Students will use the Library to search for an empirical study on an intervention used in behavioral practice. ?The article must be on an intervention to teach verbal behavior. When

The Psychological Record, 2012, 62, 165–186

We would like to acknowledge and thank the financial support that we have received during this doctoral dissertation. We extend our thanks to the Social Sciences and Humanities Research Council of Canada, the Fonds Québécois de Recherche sur la Société et la Culture, the Eleanor Cote Foundation, and the Consortium National de Recherche sur l’Intégration Sociale. We also want to thank Dr. Normand Giroux, Kelly Kerr, and Gisela Regli for their support, and we extend our gratitude to the Centre de Réadaptation Montérégie-Est, especially to Gilles Lemaire, Sylvie Gladu, and the therapists, parents, and children who participated in this study.

Correspondence concerning this article should be addressed to Mélina Rivard, Université du Québec à Montréal, C.P. 8888, Succursale Centre-ville, Montréal (Québec), Canada H3C 3P8. E-mail: melina. [email protected]

VERBAL BEHAVIOR IN YOUNG CHILDREN WITH AUTISM SPECTRUM DISORDERS AT THE ONSET OF AN EARLY

BEHAVIORAL INTERVENTION PROGRAM

Mélina Rivard and Jacques Forget Département de Psychologie, Université du Québec à Montréal

The scope of this study was direct observation of verbal behaviors of 14 children with autism spectrum disorders at the onset of an early behavioral intervention (EBI) program delivered in a public services agency. Objectives were to (1) de- scribe frequencies of vocal, verbal, and listener behaviors; (2) evaluate the rela- tionship between the behaviors and the children’s level of functioning (IQ and severity of autistic symptoms); and (3) describe the types of consequences pro- vided by EBI therapists following the children’s behaviors. The descriptive and statistical analysis of the data showed that 3 profiles of children were distinctive- ly different in vocal, verbal, and listener behaviors. The results concerning the consequences contingently delivered by therapists to those behaviors show that 65% were followed by positive attention, 5% by negative attention, and 30% by no attention. Results led to recommendations for planning EBI programs, where therapists are not formally trained in verbal behavior analysis. Key words: verbal behaviors, autism spectrum disorders, early behavioral intervention

One of the characteristic manifestations of autism spectrum disorders (ASDs) is the presence of a language deficit (Tager- Flusberg, Paul, & Lord, 2005). Some children with ASDs develop language more or less normally but have a delay in socially functional language and rarely use language to initiate social interaction (Rogé, 2003; Stone & Caro- Martinez, 1990). Furthermore, their speech seems lacking in spontaneity (Greer & Ross, 2004; William & Greer, 1993), and these children do not spontaneously use other appropriate methods of communication that could compensate for language limitations (Rogé, 2003). As mentioned by Tager- Flusberg, Paul, and Lord (2005), even among children with ASDs who acquire some functional language, there is significant variability in their rate of progress. Nevertheless, although language deficits may vary in ASDs, there are also similarities in language limitations among individuals with ASDs, such as echolalia and palilalia (Greer & Ross, 2004).

166 RIVARD AND FORGET

The assessment tools used to measure language competencies, variations, and simi- larities among children with ASDs are mainly standardized instruments. These molar assessments present some advantages but also some disadvantages, such as a lack of sensi- tivity required to capture subtle improvements during treatment (Granpeesheh, Dixon, Tarbox, Kaplan, & Wilke, 2009). These tests may also not be reflective of the language behavior demonstrated by children in everyday situations, where interactions with signifi- cant people might affect their language use. Test performance may not be constructive in assisting the instructional purposes on a day- to- day basis (Greer & Ross, 2008). Another challenge in ASD language research lies in the fact that the language abilities of many preschoolers with ASDs are so poor that formal language tests cannot capture the compe- tencies of these children or the variations among them (Charman, 2004).

