventionist correctly performed the planned beha-
composition of play group, focus of instruction, viors with a mean of 95% accuracy and a range of
initiator of activity, and materials with which the 80% to 100% accuracy.
child is engaged; (b) teacher variables, such as ESCAPE observations were conducted for
teacher definition, specific behavior of the defined three baseline sessions and three intervention
teacher, and teacher focus; and (c) student variables, sessions for each participant. Interobserver agree-
such as activity in which the student is engaged, ment was obtained on 33% of baseline sessions
competing behaviors, and verbal behaviors. and 33% of intervention sessions. During sessions
Data to assess the acceptability and perceived in which interobserver agreement on ESCAPE
effectiveness of the intervention strategy to observations were obtained, the first and second
preschool staff were collected using an anchored authors were both equipped with a computer and
7-point Likert scale survey developed by the they simultaneously and independently collected
researchers (see Appendix). The survey was the ESCAPE data. The mean interobserver
designed to examine staff perceptions regarding agreement across participants was 96.15%
(a) the importance of each step of the intervention (range = 95.51 – 96.71%) during baseline and
strategy (e.g., creating a communicative opportu- 93.08% (range = 91.36 – 95.18%) during inter-
nity, modeling desired skill, providing specific vention. All ESCAPE results are reported as the
guidance) and (b) the impact on the classroom mean percentage of intervals for each specific
environment (e.g., disruptiveness to classroom variable recorded across observation sessions
 92 S. JOHNSTON et al.

within the specified condition. Because the maintenance conditions for each participant.
influence of the use of the visual support on Results are organized to display the percentage
verbal language and challenging behaviors was a of correct use of unprompted and prompted
primary area of interest in this investigation, symbolic communication (use of the graphic
changes in the percentage of intervals during symbol and/or verbal language) for each of the
which the children were engaged in various participants to request entrance into playgroups.
student behaviors (i.e., verbal behaviors, compet- Brad, Alex, and Billy showed, respectively, stable
ing behaviors) have been reported for each baseline levels at 3.3%, 20%, and 0% mean
participant. correct use of unprompted symbolic communica-
tion to request entrance into play groups across
sessions. Baseline data reflects a consistent use of
RESULTS five opportunities per session for all three
participants. Visual inspection of the intervention
Child Outcomes
data revealed that there was a substantial increase
Figure 1 displays percent correct use of symbolic in the slope of all three children’s percent correct
communication during baseline, intervention, and use of unprompted symbolic communication.
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For personal use only.

FIGURE 1 Percent correct use of symbolic communication (graphic symbol and/or verbal language) across participants.
 VISUAL SUPPORTS AND AUTISM SPECTRUM DISORDER 93

Intervention data reflected an average of 5.2 and verbal language (82%). During the main-
opportunities (range = 5 – 8) per session for Brad, tenance phase, his unprompted correct responses
4.8 opportunities (range = 4 – 6) per session for consisted of verbal language alone (38%) as well
Alex, and 4.9 opportunities (range = 4 – 6) per as a combination of verbal language paired with
session for Billy. During maintenance, Brad the graphic symbol (43%).
averaged 87% correct use of symbolic commu-
nication, Alex averaged 100% correct use of
Classroom Ecological Variables
symbolic communication, and Billy averaged
87% correct use of symbolic communication. A comparison of baseline and intervention mean
Maintenance data reflects a consistent use of five percentages across participants was used to
opportunities per session for each participant. evaluate the effects of the intervention strategy
Generalization probes for all three participants on competing behaviors and on verbal language.
were conducted at the conclusion of the investiga- These data are summarized in Table 1. As
tion in a different activity that was not the focus of illustrated by Table 1, the data for all three
acquisition opportunities (i.e., a large group participants revealed decreases in the percentage
computer activity in which students requested of intervals coded as off-task behavior. Further-
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opportunities to take a turn activating the more, the data for all three participants revealed
computer mouse). For each participant, five probes increases in the percentage of intervals coded as
were conducted 1 day a week across two consecu- ‘talking to teacher’. Given the interest in this
tive weeks. Results revealed that Brad, Alex, and investigation in examining changes in verbal
Billy each had 100% correct use of symbolic language, ‘talking’ was defined as including only
communication (the graphic symbol and/or verbal verbal behavior and did not include any other
language) to request entrance into play groups. symbolic modes of communication (e.g., graphic,
As discussed previously, correct behaviors in gestural).
this study included the use of the graphic symbol,
verbal language, or a combination of the graphic
Preschool Staff Social Validity
For personal use only.

