ED 445 435
EC 308 039
Goldstein, Howard; Thiemann, Kathy
Effects of Visually-Mediated Intervention on the Social
Communication of Children with Pervasive Developmental
Disorders . Final Report ,
Florida State Univ., Tallahassee.
Special Education Programs (ED/OSERS) , Washington, DC.
Reports - Research (143)
MF01/PC02 Plus Postage.
♦Communication Skills ; * Developmental Disabilities;
Elementary Education; Generalization; Inclusive Schools;
Instructional Effectiveness; Interpersonal Competence;
♦Intervention; Peer Relationship; ♦Social Integration;
♦Training Methods; ♦Visual Learning
♦Pervasive Developmental Disorders
This study investigated the effects of a visually mediated
intervention (i.e., social stories, written social phrases, pictures of
social skills, and videotaped feedback) on the social communication of five
elementary students with pervasive developmental disorders . Five triads, each
with one subject and two typically developing peers were formed. A multiple
baseline design across triads and social behaviors revealed that the
intervention was effective in increasing the frequency of four specific
social communication skills for the five focus children. Two participants
demonstrated generalization of social improvements and parents and naive
judges reported improvements in social interactions for all triads.
Class-wide sociometric ratings increased for four of the five participants.
Overall, the intervention was judged effective in teaching social skills
necessary for participation in conversations and positive social interactions
with peers in inclusive settings. (Contains 37 references.) (Author/DB)
Reproductions supplied by EDRS are the best that can be made
from the original document.
Effects of Visually-Mediated Intervention
On the Social Communication of
Children with Pervasive Developmental Disorders
Office of Special Education Programs
U. S. Department of Education
Grant Number: 4230-525-21
Howard Goldstein, Ph D, Principal Investigator
Kathy Thiemann, Student Investigator
Florida State University
107 Regional Rehabilitation Center
Tallahassee, FL 32306-1200
August 12"’, 2000
^ U.S. DEPARTMENT OF EDUCATION
■ NATIONAL INSTITUTE OF EDUCATION
I EDUCATIONAL RESOURCES INFORMATION
I CENTER (ERIC)
; 0^his document has been reproduced as
received from the person or organization
□ Minor changes have been made to Improve
i reproduction quality.
• Points of view or opinions stated in this docu-
, ment do not necessarily represent official NIE
‘ position or policy.
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Effects of Visually-Mediated Intervention On the Social Communication of
Children with Pervasive Developmental Disorders
This study investigated the effects of a visually-mediated intervention (i .e., social stories, written
social phrases, pictures of social skills, and videotaped feedback) on the social-communication of
five elementary students with pervasive developmental disorders. Ten typical peers participated
as communication partners, with two peers paired with one focus child to form five triads.
Additional goals focused on (a) determining if social skill improvements would generalize to
new settings and social partners, (b) measuring parents’ and naive judges’ perceptions of changes
in the quality of the children’s social interactions with peers following intervention, and (c)
examining changes in class wide sociometric status ratings.
A multiple baseline design across triads and social behaviors revealed that visually-mediated
intervention was effective in increasing the frequency of specific social communication skills for
the five focus children. Treatment effects were replicated across four different social behaviors
with the initiation of the intervention. Two participants demonstrated generalization of social
improvements in the classroom and naive judges reported improvements in the quality of social
interactions for all triads. Class wide sociometric ratings increased for 4 of the 5 participants with
The findings support recommendations for using visually-cued instruction to guide the social
development of children with pervasive developmental disorders. Involving typical peers as
conversational partners contributed to the children’s success and peer acceptance increased
among classmates not involved in the intervention. This intervention was effective in teaching
social skills necessary for participation in conversations and positive social interactions with
peers in inclusive settings.
The results of this project have been presented at National conferences, and within the state of
Florida in the form of in-service training for teachers, speech-language pathologists, and special
educators. Recommendations were incorporated in a manual entitled “Picture My Words. Visual
Strategies for Improving Social Skills of Elementary School-Age Children”. This manual was
distributed to the Center for Autism and Related Disabilities at FSU, and other interested
TABLE OF CONTENTS
Goals and Objectives ........ 1
Theoretical Framework ........ 2
Method ......... 4
Participants ........ 4
Setting and Session Organization ..... 8
Procedures ........ 9
Experimental Design . . . . . . . 11
Data Collection and Coding ...... 12
Reliability . . . . . . . . 14
Methodological Changes . . . . . . . 15
Results . . . . . . . . . 15
Discussion . . . . . . . . . 19
Appendices ......... 24
A. Social Conversational Skills Checklist
B, Social Story Stimuli
Tables ......... 26
Figures . . . . . . . . . 31
Project Impact ........ 36
Planned Future Activities . . . . . . . 37
Assurance Statement . . . . . . . . 37
References . . . . . . . . 38
GOALS AND OBJECTIVES
Objective 1: To investigate the effects of an intervention utilizing static and dynamic visual
stimuli for instructing, modeling, and providing feedback to improve the social conversational
skills (i.e., securing attention, initiating comments and requests, and responding contingently) of
elementary school children with social impairments.
Objective 2: To investigate generalization and maintenance of treatment effects to new settings
and conversational partners.
Objective 3: To assess social validity through (a) measures of parents’ and naive judges (i.e.,
teachers and graduate students) perceptions of changes in the quality of interactions between the
focus children and the typical peer participants following the intervention, and (b) changes in
class wide sociometric status ratings.
Objective 4: To produce training materials and in-service programming for teachers, speech-
language pathologists, and special educators, and disseminate results in state and national
conferences and selected Journals.
Much research has described the restricted range of social communication skills for
children with Pervasive Developmental Disorders (PDD), including autism, such as limited
speech acts to request information from others, acknowledge others, or comment (Volkmar,
Carter, Grossman, & Klin, 1997; Wetherby & Prutting, 1984). Other researchers have
documented a lack of nonverbal or verbal initiations to greet/say farewell or engage others
(Hobson & Lee, 1998), and impaired abilities to ask questions, listen and respond to others, and
interact in simple social games (VanMeter, Fein, Morris, Waterhouse, & Allen, 1997). This
limited repertoire of social communicative behaviors may negatively influence a child’s ability
to enter into and maintain positive interactions with peers in inclusive education settings,
resulting in fewer opportunities to practice and learn important socialization skills.
