Control de Estimulos Autismo

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Research in Autism Spectrum Disorders 7 (2013) 1551–1557

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Research in Autism Spectrum Disorders


Journal homepage: http://ees.elsevier.com/RASD/default.asp

Teaching children with autism to attend to socially relevant


stimuli
Angela Persicke, Megan St. Clair, Jonathan Tarbox *, Adel Najdowski,
Jennifer Ranick, Yue Yu, Yanicka L. de Nocker
Autism Research Group & Center for Autism and Related Disorders, Inc., United States

A R T I C L E I N F O A B S T R A C T

Article history: Research has shown that children with autism often fail to attend to relevant stimuli in
Received 22 April 2013 social situations, likely resulting in unsuccessful or absent social interactions. The purpose
Received in revised form 25 July 2013 of this study was to teach children with autism to attend to stimuli with socially relevant
Accepted 3 September 2013 features. Specifically, this study evaluated a teaching package including rules, modeling,
role play, and specific feedback across multiple exemplars to teach children with autism to
Keywords: attend and respond to others’ bids for social attention (e.g., ‘‘Whoa!’’ or ‘‘Ouch!’’). Three
Autism participants successfully learned to shift attention toward others and emit a response to
Attention
gain more information in response to a socially relevant stimulus. Furthermore,
Shifting attention
generalization was observed across novel exemplars and people.
Executive function
Social stimuli
ß 2013 Elsevier Ltd. All rights reserved.

By definition, individuals with autism spectrum disorders display deficits in language and social skills along with
repetitive, stereotypical behavior and restricted interests (American Psychiatric Association (APA), 2000). Given the global
deficits encountered in autism, delays in many other areas also exist, including motor development, play, daily living skills,
cognition (Tervo, 2003) and executive function (Hughes, 2001; Ozonoff, 1995; Ozonoff & Jensen, 1999). Executive function
(EF) refers to a set of processes (presumably cognitive) required to engage in behaviors such as abstract thinking, rule
acquisition, planning, goal persistence, flexibility, task initiation, inhibition, and attending to important sensory information
(Hill, 2004). It is this last area of EF, attention skills, with which the current study is concerned, as deficits in EF may be related
to inappropriate responding to social situations (Bennetto, Pennington, & Rogers, 1996). One of the first skills a child needs to
learn in order to respond to social situations appropriately is to notice or shift their attention to them.
Shifting attention can be characterized by a process of disengaging attention from one stimulus and shifting eye gaze to
another salient stimulus for the purpose of gaining critical information from within one’s immediate environment
(Courchesne et al., 1994; Mundy & Neal, 2001; Ruff & Rothbart, 1996; Wager, Jonides, & Reading, 2004). Shifting attention to
social stimuli involves disengagement from one stimulus (an object, activity, or person) and shifting eye gaze to attend to a
social stimulus (a person) in the environment.
Although typically developing children learn to shift their attention to social environmental stimuli within the first few
months of life, a considerable amount of research has documented that children with autism are delayed in their ability to
actively attend and respond to stimuli, social and nonsocial, within their environment (Courchesne et al., 1994; Dawson,
Meltzoff, Osterling, Rinaldi, & Brown, 1998; Dawson et al., 2004; Goldstein, Johnson, & Minshew, 2001; Greene et al., 2011;
Landry & Bryson, 2004; Leekam & Ramsden, 2006; Maestro et al., 2002; Osterling & Dawson, 1994; Rinehart, Bradshaw,
Moss, Brereton, & Tonge, 2001; Swettenham et al., 1998). In fact, research has shown that children with autism present with
an unusually restricted and selective focus on particular parts of their environment at the expense of attending to salient

* Corresponding author at: Autism Research Group, 19019 Ventura Boulevard, Third Floor, United States. Tel.: +1 818 345 2345.
E-mail address: [email protected] (J. Tarbox).