symbol and verbal language. Since all three

participants had some verbal language prior to Table 2 provides a summary of the results of the
the onset of this investigation, they could sections of the classroom teacher survey addres-
potentially engage in any combination of these sing issues related to the intervention compo-
symbolic communicative behaviors to request nents. As indicated by Table 2, all of the
entrance into play activities. Figure 2 illustrates preschool staff reported that creating commu-
the percentage of unprompted correct responses nicative opportunities was very important and
that involved the use of the graphic symbol, very appropriate. Furthermore, most of the
verbal language, or the combination of the preschool staff reported that it was not very
graphic symbol and verbal language across the difficult (66%) to create communicative opportu-
intervention and maintenance phases of the nities. With regard to modeling the desired skill,
investigation for each participant. Results reveal all of the preschool staff indicated that this step
that Brad did not engage in any unprompted was very important, while most indicated that
correct responses during the no-delay phase. modeling was not difficult (89%) and very
During the delay phase of the investigation, his appropriate (89%). Finally, most of the preschool
unprompted correct responses primarily consisted staff indicated that providing specific guidance
of a combination of the graphic symbol and was very important (78%) and not very difficult
verbal language (80%). Furthermore, Brad (89%), and all of the preschool staff reported that
continued to use a combination of graphic providing specific guidance was very appropriate.
symbol and verbal language during maintenance Table 3 provides a summary of the results from
(86%). For Alex, unprompted correct responses sections of the classroom teacher checklist
primarily involved the use of the graphic symbol addressing perceptions regarding the impact of
(87%) during the no-delay phase of intervention. the strategy on the classroom environment. As
In contrast, during the delay phase and the indicated by Table 3, most of the preschool staff
maintenance phase of the investigation, Alex’s indicated that the intervention was not disruptive
unprompted correct responses primarily involved to classroom routines and activities (89%), the
the use of verbal language (delay phase = 76%, time required to implement the intervention was
maintenance phase = 90%). Results reveal that worth the observed benefits (78%), and the
Billy did not engage in any unprompted correct participants would be likely to continue to use
responses during the no-delay phase. During the the strategy after completion of the study (78%).
delay phase, Billy’s unprompted correct responses Finally, all of the preschool staff reported that it
primarily involved the use of the graphic symbol would not be difficult to use the intervention
 94 S. JOHNSTON et al.
Augment Altern Commun Downloaded from informahealthcare.com by Dicle Univ. on 11/14/14
For personal use only.

FIGURE 2 Percent of unprompted correct responses across participants that used the graphic symbol, verbal language, and a
combination of the graphic symbol and verbal language.

strategy and still meet the needs of other children teaching preschool children with ASD to use a
in the classroom. visual support to request entrance into
playgroups, (b) whether implementation of the
intervention strategy had a collateral impact on
DISCUSSION off-task behaviors and/or verbal language, and
(c) how preschool staff rated the acceptability
The purpose of this study was to examine (a) and perceived effectiveness of the use of the
the effectiveness of an intervention strategy in strategy.
 VISUAL SUPPORTS AND AUTISM SPECTRUM DISORDER 95

TABLE 1 Mean percentage of intervals (and frequency of intervals) of occurrence of ESCAPE target behaviors across
conditions

