NIH Public Access

Author Manuscript
Brain Res. Author manuscript; available in PMC 2014 May 20.
Published in final edited form as:
NIH-PA Author Manuscript

Brain Res. 2011 March 22; 1380: 229–239. doi:10.1016/[Link].2010.09.043.

Toward a technology of treatment individualization for young

children with autism spectrum disorders
Aubyn C. Stahmera,b,*, Laura Schreibmanb, and Allison B. Cunninghamb
aChildand Adolescent Services Research Center, Autism Discovery Institute, Rady Children’s
Hospital, San Diego, CA, USA
bPsychology Department, University of California, San Diego, CA, USA

Abstract
Although the etiology of autism spectrum disorders (ASD) and early development of the ASD are
not yet well understood, recent research in the field of autism has heavily emphasized the
NIH-PA Author Manuscript

importance of early intervention (i.e. treatment before the age of 4 years). Currently, several
methods have been demonstrated to be efficacious with some children however no treatment
completely ameliorates the symptoms of ASD or works for all children with the disorder. The
heterogeneity and developmental nature of the disorder make it unlikely that one specific
treatment will be best for all children, or will work for any one child throughout his or her
educational career. Thus, this paper examines early research validating different technologies for
individualizing treatment. A discussion of current research on pre-treatment characteristics
associated with differential outcomes in treatment, including child, family, and practitioner
variables; and how specific intervention techniques address each of those pre-treatment
characteristics is provided. The ultimate goal of this line of research is to enable practitioners to
prospectively tailor treatments to specific children and increase the overall rate of positives
outcomes for children with autism. Research that furthers understanding of how to match clients
with efficacious treatments will decrease the outcome variability that characterizes early
intervention research at present, and provide for the most efficient allocation of resources during
the critical early intervention time-period. This type of research is in its infancy, but is imperative
NIH-PA Author Manuscript

if we are to determine a priori which treatment method will be most effective for a specific child.

Keywords
Autism spectrum disorder; Early intervention; Individualization; Treatment; Evidence-based
practice

© 2010 Published by Elsevier B.V.

*
Corresponding author: 3020 Children’s Way, MC 5033, San Diego, CA 92123, USA. Fax: +1 858 966 7704. astahmer@[Link]
(A.C. Stahmer).
URL: [Link] (A.C. Stahmer).
 Stahmer et al. Page 2

1. Introduction to psychosocial intervention for children with autism

spectrum disorders (ASD)
NIH-PA Author Manuscript

Although the etiology of ASD and early development of the disorder are not yet well
understood, recent research in the field of autism has heavily emphasized the importance of
early intervention (i.e. treatment before the age of 4 years). This emphasis may be attributed
in part to results of treatment studies suggesting substantial gains may be achieved when
treatment is provided at a very early age (National Research Council, 2001). Although
children with ASD may face significant limitations (i.e. mental retardation, delays in social
interaction and communication, challenging behaviors), and the initial causes of the disorder
are believed to be biological, it is important to remember that the environment has a
significant influence on the outcome of the child, including the development of the brain
(Shonkoff and Phillips, 2000). Gains made by children with ASD in early intervention
programs may result in a cost savings of nearly one million dollars by the time a person with
ASD reaches 55 years of age (Columbia Pacific Consulting, 1999).

Currently, no treatment method completely ameliorates the symptoms of ASD and no

specific treatment has emerged as the established standard of care for all children with ASD.
NIH-PA Author Manuscript

However, several methods have been demonstrated to be efficacious with some children in
research settings. The most well researched programs are based on the principles of applied
behavior analysis (e.g., Dunlap, 1999; National Research Council, 2001; Schreibman, 2000).
These range from highly structured programs that are conducted in a one-on-one treatment
setting to behaviorally based inclusion programs that include typically developing children
as models. Some of these programs are distinguishable by “brand names,” such as Discrete
Trial Training (DTT) and Pivotal Response Training (PRT), while other programs use the
principles of applied behavior analysis more generally. A few programs that are not based
on behavioral principles are beginning to demonstrate effectiveness as well. These include
functional techniques that use structured environments, visual cueing, developmental models
and other strategies to assist children with ASD in navigating their environments. Case
studies and studies of components of these techniques are supportive of treatment efficacy
(e.g., Panerai et al., 2002). Developmental and relationship-based models have also shown
some promising results (Greenspan and Weider, 1997). In addition, many “model programs”
for early intervention have shown success using the techniques described above or a
NIH-PA Author Manuscript

combination of techniques (for a complete description of several model programs, see

Handleman and Harris, 2001).

The heterogeneity and developmental nature of the disorder make it unlikely that one
specific treatment will be best for all children with ASD, or will work for any one child
throughout his or her educational career. Research points to the inadequacy of one single
treatment approach for all areas of learning for children with ASD (National Research
Council, 2001; Schreibman, 2000, 2005) and, there is now a consensus that there is no “one-
size-fits-all” treatment for this population. Differential response to treatment is common for
all of the evidence-based approaches, in that up to 50% of children show substantial positive
response, and the other 50% make progress at varying rates, some with extremely limited
skill development. Moreover, evidence suggests that treatment providers working in

Brain Res. Author manuscript; available in PMC 2014 May 20.

 Stahmer et al. Page 3

community settings do not select just one intervention but rather report using a combination
of evidence-based and non-evidence-based interventions to teach these children (Stahmer et
al., 2005). Although treatment providers are combining interventions, very little is known
NIH-PA Author Manuscript

about how to individualize treatment protocols or how to best determine a priori which
intervention is most likely to benefit individual children (Schreibman, 2000; Sherer and
Schreibman, 2005; Yoder and Compton, 2004).

Thus, research validating different technologies for individualizing treatment is important.

Such research requires an understanding of the pre-treatment characteristics associated with
differential outcomes of intervention, including child, family, and practitioner variables; and
how specific intervention techniques address each of those pre-treatment characteristics. In
addition, investigation of treatment/behavior interactions is important as different behaviors
may be best approached via different treatment protocols. The ultimate goal of this line of
research is to enable practitioners to prospectively tailor treatments to specific children and
increase the overall rate of positives outcomes for children with ASD.

2. Integration of strategies
Some researchers believe that combining treatments in a systematic way may be the most
NIH-PA Author Manuscript

appropriate way to individualize intervention (e.g., Iovannone et al., 2003; Rogers and
Vismara, 2008; Schreibman, 2000; Siegel, 1996), as the exclusive use of one treatment
method may ignore important aspects of social, emotional, communicative or pre-academic
development. Early studies indicate that combining methods is a promising avenue to pursue
(e.g., Dawson et al., 2010; Stahmer and Ingersoll, 2004), however, some researchers feel it
may actually be detrimental to learning, confuse the children and reduce the fidelity with
which any one treatment is administered (e.g., McGee et al., 1999).