Studies focusing on unique cognitive and language competencies of children with PDD
have revealed particular strengths in visual-perceptual skills (Lincoln, Courchesne, Kilman,
Elmasian, & Allen, 1988), processing and interpreting static visual stimuli (Hodgdon, 1995), and
early word recognition skills (Whitehouse & Harris, 1984). Quill (1997) discussed learning
styles and instructional considerations for children with autism and stated, “the specific
communicative functions used by autistic children appear to be related to the presence or absence
of visible retrieval cues” (p.701). She recommended using visually-cued instruction (e.g., graphic
cues) to improve children’s social communication. Interventions that capitalize on cognitive
strengths and learning styles of students with PDD using visual stimuli may improve areas of
impairment such as social communication. Identifying effective social interventions in the early
elementary grades may significantly impact a student’s ability to develop friendships and engage
in successful classroom or extracurricular social activities across the school years.
Different types of visual cues or stimuli that have been effective in improving social
communication of children with autism or related developmental disabilities have included:
(a) written prompts or pictorial cues (Bryson, Landry, & Smith, 1994; Kistner, Robbins, &
Haskett, 1988; Krantz& McClannahan, 1998; Schuler, 1995), (b) peer self-evaluation books
(Sainato, Goldstein, & Strain, 1992), (c) videotape feedback of behaviors and conversations
(Charlop & Milstein, 1989; Kem-Dunlap et al., 1992), (d) videotaped peer models (Haring,
Kennedy, Adams, & Pitts-Conway, 1987), and (e) video self-modeling (Heptig & Goldstein,
1996). Kistner and colleagues (1988) capitalized on the superior word recognition skills of a
young girl with autism and hyperlexia, to improve her functional language skills. Hyperlexia has
been described as a preoccupation with letters and words at an early age, and exceptional reading
and word recognition skills with delayed comprehension of meaning (Healy, 1982). Results
indicated that written prompts (e.g., verbal prompt: “What do you want?” written prompt: “Want
cookie.”) were successful in teaching functional language skills such as responding to questions.
Progress was maintained with removal of the written cues. Charlop and Milstein (1989) assessed
the effects of video modeling on conversation skills of children with autism between the ages Of
6 to 7 years. The authors reported that not only did all 3 participants’ conversational speech
improve, but also new skills generalized to different settings and social partners.
In a study examining the effects of peer-mediated social intervention, Sainato et al. (1992)
stated that the use of illustrations within self-evaluation books (containing cartoons of facilitative
social strategies) (a) increased peer’s use of trained social strategies with children with autism,
(b) provided a way for the trainer to compare his evaluations with the peer participants, and (c)
assisted investigators in giving specific feedback for appropriate skill use. These studies provide
preliminary evidence of the potential benefits of using visually-cued instruction to improve
social communication of young children with social impairments. Additional research is needed
that examines the effectiveness of combining different types of visual stimuli to improve social
relationships among elementary students with social impairments and peers without disabilities.
In summary, given the unique qualitative differences in social, cognitive, and
communication behaviors of children with PDD (Bristol et al., 1996; Lincoln et al., 1988) some
intervention approaches may be more or less beneficial than others. Social intervention strategies
that capitalize on children’s visual strengths may improve their ability to engage in conversations
with peers; This could be accomplished through the use of visually coded information, especially
for children with emergent or acquired literacy skills. Teaching social communication skills
through concrete visual representations may enhance children’s understanding and accurate
interpretation of different social rules and situations, thereby enhancing interactions with peers
Participants were 5 children with social and language impairments and 10 typical peers
from a local elementary school. Two typical peers from each focus child’s classroom were
assigned to a triad (consisting of 1 focus child and 2 peers). The 5 focus children were males,
ranging in age from 6;6 (years;months) to 12;2, and enrolled in grades 1^ through S'*’. These
participants were assessed with the following instruments: Childhood Autism Rating Scale
(CARS) (Schopler, Reicher, DeVallis, & Daly, 1980), Peabodv Picture Vocabulary Test-Revised
(PPVT-R) (Dunn & Dunn, 1981), the Test of Language Development-2 (TOLD-2, Newcomer &
Hammill, 1988) or the Clinical Evaluation of Language Fundamentals-3'^‘* Edition (Psychological
Corporation, 1994), the Test of Nonverbal Intelligence-2"‘* Edition (TONI-2, Brown, Sherbenou,
&. Johnsen, 1990), the Parent and Teacher Reports of the Social Skills Rating System (SSRS,
Gresham & Elliott, 1990), and the Word Identification subtest of the Woodcock Reading
Mastery Tests-Revised (Woodcock, 1998). Only the Teacher Report of the SSRS was re-
administered post intervention, as minimal changes were expected on the other tests given the
short duration of the intervention. Participant information and results of the assessments are
summarized in Table 1.
Participants were selected based on the following criteria: emergent or acquired decoding
skills, functional verbal communication skills, fully or partially included in regular education,
and social impairment. Social impairment was confirmed based on results from the SSRS (Parent
or Teacher Report), the CARS, and a Social Conversational Skills Checklist (SCSC) designed by
the first author (see Appendix A). A certified school psychologist diagnosed two children with
autism, Casey and Greg. All children except Dan scored in the autistic range on the CARS. All
of the children were registered with Florida State University’s Center for Autism and Related
Disabilities (CARD). None of the focus participants or the typical peers demonstrated hearing,
vision, or physical motor impairments.
The SCSC was adapted from Prutting and Kirchner’s (1987) pragmatic protocol. Other
social skills were added based on clinical observations and parent report of common social
difficulties. The student investigator and a research assistant completed three checklists based on
10-minute observations of the focus participants and their peers during (1) small group work in
the classroom, (2) special area (e.g., music, art, or PE), and (3) recess. The total number of
ina ppropriate and not observed social behaviors checked were divided by the total number of
social behaviors possible that the child had the opportunity to express (i.e., maximum 20). This
calculation resulted in a percentage of social deficits across nonverbal, paralinguistic, and verbal
discourse categories on the SCSC. For inclusion in the study, all participants had to demonstrate
> 50% social deficits during a minimum of two out of three 10-minute observations.
