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LEARNING AS A FUNCTION OF EVENT PARTICIPATION
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LEARNING AS A FUNCTION OF EVENT PARTICIPATION
AMONG CHILDREN DIAGNOSED WITH AUTISM SPECTRUM DISORDER

By

Susan Olney Latham

A DISSERTATION
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of
DOCTOR OF PHILOSOPHY
Department of Communicative Sciences and Disorders

2007

ABSTRACT

LEARNING AS A FUNCTION OF EVENT PARTICIPATION
AMONG CHILDREN DIAGNOSED WITH AUTISM SPECTRUM DISORDER

By

Susan Olney Latham

Little empirical treatment outcome research exists for children diagnosed
with Autism Spectrum Disorder (ASD). There is a critical need to understand the
nature of Ieaming in children diagnosed with ASD so effective treatments can be
designed and implemented. This study demonstrated the differential effects of
two intervention conditions on verbal and nonverbal Ieaming within the context of
a novel event structure. The two treatment conditions were labeled as the
observation and the participation conditions. Thirty-four children, diagnosed with
ASD, were matched and randomly assigned to one of two teaching conditions.
The seventeen children assigned to the observation condition received visual
and auditory input while observing a juice-making task. The seventeen children in
the participation condition received visual, auditory, and tactual-kinesthetic input
while they participated in making orange juice. Six measurements were used to
evaluate participant learning. Four of them evaluated verbal Ieaming and two
evaluated nonverbal learning. The verbal measures, obtained at four different
points in time, were comprised of three types of questions: (1) confrontational
naming, (2) recognition, and (3) WH-questions. Two nonverbal measures, a
nonverbal score and a nonverbal rating, were obtained at two points in time.

Significant differences found between the two treatment conditions were

observed on both the verbal and nonverbal measures. Analyses revealed that
the participation group scores were significantly higher than the scores of the
observation group on all four composite verbal measures across time. An item
analysis revealed further that the participation group scored significantly higher
than the observation group on every question type. Additionally, on both the
nonverbal score and rating measures, significant differences were demonstrated,
favoring the participation group.

It is concluded that the type of sensory input impacts both verbal and
nonverbal Ieaming for children with ASD. The findings suggest that one cannot
dismiss the relevance of manually guided experiences for the child with ASD.
These outcomes are promising for continuing to explore the possible Ieaming

gains that can result when children with ASD bodily participate in Ieaming events.

To those who gave my journey a beginning:
My Parents, Blaine and Louise Olney
To those who gave my journey meaning:
Jay, Wilkin, and Hattie
And to those who have given my journey into autism a purpose:

All the Families of Children with Autism with Whom I have Worked

iv

ACKNOWLEDGMENTS

This dissertation is the result of many people providing assistance and
support. First, I would like to thank the chair of my Guidance Committee, Dr. Ida
J. Stockman, for her unwavering dedication, invaluable advice, and continual
support throughout this process. Most of all, I appreciated her understanding the
complex demands placed upon women and for supporting my priorities.

I would also like to thank my Guidance Committee members, Dr. Paul
Cooke, Dr'. Martha W. Bristor, Dr. Crystal F. Branta, and Dr. Holly E. Brophy-
Herb for their time, input, and incredible patience during this research project. I
feel so fortunate to have been a student of each of these remarkable individuals.

I would also like to thank the teachers, speech and language pathologists,
staff, administrators, families, and children in Berrien County, Michigan who
participated in this research project. I am grateful for the opportunity to have met
and worked with each of you.

I would also like to express my gratitude to all the individuals who helped
in the long and arduous task of data collection: Rhonda Rockhill, Elizabeth
Schmuhl, Sue Kolhagen, Sally Schmuhl, Jason Latham, and Louise Olney. This
listing is composed of family and friends, and is a minimal representation of those
who provided ongoing support and encouragement. Equally, everyone listed did
far more than help in data collection. Truly, without my family and friends, this
dissertation would not have been possible. I am incredibly grateful for the

continuous support and unconditional love each of you has provided me. I am

most grateful to my parents, Blaine and Louise Olney, my husband, Jay, and my
children, Wilkin and Hattie. What shall our next adventure be?
This study was supported by a Dissertation Completion Grant from the

College of Communication Arts and Sciences at Michigan State University.

vi

TABLE OF CONTENTS

Page
LIST OF TABLES ................................................................... xii
LIST OF FIGURES ................................................................. xiii
CHAPTER 1: REVIEW OF THE LITERATURE AND
STATEMENT OF THE PROBLEM FOR STUDY ............ 1
Characteristics of the Population ......................................... 3
Issues in Defining the Population ................................ 3
Symptoms ............................................................. 5
Learning Ability .............................................. 5
Sensorimotor Symptoms .................................. 6
Cognitive Symptoms ....................................... 9
Language Symptoms ..................................... 10
Social Symptoms .......................................... 10
Importance of Studying ASD ............................................. 12
Increased Incidence ............................................... 12
Provision of Resources and Legal Entitlement ............. 14
Cost of Intervention ................................................ 16
Intervention Models ......................................................... 17
Indirect Treatments ................................................ 18
Direct Treatments .................................................. 19
Conventional Methods ................................... 19
Applied Behavior Analysis (ABA) ............. 21
Treatment and Education of Autistic
and related Communication
Handicapped Children
(T EACCH) .................................. 21
Developmental, Individual Differences,
Relationship-based Approach
(DIR) .......................................... 22
Picture Exchange Communication
System (PECS) ........................... 22
Unconventional Methods ................................. 23
Sensory integration ............................... 23
Facilitated communication ....................... 24
Prompts for Restructuring Oral Muscular
Phonetic Targets (PROMPT) .......... 25
Guided Interaction Therapy (GIT) ............. 25
Issues in Clinical Efficacy ................................................... 27
Grounded or Situational Efficacy ................................ 30

vii

Theoretical Efficacy .................................................. 32

Empirical Efficacy .................................................... 34
Ecological Efficacy .................................................. 35
Statement of the Problem .................................................. 35
Seminal Research in a New Paradigm ......................... 37
The Need for Further Research .................................. 44
Purpose of Investigation .................................. 46
Research Hypotheses ..................................... 46
CHAPTER 2: RESEARCH DESIGN AND METHODS ...................... 47
Participants .................................................................... 47
Description of Participants ........................................ 47
Participant Selection Criteria ..................................... 48
Participant Selection Procedures ............................... 49
Recruitment procedures ................................. 49
Screening procedures .................................... 49
Human participant assurances ......................... 51
Participant assignment to treatment conditions....52
Description of Experimental Procedures ............................... 53
Task Selection ....................................................... 53
Stimulus Description ............................................... 54
Nonverbal stimuli and task .............................. 54
Verbal stimuli and task ................................... 56
Data Collection Procedures ............................................... 58
Overview .............................................................. 58
Task Administration ................................................ 58
The observation group ................................... 58
The participation group ................................... 60
Recording the Data ................................................. 62
Measuring of Learning Effects ............................................ 62
Description of Verbal Measures ................................ 63
Confrontational naming task ............................ 63
Recognition task ........................................... 64
WH-questions task ......................................... 65
Description of Nonverbal Measures ............................ 66
Nonverbal score ........................................... 66
Nonverbal rating ........................................... 67
Data Analysis ................................................................. 67
Raters .................................................................. 67
The rating task .............................................. 67
Training the raters ......................................... 68
Scoring Verbal Performance ..................................... 68
Scoring Nonverbal Performance ................................ 69
Nonverbal scoring and analysis
Procedures .......................................... 69

viii

Nonverbal rating and analysis

Procedures ....................................... 70

Statistical Analysis ........................................................ 71
Computation of Scores .......................................... 71
Statistical Tests .................................................... 71
CHAPTER 3: RESULTS .......................................................... 73
Verbal Perforrnanoe ....................................................... 74
Reliability of Individual Raters ................................. 74
Composite Verbal Total Scores Analysis ................... 76
Between-group comparison ........................... 77

Within—group comparison .............................. 77

Verbal Task Analysis ............................................. 78
Task-by—Time Analysis .......................................... 80
Item-by-Item Analysis ............................................ 82
Confrontational naming questions ................... 82

Recognition questions .................................. 86
Wh-Questions ............................................. 89

Summary of Verbal Performance ............................. 94
Nonverbal Performance .................................................. 95
Composite Non-Verbal Score .................................. 95
Between-group comparisons .......................... 96

Within-group comparisons ............................. 96

Composite Nonverbal Rating .................................. 97
Between group comparisons .......................... 98

Within group comparisons ............................. 98

Summary of Nonverbal Performance ........................ 98
General Conclusion ........................................................ 99
CHAPTER 4: DISCUSSION ................................................... 100
Study Outcomes and Explanatory Factors ......................... 101
Verbal Learning .................................................. 101
Confrontational Naming ............................... 102

Task description ............................... 102

Expected performance ....................... 102

Overall outcomes .............................. 103

Phonetic explanation ......................... 103

Semantic explanation ........................ 105

Syntactic explanation ......................... 107

Recognition Task ....................................... 107

Task description ............................... 107

Expected perforrnanoe ....................... 107

Outcomes ....................................... 107

WH-Question Task ..................................... 109

Task description ............................... 109

Expected performance ....................... 109

ix

Outcomes ........................................ 109

Nonverbal Learning ............................................. 1 1 1

Nonverbal Score and Rating ........................ 111

Task description ............................... 111

Expected performance ....................... 1 11

Outcomes ....................................... 1 12

Time ................................................................. 1 13

Implications for Clinical Praxis ........................................ 114
Implications for Future Research ..................................... 116
Differences Within the ASD Population .................... 117

Increasing the Sample Size ................................... 117

Extending the Types of Events .............................. 118

Altered Teaching Trial Schedules ........................... 118

Concluding Remarks .................................................... 1 18
APPENDICES ...................................................................... 119
Appendix A - Educational Definition of ASD .............................. 120
Appendix B - Approval to use Human Subjects ........................... 122
Appendix C — Informed Consent ............................................... 124

Appendix D — Berrien County Intermediate

School District Approval ....................................... 127

Appendix E — Teacher Questionnaire ........................................ 129
Appendix F - Parent Questionnaire .......................................... 132
Appendix G — Verbal Measure ................................................. 135
Appendix H- Checklist Form .................................................... 138
Appendix I — Nonverbal Score ................................................. 140
Appendix J - Nonverbal Rating ................................................ 142
Appendix K - Rater Scoring Procedures .................................... 144
Appendix L - Table 7: Raw Score Data for Figures 1.1 to 1.3 ......... 147
Appendix M — Table 8: Raw Score Data for Figures 2.1 to 2.3 ....... 149

Appendix N - Tables 9 and 10: Raw Score Data
for Figures 3.1 to 3.30 ............................................................ 151

REFERENCES .................................................................. 154

xi

LIST OF TABLES

Table 1 — Composite Verbal Score by Rater Conflated Across
Observation Conditions ............................................. 75

Table 2 - Mean Composite Verbal Scores obtained for the
Participation Group and the Observation Group
plus t Statistic Outcomes Over time .............................. 76

Table 3 - Means, Standard Deviations, & Effect Size on Verbal Tasks
for the Participation Group and Observation Group .......... 79

Table 4 — Verbal Task Type Across Time for the Participation Group

and Observation Group .............................................. 81
Table 5 — Nonverbal Scores .................................................... 95
Table 6 - Mean Non-Verbal Ratings and Standard Deviations for

the Participation and Observation Groups ...................... 97
Table 7 - Raw Score Data for Figures 1.1 to 1.3 .......................... 148
Table 8 - Raw Score Data for Figures 2.1 to 2.3 .......................... 150
Table 9 - Raw Score Data for Figures 3.1 and 3.2 ........................ 152
Table 10 - Raw Score Data for Figures 3.3a to 3.3c ...................... 153

xii

Figure 1

Figure 1.1

Figure 1.2

Figure 1.3

Figure 2.1

Figure 2.2

Figure 2.3

Figure 3.1

Figure 3.2

Figure 3.33

Figure 3.3b

Figure 3.3c

LIST OF FIGURES

Picture of the antique juicer .................................... 55

Confrontational Naming Question, “What is Orange” Mean
Scores for the Participation Group and the Observation
Group Across time ................................................ 84

Confrontational Naming Question, “What is Ipakl” Mean
Scores for the Participation Group and the Observation
Group Across Time ............................................... 85

Confrontational Naming Question, “What is lkalpl” Mean
Scores for the Participation Group and the Observation
Group Across Time ............................................... 86

Recognition Question, “Which is lkaIpl” Without Object Mean
Scores for the participation Group and the Observation
Group Across Time .............................................. 87

Recognition Question, “Which is lkaIpl” With Object Mean
Scores for the Participation Group and the Observation
Group Across Time ............................................... 88

Recognition Question, "Which is lpakl” Mean Scores for the
Participation Group and the Observation Group Across
Time .................................................................. 89

WH-Question, "Who” Mean Scores for the Participation
Group and the Observation Group Across Time .......... 90

WH-Question, “Where” Mean Scores for the Participation
Group and the Observation Group Across Time .......... 91

WH-Question, “How” Mean Scores for the Participation
Group and the Observation Group Across Time .......... 92

WH-Question, “When” Mean Scores for the Participation
Group and the Observation Group Across Time .......... 93

WH-Question, ”Why” Mean Scores for the Participation
Group and the Observation Group Across Time .......... 94

xiii

CHAPTER 1
REVIEW OF THE LITERATURE AND
STATEMENT OF THE PROBLEM FOR STUDY

Autism Spectrum Disorder (ASD) has captivated the attention of the world.
The attention stems partly from human curiosity about something that does not
appear to make sense with what is known about typical development and even
some forms of atypical development. There is curiosity about individuals who are
typical in physical appearance, yet impaired in global human functioning.
Individuals with ASD move, see and hear; yet, ASD as a pervasive disorder
affects every aspect of adaptive behavior.

Individuals with ASD do not present with symptoms that are consistent
with what is known about atypical development in other clinical populations. In
contrast to Ieaming disability (LD) and specific language impairment (SLI), ASD
is pervasive, affecting development globally, not just spoken language like SLI or
written language like LD. Unlike other pervasive disorders, such as Down
syndrome, individuals with ASD also have uneven skill profiles. That is, they are
not simply delayed in development but may be skilled in areas which typically
develop late for normal children and delayed in areas which typically develop
early for normal children. Individuals with ASD are simply a puzzle, attracting the
attention of society as a whole, and the scientific research community in
particular.

Bruno Bettleheim (1967) and Leo Kanner (1943) emphasized the role of

the social environment in the development of autism. However, research has

provided beneficial descriptions of the disorder that recognize it as not simply
due to social environment. Better diagnostic methods for early identification of
the disorder have been provided by the research community. Symptoms appear
before 36 months of age, thus rendering ASD a neurodevelopmental disability.
Although there now are methods for identifying ASD and doing so at an early
age, comparatively less is known about how to intervene to modify the
developmental trajectory.

Interventions tend to be symptom driven, i.e., the tendency is to isolate a
skill to be taught, and then use conventional teaching strategies to achieve
behavioral change. Practitioners‘ work to modify behaviors without hypotheses
about how Ieaming may differ in this population. The most popular interventions
rely mainly on auditory and visual perceptual input. Evidently, these conventional
methods have not been effective enough, otherwise families and practitioners
would not seek out new interventions. But there are little empirical data about

effective interventions for children

 

1The term, practitioners (after Stockman, 2004), refers in this dissertation to
the range of professional service providers involved in the intervention for
persons with ASD. They commonly include the speech-language,

occupational and physical therapists, teachers, and psychologists.

with ASD. Dawson and Osterling (1997) reviewed “model” intervention programs
and concluded that these programs were effective for no more than half of the
children enrolled. Wetherby and Prizant (2000) charged the research community
“to better understand which specific intervention methods work best to
accomplish which goals for which children” (p.3). Given the severity of the
disorder, it is critical to know how to intervene. Individuals with ASD do not
respond to the usual sensory modalities for Ieaming. For this reason, the
modality to use during intervention becomes particularly important.

The present investigation was concerned with intervention efficacy,
particularly the efficacy of using unconventional treatments that cater to
somatosensory input in efforts to modify behavior. This chapter will provide more
background information about ASD. It will focus specifically on what ASD is and
why it should be investigated, in addition to identifying the unconventional
approaches to intervention, which motivated the current study.

Characteristics of the Population
Issues in Defining the Population

Home caregivers, practitioners, and the general public can be confused
about who is autistic. This confusion results partly from the changing definition of
autism across time. Even today, when there is so much public awareness of the
disorder, various professional organizations use different definitions. For
example, medical and educational professionals use different definitions to
identify individuals with autism. See Appendix A for the educational definition of

ASD and the Diagnostic and Statistical Manual of Mental Disorders (4“ edition,

1994) (DSM-I V) for diagnostic criteria. Refer to the International Classification of
Diseases by the World Health Organization (1990) and to Simpson and Myles
(1998) for a discussion of definitions. Despite the differences in definition, three
core features have been used consistently across professional boundaries to
describe the autism population: (1) impaired social interaction, (2) impaired
verbal and nonverbal communication, and (3) restricted, repetitive behaviors
(American Psychiatric Association, 1994).

The meaning of the term, ASD, also can be elusive because of the
different ways in which it has been used. It has been used to describe the
individual variability among people diagnosed with autism. ASD can vary from
the minimal requisite symptoms to many other symptoms. Alternatively, ASD has
been used to describe the level of functioning, which can vary from low to high
levels of functioning. The term also has been used to refer to the continuum or
spectrum of symptomatology observed across various clinical subgroups that
encompass the pervasive developmental disorders (PDDs). The Diagnostic and
Statistical Manual of Mental Disorders-IV (DSM-IV) identifies five disorders that
fall under the broad rubric of PDD or ASD: Autism, Asperger Syndrome, Rett
Syndrome, Pervasive Developmental Disorder- Not Othenivise Specified (PDD-
N08), and Childhood Disintegrative Disorder. The term, ASD, was used
synonymously with the term PDD in the present research. Consequently, ASD is
viewed here as a spectrum disorder based on the similarity of symptomatology
across individuals, specifically the three core features as identified above. The

commonality of the five categories of PDD disorders is that the deficits are

pervasive. That is, ASD is manifested as multiple deficits across systems and
skills, which affect the individual’s adaptive function globally, and limit
participation in many aspects of life. These individuals demonstrate deficits in
both nonverbal and verbal functioning.
Symptoms

The symptomatology frequently associated with ASD includes unusual
sensory responses, abnormalities in posture and motor behaviors, and
abnormalities in the development of cognitive skills (Mesibov, 1991). Although
these behaviors are not necessary for a diagnosis of ASD, they are important
features to consider in treatment because they are commonly, although not
universally, manifested.
Leaming Ability

Individuals with ASD may have the ability to learn, i.e., they are not always
intellectually disabled. Kanner’s early descriptions of autism stated that these
children were “cognitively well endowed” (Kanner, 1943). However, traditional IQ
tests emphasize verbal ability as an index of intellectual ability, thus putting
individuals diagnosed with ASD at a disadvantage. The view that individuals with
autism are intellectually disabled is challenged by the research. Biklen (1990)
demonstrated literacy skills with assisted-written communication, claiming that
the behavior peculiarities are motor rather than cognitive impairments.

Uneven profiles of skills and deficits in this population are well
documented (Frith & Baron-Cohen, 1987; Prior, 1979; Schuler, 1995; Affolter &

Bischofberger, 2000). For example, a child with ASD can have exceptional

abilities to see spatial relationships or comprehend numerical concepts but be
unable to use these strengths in everyday tasks. Descriptions of skills of children
with ASD include: excellent rote memory for both auditory and visual information
as well as strengths in tasks demanding visual-spatial judgment and pattern
recognition. For example, some children with ASD are proficient with recognition
and production of melodic patterns; construction of visual-spatial arrays from
samples (block construction), and completion of puzzles (F rith & Baron-Cohen,
1987; Affolter & Bischofberger, 2000). Children with ASD present with uneven
profiles when comparing the outcomes of standardized tests and natural
observations. Children with ASD demonstrate greater cognitive competence
during everyday activities than during cognitive tasks (DeLoache, 1980;
Donaldson, 1978; Gelman, 1978; Nelson, 1977). Clearly, this is a challenge for
practitioners, who use decontextualized tasks for instruction. These children can
Ieam. But how do caregivers and practitioners tap a child’s Ieaming ability and
knowledge?
Sensorimotor Symptoms

Sensory disturbances in this population are well documented (Omitz,
1989; Yeung-Courchesne & Courchesne, 1997; Baranek, 1999; Kientz & Dunn,
1997). In fact, O’Neill and Jones (1997) suggested that unusual sensory
responses may be present in most children with ASD. The range of sensory
disturbance includes: tactile, auditory, visual, olfactory, and gustatory
hypersensitivities and hyposensitivities. Issues with tactile defensiveness, or

hypersensitivity to touch, are often cited in the literature. For example,

individuals may display sensitivity to tags in clothing, walking barefoot on grass,
or touching certain consistencies, such as shaving cream or finger paint. The
tactile defensive person will not tolerate great variation in pressure or
temperature.