1750-9467/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.rasd.2013.09.002
1552 A. Persicke et al. / Research in Autism Spectrum Disorders 7 (2013) 1551–1557

aspects of the social environment (Lovaas, Koegel, & Schreibman, 1979). These findings are concerning given that autism
spectrum disorders are primarily diagnosed by marked impairments in social interactions and that a lack of attention toward
socially salient stimuli could potentially result in further difficulties in more complex social exchanges.
Much research has focused on identifying deficits in social attention in children with autism as compared to other
populations. For example, Dawson and colleagues (1998) found social attention impairments in children with autism when
comparing them to children with Down syndrome and typically developing children on responses to an orienting attention
task. The orienting attention task consisted of the delivery of two social (e.g., clapping hands and calling child’s name) and
two nonsocial (e.g., playing a musical jack-in-the-box and shaking a rattle) orienting stimuli to participants within and
outside of the their field of vision while observing and recording whether or not they shifted attention by looking toward the
stimuli upon presentation. The results of this study indicated that children with autism demonstrated more delayed shifts
and more frequently failed to orient to stimuli presented, especially socially relevant stimuli.
Dawson and colleagues (2004) extended this study by comparing children with autism or PDD-NOS to children with
other developmental disorders and typically developing children on additional measures of social orienting. The additional
social orienting measures included an experimental assessment of spontaneous shifts in participants’ attention toward
naturally occurring social (e.g., humming or neutral tone, calling the child’s name, snapping fingers, and patting hands on
thighs) and nonsocial (e.g., timer beeping, phone ringing, whistle blowing, tape recording of car horn) stimuli within their
environment. The results of this study were consistent with those from the previous study by Dawson and colleagues (1998)
by finding that children with autism were less likely to orient by shifting attention to both social and nonsocial stimuli, and
that orienting impairments were most profound for social stimuli. Maestro and colleagues (2002) found similar results in a
study they conducted involving the retrospective analysis of home videos collected from the first 6 months of life of children
later diagnosed with autism. After analyzing the videos and recording instances of social attention, nonsocial attention, and
social behavior, it was found that children with autism primarily shifted their attention toward nonsocial stimuli.
Swettenham and colleagues (1998) identified shifting attention deficits in children with autism in a study that investigated
the frequency and distribution of spontaneous attention shifts between social and nonsocial stimuli by comparatively assessing
children with autism with children with other developmental delays and typically developing children. Participants were filmed
during free play sessions and researchers analyzed the videotapes by recording attention shifts from one object to another object,
from an object to a person, and from a person to another person. This study found that infants with autism shifted attention less
and for shorter durations toward people, and shifted attention more and for longer durations toward objects.
Leekam and Ramsden (2006) comparatively examined the ability of children with autism and developmentally delayed
children to shift attention toward the vocal (e.g., ‘‘(Name)’’, ‘‘Hey’’, ‘‘Look at me!’’ or whistling), nonvocal (e.g., tickling the
child or taking their hands; waving hand, finger, or object; pointing to object; snapping fingers; clapping hands, banging
objects, or touching own nose or face), and combined bids of another individual. It was found that children with autism had
significantly more difficulty than those in the control group at successfully responding by shifting attention toward the bids.
The collective findings of these research studies provide evidence for the view that children with autism have deficits
attending to social stimuli within their environment (Klin, Jones, Schultz, & Volkmar, 2003). This is particularly concerning
given that a child’s early ability to shift attention toward socially relevant stimuli is foundational to later social development and
adaptive functioning (Mundy & Neal, 2001; Nadig et al., 2007). Attention shifts are crucial for social development because they
serve as a necessary prerequisite for complex skill sets, such as social exchanges, engagement, and effective communication. In
addition, attention shifts are essential for advancing adaptive functioning because through shifting, children learn to
differentiate between the events within their environment that are salient and those that are not (Ruff & Rothbart, 1996).
In addition to research focused on identifying attention deficits in children with autism, a multitude of experimental
studies aim to distinguish attention deficits by classifying them within complex information processing (Goldstein et al.,
2001) or deficiencies of executive function (Rinehart et al., 2001) and others approach the topic from a neurocognitive
perspective wherein deficits in shifting attention are thought to be caused by dysfunctions in underlying neurological
mechanisms and cerebral pathology (Courchesne et al., 1994; Greene et al., 2011). While the priority of previous research has
been on identifying shifting attention impairments in children with autism and classifying the orientation of such deficits, it
is imperative that current research also emphasize finding methods for effective treatment of such deficits.
Within the behavioral literature, few studies have investigated teaching procedures to remediate deficits in social
attending behavior. Some research in this area has focused on the treatment of deficits in joint attention with successful
outcomes (Pollard, Betz, & Higbee, 2012; Taylor & Hoch, 2008; Whalen & Schreibman, 2003). Joint attention refers to the
capacity to coordinate attention between an object or event in the environment and a social partner. Joint attention is a social
interaction, the intent being to direct another person’s attention to an object or event of interest, specifically for the purpose
of sharing the experience. This involves one individual initiating a bid for joint attention through a vocal statement (‘‘Look!’’)
and/or pointing toward the environmental stimulus and the social partner looking at it (Taylor & Hoch, 2008). Research on
teaching children with autism to respond to and initiate bids for joint attention is encouraging in that behavioral teaching
procedures are effective for remediating deficits in social attention.
Other than joint attention research, few previous behavioral research studies of which we are aware have attempted to
teach children with autism to shift their attention to socially salient stimuli within their environment. The development and
implementation of additional strategies for teaching children to attend to their social environment could be helpful for
remediating shifting attention deficits and play a role in redirecting children with autism toward typical social
developmental trajectories (Dawson et al., 2004). The purpose of the current study was to evaluate a treatment package for
A. Persicke et al. / Research in Autism Spectrum Disorders 7 (2013) 1551–1557 1553