Casey was integrated in a regular r* grade classroom for part of the day (i.e., center time
academics, recess, and special area). He exhibited average nonverbal intellectual skills, and
above average decoding abilities. Casey demonstrated characteristics of hyperlexia (Healy,
1982), with an interest in letters, reading, and writing at an early age but weak reading
comprehension. His expressive language consisted of immediate echolalia and 2-4 word
sentences to have personal needs met. Casey’s repertoire of different communicative functions
was significantly limited, and his intelligibility was poor. Results from the SCSC revealed
deficits across all nonverbal, paralinguistic, and verbal discourse categories, with 100%, 71%,
and 79% social deficits noted during the three social interaction observations.
Greg was integrated in the same grade classroom as Casey for part of the day. Because
the intervention involved the use of written visual cues, Greg’s teacher was interviewed and
reported that he knew all letter names, was starting to associate sounds to beginning letters of
words, and recognized some sight words. Greg communicated using simple sentences to request,
comment, and respond; however, a significant number of his utterances were scripted or rote
(memorized from favorite movies or video games). He received weekly home-program services
from a behavioral consultant. Greg exhibited 60%, 65%, and 22% social deficits based on the
SCSC observations. His social communication with peers improved during recess (i.e., 22%).
John was fully integrated in a regular 1®* grade class and had received ongoing 1-1
academic support since Kindergarten. He had an expanding sight word vocabulary, emergent
knowledge of sound-letter correspondence, and comprehended simple written sentences. John’s
expressive language contained a significant amount of memorized scripts from favorite movies
or video games; however, he was capable of using complete sentences to talk about a variety of
topics. During the SCSC observations, John exhibited 55% and 50% social deficits during recess
and PE respectively, and 37% social deficits during a small group center activity in the
classroom. A discrepancy was noted between Parent and Teacher report of social difficulties on
the SSRS (see Table 1). John and his family had received ongoing consultation from CARD for
issues related to social and academic functioning since he was in preschool. John was included in
the study based on his long history of social problems, continued parent report of social
interaction difficulties, and results of the CARS and SCSC observations.
Ivan was fully integrated in 2 "^ grade, and received resource room services for reading and
math. Although Ivan’s decoding skills on the Woodcock were less than 2 standard deviations
below the mean at the beginning of the study, his literacy skills improved markedly by the time
he began the intervention. He had a large sight word vocabulary, knowledge of sound-letter
correspondence, was beginning to segment and blend sounds to read words. Ivan communicated
using multiple, complete sentences, and evidenced advanced vocabulary for topics of personal
interest; He had a high degree of awareness of his social and academic difficulties. On the SCSC,
Ivan demonstrated 53%, 59%, and 58% social deficits during the three social observations.
Dan was fully integrated in a regular 5'*’ grade classroom and had participated in regular
education since Kindergarten. He received resource support for reading, language arts, and math.
His decoding skills were within normal limits, and he comprehended simple paragraphs. Dan
communicated using full sentences and responded to simple questions appropriately. He had
difficulty understanding lengthy verbal directions, language that required abstract reasoning, and
answering complex questions (e.g., why, how). Although Dan’s score on the CARS placed him
in the non-autistic range, a social impairment was confirmed with the SSRS, Parent and Teacher
report and the SC SC. On the SC SC, Dan exhibited 68%, 63%, and 61% social deficits during the
three social observations. The majority of inappropriate social behaviors were observed in the
paralanguage (e g., low volume, flat intonation, and a fast rate of speech) and verbal discourse
categories. He was not observed to initiate activities or topics, maintain topics, ask questions, or
repair communication breakdowns with peers.
The 10 typical peers were identified and recommended by the focus children’s regular
classroom teachers. The teachers were asked to recommend children who: (a) did not evidence
social communication difficulties, (b) could provide appropriate social models, and (c)
consistently completed their assignments so they could leave the classroom twice per week to
participate. There were mixed genders (i.e., one girl and one boy without social impairments) in
each of the triads except for Greg’s group, which were all boys.
Setting and Session Organization
All of the sessions took place in an average-sized media room in the school library. Three
triads met during regular scheduled morning center-time, and two triads met in the morning prior
to the start of classes. During baseline, the triads attended two 10-minute sessions each week.
Once a group started treatment, they attended two 30-minute intervention sessions each week.
Each intervention session included: 10-minutes reading the social story followed by instruction,
discussion, and modeling of appropriate social phrases, 10-minutes engaging in a social activity,
and 10-minutes of videotaped feedback of the social interaction.
Social activities selected were mainly familiar social routines with unifying themes,
predictable turn-taking sequences, and exchangeable participant roles. A rotation of three types
of activities centered on (1) thematic or pretend play (e g., restaurant, grocery store), (2) board
games, and (3) art/science projects. To assist with participant motivation and interest, a minimum
of five different activities for each type of social play were used. Activity agendas were used to
assist with knowledge of task expectations.
Peer orientation. Two peers without social impairments from each triad met with the
investigator for a 30-45-minute orientation session before beginning intervention. Each child was
given a notebook with pictures and sentences that described skills related to “How you can talk
to your friends.” These skills consisted of (a) get your friend’s attention, (b) start talking about
what you are doing, (c) ask questions, and (d) solve problems together. The children wrote
examples of appropriate social phrases that matched the pictures of the social skills. Specific
examples of positive or negative social behaviors observed in the baseline sessions for each
focus child were discussed with the peers. Peers were told they would receive occasional prizes
for using positive social skills with their friends.