Community programs typically report using more than one method in what are called
“eclectic” programs. Indeed, the best practice committees in both New York and California
recommend the use of a combination of treatments based on the needs of the child.
However, there have been very few studies examining the efficacy of integrating best-
practice treatment methods in community settings. Two studies comparing behavioral
approaches to general eclectic approaches have found them to be lacking (Eikeseth et al.,
2002; Howard et al., 2005), however the eclectic programs were community based and the
NIH-PA Author Manuscript

method of combining various intervention strategies was not measured.

This suggests that a specific, systematic method of combining strategies may be needed to
ensure that interventions remain effective when combined in an attempt to individualize for
a particular child and family. This may involve: (a) using more than one intervention for
teaching multiple skill areas, but varying the proportions of time spent using each; (b)
combining interventions into a modified single approach, including components of multiple
modalities; (c) varying which intervention is used depending on skill area; (d) varying based
on service system variables such as service settings and program availability; or (e) varying
service provision based on childor family characteristics.

Brain Res. Author manuscript; available in PMC 2014 May 20.

 Stahmer et al. Page 4

3. Current systematic methods of individualization and integration

3.1. Combining strategies within and between activities
NIH-PA Author Manuscript

Some researchers integrate strategies within activities, during different activities and/or
based on the level of support a student requires in order to learn. For example, a program
might begin with a high level of structure and remove supports as children no longer need
them. Alternatively, other programs begin with the use of the most naturalistic strategies and
increase structure if a child does not progress. An example of this is the Alexa’s PLAYC
inclusion program (formerly Children’s Toddler School or CTS), a community program
based in Southern California in which evidence-based, developmental and behavioral
techniques are combined to serve young children with autism and their typically developing
peers (see Stahmer and Ingersoll, 2004 and Stahmer et al., in press for a detailed description
of the program. At Alexa’s PLAYC, children receive a baseline level of structure (e.g.,
consistent daily routine, transition signals), developmentally appropriate programming and
use of developmental strategies. If children have difficulty with this level of support, more
structured techniques (e.g., visual schedule, structured behavioral techniques) are added
until a skill is learned. These structures are typically systematically faded as the child is able
to participate independently. As illustrated in Fig. 1, a clear structure, as well as
NIH-PA Author Manuscript

developmental strategies to enhance engagement and ensure developmentally appropriate

goals, is infused throughout all activities. If additional structure is needed to teach a new
skill or to maintain attention, teachers use strategies based on the principles of applied
behavior analysis, beginning with the least structured, and move to more structure as needed
based on individual child characteristics. Additional environmental structure, such as visual
support, may be added if needed. These supports may be adjusted within an activity or
throughout a child’s program. Supports are faded as quickly as possible to ensure
independence, generalization and maintenance of new skills. For example, within activities,
teachers may begin by using a less structured strategy and if a child does not respond, they
may move to more structured techniques to help the child learn in that moment. This may
include a transition back to less structured techniques once the child is responsive. Providers
may also make more global changes to a child’s program, for example, adding visual
supports for a child who consistently has difficulty with transitions using the usual program
procedures, or augmentative communication for a student who is not using spoken language.
Data examining child progress are used to make more global program changes, and as
NIH-PA Author Manuscript

children’s learning improves, structured strategies are faded. Alternatively, some programs
vary the use of certain strategies based on the specific activities or times of day. Thus, they
may use highly structured behavioral strategies during one-on-one times, or select certain
strategies to teach parents to use at home. Other programs make these decisions based on
systematic decision hierarchies (see below) which help providers determine, based on data
over time, when to move to a new (typically more structured) strategy if a child is not
making progress.

In general, well-designed, programs that have used these methods to combine interventions
have reported good outcomes. The Early Start Denver Model (ESDM; Rogers and Dawson,
2009), for example, uses a combination of developmental and behavioral techniques in both
a therapist- and parent-implemented early intervention model. The program includes

Brain Res. Author manuscript; available in PMC 2014 May 20.

 Stahmer et al. Page 5

decision hierarchies to determine when to add more structured strategies or visual supports
to a child’s program (see Fig. 2). A recent randomized clinical trial showed significant
improvements in IQ, adaptive behavior, and ASD diagnosis for young children receiving
NIH-PA Author Manuscript

ESDM compared with children receiving “usual care” in the community. A parent
implemented intervention, Teaching Social Communication to Children with Autism, uses
developmental strategies as the base of interactions and intersperses directive behavioral
techniques to teach new skills. Parents are taught to intersperse directive techniques to teach
new skills while using primarily developmental strategies to increase children’s engagement
and initiation skills (see Fig. 3). This method has been shown, through controlled single-
subject and quasi-experimental studies, to contribute to progress in the areas of expressive
and receptive language and play skills (Ingersoll et al., 2005; Ingersoll and Dvortcsak,
2010).

Group inclusion programs that systematically combine strategies have also provided support
for combining methods. For example, one study examined outcomes for a group of 102
children diagnosed with an ASD at age 2 who attended an inclusive toddler program,
Alexa’s PLAYC until age 3. In quasi-experimental pre/post studies of 100 children who
participated in the program, significant improvements, with large effect sizes were found in
NIH-PA Author Manuscript

developmental level, adaptive behavior and communication (Stahmer et al., in press).

Thirty-one of the children (31%) were functioning in the typically developing range when
they exited the program at age 3, after an average of 8 months of intervention. A recent
study of long-term outcome in 29 children who participated in the program (1–5 years after
exit) found that initial gains in cognitive and language functioning continued over time and
the majority of children (over 60%) were in regular classroom placement at elementary
school (Akshoomoff et al., 2010). Project DATA at the University of Washington integrates
behavioral strategies with early childhood special education methodologies, providing
inclusion as well as individualized instruction, and parent education. Children in this
inclusive group program also showed impressive improvement across curriculum areas,
including communication, imitation, self-care, and play skills. Eighty one percent of the ten
children in a pre–post study of outcomes exited the program with some functional language
(Boulware et al., 2006).

All of these programs use data collection to examine progress and changes are made to
specific strategies used with each child based on these data. However, the choice of the next
NIH-PA Author Manuscript

strategy to implement and program procedures describing how to move through the various
strategies are often based on clinical judgment or recommended best practice, rather than
research suggesting systematic steps for making these decisions. Thus it is not clear what
would happen if the program providers began with the most structured strategy instead of a
less structured approach, or if certain child characteristics could be used to determine the
most effective strategies a priori. It must be emphasized, however, that these programs
combined strategies in a systematic way, and examined fidelity of implementation of the
model, rather than simply using many strategies haphazardly. This is an important
distinction from community programs that have used “eclectic” practices. Studies examining
eclectic models have not identified the specific components making up the model (Eikeseth
et al., 2002; Howard et al., 2005) therefore poor results may simply represent a lack of a

Brain Res. Author manuscript; available in PMC 2014 May 20.