Thus, many individuals with autism consider sensory issues as a primary
problem (Gerland, 1997; Grandin, 1995; Grandin and Scariano, 1986; Lawson,
1998; O’Neill, 1999; Willey, 1999; Williams, 1992). Van Dalen (1995) proposed
that the cause of autism is of a perceptual nature and needs to be viewed above
all else as a perceptual deficit. Grandin (1995), an individual with the diagnosis,
described her own sensory aversions to touch, and how she created a “squeeze
machine” to provide firm and consistent pressure to her body, which she
paradoxically craved. This inconsistent reaction to sensory input is commonly
described among the symptoms of individuals with ASD. Others have
hyposensitivities to touch. Some individuals have decreased sensitivity to pain.
Children are commonly reported to bang their heads against brick walls or
cement flooring with no reaction to pain. Others bite their bodies or pick at sores,
never allowing the sore to heal.

Auditory defensiveness is manifested as an oversensitivity to sound.
Reported examples include an over sensitivity to alarms, vacuum cleaners, air
conditioners, and even some music. A person with auditory defensiveness has
difficulty sleeping through noise that most individuals ignore. Electrical devices,
with high-pitched sounds, which are not heard by individuals with normal hearing,

attract the attention of individuals with ASD. In contrast, the person with

hyposensitivity to sound may press his or her ears against vibrating and noisy
surfaces, such as dishwashers, vacuum cleaners, or tape recorders. Such
individuals with reduced sensitivity to sound may fail to recognize when their
name has been called or to react to another person’s loud screams. Despite
such concerns about hearing perception, hearing acuity is reported to be within
normal limits when it is tested (Affolter & Bischofberger, 2000).

Visual defensiveness can be manifested as a squinting of the eyes in
response to bright lights. Other individuals with ASD have been reported to be
discomforted by fluorescent lighting. The visually hypersensitive individual
watches dust in the air, picks lint from the carpet, or may watch his or her spit
falling in the air for hours, if allowed. These individuals are reported to be
preoccupied with visual designs and patterns, and anything with turning parts
that create a design when in motion. In contrast, the visually hyposensitive
individual will rock back and forth while viewing an object or moving the object in
and out of sight. These individuals reportedly view objects at close range and
stare intently at objects and light sources. Visually hyposensitive individuals also
are attracted to mirrors, and shiny objects, and they may stare at them for hours.

Abnormal olfactory and gustatory sensitivities are inferred from observing
the eating habits of individuals with ASD. Commonly reported food aversions
may be related to taste, odor, or texture. Some individuals eat only “orange”
foods or black olives, for example. They may smell everything in their

environment before touching it. Individuals with hypersensitive taste are regarded

as “picky eaters” while those with hyposensitive taste, who eats everything, may
be given the diagnosis of Pica.

In addition, individuals with ASD may not be able to integrate multiple
sensory modalities. Temple Grandin ( 1995) reported difficulty speaking to
audiences when background noises are present. Paris (2000) concluded that
sensory issues may result in impaired gross motor control, hand control, oral
motor control, and other physical problems. Baranek (1999) suggested that both
motor and sensory problems are evident early in life (i.e., 9-12 months). Motor
deficits can affect a child’s exploration of the environment, thus impacting overall
cognitive development (Anzalone & Williamson, 2000; Huebner & Kraemer,
2001)

Motor problems are well documented in the literature for individuals with
ASD (T eitelbaum, Teitelbaum, Nye, Fryman 8 Mauer, 1998). Both fine and
gross motor abilities are affected. Reports include postural problems,
clumsiness, low tone, decreased complex motor skills, balance issues, speech
difficulties, apraxia, and impaired goal formulation, planning and execution
(Murray-Slutsky, 2000).

Cognitive Symptoms

The cognitive profile of individuals with ASD is mixed. They present with
. deficits in metacognitive abilities, abstract thinking, problem-solving skills,
knowledge of others and self, understanding emotions and complex memory
(Millward, Powell, Messer & Jordan, 2000; Waterhouse, 2000; Kasari,

Chamberlain, & Bauminger, 2001). Their cognitive strengths include: pattern

discrimination, rote memory, attention, visual-spatial perception, and object
knowledge (Mesibov, Adams, & Klinger, 1997; Pierce, Glad, & Schreibman,
1997; Goldstein, Johnson, & Minshew, 2001; Kanner, 1943). Children with ASD
are not like other children with intellectual impairment because they are not
simply delayed in overall development. They may have isolated areas of
superior cognitive ability which demonstrate their ability to Ieam.
Language Symptoms

Language performance varies widely among those in the ASD population,
although all have difficulty communicating. Sigman and Capps (1997) described
the language deficits of the ASD as problems with words, grammar, pragmatics,
conversational skills, perspective taking, and the use of narratives. Murray-
Slutsky (2000) suggested that speech and language proficiency require an
individual to register sensory information, formulate an idea, plan and sequence
thoughts, and finally, speak. She described this process as the same process
involved in motor planning and execution. It was hypothesized that motor
planning and language share overlapping neural structures. Approximately 50%
of autistic people do not develop meaningful communicative language
(Wetherby, Prizant, & Schuler, 2000). Those who are verbal often communicate
by using echolalia, a repetition of words spoken to them.
Social Symptoms

Social deficits are considered a defining characteristic of ASD. However,
it is no longer believed that “refrigerator mothers” cause the disorder. Some

children with ASD do become attached to their caregivers (Capps, Sigman, 8

10

Mundy, 1994; Rogers, Ozonoff, & Maslin-Cole, 1991). However, social
interactions are often limited in this population (Bailey, Philips, & Rutter, 1996).
Volkmar, Cohen, and Paul (1986) examined fifty parental responses about their
children’s early social development. The children ranged in age from 28 months
to 33 years and had a history of autism. The majority of the parental descriptions
noted that the children were emotionally distant, i.e., they ignored people,
displayed little affection, avoided eye contact, lacked interest in social interaction,
ignored displays of affection or withdrew from affection, looked through people,
and seemed to be unaware of their mothers.

The most commonly cited social deficit is in joint attentional skill. Joint
attention refers to a child’s ability to actively share attention and experiences with
another individual. These skills involve the use of eye contact, affect and
gestures. A child can share attention in several ways: declarative pointing,
referential looking, looking where others look and point, and social referencing.
Research has documented that joint attentional deficits show up early in (1)
pointing responses (Baron-Cohen, 1989; Loveland & Landry, 1986; Wetherby &
Prutting, 1984), (2) referential looking (Lewy & Dawson, 1992; Mundy, Sigmam,
Ungerer, & Sherman, 1986; Wetherby, Prizant, & Hutchinson, 1998), (3) looking
where others look and point ( Leekman, Baron-Cohen, Perett, Milders, 8. Brown,
1997), and (4) social referencing (Sigman, Kasari, Kwon, & Yirmiya, 1992).

Later in development, children and adults are marked for pragmatic

language deficits (Surian, Baron-Cohen, & Van der Lely, 1996; Tager-Flusberg,

11

1993; Happé, 1993). They have difficulty with appropriate social communication
such tum-taking, topic maintenance, figures of speech, and prosody.
Importance of Studying ASD

The important work of understanding what an autism spectrum disorder is
and how to treat it, is far from complete. While ASD is understood to be a
neurobiological disorder (Bailey, LeCouteur, Gottesman, Bolton, Simonoff,
Yuzda, & Rutter, 1995; Minshew, 1991), a genetic marker has not been identified
and, 15 to 20 different genes are most likely involved. Therefore, professionals
must rely on behavioral observations to guide diagnosis and remediation. Better
descriptions of ASD are needed to establish standard diagnostic criteria, which
provide information to families and practitioners about development and
treatment. More and more individuals are being identified with ASD, and
caregivers and professional service providers are at a loss for what to do.

Increased Incidence
ASD is no longer a rare disorder. Its incidence rate is estimated

conservatively to be one child in 1,000 in the United States (US) (Fombonne,
2002; Gilberg & Wing, 1999). The Centers for Disease Control and Prevention
have reported rates between 2 and 6 per 1,000 individuals, thus providing the
commonly cited statistic of 1 in 166 by the popular media (Autism Speaks, 2005).
Charrnan and Baird (2002) reported the incidence to be as high as 4 to 6 per
1,000 individuals. It is more prevalent than Down syndrome, Fragile X, cystic
fibrosis, or pediatric cancer (Bristol, 1996). The prevalence of ASD has

increased dramatically from the 11 cases of Autism first described by Leo Kanner

12

in 1943 and the early descriptions of Asperger Syndrome provided by German
scientist, Dr. Hans Asperger.

Based on the incidence of autism at 2 to 6 per 1,000 persons (Centers for
Disease Control and Prevention, 2001) and the 2000 US. census figure of 280
million Americans, 1 to 1.5 million Americans are diagnosed with Autism. During
the 19903, the number of persons with the autism diagnosis increased at a more
rapid rate than did the US. population and the number of persons with other
disabilities. That is, the US. population increased by 13% and persons with
disabilities other than autism increased by 16%. But the autism population
increased by 172% (US. Department of Education, 1999). The Autism Society
of American estimates that the prevalence of Autism could reach 4 million
Americans in the next decade.

The increased prevalence is due partly to better evaluation measures.
Children can be reliably diagnosed before age three (Lord, 1995), and research
suggests that effective screening and diagnostic methods can be developed for
18-month (Baron-Cohen, Allen 8 Gillberg, 1992) or even one-year old children
(Osterling 8 Dawson, 1994). Currently, Lord and colleagues are developing
assessment measures for infants as young as 6 months.

Another explanation for the increased ASD prevalence is the increased
recognition of the heterogeneity of the diagnostic category. The current use of

the spectrum term encompasses persons with minimal ASD symptomatology.

13

Provision of Resources and Legal Entitlement

The increased number of children diagnosed with ASD in public school
systems adds to the perception that this disorder is now more prevalent than it
used to be. In 1994, ASDs were the 10th most common disability among the 6 to
21 year old children in special education. According to the Centers for Disease
Control and Prevention (CDC), the number of children diagnosed with ASD
increased six-fold from 22,664 to 141,022 between 1994 and 2003. Although
more children are receiving special education services for ASD than ever before,
this diagnostic classification was not added until the early 1990’s. Therefore, the
growth of children being serviced is partly due to the addition of the autism
diagnostic category rather than the increased prevalence.

Historically, educators did not have children with ASD in their classrooms.
In the early 19703, schools even refused to enroll children with any disabilities, or
if enrolled, they were placed in programs that segregated them from their
nondisabled peers. When Congress amended the Education of the Handicapped
Act (EHA) with Public Law 94-142 in 1975, it intended to include 1 million school-
age children with disabilities without any educational placement, and 2 million
children enrolled with inappropriate placements. Federal legislation (Individuals
with Disabilities Act (IDEA) of 1990 (PL 101-476), its 1991 and 1997
amendments, and its most recently revised 2004 version, renamed the
Individuals with Disabilities Education Improvement Act, mandates that a state
provides all eligible children with a free and appropriate education (FAPE) that

meets their unique individual needs in the least restrictive environment (LRE).

14

The IDEA emphasizes legal entitlement to early intervention services and
provides more services for young children and families, who could not previously
access them.

Educators do not have a choice about providing services for this difficult
population. They are legally required to provide services and to do so at earlier
ages than were required in the past. Any child younger than 3:0 years of age,
who has a developmental delay, is eligible for the early intervention services
provided through IDEA. This government legislation provides federal grants to
individual states for their provision of early intervention services for children with
disabilities. For some families, a diagnosis of autism means provision of
services, whereas, other diagnoses may not result in intensive services. Thus,
another basis for the increased number is the preference for this diagnosis over
others by the family. I

At age 3;0 years, IDEA requires states to provide special education
services through local school districts. As previously stated, every child is
entitled to be educated in the least restrictive environment. This means that
children are placed in environments that provide the greatest potential to interact
with non-disabled peers and to participate in the general education curriculum.
More and more effort is being made to mainstream these children in regular
education classrooms. This means that regular education teachers now have
these children in their classrooms and are partly responsible for their Ieaming,

often with little preparation. So the important questions for the educators

15

become: 1) How can I teach this child? and 2) What is the most effective way for
this child to learn?
Cost of Intervention

The cost of intervention is an important issue because as stated
previously, ASD is a pervasive disorder, often requiring clinical intervention
beyond standard medical care. Several services are commonly prescribed.
They include: physical therapy, occupational therapy, and speech and language
therapy. Clinical intervention services are costly (Baum, 1998). Gantz (2006)
estimated that direct medical cost, such as physician services and behavioral
therapies, cost more than $29,000 per person per year. In addition to clinical and
medical services, IDEA requires provision of special education services from
birth. Direct non-medical costs, such as special education and child care are
estimated to cost annually more than $38,000 per person for mild disability per
year and more than $43,000 per person for more severe disability per year
(Gantz, 2006).

In addition to direct costs, the cost of autism includes indirect costs.
Indirect costs include the value of lost productivity for the person with autism as
well as for caregivers. Examples of lost productivity include loss of income as a
result of reduced work hours or the inability to work at all.

Factoring in both direct and indirect costs of autism, Gantz (2006)
estimated that caring for an individual with autism over his or her lifetime can cost

about $3.2 million and caring for all people with autism over their lifetimes costs

16

an estimated $35 billion per year. The Autism Society of America (2003) predicts
that in 10 years, the annual cost will be $200-400 billion.

Practitioners are pressured by insurance companies to demonstrate
improvement quickly. Sometimes insurance companies provide funding for a
limited number of therapy sessions and require demonstrated improvement
before allocating more funds for treatment. Insurance companies have been
hesitant to provide funding at all because individuals with ASD require sustained
financial support, and will never be completely “cured.”

Issues with funding the treatment of ASD bring to the foreground the
importance of establishing clinical efficacy. There are limited resources in autism
prevention and treatment. Gantz (2006) reported that the federal autism
research budget is historically less than $100 million per year, and the research
budgets for other conditions with similar incidence figures are much higher.
Given the limited funds relative to the numbers of individuals with the disorder, it
makes sense to spend funds on treatments that have been demonstrated to
work.

Intervention Models

Teaching individuals diagnosed with ASD can be challenging for the
caregivers and professionals involved in their development. Failures arise when
educators try to accommodate the individual by redesigning the general
education curriculum into skill sets, rather than considering how the individual
leams through natural interactions in his or her environment. Most, who take on

this challenge, do so with a clear vision of what they want to accomplish, i.e.,

17

what they want to teach an individual, or want an individual to Ieam, but they are
less clear on how to reach these goals (Brown, et al, 1989; Lave 8 Wenger,
1991). The design of educational curricula is often far removed from the goal of
achieving functional outcomes (Bricker, 1993).

This dissertation focused on treatment models that cater to the
unusual and uneven skill profile of individuals who do not seem to learn with the
usual approaches. Broadly speaking, there are both indirect and direct treatment
approaches, as described next.

Indirect Treatments

Indirect treatments focus on changing the way the body responds to a
particular treatment, which then impacts behavior indirectly. Therefore, indirect
treatments focus directly on the body system that impacts behavior. They
include the biomedical interventions, e.g., pharmacological (Cook 8 Leventhal,
1995), hormonal (Beck, Beck 8 Rimland, 1998), immunologic (Fudenberg, 1996),
dietary (Reiten, 1987) and megavitamin (Rimland, Callaway, 8 Dreyfus, 1978;
Dolske, Spollen, McKay, Lancashire, 8 Tolbert, 1993).

Ninety-nine articles were reviewed in a New York technical report (1999)
which examined the efficacy of pharmacological treatments. The report
concluded that some medications may be effective, but have high rates of side
effects. Some case studies suggested that hormone therapies (secretin)
reduced autistic symptoms (Kaminska, Czaja, Kozielska, Mazur 8 Korzon, 2002),
but other clinical trials have refuted this claim (Coniglio, et al, 2001; Corbett, et al,

2001; Dunn-Geier, et al, 2000; Lightdale, et al, 2001; Owley, et al, 2001; Roberts,

18

et al, 2001). Immunologic treatments have been supported by a pilot study
(Fudenberg, 1996), but other studies have not found significant improvement
(DelGiudice-Asch, Simon, Schmeidler, Cunningham-Rundles, 8 Hollander, 1999;
Plioplys, 1998). The New York technical report (1999) concluded that there are
no known advantages for using diet therapies for children with ASD. Although
Rimland, Callaway, and Dreyfus (1978) observed improvements in the behavior
of autistic children who received vitamin therapy, others have not (Findling,
Maxwell, Scotese-Wojtila, Huang, Yamashita, 8 Wiznitzer, 1997).
Direct Treatments

This dissertation is concerned with direct treatments. Unlike the indirect
ones, direct treatments focus on behavioral interventions that aim to explicitly
modify particular behaviors. There are both conventional and unconventional
methods for doing so. Conventional methods have received peer support and
are considered as best treatment practices. Unconventional treatments are not
established as best practices and may be generally unknown to the public.
Conventional Methods

Conventional teaching methods facilitate Ieaming by targeting specific
behaviors for remediation. Long term goals and behavioral objectives are
proposed. This process often involves a task analysis in which a behavioral goal
is decomposed into all the prerequisite and necessary steps needed to achieve
it. Then, the intervention approach is selected to establish or modify the missing

behavior.

19

Fey (1986) described interventions as falling on a “continuum of
naturalness.” Clinician-directed approaches and client-centered approaches
represent the end points of Fey’s continuum. The use of clinician-directed drills
is the least natural approach on the continuum. When using this approach, a
practitioner selects the training stimuli, identifies the target response, presents
the stimuli in a predetermined order, and reinforces the expected behavior.
Functional therapy is at the other end of the naturalness continuum. It
incorporates activities of daily living into the therapy. A child engages in these
activities with professional support.

Traditionally, clinicians have taught the desired behavior by shaping it in
small chunks until the more complex behavior is learned. They teach these
behaviors using conventional clinician-directed approaches in which stimuli are
presented either aurally and/or visually. The clinician reasons that if the child
could do the task, then he or she would demonstrate this knowledge by actually
“doing” it. If instruction is needed on how to do a task, it takes the form of
verbally telling the child what to do, or visually showing a child what to do by
using picture schedules to complete tasks. Clinicians assume that the distance
senses are adequate channels for receiving instructional input.

Conventional behavioral methods include such approaches as Applied
Behavior Analysis (ABA) (Lovaas, 1987), Division TEACCH (T reatrnent and
Education of Autistic and related Communication Handicapped Children)
(Schopler 8 Mesibov, 1988), DIR (Developmental, Individual Differences,
Relationship-based Approach) (Greenspan 8 Wreder, 1998), and augmentative

20

and alternative communication training, such as visual mediated strategies
(Hodgdon, 1996) and Picture Exchange Communication System (PECS) (Bondy
8 Frost, 1994).

Applied Behavior Analysis (ABA). ABA methods focus on teaching small
units of behavior systematically. Skills that have not been acquired are broken
down into small measurable steps, and then taught by presenting a specific cue,
typically an auditory-verbal or visual cue. Appropriate responses are followed by
a reinforcer. Teaching trials are repeated frequently until the child performs
accurately. Responses are graphed and evaluated. As skills emerge, they are
practiced in less structured environments (Harris and Handleman, 1994; Koegel
8 Koegel, 1995). The premise of an ABA method is that children with ASD will
learn from an exaggerated, intensive, and slowed presentation.

Treatment and Education of Autistic and related Communication-
Handicapped Children (TEACCH). Project TEACCH (Schopler, Mesibov 8
Hearsey, 1995) at the University of North Carolina in Chapel Hill is similar to
ABA. It claims to exploit the strengths of individuals with ASD by creating
structured teaching procedures. The procedures provide for instruction that is
systematic and predictable in organizational and temporal structure. However,
unlike ABA, there is not constant instructional control. Less redirection and fewer
prompts at predetermined levels are provided in TEACCH than in ABA. The child
is given the opportunity to problem-solve through a task. Visual schedules and
workstations in which the child has a set number of tasks to complete are integral

aspects of the model. The premise of TEACCH is that the weaknesses of a child

21

with ASD are in social, language, attention, organization, transitioning, and
auditory processing. The TEACCH intervention is designed to build on strengths
in visual processing and routine-based Ieaming.

Developmental, Individual Differences, Relationship-based Approach
(DIR). DIR, sometimes referred to as “floortime”, is an intensive, one-on-one
period in which the caregiver gets down on the floor and interacts with the child.
The premise of this intervention is that human relationships are critical to child
, development. The home caregiver is expected to “follow the child’s lead and
play at whatever captures her interest, but to do it in a way that encourages the
child to interact with you” (Greenspan 8 Wieder, p. 123-124). The goal of this
intervention is the mastery of emotional milestones in a sequential order. The
premise is that emotion regulates interaction, and that ASD is a multisystem
developmental disorder (MSDD) affecting interpersonal relating, communication,
and overall adaptation, among many others. Intervention is expected to enhance
engagement and attention towards increased reciprocal communication.

Picture Exchange Communication System (PE CS). PECS (Bondy 8
Frost, 1994), which employs augmentative and alternative communication
techniques, is a structured behavioral program that uses symbols to teach
individuals to exchange the symbol for a “real” item. After the individual can
complete this exchange with different people and under different conditions, then
other functions, such as labeling, are taught. The visual symbols are used to

augment receptive and expressive language.

22

While all four approaches described above differ in their goals and clinical
strategies or assumptions, they commonly share a reliance on the auditory and
visual modality for input. They do not focus on the sensory channel over which
input is received. They appear instead to focus only on the material stimuli
presented to the child.