Teaching use of social stories, written phrases and pictures of social skills . Four social
stories (Gray & Garand, 1993) were written to describe the four social skills targeted during
intervention. The content of the social stories included: (a) securing attention (i.e., title: “Getting
Friends to Look”), (b) initiating comments (i.e., title: “Start Talking to My Friends”), (c)
initiating requests (i.e., title: “Ask My Friends Questions”), and (d) contingent responses (i.e.,
title: “Keep Talking to My Friends”). The social stories were written according to Gray’s rules
for including descriptive, perspective, and directive sentences (see Appendix B for an example of
a social story). For the older children (i e., John, Ivan, and Dan), a hand-drawn, colored picture
depicting two children performing the target social skill was placed at the bottom of the story,
along with empty topic bubbles (as in a cartoon) above the children’s heads. Real photos were
used for the two youngest children. The pictures of the social skills were laminated on a separate
single page. Two to three social utterances (e g., sentence starters, phrases, or simple sentences)
appropriate to the target social skill were written in laminated topic bubbles, and velcroed onto
the empty topic bubbles. For example, for the skill securing attention the picture was of one child
tapping another child on the shoulder and words such as “Look,” “Watch this,” or a child’s name
were written in the topic bubbles. These utterances were rehearsed a minimum of three times
before starting the activity. The visual cues were left on the table throughout the group
interaction to provide the children with constant access to the visual prompts.
At the beginning of each intervention session the participants read one social story
targeting a specific social skill. The clinician then asked 4-5 simple interrogative and wh-
questions to monitor and improve participant’s understanding of the story content (see Appendix
B). The social story was left on a flip chart on the table during the social activity. Parents were
given a copy of each social story (as it was introduced) to read daily with their child at home.
Daily readings of the story were monitored through completion of weekly checklists that the
parents mailed in.
Once per minute during the 10-minute treatment session, the examiner provided a visual
(or if necessary verbal) prompt by pointing to one of the written social phrases if the focus child
did not spontaneously use the targeted social skill. Otherwise, the investigator remained at a
distance from the group. Casey’s peers were taught to prompt him to use the written phrase cues
due to a high level of adult dependency observed during the first few sessions.
Videotaped feedback . After the 10-minute social activity, children self-evaluated their use
of targeted social skills. The examiner taped the picture of the social skill and the written social
phrases (topic bubbles) on the bottom of a television. Each child had a clipboard with the social
skill written at the top of a sheet of paper (e.g., “1 started talking” for initiating comments). The
paper also had two columns marked “Yes” circled in green and “No” circled in red with a line
crossed through it: The examiner played the videotape of the interaction, paused it after one
conversational exchange, and asked the children if they heard examples of the targeted social
skill. The tape was paused a minimum of three times. Checks were exchanged for tickets and
used collectively to obtain small toys or other reinforcers
A multiple baseline across two to three social language skills replicated across five triads
(i.e., one participant with social delays and two typical peers) was used to assess changes in
conversational skills for the participants with social impairments. The possible pool of targeted
social skills included; (a) secures for attention, (b) initiating comments, (c) initiating requests,
and (d) contingent responses. The discourse skills taught were counterbalanced among the triads
to control for possible order effects.
During baseline, each triad engaged in one 10-minute social activity per session. No
attempts were made to reinforce or influence interactions. Following stable performance or no
upward trend in a specific social behavior, the first social story, written cues, and picture stimuli
were implemented (e g., targeting secure for attention). Baseline measurement of the other three
social skills continued. When an observable and notable upward trend in the targeted social skill
was observed over a minimum of four sessions, treatment was initiated for the second social skill
(e.g., initiating comments) and maintenance data were collected on the first social skill (i.e.,
secure for attention). Baseline data continued to be collected for the other two social skills (i.e.,
initiating requests and contingent responses. If improvements in social behaviors occurred only
when intervention was initiated, then one can claim treatment effects. If these effects were
replicated consistently across behaviors and across triads, one can make a convincing case for
For two children, a modified treatment approach was implemented for the final 5-6
sessions because of reduced maintenance on previously targeted social skills. Three social skills
were combined into one social story and represented by the original social skill pictures or
photos. One social phrase was written as a visual cue for each targeted skill. Thus, there were
three possible social skills and three possible written phrases that the children could choose to
use in the social interaction. Videotaped feedback forms also were modified to allow for self-
evaluation and feedback on all three social skills.
Data Collection and Coding
Observational coding . A direct observation coding system with a 15-second audio-
recording interval was used to code frequency of occurrence of all appropriate and inappropriate
social language measures (see Table 2) within the 10-minute social activity. All sessions were
audio- and videotaped. The four primary dependant social measures included securing attention,
initiating comments, initiating requests, and contingent responses. These social discourse skills
were selected based on a review of the literature on normal and disordered development of topic
maintenance skills (Brinton & Fujiki, 1984; Foster, 1985; Mentis, 1991,1994; Prutting, 1982;
Prutting & Kirchner, 1987). Other measures of interest included frequency of inappropriate
discourse skills such as topic changes, unintelligible responses, other, and no responses.
, The average length of multiple-turn conversational episodes was determined by totaling
the number of the focus child’s sequential utterances related to the same topic or action (ending
with a minimum of a 3 -second pause or a change in topic) and dividing by the total number of
episodes during the 10-minute coding interval. These data were collected and averaged over the
last five baseline sessions (just prior to initiation of treatment of the first social skill) and the last
five treatment sessions for each participant.
Generalization probes . Generalization data were collected in the classroom setting for 3
participants (Casey, Greg, and John) over 3-4 days. In the classroom, social story instruction and
videotaped feedback were omitted from the procedures. Written social phrases were rehearsed a
minimum of three times prior to the triad engaging in an already scheduled 10-minute center
activity. Activities ranged from reading big books , working on computers, completing math
worksheets, and doing art projects. If peers became too directive they were provided with
occasional prompts to use previously trained social skills.
Assessment of social validity. A parent questionnaire was administered pre- and post-
intervention. This questionnaire was designed to assess parent’s perceptions of meaningful
changes in their child’s social functioning. The questionnaire consisted of 10 questions (based
loosely on social interaction behaviors described in the SCSC) rated on a 5-point Likert scale
(i.e., 1 = Never observed, and 5 = Always observed). Seven regular education teachers and six
graduate students in speech-language pathology provided additional subjective ratings of
meaningful changes in social interactions between children with social impairments and their
peers by observing pre- and post-intervention videotape segments. Each baseline and treatment
segment lasted approximately 2-minutes and the sessions were counterbalanced. Judges rated the
quality and quantity of (1) the focus child’s social behaviors towards their peers, and (2) the
peer’s social behaviors toward the focus child. The questionnaire consisted of six questions rated
on a 5-point Likert Scale (i.e., 1 = No active involvement, 5 = Better than average involvement).
