Description of skills
Case Study Information
Sarah’s is a four-year-old girl with a diagnosis of autism spectrum disorder, she lives at home with her parents and sister. Her parents want to run a home program to improve her communication as they are keen for her to start mainstream school in September. The following report is based on the Verbal Behaviour and Milestones Assessment Protocol (Sundberg, 2014) and Placement Protocol (VB-MAPP), based on Skinners (1957) analysis of verbal behaviour. The following report includes the case study information, functional assessment and the results from the VB-MAPP Milestones, Barriers and Transition scoring form results. Here we will describe her strengths and weaknesses, followed by a consideration of other assessments, an outline of the target areas and intervention approaches, priorities of other skill areas to be prioritised and a recommendation of an appropriate placement based on the assessment findings.
Assessment Information
Sarah’s Milestone assessment fell at the lower end of level 1 (in the 0-18 months skill range), with a score of 9.5 out of a possible 170. This puts her roughly in the age range of 12 months and demonstrates significant gaps in her skill set. Her Barriers score was 60, scores between 31-96 indicate significant barriers to learning. The Milestones and corresponding Barriers scores will be addressed as a priority for Sarah as these will limit her access to less restrictive settings. Sarah’s transition score was 20 out of a possible 90 indicating that her limited academic skills, requires adjustments need to be made in terms of her level of inclusion in a less restrictive setting. A summary of her strengths and weaknesses from the Milestones and Barrier and Transition assessments are addressed below.
Strengths
Her listener skills are emerging, there is some eye contact and she turns her head to locate a sound in response to her name. She indicates an understanding of basic motor responding and some emerging imitation skills (including 4 motor imitations mouth imitations). She is able to make correct sounds but not the missing consonants or syllables. This puts her skill level for vocal behaviour at around 11 months of age. She is also able to track items, grasp them and attend to some age appropriate items. She shows some early matching skills from an array of 3 and is showing some promise with stacking items. She also shows some interest in objects and indicates an interested in exploring independently.
Weaknesses
Sarah has a low score out of a possible 5 for each Mand (1/2), Tact (0), Echoics (1/2) and Vocal (0) and puts her at a range of less than 12 months of age. Manding is the first verbal operant emitted by a child in the form of crying etc and echoics are the very first vocal language. Tact repertoire will not be a point of focus as we have no echoic repertoire. The scores on her Barrier assessment indicate that she has behaviour problems, defective tacts, Mands and echoics. She does not spontaneously emit speech and her current repertoire is prompt bound. Despite her higher score on the Visual Perception/Matching To Sample (VP/MTS) she is unable to make conditional discrimination in the Mand, tact and echoic areas. There are aberrant motivating operations for reinforcers which are unconditioned such as sleep, food and removal of aversive stimuli. Any demand results in a weakening of the Motivating Operation (MO) and training does not result in generalisation. Stereotypy interferes with learning, instructional control, social interactions and play (Dunlap, Dyer, ; Koegel, 1983). Her stereotypy could be competing with the low play score, as it impedes exploring behaviour, is automatically reinforcing and does not rely on adult mediated consequences. Therefore, she gets her automatic reinforcement here rather than in play, which is a significant barrier to learning. In addition, she engages in aggression to escape from demands and social interaction and SIB to access tangible items, which indicates that she is using these behaviours to “mand” for things. In addition, her lack of social engagement affects her mand acquisition and reduces the value of eye contact and so natural contingencies are ineffective.
Sarah also suffers from night terrors, which results in poor quality of sleep for her (and probably her family). Lack of sleep is a main factor here that needs to be addressed given its relationship to problem behaviour, particularly in relation to demand avoidance (O’Reilly, 1995) and cognitive problems. It is suggested that a specialist medical referral be carried out to rule out any underlying causes for this. In addition, Sarah’s problems with articulation, speech and language should be referred to a Speech and Language Therapist (SLT).

Consideration of other assessments
The other assessments that we suggest will be considered here

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Speech and Language Therapist (SLT) referral
A score of 1 on the Early Echoic Skills Assessment (EESA) subtest (Esch, LaLonde ; Esch, 2010) in the Milestones assessment showed that Sarah has a score of 1 in this test, shown by the ½ point score on the VB-MAPP. This means she emits only simple and reduplicated syllables. Sarah has no functional communication or vocal speech and this is below her age level, we suggest a referral to an SLT. The rationale for this is to assess if there is a need for Alternative Augmentative Communication (AAC). Even though, the parents are not keen to use this, a professional assessment should be carried out to help inform the intervention.