 Stahmer et al. Page 6

specific methodology for combining techniques or limited fidelity of implementation across

the approaches used.
NIH-PA Author Manuscript

3.2. Combining strategies based on curriculum area

Other programs combining interventions have based the use of various strategies on the
target skill or curriculum area. This may provide a systematic, yet simpler, way to pre-
determine strategy use. One example of this is the STAR program (Arick et al., 2003) that
combines structured and naturalistic behavioral methods. In this model, structured
behavioral strategies are used to teach receptive language and pre-academic concepts while
naturalistic strategies are used to teach play and spontaneous language concepts. This is
based on the premise, albeit non-research based, that some strategies are better suited to
teaching particular skills. Thus, some naturalistic behavioral strategies rely on a child
choosing a particular activity, or having a reward directly related to the task, which may
seem difficult when teaching academic skills or receptive language.

While it makes intuitive sense that some strategies may be better suited to specific target
areas than others, there are very little data to support specific guidelines. Some recent
preliminary data may call these ideas into question, at least for some children. Pilot data
NIH-PA Author Manuscript

evaluating structured versus naturalistic behavioral interventions for teaching expressive and
receptive language in younger children with ASD do not support this method. Cunningham
et al. (2010) used a single-subject alternating treatments design, whereby three children (28–
35 months) received both structured (Discrete Trial Teaching; DTT) and naturalistic
interventions (Pivotal Response Training; PRT) for specific expressive and receptive
language targets. As has been found in previous research with older children, these younger
children learned expressive language in both treatment conditions, but demonstrated greater
generalization and maintenance of gains when taught via PRT in the majority of cases. For
receptive language, which has not been studied in this manner, treatment conditions were
similarly effective in the acquisition of receptive language for two children, but the
naturalistic intervention appeared superior for the generalization of these skills. One child
demonstrated a distinct pattern of responding, whereby the structured intervention was
superior. Children also showed two distinct patterns of disruptive behaviors during treatment
sessions, with the children seeming to have different intervention style responses. That is,
one child exhibited increased disruptive behavior in the PRT condition, one child had more
NIH-PA Author Manuscript

disruptive behavior in the DTT condition, and the last child showed little disruptive behavior
overall. The relationship between child intervention style response and rates of learning did
not consistently match, and further analysis of these data will be important in determining
the utility of these variables in treatment individualization methods. What these preliminary
data do suggest, however, is that observing differences in child response patterns early on in
treatment (i.e. by providing two interventions to the same child for comparison) may be
more useful in individualizing treatment than using only curriculum guidelines.

4. Individualization based on service setting and system

Another decision that needs to be made when determining individualization of intervention
for children with ASD is the intervention setting. Although researchers and educators alike
typically agree that children with ASD benefit from early identification and intervention

Brain Res. Author manuscript; available in PMC 2014 May 20.

 Stahmer et al. Page 7

services, disagreement arises regarding the appropriate setting for early intervention (e.g.,
in-home or inclusion programming). In addition, most intervention researchers recognize the
importance of social integration for children with ASD, but there is little consensus as to
NIH-PA Author Manuscript

what point in intervention it should occur. Some researchers would argue that inclusion is
appropriate for higher-functioning or older children with ASD, but is not appropriate for
preschoolers who may not be “behaviorally ready” to benefit from an inclusion environment
(Strain et al., 2001). Others have suggested that preschoolers with ASD will not get
appropriate services in inclusion settings or may be socially rejected by their peers (e.g.,
Lowenthal, 1999). Programs supporting this philosophy typically advocate a period of
individualized and small group instruction prior to placement in an inclusive setting
(Anderson and Romanczyk, 1999; Harris and Handleman, 1994) in order to work on these
prerequisite skills.

Strain et al. (2001) have emphasized the fact that although the commonly held assumption of
“behavioral readiness” greatly influences early intervention programming for young children
with ASD, there are no data to support this claim. Several inclusive early intervention
programs have documented excellent child progress, and report that the majority of children
who exit their programs have functional verbal communication skills and are mainstreamed
NIH-PA Author Manuscript

into typical school environments (McGee et al., 1994, 2000; Schwartz et al., 2004; Stahmer
et al, in press; Stahmer and Ingersoll, 2004; Strain and Cordisco, 1994). Of course, as is the
case for most programs for children with ASD, there is a great deal of variability across
children in program outcome in all settings that have been studied and a dearth of data to
inform differential placement for individual children. No studies have directly compared in-
home or inclusion-based treatment settings in a randomized comparison design.

It is probable that the effectiveness of a particular setting may vary depending upon the
characteristics of the children entering the program. One study looked at the effect of peer
avoidance at entry in predicting outcome in an inclusion program (Ingersoll et al., 2001).
The study looked at six children with ASD entering a toddler inclusion program. Children
were matched for language and developmental level. Although no children were interactive
with peers at entry, three children were highly avoidant of peers (actively avoiding
proximity) and three children were low avoiders (did not avoid proximity). The children
demonstrated significant variability in outcome that could not be attributed to mental age
equivalent or language level. Pre-treatment peer social avoidance appeared to predict
NIH-PA Author Manuscript

outcome for subsequent peer avoidance and language use. Low peer avoiders made
significant progress in language and social interaction while high peer avoiders remained
avoidant of peers and made limited progress in their use of language (see Fig. 4). It is
possible, then, that peer avoidance may provide one method of determining service setting.

However, a limitation of this study was the lack of a group of children in one-on-one
intervention. Previous research has suggested that low initiations (Koegel et al., 1999) and
avoidance of therapist (Sherer and Schreibman, 1999) may suggest poor prognosis in any
treatment model. Future research that investigates whether peer avoidance is associated with
poor outcome in general should be conducted. Additionally, other research looking at other
predictors of differential response to service settings would be important.

Brain Res. Author manuscript; available in PMC 2014 May 20.

 Stahmer et al. Page 8

Service system constraints available in community settings often determine the interventions
used. ASD interventions, therefore, need to be individualized and adapted to fit the
resources available to the programs in which they will be implemented. However, there have
NIH-PA Author Manuscript

been very few efforts put forth to examine how evidence-based interventions are
implemented in the real world. The limited research that has been conducted indicates that
practitioners are not implementing interventions developed as intended by researchers.
Stahmer et al. (2005) found that 22 practitioners participating in focus groups about early
intervention for autism reported using modified versions of interventions, often combining
elements of multiple practices or applying adaptations to those practices based on child
and/or program characteristics. Practitioners likely are recognizing that interventions
designed by researchers in academic settings have to be individualized for use in applied
settings.