Sociometric status. The sociometric status of the focus children and the regular education
peers were determined by asking all classmates to rate each other using Polaroid pictures or
name cards. Three boxes with slots (to place the pictures/cards) were placed in front of the child.
Each child was individually instaicted to place a photo or name card in the box associated with
whether or not they liked to play with that person at school. Happy, neutral, and sad faces were
drawn on the front of each box to represent likes to play with , sometimes play with , and don’t
like to play with respectively. These procedures were completed pre- and post-intervention in a
quiet area of the classroom.
Prior to the beginning of the study, the examiner trained two research assistants using
previously recorded videotapes of other friendship groups. Once the interobserver agreement for
identification of the social language measures reached a minimum agreement criterion level of
80% over three days, the assistants were considered familiar enough with the coding procedures
to code on-line. A primary coder reviewed the audiotape and videotape of each session, and
made corrections as necessary prior to secondary coding and graphing. Interobserver reliability
was calculated by dividing the number of agreements by the agreements plus disagreements, and
multiplying by 100. Interobserver agreement was calculated separately for 30% of the baseline
and treatment sessions, and 30% of home videotape samples. Interobserver agreement was
consistently above 80% for all participants. Agreement ranged from 83 to 100% for Casey, 81 to
94% for Greg, 80 to 100% for John, 84 to 95% for Ivan, and 87 to 100% for Dan. Interobserver
agreement results for 30% of the home videotaped social samples ranged from 81 to 87%.
Treatment fidelity was monitored for 20% of the intervention sessions using a checklist of the
proposed intervention procedures. Treatment fidelity was consistently above 82%, with a range from 82
Originally, implementation of the intervention was planned at the FSU Speech and
Hearing Clinic. This project eventually occurred at a local elementary school for the following
reasons: (a) to improve probability of enlisting same-age typical peers to participate in the social
groups, (b) to provide the intervention in a more natural social context, and (c) to increase the
likelihood of generalization of trained social behaviors to different peers and social settings.
Focus Children’s Social Communication Progress
Frequencies of targeted social language skills for the participants are presented in Figures
1 through 5. Dan demonstrated low rates of securing attention during baseline, with clear
improvements following treatment. During treatment on the next social skill, initiating
comments, these improvements declined but still maintained above baseline levels in the absence
of prompts. The intervention was effective in increasing Dan’s frequency of comments, and
improvements were maintained in the absence of prompts. The frequency of initiating requests
seemed to improve once intervention began on the first behavior targeted, suggesting generalized
treatment effects. Prompts were mistakenly provided for comments and requests during
treatment of secures for attention (e.g., written cue: “Michelle, can I ?”). However, when
written cues for initiating requests were removed during treatment on initiating comments,
generalized improvements continued for requesting behaviors. Moderate improvements were
noted once treatment began on initiating requests. Contingent responses were not targeted in
treatment as this social skill steadily improved over the course of intervention.
During baseline, Greg demonstrated a generally low rate of securing attention with the
exception of Session 10. Following treatment, there were noticeable increases in his use of this
social skill. These improvements were maintained as prompts were faded in treatment; however,
Greg’s continued use of securing attention without visual cues during treatment of the next social
skill was variable. Greg emitted a higher number of comments during a number of baseline
sessions that involved playing a board game. The treatment resulted in higher and more stable
initiation of comments across different social activities (i.e., thematic play and art/science
projects). These improvements endured as prompts were faded. Once treatment began on
initiating requests, Greg’s number of comments as well as requests increased dramatically.
Generalized treatment effects may explain these improvements. However, generalization data
revealed no clear maintenance of improved target behavior performance in the modified
Initiating comments and requests were combined into one category (i.e., initiations) and
targeted simultaneously for John and Casey due to low baseline performance and related
definitions; Immediate treatment effects were observed for John for initiations and securing
attention. John’s improved ability to initiate to peers continued as prompts were faded.
Transitioning to treatment on a new social skill resulted in a reduction in initiations and
especially securing attention during maintenance conditions. However, improvements were
largely recovered for initiations and somewhat recovered for secures for attention during the
combined treatment condition, (i.e., visual cues available for all previously targeted skills).
During baseline, John’s contingent responses to peers were highly variable. Treatment was
effective in stabilizing his performance on this social skill, although not at a noticeably higher
level. These results may reflect an increased amount of peer-initiated requests directed towards
John. Generalization to the classroom setting was minimal for all social skills, except for
Casey demonstrated low baseline performance on all targeted social behaviors. For
example, he expressed an average of 2.7 initiations (both comments and requests) during
baseline. The treatment was effective in more than doubling Casey’s unprompted initiations to an
average of 6.3 per treatment session. Slight improvements were observed following treatment on
securing attention, as prompts were faded. Casey’s average number of unprompted secures for
attention increased from 0 in baseline to 1.8 per treatment session. Treatment effects for
initiations and secures for attention were not maintained without visual cues or prompts. Once
treatment began on contingent responses, Casey demonstrated marked improvements in his
ability to answer peer’s ves/no questions. These results may be somewhat inflated due to
increased peer-initiated requests to Casey. Combined treatment led to improvements in all
previously targeted social skills with the exception of responding contingently to peers.
Decreased use of this skill may be partly explained by increased initiations to peers, and fewer
peer-initiated requests directed to Casey. In the classroom, Casey demonstrated good
generalization for all trained behaviors.
Ivan demonstrated variable initiation of comments during baseline, which did not change
with the onset of treatment. This lack of improvement was attributed to the following: (1) his
reading skills were emergent and he often became fhjstrated when asked to read the social story
or written social cues out loud, and (2) he disliked being singled out from his peers during the
instruction time. Thus, the original treatment was modified slightly in the following manner: (1)
all children took turns reading parts of the social story, and (2) a written cue was placed in front
of each child. Following implementation of “Treatment 2,” Ivan’s frequency of comments
steadily increased and he maintained these improvements. The treatment also was effective in
improving Ivan’s ability to secure attention. Initiating requests and contingent responses were
relatively high frequency behaviors in Ivan’s repertoire, thus these skills were not targeted.