Sleep assessment and possible referral
Assessment of sleep and night terrors, given the importance of this problem in terms of how it relates to behaviour problems, it is possible that a lack of sleep could be a factor in Sarahs’ problem behaviour. It will certainly be impacting her home life and her family. It is recommended that a full sleep assessment be carried out, including a sleep diary to include sleep and wake periods over a 24 hour period for 2 weeks. In addition to this a Childrens Sleep Habit Questionnaire (CSHQ) or a Sleep Disturbance Scale (SDSC) should be carried out to screen for a sleep disorder. Night terrors are referred to as non-REM parasomnisas and are associated with a confusion in thought process after awakening. Treatment in the form of scheduled awakening is the behavioural intervention that is traditionally used if you can predict the awakenings. However a medical referral could be useful to eliminate possible epilepsy. This can occur at any age and is linked with night terrors, especially if no clear patterns emerge from the initial assessments (Moturi & Avis, 2010). Her primary medical practitioner should rule out any other problems so that the behavioural intervention (scheduled awakenings) can progress (Durand, 2002).

Vocal mand assessment
Finding the best teaching strategy for teaching vocal mands, find find out whether the reinforcer is strong enough, a generalisation problem, the mand is unusual or has not contact sufficient reinforcement and what has stimulus control over responding. Manding as an intervention for problem behaviour is referred to as Functional, Communication, Training (FCT) and it is taught using prompting, prompt fading, shaping and reinforcement. How these procedures are selected is not often focused on in the literature (Carr and Durand, 1985; Hanley, Iwata, and Thompsons, 2001). We want to develop mands that can be understood by a wider audience and these are more difficult to teach. For example, shaping will not give functional communication if there is no stimulus control and bound by prompts Or, reinforcing vocal topographies might not give us the response if it has not been shaped previously. It is possibly idiosyncratic, hence the need for this assessment (Bourret, Vollmer, and Rapp 2004).
A free operant preference assessment is carried out (see below; Roane, Vollmer, Ringdahl, & Marcus, 1998) . The item selected is paired with the target mand for the word.
Three assessments are carried to understand which type of prompting procedure would be preferred for Sarah. Each 1-minute trial is broken down into 3 parts with a 10 second time delay to allow to unprompted responding. 10 trials should be carried out
1) non-specific prompt (not the SD) 10s after onset of trial -designed to see if it would occur anyway. Duration of reinforcement 55s
2) model of complete target utterance after 20s (to increase chance of full utterance and check for imitation) this condition would favour prompting and reinforcing. Duration of reinforcement 35s
3) model of successive approximation after 30s (to ensure that this is the controlling prompt for the response) this could favour shaping approximations and reinforcement. Duration of reinforcement 25s
The duration of reinforcement is designed to increase the motivation for full utterance of the target word. The use of shaping via prompts with time delay for the 3rd stage of the procedure would be used (if this is the procedure that works for Sarah) and the prompt would be faded as the word utterances increase. Using a prompt fade strategy, taking it back a step if progression does not occur. Then the successful approach can be used to teach other mands. The unprompted responses result in quicker access to the item because of the time delay so it increases motivation to respond quicker. If there is no vocal responding then picture pointing might be a good place to start and you can start by teaching a couple then this might make the vocal mands easier to learn.

Preference assessments
The free operant preference assessment identifies edible and tangible reinforcers (Roane, Vollmer, Ringdahl, & Marcus, 1998) and is conducted at the beginning of each training trial. Sarah can select from 5-7 stimuli and the duration of her interaction timed to work out which one would act as a potential reinforcer.
which will be used to select reinforcers, a survey of Sarah’s preferred items will be given to Sarahs’ parents. This is called a Reinforcer Assessment for Individuals with Severe Disability (RAISD; Fisher, Piazza, Bowman, & Amari, 1996) and will help guide the reinforcers we could use for Sarah in her training.