Descriptive analysis and direct observation are methods that appear to provide a good ecological validity compared to evaluation through standardized testing and may therefore be more sensitive and representative of real behavior patterns (Bijou, Peterson, & Ault, 1968; Bloom, Fisher, & Orme, 2003; Cooper, Heron, & Heward, 2007). Direct measures of behavior give a very fine- grained picture of what children can do in a particular context (Granpeesheh et al., 2009). Different groups of clinicians and researchers have used Skinner’s analysis of language to observe, describe, and teach the functions of verbal behaviors for children and adults with ASDs (McGreevy, 2009). As mentioned by Greer and Ross (2008), verbal behavior analysis is suited for identifying verbal developmental capabilities, creating curricula for children with or without language deficits, and provid- ing environmental or teaching interventions to establish functional verbal repertoires.

Skinner’s Verbal Behavior In his book Verbal Behavior, Skinner (1957) defined language as a learned behavior

that is established by its antecedents and its consequences in the same manner that nonver- bal behavior is acquired. In examining the function of language, verbal behavior analysis focuses on the effect of the speaker on the behavior of the listener, and the effect of the listener on the behavior of the speaker, rather than on language structures alone (Greer, 2008; Sundberg & Michael, 2001). A single word may serve different functions. For exam- ple, “apple” could be vocalized to ask for food, to label an image, or to answer the question, “What is your favorite food?” The analysis of language by its functions is different from the analysis of language by its structures or parts of speech (Greer & Ross, 2008). Also, recent studies on verbal behavior show that although speaker responses (production response) and listener responses (observing response) are initially developmentally inde- pendent, their integration plays a crucial role in the successful language development of children (Greer & Speckman, 2009).

Different verbal behaviors are acquired during the course of development, each with a specific function, which Skinner termed verbal operants. Skinner initially identified five primary verbal operants: mand, tact, textual, intraverbal, and echoic. These verbal oper- ants may occur in various topographies (e.g., sign language, logographic symbols, vocal language) and are not limited to vocal or oral language (Greer, 2008; Greer & Speckman, 2009). In the verbal behavior analysis, there are also basic listener responses that the child has to integrate to be truly verbal, such as responding to vocal verbal instructions (Greer & Speckman, 2009).

The starting point in the development of a verbal behavior intervention plan for children with ASDs is the mand (Brady, Saunders, & Spradlin, 1994; Drash, High, & Tudor, 1999; Sundberg & Michael, 2001). This functional class of verbal operant includes demands, requests, orders, instructions, questions, warnings, and appeals. Mands are controlled by establishing operations, which are environmental events, operations, or stimuli that affect the speaker by momentarily altering the reinforcing or punitive value of other events and affect the probability of eliciting a behavior in the speaker’s repertoire that has already been reinforced by these other events (Hersen, 2005; Michael, 1982, 1985, 1988, 1993). The mand

167VERBAL BEHAVIORS IN CHILDREN WITH AuTISM

allows the speaker to benefit directly from his behavior (Stafford, Sundberg, & Braam, 1988). For example, a child who is hungry (an establishing operation) asks for an apple (a mand) and receives an apple (a specific reinforcer). This operation increases the probability that the child will emit a mand to obtain food when he is hungry in the future.

unlike mands, the four other primary verbal operants are controlled by discriminative stimuli and are maintained by nonspecific consequences, such as social attention and tan- gible reinforcers (Skinner, 1957). Tacts refer to the use of words as labels and are con- trolled by natural discriminative stimuli or concrete components of the environment, such as objects or images. However, there is some evidence that there are establishing opera- tions for tacts (Tsiouri & Greer, 2003). Tacts are reinforced by generalized reinforcers, such as attention or confirmation (Greer & Ross, 2008).

Textuals refer to reading behaviors and are controlled by symbolic discriminative stimuli, such as written words. Here, there is no formal similarity, but there is point- to- point correspondence between the discriminative stimulus and the verbal response. Textuals are under the control of printed words (Greer & Ross, 2008).

Intraverbals are controlled by the verbal behavior of other speakers. They are verbal responses related to, but not identical to, the verbal antecedents presented by another speaker. Intraverbals can occur as exchanges between two speakers or as part of a verbal chain (Greer & Ross, 2008). Conversation and responding verbally to questions are exam- ples of intraverbals.