In fact, individualization research may be informed by methods experienced practitioners

use to individualize interventions. Recently, mental health researchers have recognized the
need to improve evidence-based practice by complimenting traditional studies with
“practice-based evidence” which involves gaining a better understanding of what works in
community practice. Garland et al. (2006) suggest that evidence-based practice research
NIH-PA Author Manuscript

would benefit from studies of “practice-based evidence” (Margison et al., 2000), which can
be useful for identifying effective and ineffective elements of usual practice. In a qualitative
study interviewing 80 teachers regarding their use of evidence-based practices, providers
consistently reported the importance of individualizing treatment methods and strategies
based on the needs of the child (Stahmer, 2007). The majority of participants reported that
they chose specific interventions based on characteristics related to each individual child’s
strengths and weaknesses. One participant explained, “Depends on the child. You know, so
much of the therapy is responding to the child and not responding the way that the book says
to do it.” Because researchers have not yet determined methods for individualized treatment,
we feel that this may be an area where providers can contribute significantly through their
experiences. A collaborative move toward individualization may be needed to develop a
clear roadmap for developing evidence-based interventions designed for specific children.

5. Individualization based on child characteristics

Because of the wide heterogeneity of treatment outcomes in children with ASD, a number of
NIH-PA Author Manuscript

studies have identified child characteristics associated with positive developmental and
treatment gains. Developmental studies have used cross-sectional and longitudinal study
designs to identify early child variables associated with later child outcomes in general and
also in relation to response to a specific intervention. Early language ability and cognitive
ability have emerged as the strongest predictors of overall prognosis for ASD during
childhood, adolescence, and adulthood (Howlin et al., 2004; Sigman and Ruskin, 1999;
Venter et al., 1992). Standardized communication and nonverbal IQ scores from children as
young as 3 years old predict later language abilities (Stevens et al., 2000; Tager-Flusberg et
al., 2005; Thurm et al., 2007). However, these predictors are not as robust prior to the age of
3 (Charman et al., 2005), making prediction of response to intervention difficult for children
receiving this early diagnosis. Also, some studies have reported that early social behaviors
such as joint attention, motor imitation and toy play predict outcome in children with ASD

Brain Res. Author manuscript; available in PMC 2014 May 20.

 Stahmer et al. Page 9

(e.g., Anderson et al., 2007; Tager-Flusberg et al., 2005; Thurm et al., 2007). Despite the
fact that these data may provide information regarding long term outcome, they do not assist
with making specific intervention choices for individual children. Researchers have yet to
NIH-PA Author Manuscript

exam of the influence of physical, genetic or medical conditions on treatment outcomes for
children with autism.

More recently, researchers have begun to look for variables that may differentially predict
child response to treatment. Studies identifying predictors of treatment response continue to
be important, but they are only able to identify child variables associated with response to
one specific treatment. This is problematic, as there is no consensus on the specific
treatment model of choice for these children (National Research Council, 2001; Schreibman,
2005). While some single-subject and group comparison designs have argued for the
superiority of one treatment over the other (Delprato, 2001; Smith et al., 2000), few
investigators have examined the possibility that different treatments might be most
appropriate for different children and at different points in the treatment process. Improved
understanding of child variables associated with differential treatment outcomes may enable
researchers and practitioners to prospectively tailor treatments to specific children. This will
likely increase the overall rate of treatment effectiveness across children with ASD. This
NIH-PA Author Manuscript

research is becoming even more important as intervention approaches integrating non-

behavioral components are gaining support and other treatment options become available
(e.g., Dawson et al., 2010).

Two prospective studies have examined child variables associated with differential
responsivity to one specific naturalistic behavioral intervention, Pivotal Response Training
(PRT). The first study, a multiple baseline design reported that three 3- to 5-year-old
children demonstrating high levels of non-verbal stereotypy and avoidance, as well as low
levels of verbal stereotypy, toy play, and approach behaviors, were less likely to show
positive response to PRT than three children exhibiting the opposite behavioral profile (i.e.
low non-verbal stereotypy and avoidance and high levels of verbal stereotypy, toy play and
approach behavior) prior to treatment (Sherer and Schreibman, 2005). A follow-up study
multiple baseline design study of six children suggested that this predictive profile was
specific to PRT and not predictive of response to other more structured, behavioral
interventions, such as Discrete Trial Teaching (DTT; Schreibman et al., 2009). Although
each of the profile behaviors have not been examined in isolation, toy play and approach
NIH-PA Author Manuscript

behaviors may lead to a better response to a play based intervention that requires interaction
with toys and an adult. Verbal stereotypy is a less likely predictor; however it appears that it
may lead to shaping of more appropriate verbal skills. More recent data have suggested that
the PRT predictive profile may not be predictive of treatment response in a younger-aged
sample of children, thereby indicating the need for varying standards with child age
(Cunningham, 2007). Together, these initial studies provide evidence that specific
behavioral profiles may be useful in identifying which children are likely to respond to
particular treatments and therefore in making treatment decisions.

A recent study evaluated the differential effectiveness of two communication training

strategies commonly used to teach early communication skills to nonverbal and minimally
verbal young children with ASD (Cunningham et al., 2008). Specifically, this randomized

Brain Res. Author manuscript; available in PMC 2014 May 20.

 Stahmer et al. Page 10

trial addressed the differential effects of a language-based approach (PRT) and a visually
based approach (the Picture Exchange Communication System, PECS; Bondy and Frost,
2001) on the communication, social, and cognitive functioning of 34 very young (i.e., 2–4
NIH-PA Author Manuscript

years-old), minimally verbal children with ASD. Both programs were found to result in
substantial spoken language gains for approximately 50% of the children. While early word
use was highly predictive of verbal gains in both treatment conditions, it was not predictive
of augmentative communication gains. Children with some words (i.e. 1–9 words at intake)
were equally likely to develop verbal communication skills in PECS or PRT. Children
entering treatment with no words were unlikely to develop spoken language. However, over
80% of the PECS participants developed substantial augmentative communication skills.
These preliminary results indicate that word use at intake may be an important and
parsimonious child variable to consider when deciding between verbal and augmentative
communication programs for very young children with ASD.

One other systematic comparison of the differential effects of verbally based and visually
based communication training programs for young children with ASD has been reported.
Yoder and Stone (2006a, b) conducted a randomized comparison experiment comparing a
vocally based naturalistic intervention, Responsive Education and Prelinguistic Milieu
NIH-PA Author Manuscript

Teaching (RPMT), to PECS in 36 children in order to examine how the relative treatment
effects varied as a function of child variables. The investigators found that while both PECS
and RPMT resulted in an increase in initiating joint attention across treatment, RPMT
resulted in more initiating joint attention compared to PECS for those children who had at
least some joint attention skills prior to intervention. Alternatively, PECS resulted in more
requests in comparison to RPMT and greater gains in initiating joint attention bids for those
children with little joint attention skill at intake (2006a). In a different report based on the
same experiment, Yoder and Stone (2006b) found that pre-treatment levels of object
exploration moderated growth rates in the number of nonimitative words in PECS versus
RPMT. Children who began treatment with low object exploration benefited more from
RPMT, while children who began treatment with higher levels of object exploration
benefited more from PECS. These researchers reasoned that while both PECS and RPMT
involve objects as rewards for communicative attempts, only RPMT involves specifically
teaching children how to play with objects. Thus, children with low object exploration at
pre-treatment were more likely to benefit from intervention after learning to play with
NIH-PA Author Manuscript

objects. Both the PECS versus PRT (Cunningham et al., 2008) and PECS versus RPMT
(Yoder and Stone, 2006a,b) studies provide information about the differential effects of
visually based and vocally based interventions and illustrate how detailed information about
very specific behavioral effects may be identified.