Milestones
This area of the assessment gives us an overview of Sarahs current operant level with respect to verbal and related skills. This is the current performance as baseline. Sarah does not vocally request, labels things or vocally imitate. It is likely that if she develops these skills she will acquire more language and can still acquire fluency (Wokda, Mathy, & Kalb, 2013). The acquisition of spoken language is more likely to lead to better outcomes in many other skill areas (Eldevik, Eikeseth, Jahr, & Smith, 2006). The main goal in using the VB-MAPP is to guide IEP’s and to make sure the learner has a balanced skill set. Her scores were out of developmental balance, these were all within the level one range of mand, tact, listener, VP/MTS, Play, Social, Imitation, Echoic and Vocal. All of these are primary domains important for the social and language development. An Early Intensive Behavioural Intervention (EIBI) is found to the best way to show significant increases in vocalisations in children with autism (Dawson 2008; Eldevik et al. 2009). A greater emphasis on early language development focuses on manding and echoic behaviour (Sundberg, 2004), it is these that we will focus on predominantly.

Mand
Sarah only emits 1 mand and has defective mand score which is high in her barriers assessment. Therfore, this will be her primary target area. This verbal operant is very important because it will allow Sarah to control her delivery of conditioned and unconditioned reinforcers and they help to establish listener and speaker roles which is an essential pre-requisite for further language development. They are also more spontaneous, quickly generalised due to the EO and this skill does not come from tact or receptive training (Shafer, 1994). The methods of capturing opportunities to reinforce mands using EO’s is also straightforward (Sundberg and Partington, 1998). The training is fun, it reduces inappropriate behaviour and Sarah will be more willing to partake. The use of EO in manding will help with the later development of echoic, tact and intraverbal training, because it will help her to be more willing to participate, it pairs trainers with this reinforcement and this will reduce negative behaviours. The use of prompt, fading and differential reinforcement will transfer the stimulus control to the motivating variables (Sundberg & Partington, 1998). Then this can be brought under stimulus control (Carroll & Hesse, 1987; Drash, High, & Tudor, 1999; Skinner, 1957; Sundberg & Partington, 1998). This is carried out using natural teaching and contrive opportunities when the EO is strong (Hall & Sundberg, 1987; Sundberg & Partington, 1998).
Sarah’s vocal behaviour needs to increase, so we suggest the use of the mand-model approach so that we can use the mands to develop her echoic repertoire (Rogers-Warren and Warren (1980). The procedure for this uses a procedure called Incidental Teaching (IT; Hart ; Risley, 1975). The interventionist keeps items that Sarah wants just out of reach and then when she is given the verbal prompt “what do you want?”, she is given the item by shaping up the appropriate word approximation. This results in a mand being under the control of echoic and tact control. A procedure where shaping of new sounds paired with reinforcers will develop her repertoire (Drash, High, and Tudor (1999). See Mand assessment (above) for procedure. Then you fade the echoic prompt so that the word is under control of the item (not the verbal stimulus) so it is under the control of the MO.

EESA ; Vocal
Typically developing children usually use 2 syllable words by 6-18 months e.g. “ma-ma”. Sarah has a ½ point score on the EESA and has no vocalisation (score of 0) putting her at the lowest end of language development. Echoics are sound imitations and they are imperative for early language development. This is not possible with non-vocal children, because these responses are not occurring, so they do not contact reinforcement. Sarah has a defective echoic repertoire which is likely to be prompt bound. We have a low spontaneous vocalisation, and possibly she does not have enough muscle control to give echoic responses, so these will need to be developed and she won’t find the automatic reinforcement to control this behaviour. Therefore, a stimulus-stimulus pairing procedure might be too early, because the EO is not present.
With the use of strong motivators we can transfer the echoic sounds to mand conditions by using strong EO’s (Sundberg ; Partington 1998). A daily intervention will help utilise ways to make her echoic skills stronger.

Spontaneous vocal behaviour
A zero score means that Sarah’s frequency of vocal output should be increased. This will target strengthening of her vocal muscles and help increase her chances of getting echoic control over vocal behaviour. This will involve a variety of procedures to capture and reinforce her vocal responses, for example, pairing, mand-model, echoic trials and direct reinforcement of any vocalisations.

Tact
Sarah has a zero score on tacts and her score on imitation and echoic means it will not be effective to transfer stimulus control (Sundberg & Partington 1998) to tacts. A high score in the barriers assessment for instructional control (3), response requirements that weaken MO (4) and a low mand score on the Milestones assessment suggests it is better to delay this until we have established a few mands. An initial goal would be to tact a familiar person e.g. “mummy”.