Echoics are also controlled by the verbal behavior of other speakers but have point- to- point correspondence and formal similarity with the verbal stimuli (Greer & Speckman, 2009; Skinner, 1957). A typical example of an appropriate echoic is when a young child repeats a word that is hard to pronounce after being prompted by her parent. An example of an inappropriate echoic is if a child repeats words of an instruction several times without actually responding to the instruction itself. Here lies the distinction between vocal verbal behavior and vocal nonverbal behavior. According to Skinner (1957), a pathological echoic is seen in echolalia, in which a bit of speech is repeated once or many times. Echolalia, defined by Greer and Ross (2008), is an inappropriate immediate repetition of a proximate verbal antecedent. Other examples of nonverbal vocal behaviors are parroting (repeating verbal stimuli) and babbling (reproducing phonemic sounds of caregivers’ speech), which occur in the early stages of speaker development and automatically reinforce themselves (Greer, 2008). It is clear that vocal language is not necessarily verbal.

While Skinner (1957) emphasized that the verbal operants were independent from each other (Greer & Speckman, 2009; Lamarre & Holland, 1985), more recent research has shown that the acquisition of one operant can facilitate the acquisition of other oper- ants (Egan & Barnes- Holmes, 2009; see Grow & Kodak, 2010). Even so, learning a spe- cific verbal operant does not necessarily lead to learning other verbal operants (Shafer, 1994), and separate instructional operations may be required (Greer & Ross, 2008). In addition, verbal operants acquired under the control of a discriminative stimulus are not necessarily transferred to the control of establishing operations (Lamarre & Holland, 1985; Sundberg, Loeb, Hale, & Eigenheer, 2002). For example, the acquisition of listener responses, such as a response to the demand of a therapist in an early intervention program based on discrete trial teaching (e.g., S- R- C sequence), is not necessarily transferred to speaker responses that are consequents of establishing operations. Intervention programs that target these various language functions must therefore take into consideration every determining variable for a specific operant and explicitly teach those functions according to those variables. This also highlights the importance of considering a combination of early intervention strategies, such as discrete trial teaching and other applied behavior analysis (ABA) verbal behavior techniques (Fava & Strauss, 2011). As mentioned by Hall and Sundberg (1987), the first behavioral studies on language assumed that teaching the denomination of words and sentences led to appropriate, functional language. However, this method did not necessarily lead to spontaneous communication or to the initiation of interaction.

168 RIVARD AND FORGET

Applications of Verbal Behavior Analysis Several authors have applied Skinner’s analysis and adapted his language classifica-

tion to a variety of client groups or different learning contexts. Sundberg and Partington (1998), for example, translated the elementary verbal behaviors into several operational language skills and created an evaluation and intervention tool from this model called the Assessment of Basic Language and Learning Skills (ABLLS). The ABA- Verbal Behavior Program of McGreevy (2009) is based on teaching appropriate verbal behaviors as alterna- tives to socially mediated problem behaviors. In this sense, language is a pivotal behavior in social interactions and can be an appropriate alternative to inappropriate behaviors, such as physical aggression toward others or self- injurious behaviors, which serve the function of communicating something to people in the environment (Vismara & Rogers, 2010). Many empirical studies have focused on the impact of functional communication training, particularly mand training, as a treatment for challenging behaviors (Hanley, Iwata, & Thompson, 2001; see McGreevy, 2009; Roane, Fisher, Sgro, Falcomata, & Pabico, 2004). A study by Chu (1998) showed that teaching children with ASDs how to mand decreased the frequencies of physical assaults. Another example of an application of Skinner’s theory is the Comprehensive Application of Behavior Analysis to Schooling (CABAS) model, in which the findings from naming, relational frame theory, stimulus equivalence, develop- mental psychology, and verbal development research are integrated into a theory of verbal development (Greer, 2008; Greer & Speckman, 2009). CABAS provides a program of research in this field that identifies ways to join Skinner’s method, incidental teaching, and other strategies based on research (Greer & Keohane, 2005; Greer & Ross, 2004, 2008).

In conclusion, the contributions and benefits of verbal behavior intervention for chil- dren with language disabilities, such as ASDs, are well documented (see Greer, 2008) and could be strategically used in combination with other forms of intervention, such as early intensive behavioral intervention (EIBI; e.g., Lovaas, 1981), in order to help a child become truly verbal.