Unconventional Methods

Unlike the accepted conventional methods, unconventional methods are
largely unknown to the public and are not widely used in clinical practice. This
study specifically focused on those unconventional methods that claim to
enhance the tactile-kinesthetic perception associated with purposeful bodily
movement. They include four types of action-based therapies. Two of them are
well known, viz., sensory integration (SI) (Ayres, 1972; Ayres, 1979; Fisher,
Murry 8 Bundy, 1991; Cook and Dunn, 1998; Schneck, 2001) and Facilitated
Communication (Biklen, 1993). Two others are less well known, viz., Guided
Interaction Therapy (GIT) (Affolter, 1991; Affolter 8 Bischofberger, 2000), and
Prompts for Restructuring Oral Muscular Phonetic Targets (PROMPT) (Hayden,
1999; Hayden, 2004; Rogers et al, 2005).

Sensory integration (SI). This therapy, which was developed by
occupational therapist, Jean Ayres (1979), is perhaps the best known of the four
interventions cited above. It focuses on organizing the whole sensory system so
that an individual with ASD and sensory integration difficulty can increase his or
her alertness to stimulus input. The premise of sensory integration is that people

affected by ASD have impaired abilities to take in, organize, and react to sensory

23

stimuli effectively. The goals of SI therapy are to improve one’s ability to process
complex sensory information automatically, improve motor coordination, and
reduce over- or under-reactivity so that better social and emotional adjustment
can be achieved.

SI therapy is administered by using special equipment in a controlled
therapy environment. Physical exercises with various equipment, such as a
scooter board or bolster swing aim to promote motor development by facilitating
the processing and organizing of tactile, proprioceptive, and vestibular systems.
Ayres (1979) stated that, “Doing purposeful physical activities- rather than
thinking or talking about them — is the best way to improve human functioning
when the problem lies in the way the brain is working”(p.151).

Facilitated communication. Facilitated Communication was developed by
Rosemary Crossley in Australia and promoted in the United States by Douglas
Biklen (Biklen, 1990; Biklen, Morton, Gold, Berrigan, 8 Swaminathan, 1992).
Facilitated Communication aims to help an individual with autism to use a visual-
motor system for communicative expression. Physical support is provided at the
hand, wrist, elbow or shoulder. The premise of facilitated communication is that
ASD results from a neuromotor impairment that prevents communication skills
from being expressed. This premise is supported by other scholars who have
proposed that an underlying motor dysfunction exists in individuals with autism
(Rogers, 1996; Teitelbaum, Maurer, Fryman, Teitelbaum, Vilensky, 8 Creedon,
1996; Donnellan 8 Leary, 1995).

24

Prompts for Restructuring Oral Muscular Phonetic Targets (PROMPT).
The PROMPT therapy framework was developed by Deborah Hayden in Canada
(Chumpelik [Hayden] 8 Sherman, 1980; Chumpelik [Hayden] 8 Sherman, 1982,
Chumpelik [Hayden], 1984; Hayden, 1999). It is an intervention model for speech
production disorders. It aims to develop (1) an interactive awareness of oral
communication; 2) an integrated multisensory associative mapping for cognitive
and linguistic concepts; and 3) balance or reorganize speech subsystems at the
motor-phoneme, word, and phrase level in order to optimize speech production
(Hayden, 2003).

This model of therapy is distinguished by its emphasis on enhancing
tactual input for remediating speech production disorders in addition to auditory
and visual cues. Touch is viewed “as the single most connecting and organizing
factor in human development” (Hayden, 2004, p.260). Thus, PROMPT, as a
clinical technique, helps clinicians to manually apply tactual cues that provide
strategic postural support and cues for mapping the articulatory place, manner,
and voicing of speech sounds as well as their sequential and temporal
organization. Therapy is done in functional contexts that require social interaction
and meaningful use of language. Although speech production is its primary
focus, PROMPT’s aims to foster social communication and conceptual
development generally.

Guided Interaction Therapy (GIT). This intervention was developed in St.
Gallen, Switzerland by Felicie Affolter (Affolter, 1991; Affolter 8 Bischofberger,

2000; Affolter and Bischofberger, 2000). It is a nonverbal perceptual-cognitive

25

approach to intervention. Like PROMPT, it assumes that tactual perception is
critical to normal perceptual development and provides clinical techniques for
enhancing such input. While expressive communication is central to PROMPT
intervention, GlT’s focus on expressive communication is secondary to the more
primary goal of providing experiences with the nonverbal, problem-solving
experiences of daily life events. The multisensory experiences associated with
spontaneous daily experiences include the tactual-kinesthetic information arising
from one’s movement interactions in the world in addition to the information from
vision, audition, and other senses. GlT’s premise is that such holistic sensory
experiences are needed in order for people to perceive their nonverbal physical,
mental and social worlds as familiar and to function adaptively within them.
Holistic nonverbal experiences that include the somatosensory input are
assumed to provide the conceptual basis for the meaning of words and other
symbols used to communicate.

Thus, the nonverbal interaction between individuals and their
environments is presumed to be the source of Ieaming both nonverbal and verbal
skills. The premise is that some children along the autism spectrum may fail to
develop normally because of a perceptual disorder that either prevents the
central nervous system from adequately processing tactual-kinesthetic input or
connecting such input to other sensory information such as vision and audition.
Their nonverbal and verbal behaviors can appear to be so delayed and deviant
because most human actions, particularly those involving complex skills, rely on

integrated sensory experiences that include the tactual-kinesthetic experiences.

26

The intervention goal is to enhance a child’s perceptual experiences
during ordinary problem-solving events of daily life in ways that include the
somatosensory input. This is done by enabling a child to physically participate in
nonverbal, problem-solving activities. A clinician physically guides a child’s
hands, limbs or torso to act in a purposive or goal directed way. Alternatively, the
physical environment may be modified to enable a child to do a task on his/her
own. For example, a chair may be lowered so that a child’s feet touches the floor
in order to gauge where the body is in space; objects may be selectively chosen
to offer more or less resistance to movement patterns during an event. During
the nonverbal event, whether physically guided or not, talking is not done or
encouraged. This practice is expected to minimize distractions from the task at
hand and decrease processing load. After the nonverbal event, words, or other
communicative forms are used to represent the event just experienced, i.e., if a
child is on the level of using words or other symbols, e.g., pictures, to
communicate.

Expanding the repertoire of such experiences is expected to improve a
child’s ability to perceive environmental events as familiar and to predict and
execute causative sequences of actions that are meaningful for his/her life
experiences. It also is expected that comprehension or understanding of how
events occur will serve the meaningful use of language forms.

Issues in Clinical Efficacy
An important question to raise is how efficacious are any clinical

interventions for children with autism. Clinical efficacy is a judgment about the

27

validity of an intervention (Stockman, 2004). Does the intervention yield the
outcomes that it claims to yield? As stated earlier, Wetherby and Prizant (2000)
have charged the research community “to better understand which specific
intervention methods work best to accomplish which goals for which children
(p.3).” In other words, which interventions are efficacious?

Efficacy should be generally important for all practitioners, given the value
being placed currently on evidence—based practice (EBP) in health care and
education (Dollaghan, 2004; Drake, Rosenberg, Teague, Bartels, 8 Torrey, 2003;
Geyman, 2000; Gray, 1997; Lohr, Eleaser, 8 Mauskopf, 1998; and Straus,
Richardson, Glaszio, 8 Haynes, 2005). EBP refers to the integration of scientific
evidence with clinical expertise, client values, and circumstances (Robey, 2006).

EBP is likely to be a particularly critical issue for the unconventional,
sensorimotor—based interventions, which were the focus of the current research.
They are not well known and are not used as widely as conventional methods.
Some of these interventions have already been discredited for lack of adequate
empirical support. For example, in the case of the facilitated communication
intervention identified above, controlled experimental studies failed to
demonstrate that a written message originated in the individual with autism as
oppose to the facilitator or they failed to isolate the observed effect from the
literacy level of the participants (Wheeler, Jacobson, Paglieri, 8 Schwartz, 1993;
Eberlin, McConnachie, lbel, 8 Volpe, 1993; Bligh 8 Kuppennan, 1993; Smith 8
Belcher, 1993).

28

Baranek (2002) reviewed 29 studies published between 1974-2001 that
focused specifically on sensory and motor interventions for children with Autism.
The meta-analysis included such interventions as sensory integration, sensory
stimulation, auditory integration training, prism lenses, and physical exercise.
Some of them focused on the distant senses, namely, the auditory (auditory
integration training) and visual (prism lenses) intervention paradigms. Others can
be regarded as somatosensory approaches, which ranged along the continuum
from sensory stimulation (sensory diets) to those with a motor component
(physical exercise). Although positive, but modest outcomes were reported for
some interventions, Baranek (2002) expressed concern about the functional
utility of the sensory and motor interventions reviewed, It was concluded that,
“without direct practice in generalizing to functional tasks and in naturalistic
environments, the effects of therapeutic gains in sensory processing or motor
components may be limited” (p. 417).

However, Baranek’s (2002) review of the sensory and motor therapies did
not include two unconventional therapies, which may be regarded as
sensorimotor approaches to intervention with autism: namely, the GIT and
PROMPT interventions. These two approaches were of particular interest to the
present study for two reasons. First, they emphasize human actions and
communication in the kind of functional contexts that Baranek’s review referred to
as being ideal.

Second, GIT and PROMPT offer unique therapeutic strategies for

facilitating one’s ability to function in such contexts. Both interventions commonly

29

emphasize augmented tactual-kinesthetic input for clients who do not adequately
respond to the visual and auditory instruction so frequently used in clinical
interventions with autism. Although other therapeutic approaches do emphasize
authentic settings, they may not stress the importance of tactual input or provide
ways to facilitate meaninng action. For example, Facilitative play is such a
commonly used child directed approach (Hubbel, 1981; Shriberg 8 Kwiatkowski,
1982) used to facilitate language. It relies on auditory and visual input. That is,
the clinician may expand, extend, and recast a child’s utterance (auditory verbal
input) while also encouraging visual modeling of actions during shared play
activity (visual input). Even when functional therapies capitalize on natural
interactions involving communicative activities of daily living, practitioners do not
deliberately enhance tactual input for Ieaming to participate in such events.

Nevertheless, it is important to seek evidence for innovative procedures
such as those used in GIT and PROMPT. However, Stockman (2004, Ch.11)
suggested that some therapies may be ignored when the evidence for their
efficacy is limited to just one type of efficacy. She described four types of
evidence: 1) grounded efficacy, 2) theoretical efficacy, 3) empirical efficacy, and
4) ecological efficacy. In the review to follow, it is shown that the unconventional
therapies that augment tactual input may be clinically valued on some level of
efficacy but not others.

Grounded or Situational Efficacy
Grounded efficacy refers to an intervention effect that can be observed

during an intervention session, which could not be witnessed immediately before

30

the intervention. Stockman (2004) stated, “The word grounded is intended to
focus attention on the behavioral changes that clinicians and families can actually
witness when they intervene in a given moment to help a child to solve a
problem in therapy or in daily life (p.305).” The evidence is particularly valuable
when the change occurs. The interventions singled out already are likely to have
some impact on a child’s performance, otherwise people would not apply them.
Stockman (2004) stated that different sources of input may affect behavior, as
practitioners and caregivers probably observe routinely. The important evidence
for tactual-kinesthetic input is achieved when behaviors change following some
modified input, but have failed to be achieved with auditory or visual input in the
context of the therapy event or Ieaming event in the moments before. The
efficacy of some interventions may include only grounded evidence of efficacy.
That is, the practitioner does something with the goal of modifying a particular
behavior (e.g., provide a tactual cue) and immediately afterwards, a child
generates the desired behavior. Such a change is likely to be viewed as the
consequence of the intervention. This interpretation will be validated if a clinician
repeatedly observes repeated instances of the same kind of events in different
sessions for the same child and for different children.

It has been relatively easy to demonstrate this kind of grounded efficacy
for using tactually enhanced input, particularly when behavioral changes occur
after auditory and visual inputs have not been successful. Archived video records
provide anecdotal evidence for the effectiveness of therapy sessions when using

GIT and PROMPT. While it is important to demonstrate grounded efficacy for the

31

reality of clinical use, it alone is not adequate evidence of efficacy to stop here.
Without controlled observation however, one would not know for certain that the
behavioral change was due to the intervention strategy employed. It is possible
that some other factor caused the observed change.

Theoretical Efficacy

According to Stockman (2004), “Theoretical efficacy refers to the fit
between clinical observations and the body of empirically derived knowledge
about how people Ieam and develop” (p.307). Theory provides us with the
understanding of how we Ieam, but it can be only an indirect source of evidence
for treatment efficacy because the research observations are not designed to test
directly the validity of an approach.

There is indirect theoretical justification for believing that intervention
models that cater to enhance somatosensory input are likely to be useful for
treating autism. Both GIT and PROMPT draw on a rich scholarly literature on the
role of action as purposeful movement activity in cognitive, motor, perceptual and
language development. More than a half century ago, classic Piagetian theory
asserted that the sensory-motor system was important to early cognitive
development. Piaget (1952) described the child’s stages of sensory-motor
intelligence in the first 2 years of life as foundational for cognitive development.

A body of knowledge on the sensory and motor foundations of Ieaming
now extends beyond Piagetian theory. Neopiagetian scholars have investigated
the role of action as sensorimotor activity in the process of constructing

knowledge in real time and space. Their views broadly reflect an embodied

32

constructivist view of knowledge acquisition (Stockman, 2004). They have
shown that motor behavior is not merely a display of what is already learned, but
it is also a part of the input experience needed to acquire new conceptual
knowledge (T helen 8 Smith, 1994). Studies of the psychophysical and
perceptual properties of the haptic modality suggest it is not inferior for Ieaming
about the world as is often asserted. It is important for learning about the
material properties of objects (e.g., weight, texture) in addition to their size and
shape (Jones 8 Ledennan, 2006; Lederman 8 Klatzky, 1987; Lederman, Klatzky,
Chataway, 8 Summers, 1990; Kilgour and Ledennan, 2002; Ledennan, 1981;
Magee 8 Kennedy, 1980). Other research has called attention to the unique role
of tactual experiences in Ieaming about the nonverbal cause-effect relationships
of actions and interactions with objects and events (Affolter 8 Bischofberger,
2000; Affolter, 2004; Nelson, 1986; Nelson, 2004). Actionfrnteraction experiences
arguably grounds even visual perception (N06, 2005) and language in its oral
(Bloom, Tinker, 8 Marqulis, 1994) and written forms (Glenberg 8 Kaschak,
2002). Bloom (2000) concluded from her work that Ieaming a language requires
a child’s engagement in a world of persons, objects, and events.”

Although these theoretical formulations offer important theoretical
justification for focusing on action in an intervention framework, they do not
provide direct evidence for the effectiveness of a therapy regimen in which
perceptual-motor activity plays a central role. Therefore, they provide only
indirect support for the principles of interventions such as GIT and PROMPT,

which exploit the movement senses in efforts to modify behavior. Such

33

theoretical support, although necessary, is not enough to justify the clinical

efficacy of intervention like GIT and PROMPT. What GIT and PROMPT have

demonstrated clinically are differences in performances between children with

tactual problems and those without it in their responding to intervention.
Empirical Efficacy

Empirical evidence is direct evidence based on controlled observation.
Stockman (2004) observed that controlled clinical trials are often viewed as the
gold standard for determining clinical efficacy. This is because they attempt to
test if and how a particular intervention may cause the desired behavioral
changes by ruling out the potential effect of extraneous factors on intervention
outcomes. Although clinical controlled trials are the gold standard for determining
efficacy, they are not easy to do in a rigorous experimental way for persons with
autism. First, there is difficulty in equating the experimental groups. Individuals
diagnosed with ASD present varied profiles of strengths and weaknesses as well
as varied histories of exposures to clinical interventions.

Second, it can be difficult to identify and control for all the relevant
extraneous variables in research studies. This is because research participants
may learn from experiences that are external to an intervention, which could
impact the outcomes of the study.

To date, the empirical evidence for the use of GIT and PROMPT with ASD
populations has taken the form of case studies. This is the weakest form of
empirical evidence by some standards. Individual clinical cases can differ on

factors that influence the severity of a disorder and the progress made with an

34

intervention. Therefore generalizations across clinical cases about clinical
efficacy can be difficult to make. Single subject designs have led to more
promising outcomes, particularly when controlled, multiple baseline controlled
studies are not done as proponents of PROMPT are beginning to do.
Ecological Efficacy

Stockman (2004) stated that ecological efficacy “refers to consumer
satisfaction or to what others refer to as social validity (Goldstein 1990)” (p.312).
Therefore, it is a subjective evaluation of the validity of an intervention by
observers who may not be clinically trained or informed. Guiding ought to be
viewed positively by caregivers because it gives them a way to intervene with
children who do not respond to visual and auditory-verbal instruction. In fact,
Affolter and colleagues have reported that caregivers view GIT intervention as
helpful, but such anecdotal reports do not replace the need for studies that apply
objective measures of consumer satisfaction. Such studies do not appear to
have been done.

Statement of the Problem

This dissertation was concerned generally with the efficacy of
nonmainstream or unconventional approaches, specifically the efficacy of such
approaches that claim to provide enhanced or guided tactual input for stimulating
Ieaming, namely GIT and PROMPT. These two interventions were regarded as
promising because they promote holistic functioning in the real world
environments. Their emphasis on enhancing tactual input also offers an

alternative to treating persons with autism who do not respond well to just visual

35

and/or auditory-verbal instruction. Nevertheless, the above discussion revealed
that so far, the efficacy of GIT and PROMPT interventions rests mainly on (1)
informal grounded evidence of behavior changes as can be documented in
therapy sessions, (2) empirical and theoretical evidence supporting the
importance of action and the somatosensory senses for human development,
and (3) nonexperimentally controlled case studies of patients with a favorable
response to tactuaIIy-enhanced therapy. So rigorous empirical research is
needed to demonstrate whether these tactually-based interventions are clinically
efficacious, and if they are comparatively more effective than either the
conventional or unconventional methods that cater primarily to visual and
auditory input for Ieaming. Such empirical evidence can serve two purposes.
First, it establishes the validity of an intervention when desired behavioral
outcomes have been documented. Second, it serves as a guide to defensible
clinical practices.

The efficacy of interventions like GIT and PROMPT rests not only on
future controlled clinical trials that document effective outcomes when these
therapies are implemented as recommended by their founders; it also rests on
evidence that shows if and how Ieaming is affected by the use of any type of
manually guided input. Affolter and colleagues have argued that when children
fail to nonverbally interact with the environment on their own, they can be
manually guided to experience directly the causative events created by their own

actions. Children even report that they have done the actions themselves.

36

If tactual processing deficits exist and tactuaI-kinesthetic perception is
important to normal development, then we need ways to provide such perceptual
input. But delivering manually guided instruction pose obvious problems for
caregivers and practitioners. They may present visual and auditory stimuli easily,
but obviously cannot feel for the child. Nonetheless, the notion that manually-
guided input an provide tactual experiences well enough to promote Ieaming is
likely to be controversial. This is because such externally guided
actions/interactions are viewed as passive activity (Ledennan, 1997). Ledennan
(1997) defines passive touch as the “Mode of tactual perception in which the
observer has no voluntary control over the receipt of sensory information” (p.49).
The corresponding assumption is that such actions may not get the attention of
the nervous system well enough to support the Ieaming of complex human skills.
This assumption can be tested with controlled empirical observations of
children’s learned responses to novel events in different sensory modality
conditions, as was done in this dissertation research. Fortunately, a small
number of studies have been done to address this question and they provided a
template for the current work. They suggest that different populations of typical
and atypical learners do benefit from tactually enhanced input during novel
Ieaming tasks, as summarized below.

Seminal Research in a New Paradigm

Seminal research in which one principle, manually guided input, made a

difference in the performance of the individual is reviewed. The research

participants included adults and children, both typically and atypically developing.

37

The research demonstrated that the tactual system is not inferior to the visual
and auditory systems. The overarching paradigm in this seminal research was to
manipulate learning by augmenting the tactual input. Control groups were
employed as well as different populations of learners. A review of these studies
follows.

Wrthin the last 15 years, six studies have served as the building blocks for
developing an experimental intervention protocol that demonstrates Ieaming from
active participation in events. Taken together, they show that the addition of
tactual input to visual and auditory input is helpful to verbal and nonverbal
Ieaming. All of these studies aimed to show whether manually-guided instruction
made a difference in performance outcomes. Some of them focused on typical
Ieamers (Mitchell-Futrell, 1992; Rowe, 2003; Luce, 2004; Stockman 8 Latham,
2002) and others focused on abnormal Ieamers (Beretta, 1999; Latham 8
Stockman, 2002). Most focused on children (Mitchell-Futrell, 1992; Luce, 2004;
Stockman 8 Latham, 2002; Beretta, 1999; Latham 8 Stockman, 2002). Just one
focused on adults (Rowe, 2003). None of the abnormal studies recruited well-
defined participants from the ASD population.

Mitchell-Futrell’s study (1992) included 10 male and 10 female participants
with normal language development. The participants’ mean age was 3:6 years,
and their mean language age was 4:3 years as measured by the Preschool
Language Scale-3. All participants were taught novel action words under two
different teaching conditions: an observational Ieaming condition and a

manipulation condition. During the observation condition, children were deprived

38

of tactual-kinesthetic information about the word’s referent. During the
manipulation condition, children were deprived of visual information by blindfolds.
Each participant learned two words, one in each teaching condition. Ten
participants were taught a nonsense word in the observation condition and then
taught a second nonsense word in the manipulation condition. For the other ten
participants, the first nonsense word was taught in the manipulation condition,
and the second nonsense word was taught in the observation condition.