Listener responding
Sarah does respond to sounds, she has a splintering of skills up to level 4, meaning we can develop this repertoire as the same time as manding. The focus will be on identifying the number of items as a listener, increasing the number of items in an array, using pictures and books and then generalising these to other materials. An increase in training actions and listener discrimination in the natural environment and using socially reinforcing games that use her interaction. These will also reduce her Barriers score on defective social skills (score of 4) and defective conditional discrimination (score of 4). There are no Barriers for listener discrimination.

VP/MTS
Sarah scored highest in this skill area with splinter skills up to level 5, putting her in the 0-18 month category. The target here alongside the language training will be to strengthen hand-eye coordination, fine motor, early play, manipulation of objects (e.g. squeezing a ball) and cause and effect play. This will be carried out in the natural environment. In addition there will be Matching To Sample (MTS) activities such as puzzles (using backchaining so she can contact her reinforcer quicker to keep her motivated), matching iterms and 3d game (using differential reinforcement) Cause and effect activities, in natural environment. There is a low Barrier score for this skill area, for conditional discrimination it is high (4), so will be reduced with these types of activities.

Independent play
Sarah has a ½ point score on the Milestones assessment for this area. She also engages in high self-stimulatory behaviour (Barriers score of 4), therefore, it is likely that this is competing with reinforcement for these activities. An intervention which uses pairing, creating motivation e.g. swings, “ready-steady-go” on a bike, spinning tops, bright colours, smells, sounds or movement will be activities that can be reinforced using social attention, smiles, praise and eye-contact.

Social behaviour and social play
Sarah has a ½ point score on the Milestones assessment. A barrier here is that she also engages in problem behaviour maintained by escape from social interaction. An intervention area here should focus on pairing, making people less aversive and more reinforcing. There should be a high level of reinforcement delivery, mand training and reducing the aversiveness of interactions with people. This will start with adults. Problems arising as a result of Sarah’s sister can be overcome by using a systematic desensitisation higherarchy, where Becca is paired with joint adult mediated fun activities initially something like watching a video together, where the IPad is held by the trainer and the girls sit either side to watch and engage with it. Also, giving them opportunities to engage in enjoyable activities they both enjoy in the same room.

Motor imitation
Sarah has a score of 1.5 on the Milestones assessment, indicating that skills in this area are emerging. Increasing eye contact whilst imitating could be a target for spontaneous imitation, a skill that would be of use for a less restrictive setting. Imitating fun activities suc as “peek-a-boo”, or doing “do this” games with a goal of her generalising this to other people and settings. The guide suggests that scores of 2 on this scale and 0-1 on echoic (sarahs are 2 and 1 respectively) suggests she would benefit from mand training with sign language, especially as she does not have any echoic behaviour but can imitate some motor movements (Sundberg ; Partington, 1998).

Other skill areas
Target areas for priority are the night terrors. An intervention strategy from Durand (2002) has been shown to have good treatment effect, long term efficacy and social validity. It involves waking children at approximately 30 minutes before the time that the night terror occurs would interupt the sleep at the stage of REM sleep that is associated with this type of night-time event. After medical problems have been ruled out (such as epilepsy) and a sleep assessment and descriptive analysis has been conducted. This intervention will require parent training and how to implement this in their homes, using Skype follow/ups 2x per week (Durand, 2002) and checks on the data collection (treatment integrity). Once we have established a timeline for the night terrors we schedule to wake Sarah 30 minutes before the spontaneous awakening. The frequency of awakening is then decreased and subsequently eliminated (Durand and Mindel, 1999, Durand, 2002) and has been regarded as a promising intervention (Kuhn ; Elliott, 2003).