Contributions of the Present Study Despite the scientific and clinical scope of verbal behavior studies, many of those

studies are typically interested in describing a limited number of verbal operants in Skinner’s model or the effect of one specific intervention on the development of a certain function. A paper by Dixon, Small, and Rosales (2007) analyzing recent work on verbal operants revealed that empirical applications of Skinner’s analysis of verbal behavior tended to focus mainly on the study of mands and tacts. However, more recent research in the field, in particular the CABAS model (Greer, 2008; Greer & Ross, 2008), has combined all the verbal operants into a more comprehensive approach to the language acquisition of children with ASDs. Yet, to our knowledge, no studies have attempted a descriptive analy- sis of vocal behavior in a sample of young children with ASDs to determine how the behaviors correspond to all five primary verbal operants described by Skinner and whether they are contextually appropriate or inappropriate.

As mentioned by Greer and Ross (2008), studies on EIBI (e.g., Lovaas, 1987) have shown that while this form of intervention provides effective training procedures for chil- dren with ASDs, EIBI shows fewer gains in obtaining generalization of trained language to natural and everyday settings. Though studies have shown that EIBI programs (e.g., Lovaas, 1987) lead to significant gains in children’s development and learning in areas such as intellectual functioning, adaptive behaviors, independence, social skills, and aca- demic performance (Eikeseth, Smith, Jahr, & Eldevik, 2002; Makrygianni & Reed, 2010; Ospina et al., 2008; Perry et al., 2011; Remington et al., 2007), communication behaviors are the most resistant to intervention. To our knowledge, no studies have attempted to describe the language of children with ASDs using observation of verbal behaviors during an EIBI context, to determine if verbal operants are promoted in discrete trial teaching, or

169VERBAL BEHAVIORS IN CHILDREN WITH AuTISM

to describe the listener (EIBI therapist) responses that mediate the children’s verbal behav- ior in an EIBI context. This kind of data could help to suggest ways of integrating both discrete trial training and incidental or naturalistic (e.g., verbal behavior) language inter- ventions. In addition, there is little known about the relationship between the acquisition of verbal operants in ASDs and the individual characteristics of children, such as intellectual functioning.

The present empirical study set out to fill these gaps in the literature on verbal behav- ior analysis. It presents a description of the five primary verbal behaviors in 14 young children with ASDs occurring naturally in an early behavioral intervention (EBI) context. It analyzes the relations between verbal behavior patterns and the children’s various char- acteristics and describes the behaviors of the therapists occurring naturally and contin- gently to the verbal behavior of the children, as contingencies that affect the speaker behaviors of the children.

The first objective of the study was to analyze the vocal behavior of 14 children with ASDs ages 3 to 5 years at the onset of an EBI program, along the following parameters: (a) describe the frequencies of the five primary verbal operants proposed by Skinner (1957), the vocal nonverbal behaviors, and the listener behaviors; (b) determine whether the target behaviors were emitted in contextually appropriate or inappropriate ways; and (c) identify the similarities and the differences among the participants’ verbal behavior patterns. The second objective was to evaluate the correlations between the vocal, verbal, and listener behaviors with the severity of the autistic profile and the children’s intellectual function- ing. The third objective was to describe the behaviors of the therapists occurring naturally and contingently to verbal, vocal, and listener behaviors of the children during the community- based EBI program.

Method

Research Design This was an observational and single case study. The target behaviors of the partici-

pants were observed in their naturally occurring EBI contexts. There were no manipula- tions or modification of the intervention program of the public developmental services agency for the study. The EBI therapists were not given instructions with regard to the research project and did not know the specific objectives of the study. Intraindividual analyses of the observational data, post hoc statistical analyses of group data, and correla- tions were used.

Participant Characteristics The 14 children participating in this study were starting an EBI program delivered a

by a public developmental service agency in a French province of Canada (Quebec). The language of instruction for all participants in the program was French. Each participant had a prior diagnosis of ASD, and a multidisciplinary team that included a child psychia- trist confirmed each diagnosis. All participants were being served by the same develop- mental service agency, in the same EBI program. None of the children had received any language intervention or other intervention services prior to the study. The participants were between 3 and 5 years of age at the onset of the study. Table 1 gives each participant’s age; gender; Wechsler Preschool and Primary Scale of Intelligence Full Scale IQ (FSIQ), Verbal IQ (VIQ), and Performance IQ (PIQ); and scores on three indices of severity of autistic symptoms, from the Childhood Autism Rating Scale, the Gilliam Autism Rating Scale, and the Gilliam Asperger Disorder Scale. All children starting the EBI program at the developmental service agency in September 2007 were solicited for this study, with 87.5% acceptance.