Collectively, these studies serve as the foundation for research aimed at matching treatment
approaches to the individual needs of different children with autism. For example, it may be
that PECS may be more appropriate as a first line treatment approach for children with
fewer prerequisite abilities, including early word use and joint attention initiation skills.
Alternatively, verbally based programs, such as RPMT and PRT, may be appropriate for
children who enter treatment with some early communication skills. It is important to
emphasize that these findings must be replicated and may only apply to early

Brain Res. Author manuscript; available in PMC 2014 May 20.

 Stahmer et al. Page 11

communication treatment. The relative benefits of these interventions for older children or
longer term treatment programs, as well as on other areas of development, are yet to be
addressed.
NIH-PA Author Manuscript

6. Individualization based on family characteristics

In addition to child characteristics, it is also important to consider the characteristics of the
child’s caregivers. Active parent involvement in intervention is a recommend component of
effective intervention for this population (Breiner and Beck, 1984; Ingersoll and Dvortcsak,
2006; National Research Council, 2001; Singh et al., 2006). Yet the field is just beginning to
examine how family variables interact with treatment effectiveness. The effects of ethnicity,
culture, marital status, parental attitudes, parental age, level of education, socioeconomic
status, and other factors all may affect how treatment is best delivered and the ultimate
effectiveness of the treatment. To illustrate, a randomized trial with 58 participating families
has shown that children of more responsive and educated parents are more likely to benefit
from Prelinguistic Milieu Teaching, while children of less responsive and educated mothers
benefit more from responsive small group instruction (Yoder and Warren, 1998). In another
example, training in self-management may be more successfully implemented by parents for
NIH-PA Author Manuscript

whom child independence is important (Schreibman and Koegel, 1996). However, certain
cultures may not place a strong emphasis on child independence; thus, the parents may not
choose to use self-management with their child or may use it ineffectively.

Efficacy studies in autism have rarely examined efficacy for ethnic groups separately, and
most do not even provide information about the race/ethnicity of the subjects (Brown and
Rogers, 2003). This lack of research is a concern given the widespread recognition that
culture has a powerful impact on service utilization, treatment attendance, parenting and
other service related factors (e.g., Hough et al., 1987; MacPhee et al., 1996; McCabe et al.,
1999). Available data suggest that children from ethnic minority backgrounds are more
likely to be diagnosed and receive treatment at a later age than white children for reasons
that do not appear to be race alone (Croen et al., 2002; Mandell et al., 2002). There is some
limited research to indicate that Hispanic children perform similarly to Caucasian children in
parent education programs (Baker-Ericzen et al., 2007; McCabe et al., 2005), however, we
need much more information to effectively individualize intervention based on cultural
needs.
NIH-PA Author Manuscript

Another important family factor that may require treatment modification is the level of stress
in a family. Parents of children with autism report being under high levels of stress (e.g.,
Koegel et al., 1992). Perhaps parents who are under a good deal of stress at a point in time
would be poor candidates to implement training with their child; a clinician may then be the
treatment provider of choice. Later, if the stress is reduced, these parents could perhaps very
effectively implement the treatment.

Another potential candidate variable for individualization is parent gender. Typically,

mothers are the primary trainees in parent education programs; although researchers have
found involving fathers in parent education programs can benefit children with problem
behaviors (Horton, 1984; Webster-Stratton, 1985). Research indicates that parent education

Brain Res. Author manuscript; available in PMC 2014 May 20.

 Stahmer et al. Page 12

programs may require modifications in order to increase father involvement. Winter (2006)
examined factors contributing to increased father participation in a parent education program
for children with autism. She found that modifying an existing parent education program by:
NIH-PA Author Manuscript

(1) offering flexible days and times for training, (2) altering location of training by including
home visits, and (3) adding a recreational component all influenced father participation. In
light of Winter’s findings, ASD researchers and practitioners need to consider parent gender
when individualizing parent training programs.

In addition, collaboration between practitioners and parents is important for

individualization of intervention for parents. Brookman-Frazee (2004) found when parents
and practitioners collaborated on identifying target behaviors and method of treatment
implementation for children with problem behaviors, parents showed reduced stress and
increased confidence compared to parents who did not collaborate. The children in the
collaborative group also showed greater improvement in behavior. Forehand and Kotchick
(2002) provide guidelines to assess individual family variables that may influence
participation before training to help practitioners determine what level of intervention
parents may (or may not) be able to handle: (Level 1) Family discord is not severe: no need
to target family variables directly, parent education by itself can sometimes help resolve any
NIH-PA Author Manuscript

problems. (Level 2) Family discord is present and may interfere with treatment:
modification of original parent education plan may be helpful to directly target family
issues. (Level 3) Family discord is moderate: parent education for the child can be
concurrent with family services provided elsewhere. (Level 4) Family discord is severe and
will definitely impede any immediate parent education efforts: encourage parents to resolve
issues before beginning a parent training plan.

Often, parents have tried many ineffective ways of changing their child’s behavior by the
time the parents enter a treatment program. The practitioner can, and should help a parent to
have more positive expectations about what the parent can do to increase child outcome,
which can increase their feelings of self-efficacy. Assessing parents’ expectations can also
assist practitioners in knowing what behavior to expect from parents. Practitioners can use
information about parent expectations to individualize interventions to better fit parents’ life
circumstances and lifestyles.

7. Conclusions and future research

NIH-PA Author Manuscript

While positive results have been reported for many treatment methods, there are no ASD
treatments that currently meet criteria for well-established or probably efficacious,
empirically supported treatment (Lonigan et al., 1998). Additionally, due to the
heterogeneity and developmental nature of the disorder, it is unlikely that one specific
treatment will emerge as the treatment of choice for all children. Currently, researchers and
clinicians must use their judgment and training to choose the most suitable methodology or
combination of strategies for a specific child.

The goal, then, is not to find the one perfect treatment for all children with ASD, but to
identify the important variables that influence the effectiveness of specific interventions for
each child. Research that furthers our understanding of how to match clients with efficacious

Brain Res. Author manuscript; available in PMC 2014 May 20.

 Stahmer et al. Page 13

treatments will enable consumers to make better choices between procedures, decrease the
outcome variability that characterizes early intervention research at present, and provide for
the most efficient allocation of resources during the critical early intervention time-period.
NIH-PA Author Manuscript

This type of research is in its infancy, but is imperative if we are to determine a priori which
treatment method will be most effective for a specific child.