Brad Alex Billy

Baseline Intervention Baseline Intervention Baseline Intervention

Competing Behaviors
None 83.67 92.75 59.68 86.76 83.78 90.00
(41) (64) (37) (59) (62) (54)
Off task 10.20 1.45 37.10 10.29 5.41 0
(5) (1) (23) (7) (4) (0)
Acting out 2.04 0 0 0 0 0
(1) (0) (0) (0) (0) (0)
Can’t tell 0 1.45 0 0 8.11 5.00
(0) (1) (0) (0) (6) (3)
Missing data 4.08 4.35 3.23 2.94 2.70 5.00
(2) (3) (2) (2) (2) (3)
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Verbal behavior
No talk 83.67 71.01 90.32 73.53 78.38 71.67
(41) (49) (56) (50) (58) (43)
To teacher 4.08 21.74 3.23 20.59 5.41 16.67
(2) (15) (2) (14) (4) (10)
Undirected 6.12 1.45 1.61 1.47 5.41 1.67
(3) (1) (1) (1) (4) (1)
To peer 0 0 1.61 0 0 0
(0) (0) (1) (0) (0) (0)
Can’t tell 0 1.45 1.61 0 8.11 5.00
For personal use only.

(0) (1) (1) (0) (6) (3)

Missing data 6.12 4.35 3.23 34.41 2.70 5.00
(3) (3) (2) (3) (2) (3)

Note: Data are reported as mean percentage of intervals in which each category occurred during the free-play activity; figures in
parentheses are frequencies.

TABLE 2 Summary of classroom teacher checklists across intervention components

Teacher responses on selected social validity issuesa

Intervention components Importance n Difficulty n Appropriateness n

Creating communicative Very (6 – 7) 9 Very (6 – 7) 0 Very (6 – 7) 9
opportunities Moderately (3 – 5) 9 Moderately (3 – 5) 3 Moderately (3 – 5) 0
Not (1 – 2) 0 Not (1 – 2) 6 Not (1 – 2) 0
Modeling desired skill Very (6 – 7) 9 Very (6 – 7) 0 Very (6 – 7) 8
Moderately (3 – 5) 0 Moderately (3 – 5) 1 Moderately (3 – 5) 1
Not (1 – 2) 0 Not (1 – 2) 8 Not (1 – 2) 0
Providing specific Very (6 – 7) 7 Very (6 – 7) 0 Very (6 – 7) 9
guidance Moderately (3 – 5) 2 Moderately (3 – 5) 1 Moderately (3 – 5) 0
Not (1 – 2) 0 Not (1 – 2) 8 Not (1 – 2) 0

Note: n = 9
a
Teacher responses selected from anchored 7-point Likert scale.

Results of this investigation suggest that the ving the use of visual supports for teaching young
intervention strategy was successful in teaching children with ASD to initiate interactions (Bondy
preschool aged children with ASD to request & Frost, 1994; Jolly et al., 1993; Kranz &
entrance into playgroups. These findings add to McClannahan, 1993; Schwartz et al., 1998;
the relatively sparse data providing support for Wolfbert & Schuler, 1993; Zanolli et al., 1996).
the effectiveness of intervention strategies invol- Furthermore, these findings support existing
 96 S. JOHNSTON et al.

TABLE 3 Summary of classroom teacher checklists across environmental variables

Teacher response on selected social validity issuea

Environmental variable Response option n

Disruptive to classroom routines and activities Very disruptive (6 – 7) 0
Moderately disruptive (3 – 5) 1
Not disruptive (1 – 2) 8
Time required to implement worth observed benefits Well worth the time (6 – 7) 7
Somewhat worth the time 2
(3 – 5)
Not worth the time (1 – 2) 0
Target child is likely to continue to use acquired skill after completion Yes 7
of study No 2
It would be difficult to use this strategy and still meet the needs of Yes 0
other children in the classroom No 9

Note: N = 0
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a
Teacher responses selected from anchored 7-point Likert scale.