Maintenance and generalization data were not assessed due to the end of the school year.
Multiple-turn interactions. Table 3 summarizes changes in the children’s average number
of utterances per conversational episode during a sample of the last five baseline (before
treatment on the first social skill) and last five treatment sessions. Numbers in the table represent
the average number of utterances per episode for five sessions. By the end of treatment, all focus
children demonstrated increases in expression of sequential utterances related to specific topics.
Ivan and Casey more than doubled their utterances to maintain conversational topics. Given that
Casey rarely engaged in conversational exchanges with peers, his improved ability to take almost
three verbal turns per topic by the end of treatment is noteworthy.
Assessment of Social Validity
Minimal to no changes were noted in parents’ perceptions of their child’s social
functioning based on pre- and post-intervention completion of a Parent Perception Questionnaire.
Judgments of the quantity and quality of changes in specific social behaviors and interactions
between the focus children and their peers are presented in Table 4. These data were collected
from 13 teacher and graduate student ratings of 2-minute pre- and post-intervention videotaped
segments of social interactions. Following intervention, all 13 naive raters consistently reported
improvements in social behaviors and reciprocal interactions between the focus children and
their peers. There were only two instances where a rater did not judge the post-intervention
samples better than the pre-intervention samples. Thus, based on 63 of 65 judgments,
improvements in social interactions were readily perceptible to these judges.
Sociometric Status Changes
Class wide sociometric ratings were completed for the focus children and their classmates
prior to and at the end of study. Table 5 shows before- and after-treatment ratings for the children
with social impairments, and class averages. With the exception of John, classmates reported
positive changes in sociometric status for all other participants with social impairments. Further,
these changes were all greater than the class average pre-post sociometric status differences.
Visually mediated intervention was effective in increasing specific social language skills
for five elementary school-age children with social impairments in small group interactions with
typically developing peers. A combination of static and dynamic visual stimuli resulted in
increased frequency and/or more consistent rates of targeted social behaviors compared to
baseline data for each focus child. Treatment effects were replicated across four different social
behaviors with the introduction of the visually-mediated procedures. Clear experimental control
over three targeted social skills was demonstrated by three of the five focus children, and over
two out of three social skills for two participants. For one child (Ivan), treatment effects were not
initially observed after initiation of the treatment. However, a modification in intervention
procedures resulted in eventual treatment effects across two trained social behaviors for this
child. These findings demonstrate the importance of monitoring effects and applying clinical
judgment to individualize social interventions.
Two participants (Dan and Greg) generalized improvements across targeted social
behaviors. For example, Dan generalized initiating comments and requests after being taught to
secure attention. Once Dan started calling a peer’s name to gain their attention, he would then
ask a question or give directions. Treatment on initiating requests led to an improved ability to
initiate comments for Greg. This generalized treatment effect possibly reflects interrelated social
behaviors underlying initiations in general. In the classroom setting, two participants generalized
treatment effects (John and Casey). John generalized his ability to secure attention and Casey
continued to use the visual cues to secure attention, initiate comments and requests, and respond
contingently. All participants demonstrated improved conversational abilities by engaging in
multiple-turn dialogues on different topics. These simultaneous improvements across related
social language skills have promising clinical implications relating to goal setting and improved
generalization for children with social impairments.
Overall, maintenance data across participants was limited. In the absence of visual cues
or as new treatment phases began, three of the five participants demonstrated maintenance of
some previously targeted social skills. These three children maintained improvements in their
ability to initiate comments to peers, and one out of the three also maintained the ability to gain a
peer’s attention. Data showing a general lack of maintenance across targeted social behaviors
have important clinical implications. First, the marked or gradual return to baseline performance
observed for some participants following removal of visually-mediated cues for a target social
behavior suggests that the visual cues were primarily responsible for initial treatment effects.
Second, it appears that some participants with social impairments may require more intensive
intervention to learn certain social communication skills. For instance, the extended length of
time necessary to effect change in securing attention and the improvements observed following
‘booster’ treatment sessions indicate that this particular skill may be more challenging for some
children with social impairments to learn. Premature removal of adult or peer-mediated prompts
may lead to loss of treatment gains. These findings underscore the importance of the adult’s role
in structuring social opportunities for children to practice using new skills.
Social validation results confirmed the clinical significance of this treatment approach.
First, 13 naive judges perceived meaningful changes in social interaction behaviors for both the
focus children and their peers based on pre- and post-intervention videotaped interactions. The
second positive social validation finding came from the focus children’s classmates. The
classmates, including children not involved in the triads, reported positive changes in sociometric
status ratings for 4 of the 5 children. The lower sociometric ratings at the end of the study for
John may have been due to a high frequency of inappropriate social skills observed in the
classroom, as reported by the teacher. These inappropriate social behaviors generally consisted
of facial grimaces directed to peers, yelling out in class to gain attention, and repeating scripts
from movies and videos out loud.
The findings of this investigation contribute to the treatment efficacy literature for
improving communication of young children with social impairments in several ways. First, this
research documents the potential benefits of using visually-cued instruction to improve social
communication for children in the early elementary grades. Although it is difficult to identify
which components of the treatment package were beneficial, a number of strategies capitalized
on the visual modality to ameliorate social impairments. For example, written visual stimuli were
left on the table during the activities to allow constant access to appropriate social utterances.
These written cues also were used by the typical peers, which resulted in increased modeling of
targeted social skills. This investigation also used soda! stories (Gray & Garand, 1993) written
to increase the focus children’s understanding and awareness of specific social skills. The social
stories included descriptions of situations where it would be appropriate to use the social skill,
possible reactions of others in that social situation, and directive statements of appropriate or
desired social responses. Finally, videotaped feedback was used in conjunction with static visual
stimuli as a component of the treatment program. Generally, only the three oldest participants
demonstrated consistent self-evaluation skills. Thus, this component of treatment may be more
beneficial for older, higher-functioning children who have better developed metapragmatic
awareness. Furthermore, because there was a 2 to 5 day lapse between sessions, caution is
warranted in stating the relative contribution of videotape feedback to changes in specific
conversational skills. Additional research is necessary to evaluate the relative contributions of
videotape modeling and feedback, self or peer models, and opportunities to practice skills to
Thus far, the majority of intervention literature on improving social interactions of
children with FDD has focused on preschoolers (English, et al., 1997; Goldstein & Cisar, 1992),
adolescents (Haring & Breen, 1992; Schnorr, 1997), or elementary school children with low IQs
and moderate to severe developmental delays (Kamps, Locke, Delquadri, & Hall, 1989;
Mundschenk & Sasso, 1995). In contrast, all participants in this study were partially or fully
included in regular education classes, had emergent or acquired reading skills, and were verbal
communicators. The findings of this study augment other research efforts that seek to guide
procedural decisions and program planning for effective social intervention for children with
FDD and autism.