Intervention approach:
” Us a sleep diary to determine when Sarah experiences sleep terrors. These usually occur the same time each evening
” One the night you begin the plan wake Sarah up approximately 30 minutes before the terror time. If she wakes easily move the click back in time 15 minutes on the next night (it should be difficult to wake her)
” If the night terrors vary in time wake her up about 30 minutes prior to the earlier time.
” Do not fully waken her, gently touch or talk to her until she opens her eyes and then let her fall back to sleep.
” Repeat each night until she goes a full 7 nights without a sleep terror.
” Once you reach this level of success you can skip 1 night per week.
” If she has an episode, go back to every night.
” Then slowly reduce the number of scheduled awakening until the terror no longer occur.
Pairing
This helps to establish motivation. This delivers positive reinforcement during a behaviour and activity. The current neutral or aversive activity and the person will acquire reinforcing properties because it has been paired with reinforcement. There is no requirement for demands being placed. This will be used to condition adults, peers, activities and environments as potential reinforcers. Pairing will be used to condition attention/people as a potential reinforcer (Taylor-Santa, Sidener, Carr, ; Reeve, 2014), help to condition new reinforcers and identify other reinforcers. is a fundamental pre-requisite to the Manding-echoic program. Carrying this out in a natural setting means that the social skill development will be natural and generalised
Sessions should be scheduled throughout the day and in naturally occurring environment. Getting Sarah to Mand by being motivated will help develop her social interactions for items, missing items, attentions, removal and information. The mand repertoire needs to grow. This is the key to developing more advanced social skills. This conditions attention as the reinforcer. This needs to be done with adults before peers.
Intervention approach
” Reinforcement is free
” Pair her name with your voice by saying “Sarah” and providing her with reinforcement
” See what she is interested in and be aware of her behaviour (approach means yes and avoid means no)
” Reinforce all interactions which relate to approach behaviour eg eye contact, smiles, laughs etc
” Make sure you are aware of activities she approaches for and make sure you are part of those activities.
” When undesired behaviour occurs, withhold reinforcement
” Don’t turn it into a demand task
” Make sure you are not associated with anything aversive
” Make sure you avoid any statements such as “no”, “stop that” etc.
” Don’t ask questions, these are demands.
” Sit face to face with Sarah
” Put 10 edible items she finds reinforcing down between you both and spread them out
” Block any attempts she makes to take items without social interaction
” When she is quiet, smile and give a gestural nod before she is allowed to take the item. If there is no response, prompt and let her take the item
” Repeat and then vary time between the nod and smile. Until she only takes the item after you have given the nod and is the beginning of social referencing

Increasing eye contact
Poor eye contact has limiting effects on education, instructional control vocal manding and attending (Greer and Ross, 2007; Carbone, O’Brien, Sweeney-Kerwin, ; Albert, 2013). Increasing eye contact with you makes you a conditioned reinforcer. Reinforce any approximation for eye contact with you to obtain an item and put early approximations on extinction until she is looking at you, then transfer this to stimulus control of using discriminative stimulus “looking”

Count and Mand
approach for engagement in problem behaviour when she wants something.
Intervention approach
” Don’t give attention
” Say “quiet”
” Count on hands until she is quiet for duration of count
” Prompt approximation
” Give item
Note: use same procedure for “wait” if she cannot have something immediately

Placement
In order for Sarah to learn from her peers, she needs to have in tact listener skills, functional mands, tacts and intraverbal skills. Without this, the verbal stimuli presented by her peers will not evoke the appropriate verbal responses and could be punishing. Therefore, an inclusion environment is best to help her to develop her verbal repertoire (Sundberg & Partington, 1998). A school is not likely to provide the specialist behaviour skills that she requires to be fully integrated and it might be better for her to have an intervention program which means she can attend school for some less restricting activities and the rest of her intervention at home. As she is not affected by a wide range of reinforcers means she will be less likely to learn from a less restrictive environment. Her scores are mostly 1 on the Transition assessment, meaning she will benefit from a high staff to student ratio and this needs regular supervision and monitoring by a qualified professional.
Suggested IEP goals
” Sarah will mand for for at least 5 different items with verbals prompts such as “what do you want”, with physical echoic or imitative prompts.
” Sarah will spontaneously emit at least 2 different mands per day for a desired item or activity.
” Sarah will look at, point to at least 10 family members, pets or reinforcers when named by an adult.
” Sarah will imitate at least 8 motor movements, and 6 actions involving objects on command
” Sarah will spontaneously imitate adults or peers 10 times in one day.
” Sarah will engage in cause and effect play e.g. pushing buttons to make sounds, stacking and knocking over blocks, pushing things, pulling etc for a total of at least 2 minutes.
” Sarah will spontaneously engage in object play involving a sandbox, bean or rice tray, buckets and shovels, toys of puzzles for at least 5 minutes.
” Sarah will place items in a container or form ball, stack blocks or place rings on peg totalling at least 10 different visual motor activities
” Sarah will sort similar colours and shapes for 10 different colours or shapes.
” Sarah will spontaneously mand to a peer at least 10 times per day
” Sarah will spontaneously follow or imitate the motor behaviour of a peer at least 10 times per day.
” Sarah will echo at least 5 vowels, dipthongs, or consonants on command.
” Sarah will spontaneously emit at least 10 different sounds, averaging at least 30 total sounds each hour.

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