health psychology report · volume (), 4 Anna Budzińska

case study 1 · B,D,E,F

Anna Lubomirska
1 · B,D,E,F
Marta Wójcik
1 · B,D,E,F
Patricia J. Krantz
2 · A,E
Lynn McClannahan
2 · A,E

Use of scripts and script-fading procedures

and activity schedules
to develop spontaneous social interaction
in a three-year-old girl with autism
Autism entails serious deficiencies in communication and neous social interaction and shape joint attention skills.
social behaviors. Individuals with autism, even those who The result shows that ABA techniques were very effective
have received intensive language intervention, are often in teaching many verbal skills such as answering ques-
viewed as lacking spontaneous language. In addition, tions, making requests, initiating conversation and asking
some children with autism lack the ability of spontaneous- question. Comparison made after implemented teaching
ly seeking to share enjoyment, interests, or achievements procedure shows her initiating of joint attention skill (IJA)
with other people (e.g., a lack of showing, bringing, or is at the appropriate level for her age.
pointing out objects of interest to other people).
The aim of the study was to use ABA teaching techniques key words
such as script and script fading procedure and activity autism; activity schedules; script and script fading proce-
schedule to teach three-year-old girl with autism sponta- dure; joint attention; initiating interactions

organizations ― 1: Institute for Child Development, Gdansk, Poland · 2: Princeton Child Development Institute,
Princeton, USA
authors’ contribution ― A: Study design · B: Data collection · C: Statistical analysis · D: Data interpretation ·
E: Manuscript preparation · F: Literature search · G: Funds collection
corresponding author ― Anna Budzińska, Ph.D., Institute for Child Development, 139 Malczewskiego Str., 80-114 Gdansk,
Poland, tel. +48 58 341 44 41 or +48 665 07 80 00, e-mail: [email protected]
to cite this article ― Budzińska, A., Lubomirska, A., Wójcik, M., Krantz, P.J. & McClannahan, L. (2014). Use of scripts
and script-fading procedures and activity schedules to develop spontaneous social interaction in a three-year-old
girl with autism. Health Psychology Report, 2(1), 67–71. DOI: 10.5114/hpr.2014.42791
 Background Behavior Scale, Second Edition, Sparrow, Cicchetti,
& Balla, 2005). Jane’s Adaptive Behavior Compos-
Autism is characterized by qualitative impairments ite score showed that general adaptive functioning
in social interaction and communication and restrict- was low; she scored higher than less than 1% of
ed, repetitive, and stereotyped patterns of behavior similarly aged individuals in the Vineland-II norm
(DSM-IV, American Psychiatric Association, 2000). sample. Her standard score for the Communication
Impairments in social interaction include marked Domain was significantly lower than the median
deficits in the use of nonverbal behavior such as eye- score for all of the Vineland-II domains.
to-eye gaze. There may also be a lack of social reci- The setting was a preschool and research center
procity of facial expressions, body posture, and ges- for children with autism. Sessions were conducted in
Anna Budzińska, tures. In addition, some children with autism do not a typical classroom furnished with desks, chairs, and
Anna Lubomirska, spontaneously seek to share enjoyment, interests, or bookcases, and in a corridor that contained bookcas-
Marta Wójcik, achievements with others (that is, they display defi- es and toys, a gym with sports equipment and toys,
Patricia J. Krantz, cits in joint attention, such as showing, bringing, or a toilet and a dining room; generalization sessions
Lynn McClannahan pointing out objects of interest to others). were held in all of these settings, but with different
Deficits in joint attention are among the earliest teachers.
signs of autism in young children (Charman, 2003).
Such deficits are typically evident before one year of
age (Jones & Carr, 2004) and have been associated Experimental conditions
with difficulties in subsequent language development and measurement procedures
(Mundy, Sigman & Kasari, 1990).
Many studies indicate that joint attention skills Research design. The study used an A-B design (Bai-
may be necessary for the emergence of communica- ley & Burch, 2002). Phase A was baseline and Phase B
tion and it is important to ensure that newly acquired was intervention.
joint attention repertoires are functional – they are Measurement. In the course of therapy, Jane’s
used in different settings and with different partners, progress was recorded. The data were collected once
and are emitted in a variety of ways (Stokes & Baer, a week and graphed as percentage correct responses.
1977). In order to develop these skills, teaching must Each teaching level was considered completed if Jane
be conducted across a variety of stimuli until partic- achieved at least 80% correct, based on teaching and
ipants have acquired generalized repertoires (Reeve, generalization measures. Data collection procedures
Reeve, Townsend & Poulson, 2007). In addition, to were identical in each teaching step. At least once
increase the likelihood of response generalization, every three months, interobserver agreement (IOA)
children with autism must be taught to initiate bids data were collected to determine whether the data
for joint attention in a variety of ways. recorded by two independent observers were con-
gruent. Percentage interobserver agreement was cal-
culated by dividing the number of agreements by the
Participants and procedure number of agreements plus disagreements and multi-
plying by 100. Mean interobserver agreement on the
Participants and setting occurrence of correct responses was 96%.
Independent variables. Use of scripts and script-
One participant, Jane, began therapy at the Institute fading procedures (McClannahan & Krantz, 2005) is
for Child Development in Gdansk in September 2012, a strategy that has been applied to increase sponta-
at the age of 2 years and 10 months. She was the only neous language among individuals with autism. These
child in a two-parent family. She attended the Insti- procedures teach children to use written scripts or
tute’s intervention program for 4.5 hours per day, audiotaped recordings that provide models of appro-
5 days per week. Jane met the DSM-IV-TR (APA, 2000) priate language. As the learners begin to use scripted
criteria for autism and autism had been diagnosed language in their interactions, scripted phrases or sen-
by outside agencies. Based on DSM-IV-TR criteria, tences are systematically faded from end to beginning.
she had deficits in communication and social skills Scripts are embedded in the children’s daily activity
and displayed stereotypic behavior. At a biologi- schedules.
cal age of 2 years 10 months, she was tested using An activity schedule is a set of pictures or words
Schopler’s (1990) Psycho-Educational Profile-Revised that cues someone to engage in a sequence of activi-
(PEP-R). Her developmental age score was 1 year, 3 ties, perform tasks, or enjoy rewards (McClannahan
months. The most significant deficits were in the & Krantz, 1999). Jane’s activity schedule book con-
areas of imitation (3 months), receptive language (11 tained several pages, each of which displayed one
months), expressive language (5 months) and fine picture that showed an activity. Manual prompts
motor skills (11 months). Prior to intervention, adap- were used to teach her to follow the activity schedule
tive behaviors were evaluated (Vineland Adaptive and point to textual cues or listen to recorded scripts