This line of research may lead to guidelines similar to those available for other mental health
disorders, such as childhood depression, in which practice guidelines have been developed
for both adults and children with the disorder (American Academy of Child and Adolescent
Psychiatry, 1998; American Psychiatric Association, 2002). Treatment recommendations
vary based of many individual case factors such as the severity of the disorder, age/
developmental level of the individual, family involvement, motivation for treatment, and
comorbid features. These factors are considered when choosing the first route of treatment
as well as in treatment adjustment and maintenance. As is the case with all childhood
disorders, numerous child and environmental factors must be examined in order to obtain
appropriate guidelines that have a research base, but are also flexible enough to manage
complex cases complicate assessment and treatment.
NIH-PA Author Manuscript

References
Akshoomoff NA, Stahmer AC, Corsello C, Maher N. What happens next? Follow-up outcomes from
the Children’s Toddler School. J Posit Behav Interv. 2010; 12:245–253. [PubMed: 21113315]
American Academy of Child and Adolescent Psychiatry. Practice parameters for the assessment and
treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc
Psychiatry. 1998; 37(10 suppl)
American Psychiatric Association. Practice Guideline for the Treatment of Patients with Major
Depressive Disorder. American Psychiatric Press; 2002.
Anderson SR, Romanczyk RG. Early intervention for young children with autism: continuum-based
behavioral models. J Assoc Pers Severe Handicaps. 1999; 24:162–173.
Anderson DK, Lord C, Risi S, DiLavore PS, Shulman C, Thurm A, Welch K, Pickles A. Patterns of
growth in verbal abilities among children with autism spectrum disorder. J Consult Clin Psychol.
2007; 75:594–604. [PubMed: 17663613]
Arick JR, Young HE, Falco R, Loos LM, Krug D, Gense MH, Johnson SB. Designing an outcome
study to monitor the progress of students with autism spectrum disorders. Focus Autism Other Dev
Disabil. 2003; 18:75–87.
Baker-Ericzen M, Stahmer AC, Burns A. Association of child demographics with child outcomes in a
NIH-PA Author Manuscript

community-based pivotal response training program. J Posit Behav Interv. 2007:52–60.

Bondy AS, Frost LA. The picture exchange communication system. Behav Modif. 2001; 25:725–744.
[PubMed: 11573337]
Boulware G, Schwartz IS, Sandall SR, McBride BJ. Project DATA for toddlers: an inclusive approach
to very young children with autism spectrum disorder. Top Early Child Spec Educ. 2006; 26:94–
105.
Breiner J, Beck S. Parents as change agents in the management of their developmentally delayed
children’s noncompliant behaviors: a critical review. Appl Res Ment Retard. 1984; 5:259–278.
[PubMed: 6205627]
Brookman-Frazee L. Using parent/clinician partnerships in parent education programs for children
with autism. J Posit Behav Interv. 2004; 6:195–213.
Brown, JR.; Rogers, S. Cultural issues in autism. In: Ozonoff, S.; Rogers, S.; Hendren, RL., editors.
Autism Spectrum Disorders: A Research Review for Practitioners. American Psychiatric
Publishing, Inc; Washington, D.C: 2003.

Brain Res. Author manuscript; available in PMC 2014 May 20.

 Stahmer et al. Page 14

Charman T, Taylor E, Drew A, Cockerill H, Brown JA, Baird G. Outcome at 7 years of children
diagnosed with autism at age 2: predictive validity of assessments conducted at 2 and 3 years of
age and pattern of symptom change over time. J Child Psychol Psychiatry. 2005; 46:500–513.
NIH-PA Author Manuscript

[PubMed: 15845130]
Columbia Pacific Consulting. Preliminary report: cost–benefit analysis of Lovaas treatment for autism
and autism spectrum disorders (ASD). Harper Grey Easton Barristor and Soliciters. 1999
Croen LA, Grether JK, Selvin S. Descriptive epidemiology of autism in a California population: who
is at risk? J Autism Dev Disord. 2002; 32:217–224. [PubMed: 12108623]
Cunningham, AB. Unpublished master’s thesis. University of California; San Diego, La Jolla, CA:
2007. Individualization of treatment for young children with autism: a randomized comparison of
verbal and pictorial communication training strategies.
Cunningham, AB.; Schreibman, L.; Stahmer, AC.; Koegel, RL.; Koegel, LK. Individualization of
treatment for young children with autism: a randomized comparison of verbal and pictorial
communication systems. Paper presented at the 7th Annual International Meeting for Autism
Research; London, England. 2008 May.
Cunningham, AB.; Schreibman, L.; Stahmer, AC. Integrating treatment categories for children with
autism. Paper presented at the 9th Annual International Meeting for Autism Research;
Philadelphia, PA. 2010 May.
Dawson G, Rogers S, Munson J, Smith M, Winter J, Greenson J, Donaldson A, Varley J. Randomized,
controlled trial of an intervention for toddlers with autism: the Early Start Denver Model.
Pediatrics. 2010; 125:e17–e23. [PubMed: 19948568]
NIH-PA Author Manuscript

Delprato DJ. Comparisons of discrete-trial and normalized behavioral intervention for young children
with autism. J Autism Dev Disord. 2001; 31:315–325. [PubMed: 11518484]
Dunlap G. Consensus, engagement, and family involvement for young children with autism. JASH.
1999; 24:222–225.
Eikeseth S, Smith T, Jahr E, Eldevik S. Intensive behavioral treatment at school for 4- to 7-year-old
children with autism: a 1-year comparison controlled study. Behav Modif. 2002; 26:49–68.
(Special Issue: Autism, Part 2). [PubMed: 11799654]
Forehand R, Kotchick BA. Behavioral parent training: current challenges and potential solutions. J
Child Fam Stud. 2002; 11:377–384.
Garland AF, Hurlburt MS, Hawley KM. Examining psychotherapy processes in a services research
context. Clin Psychol. 2006; 31:30–46.
Greenspan SI, Weider S. Developmental patterns and outcomes in infants and children with disorders
in relating and communicating: a chart review of 200 cases of children with autistic spectrum
diagnosis. J Dev Learn Disord. 1997; 1:87–141.
Handleman, JS.; Harris, SL. Preschool Education Programs for Children with Autism. PRO-ED, Inc;
Austin, TX: 2001.
Harris, SL.; Handleman, JS., editors. Preschool Education Programs for Children with Autism. PRO-
ED; Austin, TX: 1994.
NIH-PA Author Manuscript

Horton L. The father’s role in behavioral parent training: a review. J Clin Child Psychol. 1984;
13:274–279.
Hough RL, Landsverk JA, Karno M, Burnam MA. Utilization of health and mental services by Los
Angeles Mexican Americans and non-Hispanic Whites. Arch Gen Psychiatry. 1987; 44:702–709.
[PubMed: 3632245]
Howard JS, Sparkman CR, Cohen HG, Green G, Stanislaw H. A comparison of intensive behavior
analytic and eclectic treatments for young children with autism. Res Dev Disabil. 2005; 26:359–
383. [PubMed: 15766629]
Howlin P, Goode S, Hutton J, Rutter M. Adult outcome for children with autism. J Child Psych
Psychiatry. 2004; 45:212–229.
Ingersoll B, Dvortcsak A. Including parent training in the early childhood special education curriculum
for children with autism spectrum disorders. J Posit Behav Interv. 2006; 8:79–87.
Ingersoll, B.; Dvortcsak, A. Teaching Social Communication to Children with Autism: A
Practitioner’s Guide to Parent Training. The Guilford Press; New York, NY: 2010.