Following the teaching conditions, three tasks were used to assess
retention of the newly learned word: (1) word recall, (2) action re-enactment, and
(3) visual recognition. The word recall task required participants to produce the
novel nonsense word. The action re-enactment task required that the participant
perform the action associated with the novel nonsense word. The visual
recognition task required the participant to watch three peeple performing actions
and point to the person performing the action that corresponded to the word
learned. Responses to each task were obtained at two time intervals: 5 minutes
after the teaching condition and 5 minutes after the initial testing procedure.

The results revealed the children in the manipulation condition, that is,
those children who were blindfolded, performed better than the children who
were not blindfolded on the visual recognition task. This unexpected result was
explained by the blindfolded children’s limited attention to the specific action
performed. A multitude of stimuli could have been attended to during the

teaching event rather than the action specifically.

39

The investigators also concluded that for actions already known to the
children, both the manipulation and observation teaching conditions were equally
effective for reproducing the action in response to the novel label. While it has
been easier to accept younger children’s dependency on “hands-on” Ieaming that
necessarily includes tactual kinesthetic input, it has been less often assumed that
adult learners need such input. In other words, they are expected to Ieam as
well from visual or auditory verbal instruction. Therefore, Rowe (2003) conducted
a study in which normal adults were recruited as participants to Ieam a novel
task.

Rowe (2003) demonstrated that auditory and/or visual input alone was not
sufficient for normal adults on a novel procedural task involving the construction
of a novel object using origami craft. The 21 male participants between the ages
of 18 and 21 attended Michigan State University. Participants leaned an origami
task under one of three input conditions: auditory verbal instructions only,
auditory verbal plus visual demonstration only, and auditory verbal, visual
demonstration and tactually-mediated or “hands-on” input. Participant learning
was assessed immediately after completion of the initial instructions for the
origami task and after a 20-minute time interval. Participants were judged on their
ability to non-verbally reproduce the origami task and their ability to verbally
describe the procedures for doing the task.

The participants, who received only auditory-verbal input, performed the
least well on both nonverbal and verbal performance measures. The participants

who received the hands-on experience with its access to tactual-kinesthetic input

40

in addition to the auditory and visual input performed the best on some verbal
measures, specifically after a 20-minute interval between the teaching and
testing conditions. It was concluded that when Ieaming a novel procedural task,
multiple sensory input that includes tactual-kinesthetic experience does matter to
both verbal and nonverbal performance even in normal adults, and that auditory
verbal input alone is not enough.

To show that manually guided input is an active process that gets the
attention of the Central Nervous System (CNS), Beretta (1999) used EEG
measures. She studied three children (6 to 10 years of age) with a moderately-
severe to severe autism diagnosis. They were exposed to both novel and familiar
tasks while EEG recordings were made. The EEG measure of brain activity used
was contingent negative variation (CNV), which has been correlated with
attention in Ieaming. Task exposure involved controlled Ieaming tasks that
provided the child with enhanced manual input on some tasks and not on others.
The tasks included: pushing a button, squeezing soft and hard balls, and picking
up light and heavy glasses.

Responses were compared under identical or similar task conditions. The
researcher compared picking up a light glass to that of picking up a heavy glass
while being guided in the task and while completing the task independently as
well as squeezing a ball while being guided and squeezing the same ball
independently.

The most severe participant recorded a strong CNV response to the

condition providing the tactual-kinesthetic input. This response suggested that

41

sensory input associated with manual guiding can elicit the attention of the
nervous system during exposure to novel tasks.

Research (Stockman 8 Latham,2002; Latham 8 Stockman, 2002) used an
orange juice-making task to study children without and those with special needs,
some of whom were labeled as ASD by their respective school districts and
serviced in Speech-Language Impaired! Autistic Impaired (SLI-Al) classrooms.
Research (Stockman 8 Latham, 2002) showed that even typically developing
children profited verbally and nonverbally from participation in an event,
especially after the opportunity to do it more than once. Participants in the first
pilot research included 15 children (mean age = 5; 1) without a special needs
history. Standard conditions were used to expose the children to a juice-making
task. The children were randomly assigned to an observation or participation
condition. The children were asked a series of WH-questions about the task
(Verbal 1 score). Then, each child was asked to reproduce the juice-making task
independently. Aftenrvards, the WH-questions were repeated to give the child
another verbal score (Verbal 2 score).

The two verbal scores were compared for the participation and
observation conditions. Analysis of Variance (ANOVA) revealed significantly
higher scores for the participation group than the observation groups on both
verbal tasks 1 and 2 with no significant group-by-task interaction.

A second pilot study included 12 children with special needs (mean age =
6; 4). They were tested under the same conditions as the typically developing

children. Their performances, scored by the same judges, were compared to

42

those observed for the typically developing children. Within the special needs
group, differences on Verbal tasks 1 and 2 were also observed. The observation
and participation groups each improved their scores from Verbal task 1 (initial
sensory input) to verbal task 2 (re-enacted input). Analysis of Variance revealed
a significant task main effect with no significant task-by-group interaction, as was
observed for typically developing children. This result indicated that the children
with special needs in the observation group profited even from one participation
experience, unlike the typically developing group, which did not.

There were no significant differences between the special needs
observation and participation groups in their ability to reenact the nonverbal task.
However, the qualitative ratings showed that the participation group performed
the task with better motor dexterity, as measured by execution and rate of
completing the task, than did the observation group. When compared to the
normal counterpart for both groups, the nonverbal scores were lower for the
special needs children. In addition, the ratings were poorer for the special needs
children, regardless of group assignment. Luce (2004) used the same paradigm
to investigate further the issue of passive versus active participation by
comparing real and simulated actions during the juice-making task used in the
earlier research.

Luce (2004) observed that typically developing preschoolers, who
received enhanced tactual-kinesthetic input during a real juice-making novel task,
performed better than their age-matched peers who participated in a pretend

version of the same task. The 14 participants included 8 females and 6 males

43

between 3; 7 and 4; 8 years. Participants were assigned to either the group
using a real juice press or the group using a visual replica. The scores of the
group using the real juice press were significantly higher than those of the
representational group on the direct questions asked about the juice-making
event. Analysis of the nonverbal scores also revealed a significant group
difference that showed the best performance for the group that used the real
juice press.

It was concluded that although the children, who performed the pretend
task, did indeed perform an action, their actions did not have the effect of
changing the environment in a salient way. The results exposed the inadequacy
of traditional teaching practices, which claim that a child actively participates in
an event just because he/she “does” or "touches” something.

The Need for Further Research

The previous work demonstrated that there is enough bias to favor the
positive effects of enhanced tactual input that it cannot be dismissed as irrelevant
to acquiring new knowledge. All of the prior studies confirmed the relevancy of
manually-guided input for both verbal and nonverbal Ieaming. They suggest that
such input, whether labeled as passive or not, is able to facilitate Ieaming.
Nevertheless, more research is needed. The earlier work provided a working
protocol that could be used, namely, a functional task of making orange juice with
an unfamiliar juice press. But several issues still need to be addressed to
determine whether this paradigm can be useful for studying children diagnosed

with ASD.

First, an ASD sample of participants needs to be studied before making
claims about the relevancy of a particular research paradigm for them. Previous
studies recruited either typically developing children or a mixed group of children
with special needs that was not clearly defined as ASD (Latham and Stockman,
2002). Beretta (1999) was the only study to include participants with ASD, and
the sample of three children with the diagnosis was very small. Thus, there is
little data so far about how well children with autism may respond to the
structured protocol used to pilot the nonverbal and verbal learning tasks that
were used in the earlier studies.

A second reason to undertake the current research is that previous
studies did not reveal how stable the learning was over time. To address Ieaming
retention, outcome measures need to be taken at different intervals across time.
It may be that the differences between children, who received and those who did
not receive enhanced tactual input on certain tasks, may be time dependent.

Finally, the research protocol used in earlier pilot studies was not
successful in eliciting children’s production of novel words. For example, Latham
and Stockman (2002), neither the atypical nor the typically developing children
were successful on confrontational naming tasks that required them to recall the
novel words to which they had been exposed, regardless of whether they
received manually-guided instructions for Ieaming the juice making task or not. It
is possible that success in recalling and naming the novel words can be

increased by using oral tactual prompts. They offer cues about the articulatory

45

features of novel words in addition to visual and auditory ones used in earlier
studies, as provided by PROMPT therapy (Hayden, 2004).
Purpose of Investigation
This study broadly aimed to demonstrate whether the differential effects of
two intervention conditions on verbal and nonverbal Ieaming within the context of
a novel event structure existed.
Research Hypotheses
1. Children diagnosed with ASD who bodily participate in a novel event will
perform better than those who only observe an event visually and aurally
on verbal and nonverbal tasks.
2. Children diagnosed with ASD who bodily participate in a novel event will
perform better than those who observe events visually and aurally on

verbal and nonverbal tasks when measured 24 to 48 hours afterwards.

46

CHAPTER 2
RESEARCH DESIGN AND METHODS

In this study, the investigator examined the differential effects of two
treatment conditions on verbal and nonverbal learning within the context of a
novel event structure. The two treatment conditions were labeled as the
observation condition and the participation condition. The children assigned to
the observation condition received visual and auditory input while observing a
juice-making task. The children in the participation condition received visual,
auditory, and tactual kinesthetic input while they participated in making orange
juice. The general methodology for this study was developed and applied in a
previous study (Stockman 8 Latham, 2002; Latham 8 Stockman, 2002).

Participants
Description of Participants

Wrth human subjects approval (Appendix B), informed consent was
obtained (Appendix C) from the parents of 34 children who participated in the
study. Although 36 persons agreed to participate, two were excluded bemuse
they did not meet the eligibility requirements. The participants included 5
females and 29 males between the ages of 4; 4 years and 14; 4 years. All
participants met the Michigan State Board of Education Administrative Rules for
determining autism or ASD. See Appendix A. Thirty-two of the participants were
enrolled in speech and language therapy; 1 participant was receiving speech and

language consultative services; and 1 participant had been dismissed from

47

speech and language services and was in the referral process to resume these
services.

The 34 participants were enrolled in nineteen different classrooms in
Berrien County, Michigan. Twelve participants were enrolled in Autistic Impaired
(AI) classrooms administered by the Berrien County Intermediate School District;
6 participants were enrolled in Al early intervention programs; 1 participant
attended a Charter school and received regular education services with
accommodations and resource room services; 3 participants were enrolled in a
Pre—Primary Impaired (PPl) program; 4 participants were enrolled in full time
special education classrooms; 5 participants were enrolled in regular education
classrooms and received accommodations and resource room services; 1
participant was enrolled in a private school and had a full time speech and
language pathologist assisting him 100% of the school day; and 2 participants
were enrolled in regular education classrooms and received accommodations
without resource room services.

Participant Selection Criteria

Thirty participants were sought initially to participate in the study. All had
to be diagnosed with autism or ASD according to the Michigan State Board of
Education Administrative Rules and be at least 4 years of age. In addition to
meeting the Autism/ASD criteria, participants also met the following inclusionary
criteria:

1. They had hearing and vision within normal limits (aided or unaided)

2. They had no physical impairments that might decrease motor abilities

48

3. American English was the primary language spoken in the home
Participant Selection Procedures

Recruitment procedures

Participants were recruited from every public and private school in Berrien
County, Michigan. After receiving consent from the Berrien County Intermediate
School District (Appendix D) and the local school districts, the parent consent
forms for eligible participants were sent through the schools to the parents. In
Berrien County, there are 16 local districts. Twelve districts agreed to participate.
Three local districts did not have any children with the ASD diagnosis enrolled in
their schools, and one local district did not want to participate in the study. Of the
12 districts that agreed to participate, only 10 received completed consent forms
from the parents. In addition to the 10 local school districts, 1 private school, and
the Berrien County Inten'nediate School District programs participated in the
study. Once parent consent was obtained, child screening was scheduled.
Screening procedures

Information regarding whether a child fit the selection criteria was obtained
from the completed teacher questionnaires (Appendix E) and parent
questionnaires (Appendix F). In addition, screening procedures required a
review of the child’s performance on language and cognitive measures. Given
the variability of the ASD population, it is not always easy to obtain
representative language and cognitive data. Equally important, the test scores
alone provided little information about the underlying processes the child may

have used. Therefore, a general review of language and cognitive functioning

49

was followed by extensive interviews. These interviews were conducted with the
speech and language pathologist, school psychologist, regular education
teacher, special education teacher, and the caregivers. This comprehensive
review aimed to verify the information about the child’s inability to comprehend
and produce language at an age appropriate level and the need for intervention
services. The most recently reported receptive and expressive language scores
were used, which had to be greater than 1.5 standard deviations below the mean
score of a standardized test population. This review also revealed whether the
child was cognitively able to complete the treatment conditions based on
reported cognitive test scores that did not exceed more than 2.0 standard
deviations below the mean of a standardized test sample.

Other screening measures consisted of the Oral Speech Mechanism
Screening Examination-Revised (St. Louis 8 Ruscello, 1987). The speech
mechanism screening was performed by the investigator to rule out any gross
abnormalities in oral structure or functioning that might compromise a child’s
participation in the research tasks.

A broad screening of motor performance was obtained from the teacher
questionnaire (Appendix E) and the parent questionnaire (Appendix F). The
teachers were asked to rate the motor abilities of a child using a 5.point scale.
The scale ranged from a rating of one to indicate below average performance to
a score of 5 to indicate above average performance. A paired samples t—test
revealed no significant differences between the observation and the participation

groups on motor performance as rated by the teachers (t=1.29, p<.216). Parents

50

also were asked to describe their child’s motor development as: good/nonnal,
questionable, or poor, and they provided comments regarding their description.
Sixteen of the 17 pairs were matched with the same description provided by the
parents. The remaining pair consisted of one child described by the parents as
“good” and the other child was described by the parents as “questionable”.

After receiving the completed parent questionnaire, the investigator
verified that a child had never participated in a juice-making task by directly
asking parents during the interview. This procedure was intended to ensure that
the experimental Ieaming task would be novel for participants. The investigator
asked caregivers to describe any tasks the child routinely did in the kitchen, such
as washing dishes or preparing food. No family reported that its child had
experienced making juice or using an antique juice press.

Human participant assurances.

The study was approved by the University Committee on Research
Involving Human Subjects. See Appendix B. The parents of the participants all
provided informed written consent before beginning the study. See Appendix C.
The participants were informed that their participation was completely voluntary
and that they could withdraw from the study at any time. The participants
provided verbal assent to participate in the study if they were able to
communicate verbally. Each participant was assigned a number and pseudonym

that was used for purposes of data collection and analysis.

51

Participant Assignment to Treatment Conditions

Among the children who met participant selection criteria, each one was
matched to another child in the group in chronological age, educational
placement, ratings of motor performance obtained from the teacher and parent
questionnaires, and scores on available standardized language and cognitive
measures. The matching procedure resulted in 17 matched pairs. Then the
children in each participant pair were randomly assigned to either an observation
or participation condition. The two resulting groups overall did not differ
significantly in their mean chronological ages or mean motor ratings. The mean
age of participants in the observation condition was 8.69 years (SD= 3.0), and it
was 8.36 (SD= 2.6) for those in the participation condition. The mean motor
rating by the teachers for those in the participation condition was 2.53 (SD = 1.0)
and 2.29 (SD = 1.05) for those in the observation group. Both groups included
approximately the same ratio of males to females, i.e., a ratio of 8:2. Every child
in each of the two groups was confirmed with a language delay of 1.5 standard
deviations or greater on a standardized test or qualified for an AI placement for
language delays and development. In addition, every child in each of the two
groups was within 2.0 standard deviations of the mean on a standardized
cognitive test or did not meet qualifications for a mentally impaired classroom.

The participants learned the task of making orange juice under one of the
two conditions. Those in the observation condition watched and heard the

investigator during the event of making orange juice. Those in the participation

52

condition watched, heard, and were physically guided by the investigator during
the orange juice making event.
Description of Experimental Procedures

The teaching event involved making orange juice using an antique juice
press. This event provided the context in which to facilitate the children’s
Ieaming of a novel noun, novel verb, and the steps to complete a novel
procedural task.

Task Selection

The task of making orange juice using an antique juice press was chosen
for several reasons. The nature of the task allowed observation of how a child
problem solves while doing a novel procedural task. The task was done in a
natural and functional context following the methodological framework presented
in Affolter and Bischofberger (2000). The juice-making task required the child to
interact with real objects, which involved eliciting changes of topological
relationships between the body and the environment in order to reach a
functional problem-solving goal. This task also was chosen because it was an
activity of daily living, but was likely to be novel to the participants. Screening
procedures ensured that no child had previous experience making orange juice
using an antique juice press.

Furthermore, the selected task required completion of a contingency of
steps. It was predetermined that such a task would require the sequencing of
five steps. This was judged to be a reasonable level of task difficulty, given the

participant population and previous research data (Latham 8 Stockman, 2002).

53

Previous research (Latham 8 Stockman, 2002) indicated that the task was not
too complicated or too simplistic for child participants to Ieam.

Stimulus Description
Nonverbal stimuli and task.

The materials used in the nonverbal teaching event were the same for
both the observation and participation conditions. The following materials were
used:

1. An antique juice press (Figure 1). The press is made out of metal and

has one operating lever.

2. Two oranges per teaching trial. For the participation group, this meant
each child used a total of 6 oranges; for the observation group, this
meant each child used 4 oranges and the examiner used 2 oranges.

3. A child-safe knife to cut the oranges. The knife had a serrated edge to
allow the child to cut through the orange, but not to harm her or
himself.

4. A glass measuring cup to collect the orange juice from under the
press.

5. A clear plastic glass

6. A plastic storage container that housed all the materials necessary to
carry out the task of making orange juice. The participants could not

see the contents of the container.

54

Figure 1.

 

Picture of antique juicer

The teaching event consisted of the following sequences of actions

leading to the goal of making orange juice:

1.

Reaching for, and grasping the knife in one hand and one orange in

the other hand. Repeating the procedure for the second orange.

. Cutting the two oranges into halves.
. Placing a half orange on the antique manually operated juice press.
. Placing the glass measuring cup at the base of the juice press.

. Pulling down on the handle of the juice press to squeeze the juice from

the first half of the orange into the measuring cup below.

55

6. Repeating steps 3 and 5 for the remaining 3 halves.

7. Pouring the juice into the glass.

8. Drinking the juice.

Verbal stimuli and task

The same stimuli were used in both the participation and observation
teaching conditions. The verbal stimuli to be Ieamed were embedded in the task.
Two strategically spoken, nonsense words were spoken during the teaching
condition. They were lpakl, which referred to the antique juice press, and lkaIpl,
which referred to the action of pulling the lever of the juice press. The words
were chosen because of their similar phonetic composition. Both words are
monosyllabic and contain the same consonant phonemes. Both lp/ and lkl are
voiceless stop consonants. The lpl sound is one of the earliest sounds to appear
in children’s speech (Sander, 1972; Smit, Hand, Freilinger, Bemthal, and Bird,
1990). About 90 % use the lpl consonant in the initial and final positions of words
at 3; 0 years of age and the lid consonant by age 3;6 years (Smit et al.1990) or
4; 0 years (Sander, 1 972).

The [a] vowel sound in lpakl is among the first vowels to appear in
children’s speech and is the most common vowel in the languages of the world
(Ladefoged, 2001). Most children have mastery by age 3; 0 years. The tongue
height for this sound is low, and the tongue position is retracted. The laI/ vowel
sound in IkaIp/ begins in the low back portion of the mouth and glides to the high
front position. It is the most frequently occurring diphthong in English (Ladefoged,

2001) and is mastered by 90% of children by age 4; 0 years. Therefore, all

56

phonemes used in the nonsense words should be developed by 4; 0 years of age
for 90% of children.

The nonsense words were each spoken four times during the juice-making
Ieaming event. No other words were spoken. The purposeful reduction of
linguistic input follows Affolter and Bischofberger’s (2000) therapeutic approach.
GIT prescribes that talking is done before or after, but not during the guided
activity. This approach posits that linguistic forms should be added after a child
experienced an event to reduce the information complexity for the child.

The nonsense word, lpakl, was spoken after the investigator set the juicer
on the table, pointed to the object, and then stopped pointing. Then, the
investigator again pointed to the object, stopped pointing, and spoke the
nonsense word, lpakl. This procedure was repeated two more times, for a total of
four presentations.

The second nonsense word, lkaIpI, referring to the action of pulling the
lever of the juicer, was spoken following the action four times. This meant that
after the first spoken trial, the word preceded and followed the action. The word
was never spoken during the action experience. The spoken words were
delivered right after the guided action.

Participant’s verbal Ieaming was assessed at four time intervals:
immediately after completing the initial Ieaming instruction (verbal composite 1),
after completing the task a second time on day 1 on his or her own without
instructional support (verbal composite 2), after completing the task a second

time without instructional support at 24 to 48 hour post-initial instruction (verbal

57

composite 3), and after immediately repeating the task again (verbal composite
4).