research that incorporates strategies such as (a) the function of requesting entrance into
the use of a least-to-most intrusive prompting playgroups and use of those behaviors as the
hierarchy (Johnston et al., 2003; Jolly et al., trigger for implementation of the intervention.
1993); (b) prompting within activities (Krantz & The use of eye-gaze as a trigger for implementa-
McClannahan, 1993); (c) the use of environ- tion of the intervention might also be problematic
mental arrangement and the gradual fading of for some individuals with ASD who engage in
For personal use only.

adult support (Wolfberg & Schuler, 1993); and (d) idiosyncratic or peripheral eye-gaze behavior. In
errorless learning involving systematic fading of cases such as these, it would be important to
prompts (Bondy & Frost, 1994; Schwartz et al., identify other observable behaviors that serve the
1998). function of requesting entrance into play groups.
It is interesting to note the variability in percent
of correct responses for Brad during the third
Collateral Impact on Verbal Language and
phase and the maintenance phase of this
Competing Behaviors
investigation. One explanation for this variability
may be that, without prompts, Brad had difficulty The participants’ use of the graphic symbol,
engaging in the correct responses. Another verbal language, or a combination of these
explanation could be related to the procedures modalities to request entrance into play activities
utilized in this investigation. According to our was noteworthy. Results revealed three different
intervention, an opportunity to use the graphic profiles of symbolic communication use during
symbol to request entrance into play activities the final stage (maintenance) of this investigation.
would be triggered when a participant indicated Brad primarily used the graphic symbol simulta-
interest via eye gaze. Post-hoc discussions with neously with verbal language to request entrance
the interventionist and other preschool staff in the into play activities. Alex primarily used verbal
classroom indicated that they felt that Brad’s use language alone to request entrance into play
of eye gaze was not necessarily an indication of activities. Billy primarily requested entrance into
interest in joining an activity but sometimes play groups by either using verbal language alone,
seemed to indicate an interest in simply observing or by using a combination of the graphic symbol
it. As a result, those instances when Brad used and verbal language. These outcomes might be
eye-gaze when he was interested only in observing explained using the tenets of matching theory,
an activity (and therefore did not use symbolic which focus on how different schedules of
communication to request entrance into the play reinforcement affect an individual’s choice.
activity) were coded as an incorrect response. In Matching theory hypothesizes that when indivi-
summary, the variability in Brad’s performance duals have the opportunity to choose between
may be an artifact of the procedures of the two or more responses, they will select the
investigation rather than an accurate reflection of response that is perceived as most efficient (Mace
his ability to use the graphic symbol to request & Roberts, 1993). Studies have demonstrated that
entrance into play groups. Future studies should an individual’s concept of efficiency is effected by
more clearly establish the behavior(s) that serve at least the following four components: (a) rate of
 VISUAL SUPPORTS AND AUTISM SPECTRUM DISORDER 97

reinforcement (e.g., Mace, Neef, Shade, & target behavior did not occur, the interven-
Mauro; 1994; Horner & Day, 1991), (b) quality tionist provided a model. An intervention
of reinforcement (e.g., Mace, Neef, Shade, & strategy that included a stronger focus on
Mauro, 1996), (c) response effort (e.g., Horner & ensuring a higher percentage of peer models,
Day, 1991; Mace et al., 1996), and (d) immediacy and therefore an increased use of the target
of reinforcement (e.g., Neef, Mace, & Shade, behavior with peers, may have influenced whom
1992; Horner & Day; 1991). Although the the participants interacted with.
influence of these components was not system- The ESCAPE (Greenwood et al., 1997) results
atically examined in the current study, the results for all three children also revealed decreases in the
may provide insight into each participant’s percentage of intervals coded as off task between
perceptions regarding efficiency. Specifically, each the baseline and intervention stages of this
of the participants may have been choosing the investigation. One plausible explanation for this
response (or responses in Billy’s case) that they outcome may be that teaching the participants an
perceived as most efficient. The participants’ effective way to request entrance into play
multi-modal use of communication supports the activities resulted in increased opportunities for
practice of providing children with a variety of them to appropriately engage in play activities.
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ways to meet their communicative needs (e.g., Another plausible explanation may be that the
verbal, gestural, graphic) so that they can utilize attention provided during the intervention (e.g.,
the mode (or modes) that they perceive as most via the models, prompts, and reinforcement)
efficient given the demands of the environment. increased the participants’ motivation to stay
In addition to examining the participants’ ‘on task’ and/or decreased the number of
modes of communication for requesting entrance opportunities for the participants to be off task.
into play groups, the ESCAPE (Greenwood et al.,
1997) results for all three children revealed
Social Validity
increases in the percentage of intervals coded as
talking to teacher between the baseline and The findings from this study add to the limited
For personal use only.