68 health psychology report

included in her schedule. Manual prompts were de- guided her, then graduated guidance, delivered from
fined as manual assistance to display the desired re- behind, was used to help her complete the sequence
sponse. of activities pictured in her activity schedule, in the
Dependent variables. Initiations to adults and order in which photographs were presented, and use
children were defined as understandable statements the scripts, both recorded and written. Prompts were
or questions that were unprompted by teachers, that faded in frequency and intensity as rapidly as possi-
were directed to another person by facing him or her, ble (Cooper, Heron & Heward, 1987).
and that were separated from Jane’s previous vocal- Generalization. For each type of task, generaliza-
izations by a change in topic or a change in recipient tion data were collected with a person who did not
of interaction. If Jane initiated and then immediately take part in teaching, and nouns that were not used
repeated the same sentence or question, the repeti- during teaching were presented. Generalization data Use of ABA
tion was not counted as an initiation. Scripted ini- were collected prior to and after teaching. teaching
tiations were those that matched the written or re- techniques to
corded script, with the exception that conjunctions, develop social
articles, prepositions, or pronouns could be altered Results interaction in
or deleted (e.g., substituting “and” for “or”), and verb a small girl
tense could be changed. For example, “I play” was During baseline, Jane did not initiate interaction, with autism
coded as a scripted initiation, although the script nor did she display any spontaneous verbal interac-
read “Let’s play”. tion during any school day. When activity schedules
Unscripted initiations were verbal productions and scripts and script-fading procedures were intro-
that differed from the script by more than conjunc- duced, she learned to initiate bids for joint attention.
tions, articles, prepositions, pronouns, or changes in Making requests. As a result of teaching, Jane re-
verb tense; the sentence “Look, I have a fireman’s quested objects, activities, and help in completing
hat” was scored as unscripted because the noun “fire- tasks. During baseline she made no requests, but
man’s hat” did not occur in the script. A response was in 12 months she learned 27 requests. In Step 1, she
defined as any contextual utterance (word, phrase, or learned two one-phoneme requests: “o” for “open”
sentence) that was not prompted by the teacher (Mc- and “daj” for “give”. In Steps 2 to 6, she learned 22
Clannahan & Krantz, 2005). two-word requests (e.g., “pomóż mi” for “help me”;
Baseline. Prior to teaching, baseline measures of and “daj sok” for “give me juice”). In Step 7 she ac-
target responses were obtained. During this time, quired 3 four-word requests (e.g., “Czy mogę się po-
teachers did not use prompts and did not reward bawić?” for “May I play?”, and “Czy możesz mi dać?”
Jane or provide feedback. Baseline measures were for “Can you give me?”. When generalization was
obtained by the instructor who would teach most assessed with another person who never participated
frequently (2 hours and 15 minutes per day), using in teaching, Jane achieved 80% to 100% correct.
materials selected for the teaching process. Polite statements. Baseline was 0%. In 12 months,
Teaching. We taught Jane to follow a daily activity Jane learned 12 polite statements. In Steps 1 to 4 she
schedule that included a series of social interactions. learned 8 one-word statements (e.g., “Dzięki” for
Every response sequence in her daily activity sched- “Thanks” and “Przepraszam” for “Excuse me”. In Step
ule was scored correct if all of the following compo- 5 she learned 4 two-word sentences (e.g., “Sto lat” for
nents appeared: (1) taking a symbol of activity from “Happy birthday”). Generalization was assessed with
the schedule; (2) approaching a teacher who stood in another person and she achieved 80% to 100% correct.