Participants’ nonverbal Ieaming was assessed at two time intervals: once
during the nonverbal task of making orange juice on day one (Nonverbal Rating
1/ Nonverbal Score 1) and once during the nonverbal task of making orange juice
on day two (Nonverbal Rating 2/ Nonverbal Score 2).

Data Collection Procedures
Overview

Once assigned to a treatment condition, the children were individually
instructed and tested in a designated room on their school premises. Each child
was exposed to a single treatment condition. The investigator administered
treatment conditions using a standard set of instructions and procedures. A
testing room was chosen which had the least amount of distraction possible. The
data collection took place on two separate days for each child. The second day
of data collection for each child was completed after 24 hours and within 48 of
the initial teaching condition. Data were collected for all the children over a three
month time period. The investigator administered all tasks to every child in each
condition. However, the children’s performances were scored by four other
people, who were blind to the study’s goals and participants’ group assignment.

Task Administration
The Observation Group
Prior to entering the testing room, the child was read a standard script of

what to expect. The child was told,

58

“Today you are going to watch me make something. After you watch me,
you are going to make something. Then, I am going to ask you some
questions.” The child was familiar with the investigator from the screening
procedures. The child indicated his or her willingness to participate by
either verbally stating, “okay”, or by non-verbally nodding his or her head

yes .
After the instructions were given, the child entered the room and was
seated beside the investigator. The child observed the investigator making
orange juice using the antique press. Observing the investigator provided the
child with auditory, visual, and olfactory input. No words were spoken during the

task except for the two strategically delivered nonsense words: lpakl, which
referred to the antique juice press, and lkaIpl, which referred to the action of

pulling the lever of the juice press.

After the teaching trial, the child was asked a series of questions to
evaluate what could be verbally expressed about the event (verbal composite 1).
See Appendix G. Next, the child was instructed to replicate the task on his or her
own. The investigator told the child, “Now it’s your turn.” They used the same
materials that had been used by the investigator with the expectation that the
child would repeat what had been observed. The investigator did not help the
child in any way to complete the task unless the child asked for help or
repeatedly struggled with a particular step in completing the task.

Following self-replication of the task, the child was again asked the same
set of questions that followed the initial teaching condition (verbal composite 2).
See Appendix G. Between 24 hours and 48 hours later, the child responded to
the set of questions for a third time without any new intervening self-experience

with the task (verbal composite 3). See Appendix G. The child was then

59

instructed to replicate the task nonverbally on his or her own. Once the child
replicated the task for a second time, the investigator asked for the fourth and
final time the child the same set of questions that followed the initial teaching
event (verbal composite 4). See Appendix G.
The Participation Group

Prior to entering the testing room, the child was read a standard script of
what to expect. The child was told,

“Today you are going to make something. Then, I am going to ask
you some questions.” The child was familiar with the investigator from the
screening procedures. The child indicated his or her willingness to
participate by either verbally stating, “okay”, or by non-verbally nodding his
or her head “yes”.

After the instructions were given, the child entered the testing room and
was seated directly in front of the investigator. The child was manually guided by

the investigator to complete the task, thus receiving tactual-kinesthetic input in

addition to the visual, auditory, and olfactory input. No words were spoken
during the task except for the two strategically delivered nonsense words: lpakl,

which referred to the antique juice press, and IkaIpI, which referred to the action
of pulling the lever of the juice press in a downward motion. The procedures for
auditory delivery of the nonsense words were the same as those used with the
observation group. In addition to just hearing and seeing the production of the
nonsense words, the participation group was guided physically for the novel word
production using tactual prompts (Hayden, 1999). Specifically surface prompts
for each phoneme in the nonsense word were used. Surface prompts are

intended to provide information to a child about place, timing, and movement

60

transitions for phoneme production in coarticulated contexts (Hayden, 1999).
Hayden (1999) differentiated tactile input by the amount and type of support
provided. That is, surface prompts provide the “most critical but least information
necessary for the neuromotor system to recognize or produce a phoneme and
maintain its essence throughout coarticulated movement transitions,” (p.275-
276)

After the teaching trial, the child was asked a series of questions to
evaluate what he or she had just Ieamed (verbal composite 1). See Appendix G.
Next, the child was instructed to replicate the nonverbal task alone. The child
was told, “Now it’s your turn.” The child was given the same materials used
during the manual guiding. The investigator did not help the child in anyway to
complete the task unless he or she requested help, or if the child was repeatedly
struggling with a particular step in the task.

After replicating the nonverbal juice-making task, the child again was
asked the same set of questions that followed the initial teaching condition
(verbal composite 2). See Appendix G. After 24 hours and within 48 hours, the
child was asked for a third time the same set of questions with no intervening
teaching or self-reproduction of the juice-making event (verbal composite 3).
See Appendix G. Immediately following this inquiry, the child was instructed to
replicate the nonverbal task alone. After doing so, the investigator asked for the
fourth and final time the same set of questions that followed the initial teaching

event (verbal composite 4). See Appendix G.

61

Recording the Data

Each participant had a data checklist form with his or her identification
number and pseudonym (Appendix H). Attached to this form were four copies of
the verbal measure (Appendix G). As the child answered the questions, the
investigator scored his or her responses on-Iine.

A SONY 360x video (Model # CCD-TRV67) handy-cam camera was used
to record each child receiving his/her assigned teaching condition and the
evaluation procedures that followed the treatment condition. A trained operator
facilitated the recording of each child. The video camera was positioned on a
tripod directly in front of the child at a distance of approximately 10 feet to ensure
the highest quality of taping. Each child was recorded on a separately assigned
8mm high quality videotape. The tape was labeled with the child’s assigned
number and pseudonym. A microphone, which fed directly into the video
camera, amplified the child’s verbal output for taping purposes.

Measuring Learning Effects

Six measures were used to evaluate participant Ieaming. Four measures
evaluated verbal performances and two evaluated non verbal performances.
The verbal measures reflected the participants’ performance on 11 questions,
which were asked at four different time points. The nonverbal measures were
based upon the participants’ event reenactment of the juice-making task at

different points across time.

62

Description of Verbal Measures

The verbal measure (Appendix G) consisted of the same questions that
were administered to the participants in both the observation and participation
treatment conditions. It included 11 items distributed across three categories of
tasks: (1) confrontational naming, (2) recognition, and (3) WH-Questions.
Administration of the verbal protocol required the investigator to elicit responses
in the following order: confrontational naming, recognition, and WH-Questions.
The order of tasks and the questions used to elicit responses within a task were
the same across all participants.

Confrontational Naming Task

The confrontational naming questions comprised three items. They
prompted a participant to name an object or action as the investigator pointed to
the referent object or performed the action by pulling down the lever of the juice
press. The participants were asked to name two objects, an orange (familiar
object), and the juice press, labeled as lpakl (an unfamiliar object). Then the
participants were asked to name the action of pulling down the lever of the press
(IkaIpl).

Each question was spoken with the same carrier phrase, “What is _?”
immediately before the investigator pointed to the object, or performed the action.
The first item required a child to name the orange. The investigator retrieved the
orange from the storage container, spoke the carrier phrase, “What is _?”,
and then presented the orange. No grammatical articles were used in the carrier

phrase. This was done to ensure that the child retrieved the label independently

63

of syntactic cues. Next, the investigator returned the orange to the storage
container and placed the antique juice press on the table. After placing the juice
press on the table, the research spoke the carrier phrase, “What is _?”, and
pointed to the juice press. Finally, the investigator delivered the carrier phrase,
“What is ___?”, and performed the action of pulling down the lever of the juice
press.

Scoring procedures for the responses are detailed on the verbal measure
recording sheet (Appendix G). The investigator recorded the child’s responses on
site. In some cases, a participant was asked to repeat his or her response when
speech was unclear. The investigator also repeated a child’s responses in some
cases to support for later transcription of the words spoken. Scoring procedures
allowed for self-correction of responses. That is, if the child changed his or her
response, the last response was recorded.

Recognition Task

The recognition task comprised three questions, items 4-6 of the verbal
measure. The recognition questions required the child to point to the randomly
ordered novel object or action on a TV monitor that displayed the object/action.
A professionally produced videotape displayed dynamic recordings of the object
and action, as well as foils of common household objects and the action
produced to use the objects. The objects included a saw, garden shears, and a
hand mixer. The dynamic images were displayed in four quadrants of the TV
screen. The four recorded images were randomly ordered in the display of the

objects/actions. A participant was shown the first of three sets of recorded

images. It displayed four different actions being performed by the investigator
without the use of objects in the action sequence. The images looked like
pantomimed actions. The investigator observed a participant’s eye tracking to
ensure that he or she visually scanned the set options. In some cases, the
investigator had to nonverbally instruct a participant to look at each quadrant on
the TV monitor. This was done by pointing to each quadrant while observing the
participants’ eye tracking. Next, the participant was asked, “Which is lkalpl,”
while still viewing the four actions being performed by the investigator without
objects. Once the participant’s response was recorded, the recording for the
second item was shown.

The second recording displayed four object images on the TV screen, one
of which was the antique-juice press. The same eye tracking procedures were
implemented for this task as described above for the first item. The participant
was then asked, “Which is lpakl?” The participant’s response was recorded.

The third and last recording was presented to the participant. It displayed
the same four actions that were shown in the first recording, however, this time
the four actions were performed with the objects acted on. The same eye
scanning procedures were used for this task. Then, the participant was
instructed, “Which is lkaIpl?” The participant’s response was then recorded.
WH-questions Task

The WH-Questions comprised questions 7-11 of the verbal measure
(Appendix G). These questions required the participant to answer questions that

were presumed to vary in level of difficulty. Answers to the questions provided

65

the investigator with information about each child’s ability to understand and
produce various syntactic-semantic structures. The answers to the questions
were scored according to a point scale that was developed in previous research
(Stockman 8 Latham, 2002; Latham 8 Stockman, 2002). Verbal and nonverbal
responses were scored.

Description of Nonverbal Measures

The nonverbal performance measures were based on a child’s ability to
reenact the juice-making event. Two performance measures were used for
participants in both the first (day 1) and second (day 2) treatment conditions: (1)
a nonverbal performance score and, (2) a nonverbal rating. The nonverbal
performance measure was obtained following the teaching event on day 1
(nonverbal score 1) and again on the second day, following verbal measure 3
(nonverbal score 2).

The nonverbal score reflected a child’s ability to do the steps needed to
achieve the action goal (logical aspect). The nonverbal rating reflected a child’s
ability to efficiently execute the actions (sensory-motor aspect). To reenact the
juice-making event, the children were given the same stimuli used by the
investigator during the teaching trial. The child was instructed to repeat exactly
what the examiner had done. All behaviors were video recorded for analysis.
Nonverbal Score

The nonverbal score was a quantitative measure based on a child’s ability
to replicate global steps in the event sequence of making orange juice (Appendix

I). Scoring was based on whether a child replicated the five steps of the event in

66

the correct order, and whether assistance was needed to complete any step.
Each step had a point range of 0-2 points and yielded an overall score range of
0-10. For each step, a child was given a score of “2” if he or she completed the
step unassisted. If a child needed assistance after self-initiated attempts, he or
she was given a score of “1”. A score of “0” was given if a child made no attempt
to initiate the step and required the investigator to initiate and assist during the
step.
Nonverbal Rating
The nonverbal rating was a qualitative score that reflected a child’s
perceived confidence and comfort level with performing the task independently,
the speed in which the child completed the task, and the need for assistance in
completing the sequence. The rating scale (Appendix J) used a 5-point scale
with a score of “1” representing competent execution and smooth transition. A
score of “5” indicated that the nonverbal task was extremely difficult, time
consuming, and required help from the investigator repeatedly. In addition to the
5-point scale, the raters were asked to provide a rationale for the score given to a
child.
Data Analysis
Raters
The Rating Task
Four female SLP’s, who hold the American Speech Language Hearing
Association’s Certificate of Clinical Competence (CCC), judged the performances

of both groups of children. The raters were naive to the study’s goals to

67

minimize scoring biases. They applied standard evaluation criteria to randomly-
ordered, video records of the children’s responses to the experimental tasks.
Raters individually watched the video records on a TVNRC in the
Communicative Disorders Department on the campus of Saint Mary’s College,
Notre Dame, Indiana.
Training the Raters

Prior to rating the video records, each rater attended an individual training
session. It familiarized her with the protocol scoring sheets (Appendices G, l and
J). Raters were given a three-ring binder that included the prepared forms and
instructions for making and recording their judgments (Appendix K). Each binder
contained every participant’s assigned pseudonym on a tab, so the rater could
easily access a child’s score sheets.

Scoring Verbal Performance

During the training session, each rater was instructed to write down
exactly what the child said or did for each question on the verbal scoring fonn’s
designated space. If a rater did not understand what a child said, she was
instructed to indicate this on the verbal scoring form. If the investigator asked a
child a question for the second time after receiving no response from the child,
the raters were instructed to score the second trial. They were also instructed to
score each response according to the point values given in Appendix K. For
example, on question 1, “What is (point to orange),” raters were instructed to
judge a child’s response as follows: If the child responded verbally by saying the

word, “orange", the performance was given two points. If the child gave a similar

68

response by referring to another type of fruit or by saying, orange juice, the
performance was given one point. If a child gave no response or an incorrect
response, the performance was given zero points.

Assigning weighted scores to the responses allowed for the expected
variability of children’s responses. Some responses were more sophisticated
than were others, even when they were not optimal. For example, one child
responded to question 3, “What is (press on juicer)?” by stating, “That’s
pressing down to get juice.” Although this was not the response that the
investigator was aiming to get (lkaIpl), partial credit was given because it showed
some understanding of the object’s function even if the name of action was not
given. Finally, the raters were instructed to total all points and record this total on
the form as designated. Raters were instructed to use these same procedures
for all four verbal measures obtained for each participant.

Scoring Nonverbal Performance
Nonverbal Scoring and Analysis Procedures

Following instruction on the verbal measures, the raters were given
directions for scoring the nonverbal measures. First, the raters were instructed on
how to obtain the nonverbal score (Appendix I). The raters were instructed to
score each step of the task according to the point values provided by placing a
check mark in the appropriate box for each step of the task. If unassisted in
completing a step, a child was given 2 points. If the child initiated the step on his
or her own, but required assistance during the task, he or she was given 1 point.

If the investigator was required to initiate the step and assist the child during the

69

step, 0 points were given for the step. Raters were then instructed to record the
chronological order in which a child performed each step of the task. To do this,
they were instructed to number a child’s performance for each step next to the
box containing the step description.

Nonverbal Rating and Analysis Procedures

Next, the investigator instructed the raters on the nonverbal ratings. The
investigator played a videotape of herself performing the task of making orange
juice. Each rater was instructed to use this example as a prototypical
comparison for rating of the child. Specifically, each rater was asked to judge
how close a child came to replicating the investigator’s performance. To assign
the nonverbal rating, the rater was instructed to subjectively rate the child’s
performance (Appendix J) according to a 5-point scale, that varied on a
continuum from 1 (perfect execution) to 5 (very poor execution). If a child
replicated the task with smooth transitions and competent execution, like the
investigator had illustrated, they were to rate the child as 1. A child’s replication
was rated as 5 if the task seemed extremely difficult for the child to do and time
consuming, or the child required help many times.

A composite mean nonverbal score for each child was computed from
each rater’s scores for each of the two nonverbal scores. A paired samples t-test
was used to determine whether statistically significant differences existed
between the two groups for each of the nonverbal scores, NV score 1 and NV
score 2. In addition to comparing the mean scores for the two groups, each one

was compared to itself over time. Nonparametric measures, namely the

70

Friedman’s rank test for k correlated samples, were used to demonstrate
significance.

A composite mean nonverbal rating for each child was computed from
each rater’s scores for each of the two nonverbal rating scores. Paired samples
t-tests were used to determine whether the participant and observation groups
differed significantly at day one and day. Within group comparisons were made
using nonparametric measures.

Statistical Analysis
Computation of Scores

The scores of the raters were averaged to produce a verbal composite
score for each child in each treatment condition for each of the four verbal
measures. An Analysis of Variance (ANOVA) was done on each composite
verbal score to evaluate whether the raters’ mean scores differed significantly.

Statistical Tests

The SPSS software was used for the statistical analysis of the data. An
Analysis of Variance (ANOVA) was performed on the raters’ scores for verbal
performance among the participants for each composite verbal score. The two
treatment groups were compared statistically using paired samples t-tests for
each composite verbal score. The Cohen’s d statistic was calculated. to
determine the magnitude of the difference between the treatment conditions.
Each treatment group was compared to itself using a one-way ANOVA.

An item analysis was done on the verbal questions using means, standard

deviations, and paired-samples t-tests to determine whether differences exist

71

between the observation and participation groups. Between-group comparisons
were made on nonverbal scores using paired samples t-tests. Within-group

comparisons were made using the Friedman’s rank test for k correlated samples.

72

CHAPTER 3
RESULTS

This study investigated the effect of sensory input modality on verbal and
nonverbal Ieaming of children with ASD. It aimed to determine if such children
who bodily participated (hands-on Ieaming) in a novel event differed on verbal
and nonverbal tasks from their matched ASD—diagnosed peers who just observed
the same events visually and aurally. The assumption was that the participation
group who received tactile-kinesthetic input through hands-on experience would
be given an advantage in Ieaming a verbal and nonverbal task. Additionally, the
study aimed to determine whether group differences show up in the retention of
both verbal and nonverbal Ieaming over time, specifically after a latency of 24 to
48 hours.

The 34 participants were taught two novel words, one noun and one verb,
within the context of performing a novel orange juice-making task. Learning
effects were measured by scores obtained on verbal and nonverbal measures. In
analyzing the results, the null hypothesis was set at p=. 10 or less instead of p=
.05 or less, the customary p value. The use of a more lenient p value was
justified by the exploratory nature of the study. It allowed the investigator to

identify significant trends in the data that could lead to further research.

73

Verbal Performances
Reliability of Individual Raters

The data consisted of each child’s composite verbal score, as averaged
across each of the four raters for all verbal performance measures observed at
each of four successive times following the initial Ieaming event. Table 1 displays
the means and standard deviations for each rater on each verbal measure.

The four composite verbal scores obtained for each of the four individual
raters were compared in a univariate Analysis of Variance (ANOVA). Raters were
compared on each of the four verbal scores obtained at times 1 through 4. Their
means ranged from 6.85 to 7.47 for Verbal Measure 1; 6.53 to 7.29 for Verbal
Measure 2; 6.76 to 7.56 for Verbal Measure 3; and 6.71 to 7.09 for Verbal
Measure 4 (Table 1). Among the raters, differences between the largest and
smallest mean did not exceed .80, which occurred on Verbal 3.

The F test results, which also are shown in Table 1, revealed no
significant differences among the four raters. Therefore, the scores for the raters

were averaged to yield a single composite verbal score as shown in Table 2.

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Table 1
Composite Verbal Score by Rater Conflated Across Observation Conditions

 

 

Task Rater Rater Rater Rater F df p
1 g 3 4

Verbal1
M 7.47 6.85 7.00 6.91 .090 3,132 .966
SD 5.68 5.43 5.40 5.38

Verbal2
M 7.29 6.59 6.53 6.59 .147 3,132 .931
SD 5.78 5.33 5.34 5.64

Verbal3
M 7.56 7.12 6.76 7.18 .133 3,132 .940
SD 5.32 5.36 4.81 5.29

Verbal4
M 7.03 6.91 6.71 7.09 .032 3,132 .992

SD 5.70 5.33 5.18 5.76

 

Note. The four verbal tasks correspond to successive performances observed
across time.

75

Table 2 Mean Composite Verbal Scores obtained for the Participation Group
and the Observation group plus t Statistic Outcomes Over Time

 

 

 

Measure Participation Observation t (if D
Day 1
Verbal 1
M 8.12 6.00
SD 5.52 5.20
Cohen’s d .395 2.22 (3,16) .041“
Verbal 2
M 7.76 5.74
SD 5.51 5.41
Cohen’s d .370 1.98 (3,16) .065“
Day 2
Verbal 3
M 8.25 6.06
SD 5.39 4.76
Cohen’s d .431 2.36 (3,16) .031”
Verbal 4
M 8.25 5.62
SD 5.66 5.02
Cohen’s d .492 2.65 (3,16) .017“
F(3,48) =.69, p<.56 F(3,48)=.72.p<.54

 

Note. *p< .10, ”p<.05, ***p<.005

Composite Verbal Total Scores Analysis
Table 2 displays composite mean verbal scores computed separately for
the participation and observation groups at each of the four time intervals, i.e.,
Verbal 1 through Verbal 4. The composite verbal scores tapped: (1)
confrontational naming, (2) recognition of the novel noun and verb, and (3)

elicited responses to WH-questions about the juice-making task.

76

Between-Group Comparison

The two groups were compared statistically on each composite verbal
score using paired samples t-tests. The results of the t-tests for this between-
group comparison are displayed in Table 2. The mean scores were consistently
higher for the participation (hands-on) than the observation (nonhands-on) group
on all four composite verbal scores. As shown, the mean scores across tasks
varied from 7.76 to 8.25 in the participation group and they ranged from 5.62 to
6.06 in the observation group.