teaching children with autism to shift attention toward an ambiguous social stimulus (e.g., ‘‘Whoa!’’ or ‘‘Ouch!’’) and emit a
response to gain more information about the social stimulus (i.e., to make an appropriate comment and/or bid or mand for
additional information about the social stimulus, such as asking, ‘‘What happened?’’). The treatment package included rules,
modeling, practice, prompting, feedback, praise, and multiple exemplar training for teaching three children with autism to
attend and respond to socially relevant stimuli within their environment.

1. Method

1.1. Participants and setting

Children were recruited for the current study from a large-scale in-home applied behavior analytic (ABA) autism
treatment agency based on referrals from clinical teams who deemed attending to social stimuli as a necessary component of
each child’s ongoing treatment program. Additionally, children were selected based on having no previous training in
shifting attention in the presence of ambiguous social stimuli. Participants were selected for participation in the study if they
had previously completed the following prerequisite lessons from the Skills1 curriculum (www.skillsforautism.com):
nonsocial stimulus orienting, eye contact, compliance, nonvocal imitation, echoics, following rules, and manding for
information. Participants were excluded from the study if they responded above 75% accuracy during baseline sessions on
both behavioral measures of shifting attention toward social stimuli and emitting an appropriate vocal response. No
participants were excluded from the study based on the above criteria.
Three children with autism participated in the study. All three children had current diagnoses of Autistic Disorder
provided by independent licensed psychologists according to DSM-IV-TR criteria (American Psychiatric Association, 2000). It
should be noted that no real names were used in order to maintain confidentiality of participants included in the study.
Shayna was a 5-year-old girl who had been receiving approximately 25 h per week of behavioral intervention throughout the
duration of the study. Shayna began intervention at the age of 4 and had been in treatment for approximately six months at
the onset of the study. Rico was an 8-year-old boy who had been receiving 4 h per week of behavioral intervention
throughout the duration of the study. Rico began receiving behavioral intervention at the age of 2. James was an 11-year-old
boy who had been receiving 8–10 h per week of behavioral intervention throughout the duration of the study. James began
receiving behavioral intervention at the age of 5.
For Shayna and Rico, most sessions were conducted in their primary residence as part of their regularly scheduled in-
home behavioral intervention sessions. For James, sessions were primarily scheduled outside of his regularly scheduled
behavioral intervention sessions, but were not significantly different from the way in which his typical behavioral
intervention sessions were conducted. Sessions occurred 1–3 days per week with only one session occurring on any given
day for an approximate duration of 60 min. Sessions were dependent on each participant’s availability and frequency of
sessions per week did not appear to have a significant effect on progress. All baseline and post-training sessions were
conducted in the context of natural play and conversation so that participants were not aware when any given trial was
occurring. Sessions were surreptitiously recorded using a video camera or smart phone and reviewed by the first author on a
regular basis. Recordings were also coded by secondary independent observers for interobserver agreement (IOA) data.