intervention stages of this investigation. These data regarding the social validity of AAC
data support previous findings that visual interventions (Schlosser, 1999). The majority
supports may promote the use of verbal language of the teachers felt that the time required to
in young children (e.g., Bondy & Frost, 1994; implement the strategy was worth the benefits,
Schwartz et al., 1998). Furthermore, it may serve that the participants were likely to continue to
to minimize concerns sometimes expressed by IEP use the strategy, and that use of the strategy
team members that the use of visual strategies for would not interfere with meeting other chil-
communication may inhibit a child’s use or dren’s needs. Furthermore, teacher perceptions
acquisition of verbal language. were generally very supportive of the interven-
Although the overall mean number of inter- tion components and the impact of the
vals coded as talking to teacher increased for all intervention. The majority of classroom staff
three participants, the use of verbal language indicated that they viewed the intervention
with peers did not increase. Possible explana- procedures as being appropriate and important
tions for this outcome might be related to the without significantly changing the social and
context for intervention or the instructional educational classroom environment. Many of
strategy. Observation of the classroom environ- the teachers surveyed (44%) felt that creating
ment revealed that most interactions were communicative opportunities was moderately
teacher – student, with very few student – student difficult. Post hoc examination of the survey
interactions. This pattern could have resulted, in results revealed that this difficulty was reported
part, from the fact that all of the students in in relation to creating opportunities for Brad.
the classroom had a diagnosis of ASD and by This finding supports the prior discussion
definition had difficulty with communication. As regarding the difficulty in interpreting whether
a result, the participants’ choice of communica- Brad’s eye gaze toward an activity constituted
tion partners in this context mirrored typical an opportunity for intervention.
communicative interactions in the classroom.
The instructional strategy employed in this
Limitations
study may also have contributed to the
outcome. All peers in the classroom received There are some limitations associated with this
verbal instruction on the use of the graphic study that may affect the extent to which the
symbol to request entrance into play activities results might generalize to other individuals,
and were encouraged to use the graphic symbol settings, or intervention targets. Factors that
whenever they liked. If peer modeling of the could limit the generalizability of the results
 98 S. JOHNSTON et al.

include that study participants shared a number References

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 100 S. JOHNSTON et al.

APPENDIX A: Augmentative and Alternative Communication Intervention in Preschool Programs

PreSchool Teacher Survey

Dear Teacher
Please complete this checklist following your observation of an intervention session with the
participant. All questions, unless otherwise indicated, refer to the target child and his/her identified goal.
Information gained from this questionnaire will be used to help revise the teaching procedures for use
within developmentally appropriate programs in ways that benefit all children, families, and educators.
Your ideas are important. Thanks for taking time to share them with us.

1) Do you think that the intervention strategy was an appropriate instructional procedure for teaching
the child the identified skill?
Augment Altern Commun Downloaded from informahealthcare.com by Dicle Univ. on 11/14/14

Not Moderately Very

Appropriate Appropriate Appropriate
1 2 3 4 5 6 7

2) Was the intervention strategy effective in teaching the child the identified skill?

Not Moderately Very

Effective Effective Effective
1 2 3 4 5 6 7
For personal use only.

3) How difficult did it appear to be to implement the intervention strategy in the classroom setting?

Not Moderately Very

Difficult Difficult Difficult
1 2 3 4 5 6 7

4) Do you feel that it was important to create communicative opportunities in order to effectively teach
the identified skill to the child?