A paired samples t-test yielded statistically significant differences between
the two groups at p values ranging from p=.017 (Verbal 4) to p=.065 (Verbal 2).
To determine the magnitude of the difference, or the effect size, the Cohen’s d
statistic was calculated. The d values, ranging from .370 (Verbal 2) to .492
(Verbal 4), yielded moderate effect sizes.
Within-Group Comparison

A within-group analysis was done to reveal if the mean scores changed
over time for each group (i.e., for each of the four successive elicitations of
responses following the Ieaming input condition). A One-Way ANOVA was
performed on each treatment group to statistically measure whether differences
occurred from the first to the fourth composite verbal score. Table 2 reveals
mean scores that varied from 7.76 (Verbal 2) to 8.25 (Verbal 3 8 4) for the
participation group and 5.62 (Verbal 4) to 6.06 (Verbal 3) for the observation

group. A one-way ANOVA revealed no significant differences among the four

77

composite scores for neither the participation group nor the observation group.
Although no score shifts over time were statistically significant, it is worth noting
one consistent data trend for both groups, namely, the mean score decrease
from Verbal 1 (Time 1) to Verbal 2 (Time 2). The mean scores decreased from
8.12 to 7.76 and from 6.00 to 5.74 for the participation and observation groups,
respectively (Table 2). A subsequent increase from Verbal 2 (Time 2) to Verbal 3
(Time 3) was followed by either a score decrease (observation group) or
maintenance (participation group) from Verbal 3 (Time 3) to Verbal 4 (Time 4).
Verbal Task Analysis

The previous analysis focused on composite verbal scores, which
conflated scores for three different types of tasks: (1) confrontational naming, (2)
word recognition, and (3) WH-questions. A separate analysis of each of these
tasks was done to determine if some verbal tasks contributed more than others
to the composite score differences observed between and within groups. Table 3
displays the means, standard deviations, and the paired samples t-statistic for
the three tasks by treatment group.

The confrontational naming task required participants to spontaneously
generate the name of the object or action upon physical presentation by the
examiner. The word recognition questions required the participants to point to a
dynamic video image of the novel noun and novel verb upon request. The WH-
Questions task required the participants to answer questions about the event,
reflecting the participant’s understanding of the question form and knowledge of

the event.

78

Table 3 shows significantly higher mean scores for the participation than
the observation group on each task. The means, ranged from 2.54 to 3.97 for
the participation group and from 1.59 to 2.99 for the observation group. For both
groups, the mean scores were the highest on the confrontational naming tasks,
followed in order by the recognition and WH-Questions tasks. The paired t-test
yielded significant group differences for each task. These differences were
associated with moderate to robust effect sizes, as shown. The Cohen’s d
statistic ranged from d =.574 for the confrontational naming task to d=.838 for the
WH-Questions task.

Table 3

Means, Standard Deviations, 8 Effect Size on Verbal Tasks for the Participation
Group and Observation Group

 

 

 

_Ta_sk Participation Obseeration t p d
Confrontational
Naming

M 3.97 2.99

SD 1.76 1.65 4.66 .001*** .574
Recognition

M 3.10 2.45

SD 1.21 .55 1.79 .101* .692
WH-Questions

M 2.54 1.59

SD 1.04 1.22 9.27 .0001*** .838

 

Note. *p<.10, **p<.05, *** ,.005

79

Task-by- Time Analysis
While the previous analysis revealed a participation group advantage on
composite scores for each of the three types of tasks that comprised the verbal
measure, this analysis focused on trial-by-task effects.
Table 4 displays the mean scores of the two treatment groups on each of
the four performance trials. It shows that the mean scores for the participation
group were higher than the observation group on all four performance trials for all

three tasks. However, the differences were not significant for every task.

80

Table 4
Verbal Task Type Across Time for the Participation Group and Observation
Group

 

 

 

Esk Type Participation Observation Difference t p
Confrontational Naming
Time1 M 4.20 3.88

SD 3.51 3.55 .32 .82 .417
Time2 M 3.16 2.50

SD 3.04 2.98 .66 2.65 .011**
Time3 M 4.18 2.74

SD 3.33 3.08 1.47 3.61 .001***
Time4 M 4.33 2.84

SD 3.33 3.19 1.49 3.10 003*"
Recognition
Time1 M 2.57 2.29

SD 2.71 2.63 .28 .60 .553
Time2 M 3.02 2.29

SD 2.89 2.79 .73 1.38 .174
Time3 M 2.88 2.84

SD 2.78 2.90 .04 .10 .921
Time4 M 2.59 2.37

SD 2.75 2.66 .22 .51 .612
WH-Questions
Time1 M 2.76 1.75

SD 3.34 2.82 1.01 2.91 .005***
Time2 M 2.58 1.73

SD 3.42 2.93 .85 2.45 .016**
Time3 M 2.36 1.51

SD 3.08 2.64 .85 2.46 .016**
Time4 M 2.45 1.36

SD 3.17 2.76 1.09 3.37 .001***

 

Note. * p < .10; **p < .05; ***p < .005

81

The confrontational naming task group yielded significantly higher scores
for the participation than observation group for all trials except Time 1. The
differences were more robust for trials 3 and 4 than 2. On the recognition task,
none of the group differences in mean scores was significant across time despite
the bias toward higher mean scores for the participation compared to observation
group. The WH-Questions yielded the largest and most robust differences as
shown across all trials. The participation and observation groups differed

significantly on the WH-Questions task at every time interval.

Item-by-ltem Analysis

Whereas the previous item analyses of question types conflated the
outcomes for individual items within a question category, a narrower analysis
was done to determine whether some of the individual items within each category
of verbal tasks contributed more than others to the group differences observed.
Confrontational Naming Questions

The results of the item analyses are displayed in Figures 1.1 to 1.3. for the
items in the confrontational naming task. Paired sample t-tests revealed
significant differences between the treatment groups across time on two
confrontational naming questions, “What is orange?” at times 2 and 3, and “What
is lpakl?” at times 2,3, and 4. There were no significant group differences for the
question, “What is lkaIpl?” during any of the four performance trials, even though
the means were highest for the participation group on three of the four trials. See

raw score data for Figures 1.1 to 1.3 in Appendix L.

82

The within-group analysis revealed that both groups fluctuated in their
performances across trials. At the second performance trial, the mean scores for
both groups decreased relative to the first time probe. The score depression is
especially marked for naming the novel object, “lpakl.” (Figure 1.2) The
participation group differed from the observation group in that it increased its
scores across time on two of the confrontational naming questions, “What is
orange?” and “What is lkaIpl?”. The participation group scored higher than the
observation group at almost every point across time and across performance
task. Thus the score distance between the two treatment group means
increased across trials. This trend suggested greater retention of verbal learning
by the participation than the observation group. The decreased means across

trials for the observation group suggested reduced retention.

83

3-0' What is Orange?

7.5
7 o 'P' Participation
' -0- Observation

6.5— P\
6.0 L / P
5.5— 9‘ —P

5.o~ 0\ o

4. 5 _ 0/

3.5 -
3.0
2.5
2.0
1.5
1.0
0.5
0.0

I

 

 

 

 

 

Mean Scores

I T I T
O

1

7

_

1

1 2 3 4
Time

_
b

 

Figure 1.1
Mean Scores for the Participation and Observation Groups Across Time on the
Confrontational Naming Question, “What is Orange”

34

8'0” What is lpakl?

7.0 _ -P- Participation
-0- Observation
6.5
6.0
5.5
5.0 P
4.5
4.0 l- ___p
3.5
3.0
2.5
2.0
1.5 0* 0“ ‘0
1.0
0.5

0‘0 i z 3 4

Time

 

 

 

 

Mean Scores
I I I I I
O

.0
\1
l

T

 

TI

1

 

.—
-

Figure 1.2
Mean Scores for the Participation and Observation Groups Across Time
on the Confrontational Naming Question, “What is /pak/’

85

8-0' What is Ikatpl?

-P- Participation
-0- Observation

 

7.0
6.5
6.0
5.5 -
5.0 -

1

 

 

 

T

T

:h
0|
1

4.0 -
3.5 ~

3.0 " /P
2.5 h p

2.0 K P/ /O
1.5 cr “‘0
1.0

0.5

0'0 i i 3 4

Time

Mean Scores

ffi T

T

 

_
_

32:23.;ng for the Participation and Observation Groups Across Time

on the Confrontational Naming Question, “What is /kaIp/”
Recognition Questions

Figures 2.1 to 2.3 display the comparison of the treatment groups on the
recognition task. See raw score data for Figures 2.1 to 2.3 in Appendix M. Only
one recognition question (lkaIp/ without object) contributed to the group
difference displayed in Table 4. Paired sample t-tests revealed significantly

higher mean scores for the participation than the observation group across time

on the item, “Which is IkaIp/” with object at time one (Figure 2.2). On the two

86

remaining items, the performance of the two groups overlapped (Figures 2.1 and
2.3). The overlapping performance indicated that the participation group was not
consistently better than the observation group for each performance trial. As a
result, no statistical differences between the groups were found on the

recognition task.

8-0' Which is lkatpl? Without Object

7.5 - '
7'0 ” -P- Participation i

 

 

 

6.5 P '0- Observation

6.0- E
5.5 —

5.0 -
4.5 -

4.0 — P 0
3.5 .

2.5 r
2.0
1.5
1.0
0.5

0'0 i '2 3 4

Time

 

Mean Scores

1 I l

I

 

_
b

Figure 2.1
Without Object Mean Scores for the Participation and Observation Groups
Across Time on the Recognition Question, “Which is /kaIp/” .

 

87

Mean Scores

8.0 -
7.5 -

Which is lkaIpl? With Object

 

 

6.5 -

-P- Participation
-0- Observation

 

 

6.0
5.5 -
5.0
4.5

I

3.5
3.0
2.5 F

I

I

1 .5
1.0 -
0.5
0.0

T

I

 

Figure 2.2

 

l"

 

_-
.—
'—

Time

Mean Scores for the Participation and Observation Groups Across
Time on the Recognition Question, “Which is /kaIp/’ IMth Object

88

80— Which is lpakl?
7.5 -
7.0 ~
6.5 -
6.0 -
5.5 ~
5.0
4.5
4.0
3.5
3.0
2.5
2.0
1.5
1.0
0.5

I T

I

Mean Scores
r

1

r

 

0><874 ‘* 7‘0
P P ———P

-P- Participation
-0- Observation

 

T

 

 

 

T

T

 

 

Time

Figure 2.3
Mean Scores for the Participation and Observation Groups Across
Time on the Recognition Question, “Which is /pak/’
Wh-Questions
Figures 3.1-3.3 display the mean scores for the two treatment groups on
the WH-Questions. Paired sample t-tests revealed robust significant group
differences (p< .001 to .016) on one or more trials for each of the following
questions: how, why, and when. The significant differences across time were

observed on the how question at times 1 and 2, the why question at times 1, 2, 3,

and 4, and the when question at time 3.

89

The scores on the who and where questions also were consistently
ranked higher for the participation than the observation group although the
differences were not large enough to reach significance on any of the
performance trials, with one exception, the where question at time 3. See raw

score data for Figures 3.1 to 3.3c in Appendix N.

8.0
7.5
7.0
6.5
6.0
5.5
5.0
4.5
4.0
3.5
3.0
2.5
2.0
1 .5
1.0

0.5

0'0 i i 3 4

Time

I

Who?

I

 

-P- Participation
-O- Observation

1

 

 

 

l l l T r

Mean Scores

l
/
\.

l
l
l

l T T

T

 

_
_-

Figure 3.1
Mean Scores for the Participation and Observation Groups Across Time
on the llVH-Question, ” Who”

90

8.0
7.5
7.0
5.5 '-
6.0 l'
5.5 -
5.0 -
4.5 '—

1

Where?

r

 

-P- Participation
-0- Observation

 

 

 

 

Mean Scores

3.o~ P
25 .
2.0 -
1.5 —
1.0 ~
0.5 r-
o.o 1 1

 

-
b

Time

Figure 3.2
Mean Scores for the Participation and Observation Groups Across Time
on the Wh-Question, “Where”

9]

Mean Scores

I

8.0

 

7.5

T

-P- Participation
-0- Observation

 

I

 

 

7.0
6.5 -
6.0 F
5.5 -
5.0 -
4.5 -
4.0 .
3.5 ..
3.0 r
2.5- P
2.0 .

I

 

0.0 I

Figure 3.3a

How?

1.5 — \P/P\

1.04 0 P
0.5 \O/O\o

Mean Scores for the Participation and Observation Groups Across
Time on the WH-Question, “How”

92

Mean Scores

8.0
7.5 -P- Participation When 7
7.0 -0- Observation
6.5
6.0
5.5
5.0 ~
4.5
4.0 -
3.5 -
3.0 -
2.5 ~
2.0 r
1.5

p P
1-0 o o
0.5 0
°-° l ‘2 5 it
Time

 

r

 

 

I

 

I

I

 

T

 

 

Figure 3.3b
Mean Scores for the Participation and Observation Groups Across
Time on the WH-Question, “When”

93

8.0
7.5
7.0
6.5
6.0
5.5
5.0
4.5
4.0
3.5 *-
3.0
2.5

1

Why?

 

-P- Participation
-0- Observation

I

 

 

 

T T T T T I

Mean Scores

f

I

 

 

1.5
1.0
0.5
0.0

I

T

 

 

 

O

l
l

“O

l

l
'0
AFC

Figure 3.3c
Mean Scores for the Participation and Observation Groups Across Time
on the WH-Question, “Why
Summary of Verbal Performance
The results for the verbal performances revealed that children with ASD
who bodily participated in a novel event differed from their age-matched ASD

peers, who observed an event just visually and aurally. In general, the children

in the participation group scored significantly higher on each of three types of

94

verbal tasks: Confrontational Naming, Recognition, and WH-Questions, and on
the items within these tasks. Over time, the differences between the participation
and observation groups increased on the confrontational naming task and WH-
Questions task. The performance on the recognition task overlapped between
the two groups, given that neither group performed consistently better than the

other across all the trials.

Nonverbal Performance
Composite Nonverbal Score
Two non-verbal scores were used to determine if the children diagnosed
with ASD who bodily participated in a novel event differed from those who
observed an event visually and aurally. The nonverbal score reflected the child’s
ability to replicate the logical steps of making orange juice as outlined in the non-
verbal scoring procedures. Table 5 displays the nonverbal scores of the
participation and observation groups.

Table 5
Nonverbal Scores

Day Measure Participation Observation t p d
1

NV Score 1
M 8.10 4.60
SD 1.97 3.42 3.88 .001*** 1.254
2
NV Score 2
M 8.35 6.13
SD 1.66 3.47 2.92 .010“ .816
p= .366 .021**

 

Note. *p<.10, **p<.05, ***p<.005

95

Between-Group Comparisons

The participation group scored higher than the observation group on both
day 1 and day 2. A paired samples t-test revealed a significant group difference
for nonverbal 1 at the p=.001 level. Another paired samples t-test, which
compared the two groups on the second nonverbal score, revealed a significant
difference at the p=.010 level. Therefore, children diagnosed with ASD who
bodily participated in a novel event did differ from those who observed the
nonverbal event. The Cohen’s d=1.254 indicated an extremely large effect size
at time 1. At time 2, Cohen’s d=.816, which also indicated a large effect size.
Within-Group Comparisons

Within group comparisons also are displayed in Table 5. In addition to
comparing the two treatment groups with each other, each group was compared
to itself over time with the goal of determining if nonverbal performance was
affected by group assignment over time. The participation group slightly
increased its mean score from Time 1 (M= 8.10) to Time 2 (M= 8.35). This
difference was not statistically significant. But the observation group’s increased
mean score from Time 1 (M=4.60) to Time 2 (M=6.13) was statistically
significant. Using nonparametric measures, specifically the Friedman’s rank test
for k correlated samples, a statistically significant difference was obtained (p

=.021) for the observation group. This outcome demonstrated that by interacting

96

tactually with objects, a child can improve his/her performance over time even if
the original learning trial did not include manually guided procedures.
Composite Non verbal Rating

Two non-verbal ratings were obtained to determine if the children who
bodily participate in a novel event differed qualitatively from those who observed
an event visually and aurally on non-verbal tasks. The two treatment groups can
be compared in Table 6.
Table 6

Mean Non- Verbal Ratings and Standard Deviations for the Participation
and Observation Groups

 

Day Measure Participation Observattion t p d
1
NV Rating1
M 2.95 3.90
SD 1.08 1.16 -2.94 .010** -.848
2
NV Rating2
M 2.88 3.57
SD .96 1.23 -2.59 .020“ -.625

 

Note. *p<.10, **p<.05

Lower ratings corresponded to better performance while higher ratings
corresponded to poorer performance. A rating of “1” reflected the rater’s
judgment that the task replication was competently executed and done with
smooth transitions. The “5” reflected the ratei’s judgment that the task replication
was extremely difficult, time consuming, and required the child to ask for help
many times. Mean nonverbal ratings are shown for Day 1 and Day 2 of the

testing in Table 6.

97

Between-Group Comparisons

The mean scores were lower for the participation than the observation
group at both times, i.e., Day 1 and Day 2. This meant that the participation
group was judged to be qualitatively better at executing the juice-making task at
both sampling times. A paired samples t-test revealed statistically significant
group differences at the p=.01 level. Another paired samples t-test, compared
the two groups at day 2 and revealed statistically significant differences at the p=
.02 level. These findings suggested that although the children in the observation
condition may have improved with their nonverbal performance from day 1 to day
2, they were rated qualitatively different from the children who received the
tactual-kinesthetic input in addition to the visual and auditory input during the
teaching trial.
lMthin-Group Comparisons

Table 6 also displays the within group non-verbal ratings. The
participation group’s nonverbal rating improved from day 1 (M=2.95) to day 2
(M=2.88) as did the observation group (cf. M=3.90 on day 1 and M=3.57 on day
2). Neither the participation group nor the observation group demonstrated
statistically significant differences over time.

Summary of Non- Verbal Performance

The results from this study revealed significant verbal and nonverbal
differences between children with ASD who had hands-on participation in the
novel juice-making and those who just experienced the same visually and

aurally. The hands—on group obtained significantly higher verbal and nonverbal

98

scores. They demonstrated these higher nonverbal scores not only initially, but
also maintained their differences across a 24-48 hour time span. Therefore, the
initial intervention was adequate enough to stimulate learning that could be
detected in the children’s performance beyond the initial Ieaming trials.

The results did not reveal significant score increases for either group over
time. While the observation group benefited from interacting with the materials, it
did so to less extent than did the participation group.

The raters subjectively assigned better ratings to the participation group
than the observation group at both time 1 and time 2. The raters did not score
the participation group or the observation group as being subjectively different
from time 1 to time 2.

General Conclusion

The results revealed an empirical bias in the data that favored better
verbal and nonverbal performance for the participation than the observation
group with ASD on novel tasks. Given these results, it can be concluded that
both verbal and nonverbal Ieaming are likely to be facilitated when children

diagnosed with ASD are manually instructed to do a task or say a new word.

99

CHAPTER 4

DISCUSSION

This dissertation investigated the effect of using different sensory
modalities on learning novel verbal and nonverbal tasks among children with
ASD, and whether such Ieaming effects are sustained across time. It was
hypothesized that the children who manually participated in a novel juice-making
event would receive more effective input than the children who only watched and
heard the same event. Consequently, they were expected to better store and
retrieve novel words and their meanings as well as nonverbally reenact the newly
Ieamed functional event when compared to children who just observed the same
event visually and aurally. In addition, it was hypothesized that the differential
Ieaming effects for the two groups would be sustained after a latency of 24 to 48
hours.

The results generally confirmed the expected outcomes. Manual
participation in a novel event resulted in not only significantly higher nonverbal
performance, but also significantly higher verbal performance when compared to
the performance of participants in the visual and auditory observation condition.
These findings suggested that even brief exposure to the hands-on intervention
led to a significant shift in both nonverbal and verbal Ieaming for some children.
The practical implication is that enhanced somatosensory perception via manual
guiding allows professional service providers and caregivers to effectively
intervene when a child does not respond to auditory and visual instruction. The

theoretical implication is that manually guided input should not be viewed as a

100

passive source of perceptual input for acquiring knowledge. If anything, this
study, like earlier pilot research, suggests that such input may be even more
effective than just providing auditory, visual, and olfactory experiences. Adding
the tactual systems seems to be helpful. The purpose of this chapter is to
discuss the possible reasons for the observed outcomes in this study and their
implications for clinical and research work.

Study Outcomes and Explanatory Factors

Verbal Learning

The verbal tasks entailed asking the participants a series of probe
questions in three broad categories of tasks: (1) confrontational naming, (2) word
recognition, and (3) Wh—Question responses following the event of making
orange juice. The composite mean verbal score, which included all three tasks,
was significantly higher for the participation than the observation group. This
finding was supported by robust statistical outcomes that exceeded the
conventional .05 level of probability for determining statistical significance.

This predicted outcome was consistent with earlier studies, which have
shown manually guided, nonverbal interaction experience to be a more effective
instructional strategy than just watching and listening when Ieaming novel word
meaning and nonverbal tasks (Mitchell-Futrell, 1992; Rowe, 2003; Beretta, 1999;
Luce, 2004; Stockman 8 Latham, 2002; Latham 8 Stockman, 2002). However,
every task did not contribute equally to the strength of this outcome. The verbal

composite score pooled outcomes from different tasks with different processing

101

and retrieval demands. The discussion to follow, examines the contribution of
individual items to the group differences observed on the three types of tasks.
Confrontational Naming

Task description. The confrontational naming task consisted of three
questions: (1) What is (orange)?, (2) What is /pakl?, and (3) What is IkaIpl? To

answer these questions, a child had to know the name or verbal form for the
object or action in the orange juice-making event and know what the word
referred to, i.e., the semantics or the meaning of the word. This naming task had
complex requirements for success. It required the child to have stored the word
in memory and to have created an oral motor map for articulating the speech
sounds in the novel words so that they could be understood.