2. Response measurement and interobserver agreement

Data were collected on two responses: (1) shifting attention toward ambiguous social stimuli and (2) appropriate vocal
responses. During baseline, multiple exemplar training, and post-training phases, the percentage of correct responses were
calculated and graphed separately for each of the two responses. During first trial probes, both responses were required in
order for the trial to receive a correct score; otherwise the trial was scored as incorrect. Shifting attention was defined as the
child turning his or her head and averting eye gaze from the current stimulus/activity toward the ambiguous social stimulus
(i.e., person) within 3 s after presentation. Appropriate vocal responses were defined as any questions or statements relevant
to the social stimulus within 3 s of presentation. For example, if the social stimulus was the vocal stimulus, ‘‘Ouch,’’
appropriate vocal responses might include, ‘‘What happened?’’ or ‘‘Are you okay?’’ If the stimulus was a loud scream,
appropriate vocal responses might include, ‘‘You sound scared!’’ or ‘‘What is it?’’
Videos of sessions were viewed and coded by independent observers on 33% of baseline/post-training and training
sessions for Shayna, 36% of baseline/post-training sessions and 41% of training sessions for Rico, and 40% of baseline/post-
training sessions and 58% of training sessions for James. These data were compared with data from the primary observer’s
data on a trial-by-trial basis to calculate the percentage of agreement across observers. IOA percentages were calculated by
taking the number of agreements and dividing by the sum of agreements and disagreements and multiplying by 100. Mean
IOA scores for Shayna, Rico and James were 89.9%, 93.2%, and 99%, respectively.

3. Procedure

3.1. General procedure

Ambiguous social stimuli were presented in the context of natural play and conversation across 60-min sessions. During
any given trial, the investigator ensured that the child was engaged in an activity where attention was focused on a stimulus
1554 A. Persicke et al. / Research in Autism Spectrum Disorders 7 (2013) 1551–1557

other than the person presenting the social stimulus. The social stimulus had either auditory only or auditory combined with
visual properties. For example, an auditory only stimulus included statements or sounds outside the participant’s field of
vision (e.g., a therapist in a different room from the child proclaimed loudly, ‘‘Ouch!’’). A stimulus with auditory and visual
properties was presented within the participant’s field of vision (e.g., while the child was playing a board game with his or
her mother, the mother proclaimed, ‘‘Oh no!’’). Data were collected on correct or incorrect shifting attention responses and
appropriate vocal responses on each trial. Percentages of correct responses were calculated and graphed after each session.

3.2. Baseline/post-training

During each session in baseline and post-training, four different exemplars (two with auditory only properties and two
with auditory + visual properties) were presented. Each of the four exemplars was presented three times during each session,
for a total of 12 trials per session. Consequences were not provided for responding. Stimuli were presented by three different
individuals, including each participant’s parent or sibling. The same three people were included both within baseline and
post-training.

3.3. Multiple exemplar training (MET)

The teaching procedure was adapted from activities in the ‘‘disengagement’’ lesson of the Skills1 curriculum
(www.skillsforautism.com). Upon initiation of the first training session, participants were given a rule stated aloud by the
investigator: ‘‘When someone says or does something and they sound surprised, frustrated, angry, or sad, you should look at
them and say something like ‘What is it?’ or ‘Are you okay?’’’ After the rule was stated, the researcher immediately modeled
the shifting attention behavior and appropriate vocal responses. Practice trials were then conducted with the participants
with one exemplar (auditory + visual) until correct responding occurred across three consecutive trials. Then a second
exemplar (auditory + visual) was introduced and placed in semi-random rotation (each stimulus never presented more than
twice in a row) with the first exemplar until accuracy was observed across five consecutive randomly presented trials, thus
concluding the first session. Two novel exemplars (one auditory only and one auditory + visual) were introduced in each
subsequent session once accuracy was observed at or above 70% on previously trained exemplars. Once introduced, novel
exemplars were placed in semi-random rotation with all trained exemplars from previous sessions. None of the exemplars
included in the baseline/post-training phase were targeted during MET. Correct responses were praised (‘‘Awesome, Shayna!
Great job looking at me and saying, ‘What happened?’’’). If the participant did not respond or responded incorrectly, the
therapist: (a) gained the attention of the participant by saying his or her name, (b) asked an attending question (e.g., ‘‘Rico,
did you hear me?), (c) repeated the social stimulus and rule, and (d) conducted a prompted practice trial (e.g., ‘‘I said, ‘Oh
wow!’ Remember, when someone sounds surprised you should look at them and say something. Let’s practice that one
again. ‘Oh wow!’ What should you do?’’). Prompting was provided in a least-to-most intrusive fashion as needed. If the
participant was unable to produce an appropriate vocal response with the above prompting strategy, the investigator would
use an echoic prompt (e.g., ‘‘What happened?’’) immediately after the presentation of the social stimulus, systematically
fading the echoic prompt until independent responding was observed.