different parts of the room; (3) visually attending to Initiating mutual activities. During baseline, Jane
the conversation partner; (4) giving a picture or sym- did not initiate any mutual activities. In 12 months,
bol of an activity to the teacher, or saying a script; (5) she learned 6 initiations. In Steps 1 to 4, she learned
waiting for the teacher’s comment; (6) engaging in 4 single-word initiations (e.g., “Chodź” for “Come”
the activity with a teacher. and “Gramy” for “Let’s play”). In Step 5, she learned
When verbal competence expanded, we taught 2 simple sentences (e.g., “Chodź ze mną” for “Come
Jane additional social interactions, using scripts and with me”). Generalization was assessed by indepen-
script-fading procedures. These included (1) making dent observers, and she achieved 80% to 100% correct.
requests for objects, activities, or help in completing Initiation and continuation of conversation. Jane’s
a task: (2) polite statements such as “Hello”, “Thanks”, baseline score was 0% correct. In 12 months she
and “Excuse me”; (3) initiating mutual activities, such learned 37 conversation initiations. In Step 1 she
as coloring, drawing, or molding from Play-Doh; or used syllables. She learned 8 sounds (e.g., “hop” for
(4) initiating conversation with other persons; and “jumping”, “a” for “car”, and “pi” for “drink”). In
(5) asking questions about unknown objects, pictures, Steps 2 to 4 she learned 24 single words (e.g., “baw-
activities, or persons. ię” for “I am playing”, and “lala” for “doll”. In Step 5
If Jane did not follow the activity schedule, or did she learned to continue conversation after teachers’
not use the scripts to which the teacher manually comments – she said a simple sentence, “lubię...” for

volume (), 4 69

 “I like (activity)”. In Step 6 she learned 4 two to four mental age was the same as her chronological age –
word sentences (e.g., “Pobaw się ze mną” for “Play both developmental age and chronological age scores
with me”). When generalization was assessed with were 49 months.
a person who did not participate in teaching, she After 15 months of therapy, we conducted an
scored 80% to 100% correct. analysis of Jane’s spontaneous verbal interaction
Asking questions about unknown objects. During with adults and other children, during 4.5 hours at
baseline, Jane did not ask any questions. In Steps 1 to the treatment center and kindergarten. Initiating in-
4, she learned to ask “Co to?” for “What’s this?” when teraction was assessed during independent play, and
she saw an unknown object, picture or situation. In during organized tasks in small group sessions, in-
dividual instruction, tasks in regular kindergarten,
Step 5 she learned to ask a longer question, “Co to
Anna Budzińska, mealtime, and transitions between rooms. Holding
jest?” for “What is this?” when encountering objects or
Anna Lubomirska, time constant, we compared Jane’s initiations with
events that were unknown to her. Generalization was
Marta Wójcik, the number of initiations made by a typically devel-
assessed when she was working with a new teacher, oping boy and a typically developing girl of the same
Patricia J. Krantz,
Lynn McClannahan and she achieved 80% to 100% correct responses. age, who attended regular kindergarten. We selected
We assessed Jane’s functioning levels at the be- these children because our observations suggested
ginning of treatment and after 12 months, using the that they represented an average level of verbal and
PEP-R Test (Schopler, 1990). Figure 1 shows PEP-R social competencies (see Table 1).
scores before intervention. At the beginning of treat- The data show that Jane initiated more interac-
ment Jane’s developmental age was much lower than tions than two typically developing children of the
her chronological age. Figure 2 shows PEP-R Test re- same age; the differences were especially marked be-
sults after 12 months of intervention; Jane’s develop- tween Jane and a typically developing girl.