Expected performance. We expected the participation group to perform
better than the observation group on each item probe, and especially on recalling
the action, lkaIpl. It was reasoned that the observation group would have had
less information about the action word, IkaIpl, because it did not perform the
action during the Ieaming trial. Visual and auditory information were accessible
but not the experience of tactually interacting with the objects to gain important
information about the action meaning for this novel verb. In addition, the
participation group received oral tactual prompting that ought to have helped
them to create an oral motor map to guide productions. If there were going to be
any group difference that favored the observation group, it was expected to occur
for the word lpakl. Its phonetic properties were visually salient, thus matching the

initial input received by the observation group during the Ieaming trial. It was

102

reasoned that just seeing and hearing the stimuli may have been enough to
retrieve the name of this object. In contrast, the participation group interacted
with the object. As a result, Ieaming the novel object name as part of an action
could have made the novel noun word less salient for the participation group than
the observation group.

Overall outcomes. Although differences between the two groups on the
confrontational naming tasks were observed as expected, the results were
surprising. The group differences that favored the participation group were

significant for only the object words (i.e., the familiar word, orange, and the
unfamiliar word lpakl), and not for the action word lkaIpl, as was predicted. That

is, the participation group performed better than the observation group even on
the word, lpakl, which was expected to favor the observation group, given the
visually salient phonetic properties for the lpl and la/ sounds. This outcome
differs from the earlier pilot studies, which revealed significantly higher scores for
the participation than observation group on all verbal items (Stockman 8 Latham,
2002; Latham 8 Stockman, 2002).

Several factors could have contributed to the observed confrontational-
naming results. They relate to phonetic and semantic differences between the
requirements for Ieaming the noun object word used in this study as opposed to
the action word. These two words differed both in their phonetic and semantic
properties.

Phonetic explanation. Regarding phonetic properties, better object word

naming by the participation than the observation group could be explained by its

103

exposure to oral tactual surface prompts during the learning trial for the word
lpakl. The participation group was required to actually articulate the word while
surface prompts were given to guide the production efforts. That is, the
investigator provided the children in the participation group with auditory, visual
and tactual input. Surface prompts provided information about the place,
manner, voicing, and the sequential and temporal organization of the speech
sounds in the novel words. The observation group was not provided with the
same information for learning the same word.

Although PROMPT cues were used for both the novel object word, lpakl,
and the novel action word, lkaIpl, significant group differences were not observed
for both. Perhaps it was the phonetic complexity of the stimulus that led to
significant group differences on lpakl. The first sound, lpl, in the name of the
object word was both visually and tactually salient as was the open mouth
posture for the vowel lal. In contrast, the first sound, lkl, in lkaIp/ was not
visually salient although it may have been tactually salient.

The complexity of the phonetic form, however, cannot completely account
for the observed group differences because both groups produced the word
orange, more often than either of the novel words, lpakl and IkaIpI. Yet it
arguably required the most phonetically complex production and it was not
tactually prompted for either group. The word orange has two syllables, unlike
the novel object and action words, and it includes, for example, two later

developing consonants, a liquid and an affricate.

104

However, any explanation based on prompt cueing does not account for
why the participation and observation groups differed on lpakl and lkaIpl, but not
the familiar word, orange. Recall that PROMPT cues were not provided for the
word, orange, for either group and children in both groups were required to know
the word, orange, as a condition for their participation in the study. The observed
differences between the two groups for the word, orange, may be explained by
other factors. The participation group may have had better recall of the familiar
word because it handled the oranges in addition to seeing and smelling them
during the initial teaching condition. That is, multimodal input with handling the
oranges may have stimulated better recall of known information than did just
seeing and smelling the oranges.

Semantic explanations. The most surprising results of the confrontational
naming task involved verb learning. It had been hypothesized that because the
children in the participation condition actually performed the action that they
would more easily map the targeted novel word to the action performed during

the initial learning event. But, there were no significant group differences in
naming the action lkaIp/ on any of the four trials, despite the bias toward higher

scores for the participation group. The PROMPT cues that presumably helped
the recall of the novel object word, lpakl, did not have the same effect for the
novel verb word, IkaIpl. Thus, action verb word learning may have differed from
object word Ieaming. It is already known that acquiring the meaning of an action
verb word may require attention to multiple aspects of an event. For example,

one must figure out whether meaning refers to the instrument involved; the action

105

performed, or the result of the action (T almy, 1985; Gentner, 1982). So it is
possible some of the children in the observation group responded incorrectly to
the action question with the object name lpakl because they mapped the
meaning in terms of the visually observed instrument used. The participation
group could have relied on other available properties such as tactuaI-kinesthetic
input

The different outcomes observed for verb and action Ieaming reinforced
the idea that verb and noun learning differ. Verb learning poses several
problems for children. One problem is that adults do not label actions frequently
for children (T omasello, 1995). In fact, verbs cannot be labeled for children in the
same way that a noun can be labeled. In most cases the referent action is not
perceptually available to the child before, during, and after the label is provided,
as is the case with causative action. For example, the verb “disappear” would
not be labeled following the event of hiding a teddy bear as “I disappeared the
teddy bear.” This is contrary to object labeling. If one were teaching the word,
“teddy bear,” it would always be labeled as such. So part of the problem is the
transient nature of action verb referents whereas objects can have a static reality.
Many children with autism have difficulties effectively processing transient
information (Hodgdon, 1996).

Regarding differences in semantic properties, noun object words and
action verb words may involve different processes (T omasello 8 Farrar, 1984;
Gopnik 8 Meltzoff, 1987; Adamson 8 Tomasello, 1984; Gopnik, 1988; Tomasello

8 Farrar, 1986). Other factors may have been previous event experience

106

(Nelson, 1986), event knowledge (Slackman, 1985), and input modality
(Stockman 8 Latham, 2002; Latham 8 Stockman, 2002).

Syntactic explanation. Another possible explanation for the difference
between the object and verb labeling performances is that syntactic cues were
not available. The theory of syntactic bootstrapping (Landau 8 Gleitrnan, 1985)
proposed that syntactic cues surrounding verbs reduce possible word meanings,

thereby helping a child to determine that a referent is a verb. In this study, only
the stimulus word was presented, e.g., “/kaIpl” or “lpakl”. So the participants

could not use syntactic cues to help figure out whether the stimulus word was a
verb or noun.
Recognition Task

Task description. The recognition task required the child to point to a
dynamic visual display of the novel object or of the examiner performing the
novel action in a field of four stimulus acts. The child had to look at the video
screen and perceptually process the multiple images before choosing a response
to the verbal stimulus. The child had to associate the novel object or action with
a visual referent. This task also required the child to translate the real-life event
experienced in real time to a video image in the here and now on a TV screen.

Expected performance. The participation group was expected to have
significantly higher mean scores than the observation group on the recognition
task attributed to group differences on the confrontational naming tasks above.

Outcomes. The significant overall differences observed between the two

groups favored the participation group, as expected. However, the group

107

differences on the recognition task were weak (p=.10) relative to the
confrontational naming and Wh—question tasks. The only significant between-
group difference observed was on lkaIp/ with the object at time 1, which yielded
the better performance for the participation group. The observation group did
this task as well as the participation group even though no tactual input had been
given during the teaching trial.

Explanations for this observed outcome can appeal to the nature of the
input stimulus presentations during the teaching trial. That is, this task was likely
to be easier for the observation than the participation group, as predicted,
because its input training task resembled the task used to judge the Ieaming
outcome. The inputs for both the Ieaming and evaluation tasks were similar in
that they both involved experience with predominantly visual and auditory events.

Another expected outcome was that the participation group had higher
mean scores than the observation group for the recognition item probes that
evaluated verb understanding. For lkaIpl with and without the object, the
participation group had higher mean scores on 7 of the 8 opportunities across
time. The verb/action versus noun/object outcomes were in the expected
direction despite the lack of significance difference. That is, the object item,
lpakl, was most successful for the observation group, while the verb/action item
was the most successful for the participation group. It is inferred that information
about object properties (e.g., shape, size, color) were more readily available via

vision to which the observation group had access while information about

108

transforrnative properties of action were more readily available to the
participation group.
WH-Question Task

Task description. The WH-Questions task required a child to understand
both the form and meaning of the question asked. That is, a child had to know
the form, connect it to meaning, and then generate a spontaneous response.
The questions were open-ended, although “who” and “where” were much less
open-ended than “how", “why” and “when”. Accurate responses to the questions
“how”, "why" and “when” required an understanding of causative relationships
among objects and the actions performed on the objects. The “who” question
required an understanding of person, and the “where” question required the
understanding of content related to the location of objects and the sequences of
actions.

Expected performance. The participation group was expected to have
higher mean scores than the observation group on the WH-Questions task
relative to the confrontational naming and recognition tasks just described. The
largest group differences were expected on the “how,” “why,” and “when”
questions because they required integration of event knowledge and action
sequences.

Outcomes. The significant overall differences observed between the two
groups on the WH-Questions supported the hypothesis that children’s ability to

describe an event may be enhanced by participation in an event, as opposed to

109

just visually and aurally observing it. But the five questions did not contribute
equally to this effect as discussed below.

Two of the WH-Questions, who (object) and where (object place), did not
yield statistical significances between the two groups, as predicted. It is likely
that these questions could be answered correctly based on object knowledge
alone, which the observation group had available from just the distant senses
(i.e., audition, vision, olfaction) during its Ieaming trial. However, the participation
group was not at a disadvantage by having tactuaI-kinesthetic input. In fact, the
participation group was favored on all but one question (where at time 3) at one
or another point in time.

The WH-Questions for which significant group differences were observed
included how, why, and when. When comparing the two treatment groups by
mean scores, the participation group’s mean scores were ranked higher than the
observation group on each of the three questions at times 1, 2, 3, and 4. It is
inferred that having access to multimodal input with tactual information aided the
ability to describe the cause and effect relationship during the event as Slackman
(1985) also inferred from a study of the role of action in children’s Ieaming of an
unfamiliar event. The test questions in the current study required children to
comprehend the goal and temporally organize the juice-making event. Having
interacted with the objects during the Ieaming trial, the children in the
participation group were likely to have gained better understanding of the
causative relationships among the objects than did the children in the

observation group. Recall that the latter group experienced the same event via

110

just the distance senses, namely, vision, audition, and olfaction. Therefore its
cause-effect information had to be based inferences from the auditory and visual
information given. Affolter and Bischofberger (2000) argued that “tactually
anchored input is more critical than is vision for acquiring conceptual knowledge
about causes and effects underlying a sentence grammar,” (p.210).

The importance of the initial input for learning an event was evident, given
that the performance of the observation group continued to lag behind the
participation group even after being given the opportunity to do the task on its
own. But it never reached the performance level of the participation group.

Nonverbal Leaming
Nonverbal Score and Rating

Task description. The nonverbal measures required a child to
independently reenact the juice-making event. The task of making orange juice
required the child to interact with real objects that included an antique juice
press. The task required a contingency of steps to be completed. Refer to
Chapter 2 for a detailed description of the nonverbal task.

Expected performance. Affolter (1991) and Affolter 8 Bischofberger (2000)
suggested that participation in everyday events provides a child with functional
knowledge for concepts and language. Therefore, it was expected that the
’ participation group would differ significantly from the observation group both
qualitatively (nonverbal rating) and quantitatively (nonverbal score) on the

nonverbal measures. Hands-on participation in the novel event was expected to

111

provide multimodal input experience, namely, the integration of tactual-
kinesthetic with auditory and visual sensory input.

Outcomes. The expected group differences in nonverbal performance
were observed. The significant differences favored the participation group in
both the nonverbal scores and ratings. The largest group discrepancy occurred in
the first trial after the participation group had just received hands-on experience
during the Ieaming event while the observation group had received just auditory
and visual exposure to the same event before replicating it for the first time. It is
inferred that the participation group had received an integrated perceptual
experience that included not only vision and audition but also relevant tactual-
kinesthetic information while being manually guided to do the novel task. As a
result the participation group was expected to gain better understanding about
the relationship between self and the environment as well as cause-effect
relationships within the event when compared to the observation group (Affolter,
1991; Slackman, 1985). They experienced what needed to be done to achieve
task success. For example, if a child was not pulling down hard enough on the
handle of the juice press, the examiner provided the resistance to extract the
juice. The observation group did not benefit from such feedback during the
Ieaming cycle.

Therefore, some children may not have been able to grade the amount of
resistance required to effectively carry out each action in the event when asked

to replicate the task. Its poorer performance relative to the participation group

112

suggests that it may have been helpful to have this kind of information during the
Ieaming cycle.
‘ Time

The participation group was expected to have higher mean scores on
every task over time, on the assumption that it received the more salient
information. In general, this expectation was supported by the data. The results
revealed two trends in the data. First, both groups had decreased mean scores
at Verbal 2. Second, there was a widening gap between the two group’s overall
verbal scores at time 3 and 4.

The decreased mean scores at Verbal 2 can be explained by information
processing load. Verbal 2 was the first time that children in both groups were
expected to reenact the event independently. Task success required an
increased information load. A child had to remember or recall the steps needed
and then execute the steps while performing the task.

The second trend in the data was the widening performance gap between
the two groups over time. Although both groups were expected to increase
mean scores over time, given past research (Stockman 8 Latham, 2002; Latham
8 Stockman, 2002), this outcome was observed only for the participation group.
One interpretation of this outcome is that the participation group received more
salient information through manual input during the event and therefore retained
the information over time while the observation group decreased retention over

time.

113

Although no significant within group differences over time were observed
for the participation group, it maintained a similar performance level over time. It
is inferred that the multimodal input given during the Ieaming cycle was enough
to sustain Ieaming over time.

Implications for Clinical Praxis

There is now greater public awareness of ASD, given the current national
focus on “curing” autism. Even though research has focused on finding a “cure”,
both the public and research communities are likely to agree that efficacious [

interventions are needed for children with autism right now. Current,

..
I.
l-‘
.
’Q
II-
I-‘
I;
—

interventions typically do not focus on “real life” events. Isolated skills are taught
in sterile environments (Applied Behavioral Analysis). Representations, usually
in the form of pictures, are used to teach children about language. Practitioners
rely on auditory-verbal and visual instruction as is done to teach typically
developing children. “Real life” events are too “messy.” Practitioners may
assume from anecdotal evidence that it is too difficult for children with ASD to
learn a new skill when there are competing stimuli commanding attention at the
same time. A child may not be able to figure out what is most important to pay

attention. It is, therefore, common practice to teach a child in an environment

 

where “distractions” are removed. For example, potential visual distractions are
removed from the walls of Autism Impaired (Al) rooms in educational settings.
Children may be taught at individually partitioned worktables in rooms that look

and feel like laboratories. However, teaching and Ieaming in such an

114

environment require a skill to be transferred to real life, once it is Ieamed
(Stockman, 2004).

The current study offered support for using another intervention approach
to teach children with ASD. This approach emphasizes hands-on interaction
experience during real events that are easily applicable to everyday real world
experiences. By interacting with objects in the context of an event structure, the
children appeared to learn some aspects of language better than did their age
peers in the observation group.

This study’s goal went beyond just suggesting that we should carry out
treatment for children with ASD in real life events. It also revealed that in
meaningful contexts, children can learn without being drilled on the correct
sequential order of performing the task or on vocabulary comprehension or on
correctly answering WH-Questions. Drilling procedures are likely to teach a child
to produce certain linguistic forms without their meaning or appropriate contexts
for their use. That is, form is stressed without meaning or functional use. This
study suggested that holistic Ieaming that combined action/interaction events
with their representations required multiple subsystems that included
somatosensory input. Knowledge appears to be gained from tactual-kinesthetic
experiences, that is, not obtained from just vision and audition. Some
practitioners may take this to mean that they should just provide opportunities for
“hands on” Ieaming experiences. However, results of this study suggested that
while Ieaming can still occur in the absence of somatosensory input, as was

observed when the observation group replicated the juice-making event, this

115

group did not seem to benefit to the same extent as the participation group. This
observation suggests that practitioners should not just have real objects available
for children to interact with, but they may also facilitate Ieaming about object
relationships by manually guiding them to interact with the environment during
purposeful daily events. As a result, the opportunity to receive important tactual-
kinesthetic input ought to be maximized. The model of intervention developed by
Affolter (1991) is useful because it aims to combine nonverbal and verbal
Ieaming.

In addition to targeting both nonverbal and verbal Ieaming experiences,
this study revealed that even with minimal instructional input, the children learned
and retained some aspects of the novel task, both verbally and nonverbally. This
alone is important because it suggests the possibility that multiple exposures
could solidify Ieaming outcomes even more than the single exposure presented
in this research study.

Implications for Future Research

This study provided some empirical support for interventions, like
PROMPT and GIT, which assume that tactual-kinesthetic input is a primary
source of Ieaming about spoken verbal and nonverbal events for children with
ASD. More research is needed on the efficacy of augmented tactual input for
Children with ASD. Specifically, research needs to determine which children on
the autism spectrum can best profit from augmented tactuaI-kinesthetic input.
The treatment goal for children with ASD is independent function in society like

other children. There is limited empirically-based evidence that current

116

interventions do support use of an augmented tactual-kinesthetic model. Future
research should: 1) address the heterogeneous nature of the ASD population in
research designs, 2) increase the number of participants in the ASD category, 3)
extend the type teaching events studied to include tasks varying in sequential
and complexity combinations of perceptual input, 4) track longitudinally the
Ieaming of children with ASD, and 5) extend the research to include clinical trials.
Each potential area for future research is discussed below.
Difi'erences Wrthin the ASD Population
The current research study recruited a critical mass of individuals with ASD and
employed a control matched-pair design. Still this study was conducted on an
undifferentiated group of children with the ASD diagnosis. Future research needs
to investigate if and how the interventions used in this study may apply to
different disorders under the ASD category: Autism, Asperger Syndrome, Rett
Syndrome, Pervasive Developmental Disorder-Non Otherwise Specified (PDD-
NOS), and Childhood Disintegrative Disorder. Some sub-classifications may
have more focal tactual deficits than others. Stockman (2000) argued that of the
three clinical subgroups identified by Affolter 8 Bischofberger (2000), the one
with primary tactual deficits appears to be fit the profile of PDD-NOS
classification.
Increasing the Sample Size
Future research should use a larger number of participants in order to
stabilize group trends so that they are less susceptible to individual fluctuations.

The larger the population sample (n) the more likely the results will generalize to

117

a specified population (N) as a whole and become more relevant for clinical
practice.
Extending the Types of Events

The results of the present study, demonstrated learning outcomes for a
single event, making orange juice. Thus we do not know whether the Ieaming
outcomes demonstrated in the current study would apply to other daily living
tasks. Future research should expand the focus to varied types of tasks.

Altered Teaching Trial Schedules

An important question for this study was whether Ieaming from enhanced
tactual input was retained across time. Again, the participation group seemed to
have a better retention rate than those who just received visual, auditory, and
olfactory input. Therefore, given that this outcome was observed after just one
teaching trial, the question can be raised whether performance could improve
with multiple teaching trials.

Concluding Remarks

Children with ASD who manually participate in a novel event achieve
better verbal and nonverbal outcomes than do those who just observe an event
visually and aurally. While this study provided some clinical support for specific
intervention methods such as, GIT and PROMPT, more research needs to be
done on manually guided intervention strategies for individuals diagnosed with

ASD.

118

APPENDICES

119

APPENDIX A

EDUCATIONAL DEFINITION OF ASD

120

R 340.1715 “Autism” defined; determination.

Rule 15. (1) “Autism” means a lifelong developmental disability which is
typically manifested before 30 months of age. “Autism” is characterized by disturbances
in the rates and sequences of cognitive, affective, psychomotor, language, and speech
development.

(2) The manifestation of the characteristics specified in subrule (1) of this rule

and all of the following characteristics shall determine if a person is autistic:

(a) Disturbance in the capacity to relate appropriately to people, events, and

objects.
(b) Absence, disorder, or delay of language, speech, or meaningful
communication.
(c) Unusual, or inconsistent response to sensory stimuli in l or more of the
following:
(i) Sight.
(ii) Hearing.
(iii) Touch.
(iv) Pain.
(v) Balance.
(vi) Smell.
(vii) Taste.

(viii) The way a child holds his or her body.

((1) Insistence on sameness as shown by stereotyped play patterns, repetitive
movements, abnormal preoccupation, or resistance to change.

(3) To be eligible under this rule, there shall be an absence of the characteristics
associated with schizophrenia, such as delusions, hallucinations, loosening of
associations, and incoherence.

(4) A determination of impairment shall be based upon a comprehensive
evaluation by a multidisciplinary evaluation team. The team shall include, at
a minimum, a psychologist or psychiatrist, a teacher of speech and language
impaired, and a school social worker.

(5) A determination of impairment shall not be based solely on, behaviors
relating to environmental, cultural, or economic differences.