Not Moderately Very

important important important
1 2 3 4 5 6 7

5) Did it appear difficult to create communicative opportunities before giving directions or cues within
the context of regular preschool activities?

Not Moderately Very

Difficult Difficult Difficult
1 2 3 4 5 6 7

6) Do you feel that creating communicative opportunities was an appropriate instructional procedure for
teaching the identified skill to the child?

Not Moderately Very

Appropriate Appropriate Appropriate
1 2 3 4 5 6 7
 VISUAL SUPPORTS AND AUTISM SPECTRUM DISORDER 101

7) Do you feel that it was important to model the desired skill in order to effectively teach the identified
skill to the child?

Not Moderately Very

Important Important Important
1 2 3 4 5 6 7

8) Did it appear difficult to model the desired skill within the context of regular preschool activities?

Not Moderately Very

Difficult Difficult Difficult
1 2 3 4 5 6 7

9) Do you feel that modeling the desired skill was an appropriate instructional procedure for teaching
the identified skill to the child?
Augment Altern Commun Downloaded from informahealthcare.com by Dicle Univ. on 11/14/14

Not Moderately Very

Appropriate Appropriate Appropriate
1 2 3 4 5 6 7

10) Do you feel that it was important to provide specific guidance (e.g., verbal or physical prompts) in
order to effectively teach the identified skill to the child?

Not Moderately Very

Important Important Important
1 2 3 4 5 6 7
For personal use only.

11) Did it appear difficult to provide specific guidance (e.g., verbal or physical prompts) within the
context of regular preschool activities?

Not Moderately Very

Difficult Difficult Difficult
1 2 3 4 5 6 7

12) Do you feel that providing specific guidance (e.g., verbal or physical prompts) was an appropriate
instructional procedure for teaching the identified skill to the child?

Not Moderately Very

Appropriate Appropriate Appropriate
1 2 3 4 5 6 7

13 Did the strategy appear to be disruptive to the classroom routines and activities?

Not Moderately Very

Disruptive Disruptive Disruptive
1 2 3 4 5 6 7

14) Did the strategy make the child stand out in any way from the rest of the class?

Stood Out Sometimes Did not Stand

A Great Deal Stood Out Out at All
1 2 3 4 5 6 7
 102 S. JOHNSTON et al.

15) Did you observe the child verbally or nonverbally express dislike of the strategy?

Strongly Some Dislike No Dislike

Expressed Dislike Expressed Expressed
1 2 3 4 5 6 7

16) Did the child seem to enjoy the intervention strategy?

Did Not Enjoyed Seemed

Seem to Enjoy Some of the Time To Enjoy
1 2 3 4 5 6 7

17) Has the child displayed any new inappropriate behaviors, which may be associated with the use of
the intervention strategy and were not observed prior to the use of the procedures?

Displayed Displayed Some Did Not

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Frequently of the Time Display

1 2 3 4 5 6 7

18) Do you feel that the time required to implement the strategy in the preschool was worth the
observed benefits to the child?

Too Much Somewhat Worth Well Worth

Time The Time The Time
1 2 3 4 5 6 7
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19) If given training and support would you feel confident implementing the intervention strategy
yourself?

Not at All Moderately Very

Confident Confident Confident
1 2 3 4 5 6 7

20) If given training and support would you be willing to implement the strategy in your classroom?

Not at all Moderately Very

Willing Willing Willing
1 2 3 4 5 6 7

21) Is it likely that the target child will continue to use the identified skill in the classroom after
completion of the study?

Yes No
1 2

22) It would be difficult to use this strategy and still meet the needs of the other children in the
classroom.

Yes No
1 2

23) Has the intervention strategy had any noticeable effect on the other children in the classroom? If so,
what effects did you observe?
 VISUAL SUPPORTS AND AUTISM SPECTRUM DISORDER 103

24) What changes would you recommend to improve the implementation or the design of the
intervention strategy?

Comments:
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