3.4. Generalization

As stated earlier, two novel exemplars were introduced into each session after accuracy was observed at or above 70% on
exemplars introduced in previous sessions. Each time two novel exemplars were introduced across MET sessions, the first
trials in which they were each presented were calculated together as a percentage correct (i.e., 0%, 50%, or 100% correct) and
graphed separately from trained exemplars as a means to visually analyze and measure generalization to untrained
exemplars. MET was concluded and post-training was initiated after 100% accuracy was observed on first-trial
generalization probes across three consecutive sessions. Three novel trainers (not included during baseline and post-
training) were included in training phases to promote generalization across people. One of the three novel trainers was either
a parent or sibling of the participant.

4. Results

Fig. 1 depicts percentage of correct responding across all phases of the study in a multiple baseline across participants
design. In baseline, Shayna (top panel) scored below 42% (m = 22.2%; range, 8.3–41.7%) on appropriate vocal responses, and
33.3%, 75%, and 16.7% respectively (m = 41.7) for shifting attention. Although Shayna shifted attention with 75% accuracy in
the second baseline session, responding was inconsistent and low levels of appropriate vocal responses warranted
introduction of MET. With MET, Shayna’s responding increased gradually until 100% accuracy was observed on first-trial
generalization probes of novel exemplars across three consecutive sessions. In post-training, accurate responding
maintained above 83% accuracy for both shifting attention and appropriate vocal responses. Eighteen exemplars were
presented during MET and twelve exemplars were presented during baseline/post-training sessions.
Rico’s (middle panel) accuracy was 33% and lower for both shifting attention (m = 16.5%; range, 0–33%) and appropriate
vocal responses (m = 23%; range, 17–33%). Upon initiation of MET, there was an immediate increase in responding to 83%.
A. Persicke et al. / Research in Autism Spectrum Disorders 7 (2013) 1551–1557 1555

Fig. 1. Percentage of correct shifting attention and vocal responding for all participants.

Responding slightly decreased with the introduction of novel exemplars but stabilized at 100% accuracy after 13 sessions of
MET. Post-training was initiated after 100% accuracy was observed on first-trial generalization probes across three
consecutive sessions. During the first two sessions of post-training, responding maintained at 100% accuracy for shifting
attention and appropriate vocal responses but began to decrease for appropriate vocal responses on the third session and for
both behaviors on the fourth session. Novel exemplars never included in any phase of the study were probed to evaluate if
the downward trend was due to lack of maintenance. After six sessions of novel exemplars and one additional probe of
exemplars presented in session 23, it was apparent that the skill was not maintaining. Booster sessions were initiated with a
rule reminder (e.g., ‘‘Remember, when someone says or does something and they sound surprised, frustrated, angry, or sad,
you should look at them and say something like ‘What is it?’ or ‘Are you okay?’’’). Accuracy during the booster sessions
1556 A. Persicke et al. / Research in Autism Spectrum Disorders 7 (2013) 1551–1557

stabilized at 100% after seven sessions and post-training was again initiated. Post-training sessions were presented again but
in a different order than the previous post-training phase and responding began to decrease specifically for making
appropriate vocal responses. The final two sessions (sessions 44 and 45) included the same exemplars from sessions 40 and
41 and responding returned to 100% accuracy. Eighteen exemplars were presented during the first MET phase with Rico, and
an additional 14 exemplars were presented during the second MET booster phase. Sixteen exemplars were presented during
baseline/post-training phases with an additional twelve probe exemplars during the second post-training phase.
James’ (bottom panel) baseline accuracy of responding was 50% and lower (m = 34.9; range, 16.6–50%) for shifting
attention and 58.3% and lower for appropriate vocal responses (m = 41.6%; range, 25–58.3%). Upon initiation of MET,
accuracy increased to 83% and 89.9% for shifting attention and appropriate vocal responses, respectively. Responding
remained above 71% for the entirety of training. After 12 sessions of MET and 100% accuracy on first-trial exemplars across
three consecutive sessions, post-training was initiated. Accuracy during post-training remained above 75% for shifting
attention and appropriate vocal responses. Twenty exemplars were presented during MET, and 20 exemplars were
presented during baseline/post-training sessions.