In summary, this study examined the effects of a visually-mediated intervention on the
social communication of five elementary students with social impairments associated with FDD.
The visual strategies were effective in improving specific social communication skills of the
focus children as they interacted with peers without disabilities. Capitalizing on the visual
modality resulted in higher rates of socially desirable behaviors, with generalized treatment
effects observed across untrained behaviors. General education teachers and graduate students
unfamiliar with the study socially validated improved reciprocal social interactions. Improved
relationships with other classmates not involved in the intervention were noted based on positive
changes in sociometric status. These findings support recommendations for using visually-cued
instruction to guide the social development of children with social impairments (Quill, 1997;
Schuler, 1995), and add to the scant literature available for effective social intervention supports
and strategies for elementary students with more developed language and reading skills.
Social Conversational Skills Checklist
(Thiemann, 1997; adapted from Prutting & Kirchner, 1987)
Name; Date:_ Age;
Relationship of Social Partner;.
Comments (examples or note lack of
opportunity to observe)
1. Nonverbal Discourse Skills:
a) Communicative gestures (points, waves)
b) Eye gaze (e.g., eye contact, to signal attention)
c) Proximity (e.g., appropriate distance to partner)
d) Physical contacts (uses approp. touch to gain atten)
e) Facial expression (e g,, uses positive, negative, or
neutral expressions as appropriate)
2. Paralanguage Skills:
a) Vplume/intensity (varies with setting)
b) Intonation (prosody and stress patterns)
c) Fluency/rate (smoothness/speed)
d) Pitch/quality (appropriate for age and setting)
3. Verbal Discourse Skills:
a) Initiates topics, games, activities with others using
different speech acts (e g., requests, comments)
b) Introduces new topics within social interactions
c) Takes other’s perspective (e.g., comments on peer’s
d) Maintains topics with more than 5 verbal turns
e) Asks different questions (e.g., what, where, why)
0 Contributes relevant comments to the conversation
g) Gives verbal/nonverbal feedback to the listener (e.g.,
nods head, ‘‘mhmm”)
h) Recognizes pauses or eye gaze as turn signals (i.e.,
knows not to interrupt speaker)
i) Recognizes and repairs breakdowns (e.g.. requests
clarification, responds to peers requests)
j) Adjusts message based on listener’s knowledge of
the event (i.e., provides background information)
k) Uses socially polite words (e.g., please, thank-you)
Social Story Stimuli
Example Social Story:
“Getting Friends to Look”
Friends like playing with different toys and games.
Friends like to show each other what they are doing.
Sometimes a friend calls my name and says “look.”
This means they want to show me something, and they like it if I look.
I can try to call my friend’s name or say “look” to show them what I am doing.
Comprehension Questions for Social Story “Getting Friends to Look”:
1 . What can friends show each other?
2. Do friends say your name to get you to look at them?
, 3 . If a friend calls your name, what should you do?
4. Do they like it if you don’t look at them?
5. What can you say to get your friends to look at you?
Particioants’ Test Performance
Mild to Mod
Mild to Mod
Mild to Mod
WRMT-R: WI Subtest
Note. All scores reported are Standard Scores with the exception of Raw Scores reported for the CARS
and percentiles reported for TOLD-2 Primary, CELF-3, and TONI-2.
“Problem Behaviors scale on the SSRS assesses negative behaviors, therefore higher scores = more
problem behaviors than the average student in the standardization comparison group.
Definitions for Appropriate and Inappropriate Social Language Measures
Appropriate Social Skills
Securing Attention (SA)
Initiating Requests (IR)
Coded if the target child’s utterance is contingent upon a peer ’s immediate
prior utterance, within a 2-second interval following the peer’s utterance,
through (a) acknowledging (e g,, “hmm”) and direct or partial repetition of
the utterance, (b) agreeing (e g., head nod, "y^ah”), (c) answering peer’s
question(s), (d) responding with a related comment about observable objects
or events within the ongoing activity, (e) confirming/clarifying a question or
comment from the peer (e g:, ‘‘What did you say?”).
Coded if the target child (a) requests attention or acknowledgement from
peers (e.g., “Hey!” “See this?” or “Look.”), (b) calls the peer’s name to gain
attention, or (c) uses gestures or vocalizations to establish joint attention
with the peer (e g., taps on shoulder, hold an object up to show peers).
Descriptive comments that are related to the ongoing topic/event, but not
contingent upon a peer’s prior utterance and not used to request information,
and the target child (a) provides a comment following a 3-second interval
after a peer’s last utterance, (b) initiates a new idea or topic that relates to the
ongoing joint activity/topic, but is not a request, (c) compliments the peer
(e.g., “You did it!”) or himself, (d) reinforces the peer for winning, (e)
expresses enjoyment to the peer regarding their interaction together (e.g.,
“This is fun!”). Note: Child’s utterances coded as IC if it met the criteria of
(b) to (e) and if within the 3-second interval.
Coded if target child’s utterance is related to the ongoing topic/event, but not
contingent upon a peer’s prior utterance and not used to clarify something
the peer said (would be CR), and the target child requests information or
actions following a 3-second interval after a peer’s last utterance..
(Table 2 Continued)
Inappropriate Social Skills Description
Topic Change (TC)
No Response (NR)
Coded with or without a change in materials/games if the target child: (a)
interrupts (definite overlap of words) a peer to introduce a new topic that
has not been discussed previously, or to reintroduce a previous topic, (b)
changes the topic to something unrelated to and noncontingent upon the
peer’s prior utterance, (c) comments tangential to some aspect of the peer’s
previous utterance, but there is an ambiguous semantic referent not
immediately recognizable, (d) verbal turns that follow a TC are coded as
CR, IC, IR, SA if the conversation follows the changed or shifted topic.