40
developmental age – months

35 chronological age
30
25
20
15
10
5
0
imitation perception fine motor gross motor eye-hand cognitive cognitive developmental
integration performance verbal age
passing scores

emerging scores

Figure 1. PEP-R scores before intervention.

80
70
developmental age – months

60
50 chronological age
40
30
20
10
0
imitation perception fine motor gross motor eye-hand cognitive cognitive developmental
integration performance verbal age

passing scores

emerging scores

Figure 2. PEP-R scores after 12 months of intervention.

70 health psychology report

Table 1
Number of spontaneous social interactions displayed by Jane and by two typically developing 4-year-old

Number of spontaneous social interactions Jane Girl Boy

Directed toward adults 80 5 44
Directed toward other children 120 78 97

Discussion Cooper, J.O., Heron, T.E. & Heward, W.L. (1987). Ap-
plied Behavior Analysis. Upper Sadle River: Pren-
Use of ABA
At the beginning of intervention, Jane presented no tice-Hall.
teaching
appropriate verbal or social behavior, did not imitate Jones, E.A. & Carr, E.G. (2004). Joint Attention in techniques to
sounds or name objects, did not follow others’ gaze, Children With Autism: Theory and Intervention. develop social
and did not notice others’ responses, or changes in Focus on Autism and Other Developmental Disabil- interaction in
her environment. Further, she did not initiate inter- ities, 19, 13-26. a small girl
action with others, nor did she bring objects to oth- McClannahan, L.E. & Krantz, P.J. (1999). Activity with autism
ers or point to objects of interest. In short, she had schedules for children with autism: Teaching in-
no joint attention skills, and she frequently engaged dependent behavior. Bethesda, MD: Woodbine
in stereotypy. The results of the PEP-R Test showed House.
that her developmental age score was lower than her McClannahan, L.E. & Krantz, P.J. (2005). Teaching
chronological age score. conversation to children with autism: Scripts and
Jane’s intensive, daily therapy was based on ap- script fading. Bethesda, MD: Woodbine House.
plied behavior analysis (ABA), which focused on Mundy, P., Sigman, M. & Kasari, C. (1990). A longitu-
shaping verbal and social behavior. Skill deficits were dinal study of joint attention and language devel-
primarily addressed using scripts and script-fading opment in autistic children. Journal of Autism and
procedures and activity schedules. Teaching episodes Developmental Disorders, 20, 115-128.
were brief and concise. After twelve months of in- Reeve, S.A., Reeve, K.F., Townsend, D.B. & Poulson,
tervention, her developmental age scores increased C.L. (2007). Establishing a generalized repertoire
and were comparable to her chronological age. She of helping behavior in children with autism. Jour-
initiated social interaction with others about new or nal of Applied Behavior Analysis, 40, 123-136.
unfamiliar objects and events, about new people, and Schopler, E., Reichler, R.J., Bashford, A., Lansing, M.
about topics of interest to her. Anecdotal observation & Marcus, L. (1990). Individualized assessment for
indicated that her verbal repertoire includes previ- autistic and developmentally disabled children: psy-
ously taught conversation skills. Social validity mea- choeducational profile revised (PEP-R). Austin, TX:
sures showed that her spontaneous social interac- PRO-ED.
tions were comparable to those of two typical peers. Sparrow, S.S., Cicchetti, D.V. & Balla, D.A. (2005).
Presently, the differences between Jane and typically Vineland Adaptive Behavior Scale (2nd ed.). Livonia,
developing children are that her interactions are lim- MN: Pearson Assessments.
ited to one or two sentences, although children her Stokes, T.F. & Baer, D.M. (1977). An implicit technol-
age typically continue interaction using three or four ogy of generalization. Journal of Applied Behavior
sentences. Our future research will focus on using Analysis, 10, 349-367.
scripts and script-fading procedures to build more
and longer sentences used in conversation.

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volume (), 4 71