Brain Res. Author manuscript; available in PMC 2014 May 20.

 Stahmer et al. Page 15

Ingersoll B, Stahmer AC, Schreibman L. Differential treatment outcomes for children with autistic
spectrum disorder based on level of peer social avoidance. J Autism Dev Disord. 2001; 31:343–
349. [PubMed: 11518487]
NIH-PA Author Manuscript

Ingersoll B, Dvortcsak A, Whalen C, Sikora D. The effects of a developmental, social-pragmatic

language intervention on rate of expressive language production in young children with autistic
spectrum disorders. Focus Autism Other Dev Disabil. 2005; 20:213–222.
Iovannone R, Dunlap G, Huber H, Kincaid D. Effective educational practices for students with autism
spectrum disorders. Focus Autism Other Dev Disabil. 2003; 18:150–165.
Koegel RL, Koegel LK, Surratt A. Language intervention and disruptive behavior in preschool
children with autism. J Autism Dev Disord. 1992; 22:141–153. [PubMed: 1378049]
Koegel LK, Koegel RL, Shoshan Y, McNerney E. Pivotal response intervention: II. Preliminary long-
term outcomes data. J Assoc Pers Severe Handicaps. 1999; 24:186–198.
Lonigan CJ, Elbert JC, Johnson SB. Empirically supported psychosocial interventions for children: an
overview. J Clin Child Psychol. 1998; 27:138–145. [PubMed: 9648031]
Lowenthal B. Early childhood inclusion in the United States. Early Child Dev Care. 1999; 150:17–32.
MacPhee D, Fritz J, Miller-Heyl J. Ethnic variations in personal social networks and parenting. Child
Dev. 1996; 67:3278–3295.
Mandell DS, Listerud J, Levy SE, Pinto-Martin JA. Race differences in the age of diagnosis among
Medicaid-eligible children with autism. J Am Acad Child Adolesc Psychiatry. 2002; 41:1447–
1453. [PubMed: 12447031]
Margison FR, Barkham M, Evans C, McGrath G, Clark JM, Audin K, Connell J. Measurement and
NIH-PA Author Manuscript

psychotherapy: evidence-based practice and practice-based evidence. Br J Psychiatry. 2000;

177:123–130. [PubMed: 11026951]
McCabe KM, Clark R, Barnett D. Family protective factors among urban African American youths. J
Clin Child Psychol. 1999; 28:137–150. [PubMed: 10353074]
McCabe K, Yeh M, Garland AF, Lau AS, Chavez G. The GANA program: a tailoring approach to
adapting parent child interaction therapy for Mexican Americans. Educ Treat Child. 2005; 28:111–
129.
McGee, GG.; Daly, T.; Jacobs, HA. The Walden Preschool. In: Harris, SL.; Handleman, JS., editors.
Preschool education programs for children with autism. Pro-Ed; Austin, TX: 1994. p. 127-162.
McGee GG, Morrier M, Daly T. An incidental teaching approach to early intervention for toddlers
with autism. J Assoc Pers Severe Handicaps. 1999; 24:133–146.
McGee, GG.; Morrier, MJ.; Daly, T. The Walden Preschool. In: Handleman, JS.; Harris, SL., editors.
Preschool Education Programs for Children with Autism. PRO-ED; Austin, TX: 2000. p. 157-190.
National Research Council. Educating Children with Autism. Committee on Educational Interventions
for Children with Autism. Division of Behavioral and Social Sciences and Education, National
Academy Press; Washington, DC: 2001.
Panerai S, Farrante L, Zingale M. Benefits of the Treatment and Education of Autistic and
Communication Handicapped Children (TEACCH) programme as compared with a non-specific
NIH-PA Author Manuscript

approach. J Intellect Disabil Res. 2002; 46:318–327. [PubMed: 12000583]

Rogers, SJ.; Dawson, G. Early start Denver model for young children with autism: promoting
language, learning, and engagement. The Guildford Press; New York: 2009.
Rogers SJ, Vismara LA. Evidence-based comprehensive treatments for early autism. J Clin Child
Adolesc Psychol. 2008; 3:8–38. [PubMed: 18444052]
Schreibman L. Intensive behavioral/psychoeducational treatments for autism: research needs and
future directions. J Autism Dev Disord. 2000; 30:373–378. [PubMed: 11098871]
Schreibman, L., editor. The Science and Fiction of Autism. Harvard University Press; Cambridge,
MA: 2005.
Schreibman, L.; Koegel, RL. Fostering self-management: parent delivered pivotal response training for
children with autistic disorder. In: Hibbs, E.; Jensen, P., editors. Psychosocial Treatments for Child
and Adolescent Disorders: Empirically based Strategies for Clinical Practice. American
Psychological Association; Washington, D.C: 1996. p. 525-552.

Brain Res. Author manuscript; available in PMC 2014 May 20.

 Stahmer et al. Page 16

Schreibman L, Stahmer AC, Cestone Barlett V, Dufek S. Brief report: toward refinement of a
predictive behavioral profile for treatment outcome in children with autism. Res Autism Spectr
Disord. 2009; 3:163–172. [PubMed: 20046210]
NIH-PA Author Manuscript

Schwartz IS, Sandall SR, McBride BJ, Boulware GL. Project DATA (Developmentally appropriate
treatment for autism): an inclusive school based approach to educating young children with
autism. Top Early Child Spec Educ. 2004; 24:156–168.
Sherer, MR.; Schreibman, L. Client treatment matching for children with autism. In: Schreibman, L.,
Chair, editor. Linking Assessment to Treatment for Children with Autism; Symposium conducted
at the 25th Meeting of the Association for Behavior Analysis; Chicago, IL. 1999 May.
Sherer MR, Schreibman L. Individual behavioral profiles and predictors of treatment effectiveness for
children with autism. J Consult Clin Psychol. 2005; 73:525–538. [PubMed: 15982150]
Shonkoff, JP.; Phillips, PA., editors. From Neurons to Neighborhoods: The Science of Early
Childhood Development. National Academy Press; Washington, DC: 2000.
Siegel, B. The World of the Autistic Child. Oxford University Press; New York: 1996.
Sigman M, Ruskin E. Continuity and change in the social competence of children with autism, Down
Syndrome, and developmental delays. Monogr Soc Res Child Dev. 1999; 64:1–114. [PubMed:
10412222]
Singh NN, Lancioni GE, Winton ASW, Fisher BC, Wahler RG, McAleavey K. Mindful parenting
decreases aggression, noncompliance, and self-injury in children with autism. J Emot Behav
Disord. 2006; 14:169–177.
Smith T, Groen AD, Wynn JW. Randomized trial of intensive early intervention for children with
NIH-PA Author Manuscript

pervasive developmental disorder. Am J Ment Retard. 2000; 105:269–285. [PubMed: 10934569]