170 RIVARD AND FORGET

Table 1 Participants’ Descriptions Participant Age Gender FSIQ VIQ PIQ CARS GARS GADS

1 3-5 M 45 52 55 44 103 N/A 2 4-6 M 60 60 69 36 91 N/A 3 3-2 F 68 66 77 30 81 N/A 4 3-4 M 111 100 121 25 74 52 5 3-1 M 117 111 118 22.5 64 72 6 4-6 M 51 52 67 38 96 N/A 7 4-8 M 67 54 83 34 72 N/A 8 4-5 M N/A N/A N/A 36.5 91 N/A 9 4-11 M N/A N/A N/A 36.5 76 N/A 10 4-0 F 57 58 77 37.5 100 N/A 11 4-2 M 44 52 53 44.5 117 N/A 12 4-5 M 44 52 53 31 83 N/A 13 3-1 M 79 64 89 31 83 N/A 14 4-3 M N/A N/A N/A 48.5 115 N/A

Note. FSIQ = Full Scale IQ from Wechsler Preschool and Primary Scale of Intelligence (WPPSI–III; Wechsler, 2002); VIQ = Verbal IQ from WPPSI–III; PIQ = Performance IQ from WPPSI–III; CARS = Childhood Autism Rating Scale (Schopler, Reichler, & Rochen Renner, 1988); GARS = Gilliam Autism Rating Scale (Gilliam, 1995); GADS = Gilliam Asperger Disorder Scale (Gilliam, 2001); N/A = not available.

Settings The community- based EBI program consisted of one- on- one (one child to one thera-

pist ratio) therapy in each participant’s public kindergarten. Each participant had two therapists during the year of the EBI program: a principal therapist who gave two thirds of the sessions and another therapist who gave one third of the sessions. The number of hours of intervention per week per participant varied from 10.5 to 17.38 hr, with a mean of 14.46 hr.

Observation sessions for the present study were carried out during the first 7 weeks of the EBI program and took place in each participant’s EBI room: a small room containing a child- sized table and chair and few stimuli other than the material used for the interven- tion. During these sessions, the therapist worked one- on- one with the participant, with the exception of the presence of a research observer with a handheld camera in the corner of the room. This observer did not interact with the therapist or the participant during the observation sessions.

The structured activities used by the therapists with the participants during the observa- tion periods were those recommended in the developmental service agency’s EBI program. The basic structure of the program was based on the intensive behavioral intervention (IBI) curriculum of Lovaas (1987) and principally focused on discrete trial training. The term IBI is not used in the present study because the researchers could not control the various IBI parameters, namely the intensity of teaching. The EBI program followed the criteria of the National Research Council (2001) for early intervention programs: an early start, active engagement of the child, use of a structured curriculum that includes specific objectives, intervention priority on direct teaching of basic skills, procedures for generalizing learning, individualized intervention, low therapist–child ratio, parental involvement, specialized therapist training, and ongoing assessment of the child’s progress. The therapists were not formally trained in applied verbal behavior analysis, such as in the programs of Greer and Ross (2008), McGreevy (2009), or Sundberg and Partington (1998).

Two research ethics committees evaluated this study: the university Research Ethics Board at the researchers’ university (université du Québec à Montréal) and the Joint Research Evaluation Committee at the public developmental services agency in Quebec, the Canadian province where the research was carried out.

171VERBAL BEHAVIORS IN CHILDREN WITH AuTISM

Measures Observations of vocal, verbal, and listener behaviors. The target behaviors were

selected via a direct observation grid created and validated for the current study. A com- mittee of five experts in ASDs, language, and ABA completed a content analysis and vali- dation of the grid, which was trialed on the videotaped observations of nine children with ASDs (not the participants in the present study) in their family settings. This process enabled the researchers to identify 13 target behaviors for the participants of the current study and nine target behaviors for the therapists, which served as antecedents or conse- quences for the participants’ behavior.