5. Discussion

The current study evaluated a training package including rules, modeling, practice, prompting, feedback, and praise with
multiple exemplars for teaching children with autism to attend to stimuli in the environment with socially relevant and
ambiguous features. The results of this study suggest that the multiple exemplar training package was effective for teaching
three children with autism generalized responding to socially relevant stimuli. All participants demonstrated high levels of
accurate responding to trained and untrained exemplars, suggesting that participants did not learn to merely respond to
specific stimuli but a broader class of stimuli (i.e., a generalized operant was established). This study demonstrates that
deficits in attending and responding to social stimuli may be remediated using behavioral teaching procedures.
This study has several implications worthy of discussion. First, this study validates and extends upon previous research
that children with autism can learn to attend to socially relevant stimuli in their environments through the use of behavioral
teaching procedures. Specifically, this study supports the findings of previous research on teaching children to respond to
bids for joint attention and extends upon research in this area by demonstrating that behavioral teaching procedures are
effective for teaching responding to more ambiguous bids for social attention. Additionally, the training procedure was
effective with both types of stimuli (auditory only and auditory plus visual), and neither class of stimuli posed more difficulty
for any of the participants; thus, this suggests that socially ambiguous stimuli with various properties can be successfully
taught using this procedure. This skill may be relevant to overall social functioning as a prerequisite for engaging in more
advanced social interactions. If children do not attend to basic changes in social stimuli in the environment, it is likely that
they will fail to attend to more complex forms of social stimuli, such as changes in an individual’s affect, and will therefore
fail to adjust their interactions with individuals accordingly. Second, the study extends upon the current body of literature
supporting the use of multiple exemplar training as a procedure to teach a generalized operant, as opposed to teaching rote
responding to specific stimuli. The generalization that was observed for all participants in this study suggests that the
procedure helped to establish a generalized ability to shift attention toward socially relevant stimuli, not merely to particular
stimuli that had been directly trained. Finally, this study provides support for the possibility of applying behavioral
interventions to improving skills referred to as executive functions and therefore typically relegated to brain mechanisms
(e.g., attention, working memory, planning, inhibition, etc.).
Although the results of this study are encouraging, there are several limitations that should be evaluated in future
research. First, generalization across settings, outside of each participant’s home, was not evaluated in this study. It is
possible that the participants of this study may not demonstrate the skill outside of the home setting, such as public spaces or
school settings. Future studies should assess for generalization outside of the home setting. Equally important is the absence
of demonstration of long-term maintenance. Although encouraging that the participants’ accuracy of responding remained
high during post-training when reinforcement was no longer contingent on correct responding, long-term maintenance was
not evaluated and should be addressed in future studies on this topic.
Second, ultimately the goal of teaching a skill such as attending to social stimuli is for this skill to come under the control
of natural contingencies of reinforcement in the environment. For example, in this study the natural contingency of
attending to socially relevant and ambiguous stimuli is to obtain information about the ambiguous stimulus. If someone
says, ‘‘Ouch’’ and the attender says, ‘‘What is it?’’ the natural contingency for the mand (request) for information is receiving
the unknown information. Throughout training, reinforcement in the form of social praise was provided for correct
responding, thus the extent to which the response came under the control of natural contingencies is unknown. We can
assume from the high performance of Shayna and James in post-training, when responses were not reinforced with contrived
forms of reinforcement, that their responses were under the control of natural contingencies of reinforcement. It is possible
that this did not occur for Rico whose performance decreased in post-training phases once contrived reinforcement was
removed. Further research should evaluate the extent to which natural contingencies of reinforcement maintain attending to
socially relevant stimuli.
Third, multiple components were included in the multiple exemplar training package. It is unknown which components
were necessary. For example, we included a rule in the beginning of the training phase, but it is unknown whether the rule
was necessary. Presumably, the rule was effective because accuracy during the first session for at least two children was high,
A. Persicke et al. / Research in Autism Spectrum Disorders 7 (2013) 1551–1557 1557

suggesting that these participants did not necessarily need to directly contact reinforcement for responding to increase. That
said, it is possible that the skill could have been acquired efficiently without the use of rules or other components of the
treatment package, thus future research should evaluate components of the treatment package to determine which
components are necessary to obtain accurate responding.
Lastly, there are social stimuli that may only require either the shifting attention component or the appropriate vocal
response and not necessarily both. In this study, we required both responses during training in order for the participants to
advance into post training, but future research could attempt to teach children the complex conditional discrimination of
when an eye gaze shift alone is appropriate versus when an appropriate vocalization should be included.
Despite the limitations, the results of this study are encouraging for the remediation of deficits in attention skills among
children with autism, specifically in regard to attending to stimuli with socially relevant properties. Future research is
necessary to further evaluate the necessary components of the treatment package, and the extent to which other children
with autism can learn this generalized skill.

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