Stahmer AC. The basic structure of community early intervention programs for children with autism:
provider descriptions. J Autism Dev Disord. 2007; 37:1344–1354. [PubMed: 17086438]
Stahmer AC, Ingersoll B. Inclusive programming for toddlers with autistic spectrum disorders:
outcomes from the Children’s Toddler School. J Posit Behav Interv. 2004; 6
Stahmer AC, Collings NM, Palinkas LA. Early intervention practices for children with autism:
descriptions from community providers. Focus Autism Other Dev Disabil. 2005; 20:66–79.
Stahmer AC, Akshoomoff NA, Cunningham AB. Inclusion for toddlers with autism spectrum
disorders: the first ten years of a community program. Autism. in press.
Stevens MC, Fein DA, Dunn M, Allen D, Waterhouse LH, Feinstein C, Rapin I. Subgroups of children
with autism by cluster analysis: a longitudinal examination. J Am Acad Child Adolesc Psychiatry.
2000; 39:346–352. [PubMed: 10714055]
Strain, PS.; Cordisco, LK. LEAP Preschool. In: Harris, SL.; Handleman, JS., editors. Preschool
Education Programs for Children with Autism. PRO-ED; Austin, TX: 1994. p. 225-244.
Strain, P.; McGee, G.; WKF. Early Childhood Inclusion: Focus on Change. Paul H. Brooks;
Baltimore, MD: 2001. Inclusion of children with autism in early intervention settings: an
examination of rationale, myths, and procedures.
Tager-Flusberg, H.; Paul, R.; Lord, C. Language and communication in autism. In: Cohen, D.;
NIH-PA Author Manuscript

Volkmar, F., editors. Handbook of Autism and Pervasive Developmental Disorders. Vol. 1. John
Wiley & Sons, Inc; New Jersey: 2005. p. 335-364.
Thurm A, Lord C, Lee LC, Newschaffer C. Predictors of language acquisition in preschool children
with autism spectrum disorders. J Autism Dev Disord. 2007; 37:1721–1734. [PubMed: 17180717]
Venter A, Lord C, Schopler E. A follow-up study of high-functioning autistic children. J Child Psychol
Psychiatry. 1992; 33:489–507. [PubMed: 1577895]
Webster-Stratton C. Predictors of treatment outcome in parent training for conduct disordered children.
Behav Ther. 1985; 16:223–243.
Winter J. Father involvement in parent training interventions for children with autism: effects of
tailoring treatment to meet the unique needs of fathers. Dissertation Abstracts International. 2006;
67:1751B.
Yoder P, Compton D. Identifying predictors of treatment response. Ment Retard Dev Disabil Res Rev.
2004; 10:162–168. [PubMed: 15611985]

Brain Res. Author manuscript; available in PMC 2014 May 20.

 Stahmer et al. Page 17

Yoder P, Stone WL. Randomized comparison of two communication interventions for preschoolers
with autism spectrum disorders. J Consult Clin Psychol. 2006a; 74:426–435. [PubMed: 16822100]
Yoder P, Stone WL. A randomized comparison of the effect of two prelinguistic communication
NIH-PA Author Manuscript

intervention on the acquisition of spoken communication in preschoolers with ASD. J Speech

Lang Hear Res. 2006b; 49:698–711. [PubMed: 16908870]
Yoder PJ, Warren SW. Maternal responsivity predicts the prelinguistic communication intervention
that facilitates generalized intentional communication. J Speech Lang Hear Res. 1998; 41:1207–
1219. [PubMed: 9771641]
NIH-PA Author Manuscript
NIH-PA Author Manuscript

Brain Res. Author manuscript; available in PMC 2014 May 20.

 Stahmer et al. Page 18
NIH-PA Author Manuscript

Fig. 1.
NIH-PA Author Manuscript

Strategy Integration at Alexa’s PLAYC. Legend: At Alexa’s PLAYC a structured

environmental approach and developmentally appropriate goals are infused throughout all
activities. If additional structure is needed teachers add behavioral strategies, beginning with
the least structured, and moving to more structure. Supports are faded as quickly as possible.
NIH-PA Author Manuscript

Brain Res. Author manuscript; available in PMC 2014 May 20.

 Stahmer et al. Page 19
NIH-PA Author Manuscript
NIH-PA Author Manuscript

Fig. 2.
Early Start Denver Model (ESDM) Alternative Communication Decision Tree. Legend: In
the ESDM model the team (which includes a speech language pathologist) follows the
decision tree to alter the teaching approach for children who appear unable to produce
speech with the typical intervention model. The decision tree is used in decision making
about what alternative or augmentative system to use. From: Early Start Denver Model for
Young Children with Autism, Rogers and Dawson, 2009. Copyright Guilford Press.
Reprinted with permission of The Guilford Press.
NIH-PA Author Manuscript

Brain Res. Author manuscript; available in PMC 2014 May 20.

 Stahmer et al. Page 20
NIH-PA Author Manuscript
NIH-PA Author Manuscript

Fig. 3.
Integration of teaching techniques from Teaching Social Communication Skills to Children
with Autism. Legend: Teaching Social Communication to Children with Autism calls for the
use of both Interactive Techniques and the Direct Teaching Techniques together. The figure
illustrates that the interactive techniques provide the background for all of the teaching
techniques, with more directive techniques being used within the interactive techniques to
teach new social-communication skills. From: Teaching Social Communication to Children
with Autism, Ingersoll and Dvorszak, 2010. Copyright Guilford Press. Reprinted with
permission of The Guilford Press.
NIH-PA Author Manuscript

Brain Res. Author manuscript; available in PMC 2014 May 20.

 Stahmer et al. Page 21
NIH-PA Author Manuscript

Fig. 4.
NIH-PA Author Manuscript

Mean percentage of language use at intake and 6 months for high peer avoiders (HPA), low
peer avoiders (LPA) and typical peers (TP). Legend: In the Alexa’s PLAYC program,
children who were less avoidant of peers had greater improvement in language skills than
children who were avoidant of peers at entry. With kind permission from Springer Science
+Business Media: Journal of Autism and Developmental Disorders, Differential treatment
outcomes for children with autistic spectrum disorder based on level of peer social
avoidance, 31, 2001, 347, Brooke Ingersoll, Aubyn C. Stahmer and Laura Schreibman, Fig.
2.
NIH-PA Author Manuscript

Brain Res. Author manuscript; available in PMC 2014 May 20.