The target verbal operants for each participant as a speaker were mand, tact, intraver- bal, echoic, and textual. Each mand, tact, intraverbal, or textual operant was coded as either contextually appropriate or contextually inappropriate. Contextually appropriate verbal behavior occurred when the participant’s speech was socially appropriate (e.g., the child manded for milk during an activity by saying, “Burrhus, I want milk”) and/or was emitted in a correct manner (e.g., the participant said “bear” when he saw a bear in his book). Contextually inappropriate verbal behavior occurred when the participant’s speech was socially inappropriate (e.g., if the participant manded “stop the activity” by pushing the therapist) and/or was emitted in an incorrect way (e.g., the participant said “cat” when she saw a snake). Two other kinds of vocal behaviors that do not correspond to verbal func- tions were also targeted: babbling and vocal stereotypy. In order to record each partici- pant’s capacity to understand the verbal instructions/demands of her therapist and her ability to respond as a listener, two forms of listener behaviors were also targeted: appro- priate nonverbal response to a request and inappropriate nonverbal response to a request. Table 2 presents and briefly defines the 13 target behaviors for the participants.

It is important to note that in the case of the mand, the observation system did not include the distinction between pure and impure mands. In the context of this observa- tional study, the researchers had no control over establishing operations, and some of these variables were difficult to measure (e.g., thirst, hunger). To make the distinction between mands and other operants, the observers noted the antecedents and consequences for each behavior, recorded all words or sentences emitted, and then made a decision about which code should be accorded.

The nine target behaviors for the therapists as listeners and speakers (i.e., the anteced- ents and consequences of the participants’ behaviors) were request/demand (D: the thera- pist made a request to the participant to obtain a verbal or nonverbal response; e.g., giving instructions, asking the participant to sit on her chair, asking a question); environment (E: a change in environment preceded or followed the participant’s target behavior, or the participant’s target behavior generated a change in the environment; e.g., a fork fell on the floor before the child said, “The fork fell”); verbal reprimand (Rv: the therapist repri- manded the participant or made a negative comment about what the participant was doing; e.g., the therapist raised his voice when the participant made a mistake, the therapist threat- ened to withdraw a toy if the child would not stop screaming); withdrawal of privilege (Rp: the therapist withdrew something [e.g., a toy, food, an activity] because the participant was doing something particular. This category was also used when the participant was in a time- out); no attention (−: when the participant engaged in a target behavior, the therapist gave no attention to the child before or after the behavior); social reinforcer (Rs: before or after the participant’s target behavior or in response to a request, the therapist gave her a social reinforcer, such as smiling, a hug, or a positive comment); material reinforcer (Rm: before or after the participant’s target behavior or in response to a request, the therapist gave him something that was known to be an object of reinforcement, such as food, a toy, or a token); verbal behavior (Vb: the therapist engaged in verbal behavior other than Rs or Rv before or after the child’s target behavior; e.g., the participant asked about the next activity and the therapist responded, the therapist made a comment about what she saw in a book and the participant agreed).

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Table 2 Operational Definitions of Target Verbal Behaviors for Participants

Behavior Operational definition

Verbal operant

Ma: appropriate mand Makes a contextually appropriate request that specifies the reinforcer delivered by the listener (e.g., verbally asks to have an apple, gives his therapist a picture of his favorite toy to request it).

Mi: inappropriate mand

Makes a contextually inappropriate request (e.g., requests to stop an activity by biting her hand, requests to play with his therapist by hitting the therapist’s leg).

Ec: echoic Repeats words or sentences after a verbal stimuli. The vocal response of the participant has point-to-point correspondence and formal similarity with the verbal stimuli (e.g., repeats the word dog when his therapist presents a picture of dog).

Ta: appropriate textual

Adequately reads words or sentences. The textual is under the control of printed words (e.g., reads her name on a ticket, reads a word on a flash card).

Ti: inappropriate textual

Inadequately reads words or sentences (e.g., does not read the right letters on a flash card, does not pronounce the right word on a ticket).

Ia: appropriate intraverbal

Has a contextually appropriate and coherent conversation or makes a contextually appropriate remark. There is no point-to-point correspondence with the previous verbal stimuli of the therapist (e.g., explains to

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