121

APPENDIX B

APPROVAL TO USE HUMAN PARTICIPANTS

122

 

OFFICEIF

RESEARCH
ETHICS AND
STANDARDS

Unlierxlty Committee on
Research Ievelvleg
Iluiiiee Subjects

Michigan Stan University
202 Old: Hal

East Lansing, MI

48824

. 517/355-2151
FAIC 51 ”432-4583

Web: mmsuedu/usarlucrihs
E-Mail: ucrli‘isamsuedu

MSU is m elf/"Wm
cowl-apparently mutation.

MICHIGAN STATE

UNIVERSITY

February 11, 2004

TO: Ida STOCKMAN
378 Com. Arts and Sciences

RE: IRB# 03-955 CATEGORY: EXPEDITED 2-6, 2-7

APPROVAL DATE: February 11, 2004
EXPIRATION DATE January 11, 2005 1

TITLE: LEARNING AS A FUNCTION OF EVENT PARTICIPATION AMONG AUTISM

SPECTRUM DISORDER (ASD) CHILDREN
The University Committee on Research Involving Human Subjects' (UCRIHS) review of this
project is complete and I am pleased to advise that the rights and welfare of the human
subjects appear to be adequately protected and methods to obtain informed consent are
appropriate. Therefore, the UCRIHS approved this project. ‘ '

RENEWALS: ' UCRIHS approval is valid until the expiration date listed above. Projects
continuing beyond this date must be renewed with the renewal form. A maximum of four such
expedited renewals are possible. Investigators wishing to continue a project beyond that time
need to submit a 5-year application for a complete review.

REVISIONS: UCRIHS must review any changes in procedures involving human subjects, prior
to initiation of the change. If this is done at the time of renewal, please include a revision form
with the renewal. To revise an approved protocol at any other time during the year, send your
written request with an attached revision cover sheet to the UCRIHS Chair, requesting revised
approval and referencing the project's IRB# and title. Include in your request a description of
the change and any revised instruments, consent forms or advertisements that are applicable.
PROBLEMS/CHANGES: Should either of the following arise during the course of the work,
notify UCRIHS promptly 1) problems (unexpected side effects, complaints, etc.) involving
human Subjects or 2) changes in the research environment or new inforrnalion indicating

I greater risk to the human subjects than existed when the protocol was previously reviewed and

approved.

If we can be *of further assistance, please contact us at (517) 355-2180 or via email:
UCRIHS@msu.edu. Please note that all UCRIHS forms are located on the web:
http://www.humanresearch.msu.edu

Sincerely,

Mia

Peter Vasilenko, Ph.D.
UCRIHS Chair

PV: rt

CCI Susan Latham
3459 Schmuhl Road
Benton Harbor, MI 49022

123 '

APPENDIX C

INFORMED CONSENT

124

Parent Consent for Participation in Study:
Learning as a Function of Event Particmation Among Autism Spectrum Disorder (ASD)
Children

Dear Parent,

My name is Susan Latham and I am a graduate student at Michigan State University. I
am requesting permission to have your child participate in a research project on how
children Ieam and use new words. I am specifically interested in knowing the best way
to teach children new words. Participation in this study is voluntary and you can
withdraw anytime without penalty.

If you agree to participate you and a member of your child’s multidisciplinary team will
be asked to fill out a brief questionnaire about your child’s overall development and
provide current levels of speech, language, and cognitive functioning. Upon completion
of these tasks, your child will be given a free speech screening. I will videotape and
audiotape two 20- to 25-minute sessions in which your child will be taught new words.
These sessions will consist of either watching a person saying the new words or doing an
activity in which the words are used. The tapes will be used to record your child’s verbal
and nonverbal responses. The tapes will be secured in a locked cabinet, only accessible
to the researcher. The videotapes will be kept at the end of the study for analysis. The
research study will take place during school hours at your child’s school or at your
child’s place of speech and language services. The time that your child will be
participating in the study will be arranged carefirlly with your child’s teacher and
multidisciplinary team so interference with your child’s schoolwork will be kept to a
minimum. Your child will be asked if he or she wants to participate. If your child does
not; want to participate, indicating this verbally or nonverbally, he or she will not be
forced. All information about your child’s identity will be kept confidential and will not
be revealed in the results of the study.

If you are interested, your child may participate in my research project, by filling out the
consent statement attached and return it to school with your child. Aside from filling out
a brief questionnaire, there will not be any additional requirements of you. If you have -
any questions regarding this project, please call me at my home in Berrien County (269-
927-1721). If you have questions or concerns regarding your rights as a study
participant, or are dissatisfied at any time with any aspect of this study, you may contact
— anonymously, if you wish- Peter Vasilenko, Ph.D., Chair of the University Committee
on Research Involving Human Subjects (UCRIHS) by phone: (517) 355-2180, fax: (517)
432-4503, e-mail: ucrihs@msu.edu, or regular mail: 202 Olds Hall, East Lansing, MI
48824.

 

Page 1 of 2

125

Parent Consent Statement

Title of the Project: Learning as a Function of Event Participation among ASD Children
Investigator: Susan Latham

Michigan State University

Department of Audiology and Speech Sciences

East Lansing, MI 48824

Your child CAN/CANN OT participate in the research
project on children’s word learning and use on a functional task.

 

Your child’s participation is voluntary and your consent may be withdrawn at any time
without penalty. The results of the study will be used for research purposes and NOT for
educational placement. Report of these observations will respect your child’s right to
privacy by not revealing his/her identity. Your child’s privacy will be protected to the
maximum extent allowable by law. Your participation in this research project will not
involve any additional costs to you or your health care insurer. Your signature below
indicates your permission for your child to be a participant in this study.

 

 

Caregiver’s Signature Date of Signature

Page 2 of 2

126

APPENDIX D

BERRIEN COUNTY INTERMEDIATE SCHOOL DISTRICT APPROVAL

127

March 22, 2004

Susan Latham
3459 Schmuhl Road
Benton Harbor, Michigan 49022

Dear Ms. Latham:

I am in receipt of and have reviewed your letter dated March 3, 2004 requesting permission from Berrien County
Intermediate School District to recruit participants for your dissertation research project. Your request as written is
granted , per our Board Policy.

The procedure to follow would be for you to contact Jack Houser, Principal at Lighthouse Education Center and
Mark Reigle, Supervisor of Early On Programs and request that your Parent Consent for Participation in Stuajl be
forwarded through the school to parents of eligible students. The forms will be returned back to the school and you
may pick them up and arrange with the two program supervisors the dates/times the study will take place.

I wish you well in your endeavors in regards to increasing professional knowledge of teaching and Ieaming process.

 

Jim Palm, Assistant Superintendent

Stephanie Mack, Director of Special Education

Jack Houser, Principal Lighthouse Education Center

Mark Reigle, Supervisor of Ancillary Programs and Services

128

APPENDIX E

TEACHER QUESTIONNAIRE

129

Teacher Questionnaire

Instructions: You are asked to provide information for the child listed below. Please
use the following rating scale when appropriate: GIN = Good/Normal; Q= Questionable;
P= Poor. If you are uncertain about how to judge a category, place a question mark (?)
in the space. You may be assured that all information provided by you will be kept
confidential. Thank you for your cooperation.

Child:

 

Date: Name of School:

 

Teacher:

 

Birthdate of child:

 

Gender: M or F

1. Hearing: GIN Q P

2. Vision (with or without glasses): GIN Q P

3. Social Interaction: GIN Q P

4. Behavior: GIN Q P

5. Communication Skills: GIN Q P

6. Has received or currently receiving speech and language therapy:

YES NO
Comments:

7. English spoken in home: YES NO

8. History of Developmental Difficulties: YES NO
Comments:

9. History of Emotional Difficulties: YES NO
Comments:

10. Physical lmpainnents: YES NO
Comments:

130

11. Has received or currently receiving OT and/or PT? YES NO
Comments:

12. Mother’s occupation:
13. Father’s occupation:
14. Please provide two measures of Language:

A) Name of Language Test:
Language Scores:

Date Test Given:

8) Name of Language Test:
Language Scores:

Date Test Given:

15. Please provide one measure of Cognitive Functioning:

Name of Cognitive Test:
Cognitive Scores:

Date Test Given:

16. Using the following scale, how would you rate the motor abilities of this child?

1 2 3 4 5
Below Average Above
Average Average

Thank you for your time and help on this research project. it is very much
appreciated. if, at any time, you have questions about this questionnaire or any
aspect of the research project, please feel free to call me at 269-927-1721 . You
may be assured that all information provided by you will be kept confidential.
Please note that the child’s name will be blocked out and a random number
assignment will be used in its place.

Sincerely,

Susan Latham, M.A., CCC-SLP

131

APPENDIX F

PARENT QUESTIONNAIRE

132

Parent Questionnaire

First, I want to thank you for allowing your child to participate in this research
project. I appreciate your cooperation and look forward to providing you with the
results of this study. If, at any time, you have questions, please feel free to
contact me at 269-927-1721.

instructions for completing Questionnaire: You are asked to

provide information on your child, which will help with the
overall research project. If you are uncertain about how to
answer a question, place a question mark in the space. You may
be assured that all information provided by you will be kept
confidential. Names will be blocked out and number
assignments will be used it its place. Thank you for your time
and help.

Child’s Name:

 

Name of School:

 

Teacher:

 

Child’s Date of Birth:

 

Your Phone Number: Please provide
your number if you want me to call you the night before I plan to
work with your child. This will allow me to ensure your child
plans to be in school the next day, and also allows you to know
when i will be working with your child.

When was your child diagnosed with Autism Spectrum Disorder:

 

Is your child bilingual? YES NO

133

How would you describe your child’s language development?
Good/Nomal Questionable Poor

Comments:

 

 

 

 

 

How would you describe your child’s hearing?
Good/Normal Questionable Poor

Comments:

 

 

 

 

 

How would you describe your child’s motor development?
Good/Normal Questionable Poor

Comments:

 

 

 

 

 

Sincerely,

Susan Latham
M.A., CCC-SLP, Speech and Language Pathologist

134

APPENDIX G

VERBAL MEASURE

135

Verbal Measures

 

 

 

 

 

 

 

 

 

 

WH uestio
QUESTION RESPONSE 2pt. 1pt. 0 pt SCORE
RESPONSE RESPONSE RESPONSE
1. What is Orange Similar No Response
(point to
orange)?
2. What is “[pak]" Object No Response
(point to
juicer?)
3. What is “[kaipj’ Function No response
(press on
juicer)?
4. Which is Point to on No response.
[kaip]? (video screen Point to
without object wrong portion
of screen
5. Which is Point to on No response.
[poo]? (video: screen Point to
object) wrong portion
of screen.
6. Which is Point to on No response.
[kaip]? (video screen Point to
action with wrong portion
object) of screen.
7. Who made Indicates self Indicates self No response.
the orange (verbal (nonverbal Incorrect
juice? correct, “l correct — response.
did”, “me". points to self)
8. How did Semantic Reference to No response.
you get the reference to action with No reference
juice? process; must another to action.
include action apparatus
(squeeze) (i.e., squeeze
with object with hands)
(P80)

 

 

 

 

 

 

136

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

QUESTION RESPONSE 3 pt 2 pt 1pt 0 pt. Score
RESPONSE RESPONSE RESPONSE RESPONSE
9. Where Locative + Locative Nonverbal No
did the serial content relevant response.
juice go? content correct response No Iocative
(point to content
some object
connected
to event)
10. Why Causal Causal No
did you cut relationship relationship. response.
the expressed. Reference No causal
orange? Reference to overall relations.
to specific action goal.
action goal.
Reference
to fit.
11. When Temporal Temporal No
did you element element Response.
drink the (i.e., General No temporal
juice? “finished') element
Specific
Total Score

 

 

137

 

 

APPENDIX H

CHECKLIST FORM

138

Child Checklist for Folder

Child #

 

Age
Date of Testing
DOB

Consent Form

 

Teacher Checklist

 

Parent Checklist

 

Language Scores

Cognitive Scores

Oral-Speech Screening

Experimental Design: Observation

139

Participation

APPENDIX |

NONVERBAL SCORE

140

Nonverbal Score
Globall ngical Steg and Scoring Procedures

 

STEP

2 Points 1 Point 0 Points

Score

 

1. Make
contact with
knife and
orange to start
event;
recognize
need for both
objects by
touching each.

 

2. Recognize
need to cut
orange -
makes attempt
to cut orange -
separates
orange into
two parts with
knife.

 

3. Places
orange
segment in
juicer correctly

 

4. Puts
measuring cup
under juicer

 

 

5. Pulls
handle down to
get juice out.

 

 

 

 

 

 

 

Total Score

 

 

 

 

2 Points = unassisted
1 point = Assisted after self-initiated attempts

0 points = Clinician initiated step and assisted

 

141

 

 

 

APPENDIX J

NONVERBAL RATING

142

Nonverbal Rating

Qualitative Rating Procedure

First you will observe an adult completing the sequence. You are asked to rate how close
the child comes to repeating the adult.

Rating Scale

1 2 3 4 5
smooth transition extremely difficult
competent execution time consuming,

struggling, ask
for help many times.

Why did you judge the child to have this score?

Additional Comments:

143

APPENDIX K

RATING SCORING PROCEDURES

144

General Guidelines for Scon'ng Procedures

Verbal Measures

In the response section, write down exactly what the child says or does for
each of the eleven questions.

If you cannot understand what the child says, indicate so on the form.

If the examiner asks a question more than one time, give the child credit
for the response that earns the most points. Indicate on the form that the
child had more than one response by recording all responses. For
example: Question 1: examiner: “What is (orange)?

Child: no response

Examiner: “What is (orange)?

Child: “orange”

Score: 2 points

Pay attention to page 2 scoring — 4 levels rather than 3 on page 1. Make
sure you look at the top of the column for appropriate scores.

Specific scoring:

0 Question 1: “similar" refers to another type of fruit, orange juice,
etc.

0 Question 2: “object” refers to any noun, even a nonsense noun.
Anything close to “juice king”, score as an object.

0 Question 3: “function” refers to any action, even a made up
function, like “squasher”

0 Questions 4-6: If you cannot see where on the screen the child is
pointing, indicate so on the form. If the examiner points to indicate
where the child pointed, score as if the child pointed.

0 Question 7: Any verbal response indicating self, score as 2 points.
Some children may say their own name, score as 2. If he or she
points to himself or herself, score as 1. If the child says, “the
juicer”, “you did”, or “we did”, score as O.

0 Question 8: If the child refers to the process of making OJ by
including that he or she squeezed the oranges with the juicer, score
2 points. if he or she refers to squeezing the oranges, but does not
refer to the juicer specifically, score as 1 point. Think of 2 points as
referring to the action and the object, in some way verbally; one
point referring only to the action; and 0 points for no response to
action.

0 Question 9: If the child indicates a correct location and includes a
serial order (child response: “in the measuring cup and in the
glass”), helshe receives 3 points. If the child says a correct location
(“in the cup”), helshe receives 2 points. If the child points to some

145

object connected to the event, like the juicer, measuring cup, or
glass, helshe receives 1 point.

0 Question 10: To receive 2 points, the child must indicate that
helshe had to cut the orange to get the juice out/to make OJ, etc.
He Ishe must also refer to an action — squeeze, kaip, to make OJ,
etc. He/ she must also refer to the need to cut the orange in order
for it to fit in the juicer. He Ishe would only receive 1 point if they do
not include a reference to the orange only being able to fit into the
juicer when cut, but they do include the other elements referred to
above.

0 Question 11: To receive 2 points, the child must state a specific
temporal element. This could be something like “now”, “when we
are done”. He or she only receives one point for a general
temporal response, like “today”, “yesterday”.

Nonverbal Measures

Global / Logical Steps

When the video begins, if for example, the measuring cup is under the
juicer, assume that the child placed it there. Likewise, if the child is
already holding the knife and orange, assume that helshe initiated the
contact first.

Record the chronological order of events by placing the numbers 1-5 in
the left column next to each step.

Score each step according to the point values given by placing a check
mark in the appropriate box.

Qualitative Rating

Measure each child against my performance. Do not take into account
what you think the child’s age, or cognitive level, etc. might be.

If the child has smooth transitions and competent execution, he/ she
receives a score of 1. If the task is extremely difficult, time consuming,
effortful, and the child receives help many times, helshe receives a score
of 5.

Subjectively rate the child’s performance based on this information only. It
is your decision what constitutes a 2 versus a 3, etc. This will be reflected
in the reasoning for the score given.

146

APPENDIX L

RAW SCORE DATA FOR FIGURES 1.1 TO 1.3

147

Table 7 Raw Score Data for Figures 1.1 to 1.3

 

Qu_estion

 

 

1. What is (orange)?

Time 1

Time 2

Time 3

Time 4

Grand

M
SD

M
SD

M
SD

M
SD

M
SD

2. What is (pak)?

Time 1

Time 2

Time 3

Time 4

Grand

M
SD

M
SD

M
SD

M
SD

M
SD

3. What is (kaip)?

Time 1

Time 2

Time 3

Time 4

Grand

M
SD

M
SD

M
SD

M
SD

M
SD

Participation Obsemn t p Cohenfl

5.59 5.24

3.45 3.87 .56 .58

5.47 4.35

3.24 4.01 2.56 .021* .307
6.53 4.94

2.65 3.77 2.21 .042* .488
6.18 2.96

5.24 3.60 1.26 .225

5.94 4.94

3.05 3.75 3.13 .003*
5.18 4.35

3.00 3.22 1.46 .163

2.41 1.59

2.62 1.73 1.99 .064* .369
3.59 1.71

3.22 1.61 3.05 .008" .739
3.76 1.47

3.01 1.77 3.65 .002“ .927
3.74 2.23

3.07 2.45 5.09 .000“

1.82 2.06

2.92 2.90 -.30 .771

1.59 1.53

1.62 1.77 .13 .896

2.41 1.59

2.76 2.29 1.12 .278

3.06 1.82

3.34 2.56 1.15 .266

2.22 1.75

2.74 2.37 1.20 .236

 

148

APPENDIX M

RAW SCORE DATA FOR FIGURES 2.1 TO 2.3

149

Table 8 Raw Score Data for Figures 2.1 to 2. 3

 

 

 

 

Question Particigtion Observation t D
4. Which is kaip? (without object)
Time 1
M 2.94 2.35
SD 3.88 3.76 .48 .640
Time 2
M 4.12 2.82
SD 4.03 3.94 .94 .363
Time 3
M 3.29 3.76
SD 4.06 4.12 —.57 .579
Time 4
M 2.82 2.35
SD 3.94 3.76 .44 .668
Grand
M 3.29 2.82
SD 3.92 3.85 .83 .410
5. Which is pak?
fime1
M 2.35 2.65
SD 1.93 1.84 -.50 .623
Time 2
M 2.59 2.35
SD 1.97 2.03 .44 .668
Time 3
M 2.53 2.82
SD 1.94 1.88 -.46 .652
Time 4
M 2.35 2.59
SD 2.03 1.97 -.44 .668
Grand
M 2.46 2.60
SD 1.93 1.89 -.52 .606
6. Which is kaip? (with object)
Time 1
M 2.41 1.88
SD 1.97 1.96 1.85 .083
Cohen’s d = .270
Time 2
M 2.35 1.71
SD 2.03 1.99 1.08 .297
Time 3
M 2.82 1.94
SD 1.94 2.01 1.67 .114
Time 4
M 2.59 2.18
SD 1.97 2.01 .92 .370
Grand
M 2.54 1.93
SD 1.93 1.96 2.63 .011*

 

150

APPENDIX N

RAW SCORE DATA FOR FIGURES 3.1 T0 3.3C

151

Table 9 Raw Score Data for Figures 3.1 to 3. 2

 

 

 

@estion Participation Obsergtion t p
7. Who?
Time 1
M 3.29 2.71
SD 3.80 2.91 .77 .452
Time2
M 3.76 2.94
SD 3.87 3.88 .84 .416
Time 3
M 2.94 2.24
SD 3.61 3.46 .71 .490
Time4
M 3.59 2.47
SD 3.92 3.36 1.26 .228
9. Where?
Time 1
M 4.06 3.65
SD 3.80 4.00 .49 .660
Time2
M 4.41 3.59
SD 4.43 3.71 .81 .428
Time 3
M 3.24 3.41
SD 3.72 3.36 -.19 .851
Time4
M 4.12 2.82
SD 3.60 3.97 1.41 .178

 

152

Table 10 Raw Score Data for Figures 3. 3a to 3. 3c

 

 

 

ngstion Participation Observation t p g
8. How?
Time1
M 2.59 1.06
SD 3.39 1.60 2.34 .033 .577
Time2
M 1.47 .71
SD 2.55 1.40 2.02 .061 .369
Time3
M 1.76 .88
SD 2.73 2.03 1.36 .191
Time4
M 1.06 .35
SD 2.38 1.46 1.60 .131
10. Why?
Time1
M 1.94 .41
SD 2.46 1.06 2.52 .023 .808
Time2
M 1.82 .53
SD 2.07 1.23 2.60 .019 .758
Time3
M 2.00 .41
SD 2.45 1.06 2.76 .014 .842
Time4
M 2.00 .41
SD 2.52 1.06 2.62 .019 .822
11. When?
Time1
M 1.94 .94
SD 2.93 2.36 1.07 .303
Time2
M 1.41 .88
SD 2.74 2.06 .62 .544
Time3
M 1.88 .59
SD 2.76 1.12 1.86 .081 .612
Time4
M 1.47 .76
SD 2.15 1.89 1.03 .318

 

153

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