Utterances that are not interpretable or are unintelligible to the coder on-
line and after listening to the audiotape a maximum of three times.
Code as “Other” any (a) animal noises or other vocalizations, (b)
stereotypic or perseverative utterances (considered perseverative on the
THIRD utterance - code as OT; if another child speaks or the child
continues the perseveration at a later time, start over and code the first two
utterances as they are defined), (c) delayed echolalia that is non-interactive
Child does not respond verbally or nonverbally within 3 -seconds to a
peer’s requests for: (a) information, requests for actions, or protests, (b) if
the child is performing an action requested by the peer that takes longer
than 3 -seconds, wait to see if he completes the task and give him credit if
he does, or (c) if the peer asks the same question again within the 3-second
interval, the utterance is not coded, and the time frame starts at 0 after the
peers second question; if the child does not respond after the peer repeats
themselves 2 or more times, code as “NR”.
Average Number of Target Children's Utterances per Conversational Episode
Based on Last Five Baseline and Last Five Treatment Sessions
Summary^ of Teacher and Graduate Student Social Validity Ratings Pre- and Post-Intervention
Graduate Student Ratings
Note. 1 = No active involvement in activity, verbal initiations, or responses to peer's comments, 5 =
Better than average engagement in these 3 behaviors.
"^TC = Target child's social behavior ratings. = Peer's social behavior ratings.
Summary of Sociometric Status Before and After Visually-Mediated Treatment
Before Tx After Tx Pre-Post Class-Wide
Participant M SD M SD Change M Change
on class-wide ratings
; on a
scale of 1 to 3
with 1 ==
Doesn’t like to play
3 = Likes to play with.
Number of Behaviors per 10-Minute Session
Figure 1. Frequency of Appropriate Social Language Skills During Baseline, Treatment,
and Maintenance Social Activities.
Number of Behaviors per 10-Minute Session
Figure 2. Frequency of Coded Social Language Skills During Baseline, Treatment,
Maintenance, and Classroom Social Activities.
Number of Sessions
Number of Behaviors per 10-Minute Session
Figure 3. Frequency of Coded Social Language Skills During Baseline, Treatment,
Maintenance, and Classroom Social Interactions.
Number of Sessions
Frequency of Coded Social Language Skills During Baseline,
it, Maintenance, and Classroom Social Interactions.
Initiates Comments and Requests
Number of Behaviors per 10-MinuteSession
Figure 5. Frequency of Appropriate Social Language Skills During Baseline, Treatment,
and Maintenance Social Activities.
Implications of Findings.
(1) The outcomes of this research generate new knowledge on the effectiveness of an
intervention that capitalizes on the visual modality to remediate social deficiencies. The
results may directly influence early intervention efforts for improving reciprocal social
interactions between young children with PDD and their peers in inclusive classrooms.
(2) Implementing this intervention in the early elementary grades may have a significant
impact on later emotional, cognitive and language development, and possibly prevent
continued social difficulties in adulthood.
(3) The results add to the scant literature available on effective intervention strategies for
young children with PDD who exhibit basic expressive language and reading skills.
(4) The results extend research investigating the role of typical peers as mediators of social
interventions for elementary students with social impairments. Although only limited
peer training was provided, it was evident that involving peers as conversational partners
contributed to the focus children’s success. Interacting with peers during typical social
activities created multiple opportunities for the focus children to respond to and use a
variety of functional social communication skills. Involving typical peers as
conversational partners contributed to the children’s acceptance among classmates not
involved in the intervention.
(1) Thiemann, K. S. & Goldstein, H. (July, 1999). Effects of Visually-Mediated Intervention
on the Social Communication of Children with Pervasive Developmental Disorders.
Poster presented at the annual OSEP Leadership Project Director’s Conference,
(2) Thiemann, K. S. & Goldstein, H. (November, 1999). Effects of Visually-Mediated
Intervention on the Social Communication of Children with Pervasive Developmental
Disorders. Poster presented at the Annual Convention of the American Speech-Language
and Hearing Association, San Francisco, CA.
(3) Thiemann, K. S. (July, 1999). Guiding Social Development Through Visual- and Peer-
Mediated Approaches. In-service presented to the Center for Autism and Related
Disabilities, Florida State University, Tallahassee, FL.
(4) Thiemann, K. S. (February, 2000). Enhancing Friendships Between Children with
Autism Spectrum Disorders and Their Peers. In-service presented to Valparaiso
Elementary School, Okaloosa County, FL.
(5) Thiemann, K. S. (June, 2000). Enhancing Social Competence and Friendships of High-
Functioning Elementary Students with Autism Spectrum Disorders. Presentation at the
Institute on Autism at Florida State University, Tallahassee, FL.
(6) Thiemann, K. S. (February, 1999). Picture My Words; Visual Strategies for Improving
Social Skills of Elementary School-Age Children. Social intervention manual provided to
the Florida State University Center for Autism and Related Disabilities, Tallahassee, FL.
PLANNED FUTURE ACTIVITIES
(1) Research findings will be submitted for presentation at regional and national conferences
on early intervention/education for children with disabilities in the upcoming year.
(2) Continued in-service training for local and/or regional educators and speech-language
pathologists as invited.
(3) Investigators will be submitting manuscript for publication to appropriate journals.
We assure that copies of the full final report has been sent to:
(1) Ms. Rose Sayer, Office of Special Education
US. Department of Education
400 Maryland Avenue SW
Switzer Building Room 33 1 7
Washington, D.C. 20202-2626
(2) ERIC/OSEP Special Project
ERIC Clearinghouse on Handicapped and Gifted Children
Council for Exceptional Children
1920 Association Drive
Reston, Virginia 22091
We assure that the copies of the title page and abstract have been sent to:
NECTAS Coordinating Office
137 East Franklin Street, Suite 500
Chapel Hill,NC 27514-3628
Kathy Thiemann, MA
Howard Goldstein, Ph D.
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