Teaching Children with Autism – Investigating Training Methods That Work
Section 1: Most-to-Least Prompting
For Lauren Anderson*, day 1 of swimming lessons represented the worst day in her young son’s life.
It didn’t start out that way. Derek was eight. It was time to learn to swim and Derek was at least interested. The family headed out to the local therapy pool which specialised in working with people living with disability and the special needs population.
“It went down-hill fast,” recalls Anderson.
Derek loved his time in the pool… in fact, he loved it so much, he could not let go of the moment. “He just kept perseverating on it,” said Anderson.
For the boy, the 15-minute aquatic assessment was a delight. It was the going-home part that started the melt-down.
“I know the instructor had worked with kids with autism before, but she kept unwittingly feeding into his cycle,” recalls Anderson. “There we were, sitting in her office, dressed, discussing his assessment, and all Derek wanted to do was get back into the pool. He couldn’t let it go.”
“He could see the pool through the large glass windows in the office. It was too much for him to understand – the water was right there and no one would let him touch it.”
There came a moment when Derek realised that – no matter what he said — he wasn’t going to get what he wanted.
“That’s when he made a break for the pool,” recalls Anderson.
There was a moment of collective disbelief, then the world imploded. Everyone gave chase.
Once caught, poolside, Derek lashed out, throwing objects, ramping up into a full-on rage. The facility called for help and the EMTs came. The EMTs strapped Derek down and wheeled him away.
And so ended Derek’s first day at the swimming pool.
*Not her real name
Autism – Across the Spectrum
Autism is a pervasive developmental disorder that appears during the first three years of life and persists to adulthood. It is characterised by difficulties in communication and social interaction, as well as restricted and repetitive behaviours and interests.
Children with autism manifest with symptoms such as failure to develop interests and peer relationships, lack of development in spoken language, persistent preoccupation and stereotypic behaviours.
Children with autism are often unable to participate in normal childhood physical activities. They don’t play the same as other children; sometimes, they just don’t play.
This deprives children with autism of the numerous mental and physical benefits associated with physical activities and sports, such as motor skills development and enhancing self-determination.
Research in training sports to children with autism indicate its potential use in reducing stereotypical and repetitive behaviours, improving social integration and interaction, and improving general physical fitness.
However, the special needs of children with autism require a special approach to teaching behaviours and skills.
This article discusses several fundamental approaches to teaching exercises and sports, detailing, in particular, the ‘most-to-least prompting’ and ‘time delay’ techniques.
These techniques can be applied to any situation where a skill must be taught, especially in engaging and educating a patient with autism on particular self care behaviours.
The theory of applied behaviour analysis (ABA) has been used for over fifty years to decrease inappropriate behaviours while increasing appropriate behaviours, teaching new skills, and maintaining acquired skills.
Most-to-least prompting is one of several forms of the errorless teaching approach, which is based on the ABA. The basic elements of the errorless teaching strategies are:
- Providing attention clues for the children with autism,
- Delivering task direction or doing environmental arrangements,
- Delivering prompting,
- Providing a response from the child,
- Delivering reinforcement when the child responds appropriately, and
- Frequent assessment performance of the child before, during and after teaching.
So, how do you start using this method? It is important that any task direction (e.g., “throw the ball”) should be given with a prompt for the child to initiate the target skill. Prompting is a controllable stimulus that induces the child to perform the target motor skill.
Prompting can be physical (full or partial), model, visual, verbal, or gestural. Physical prompting is the least moderate (most intrusive), while verbal and gesture-mimicking are the most moderate (least intrusive) in the spectrum of prompting.
The spectrum of prompts is illustrated in the figure below.
Teaching is usually based on a one-to-one interaction between the therapist and the child. The prompting level chosen is based on the child’s behaviour, abilities and skills. Reinforcement is given when the child performs the planned skilled successfully. The ultimate goal of errorless teaching is for the child to be able to perform the target skill independently, with only minimal prompting.
Most-to-Least Prompting Approach
The most-to-least prompting approach has three progressive stages of decreasing intrusiveness of prompting. This approach gradually reduces the prompts used by the therapist for the child to complete the tasks, from the most intrusive to the least intrusive.
The most to least prompting approach is summarised in Figure 2 below.
In the first stage, both physical and verbal cues are provided by the therapist. For example, to teach swimming, the trainer may tell the child, “Lay back into the water”, accompanied with the physical cue of supporting the child’s back. This may be accompanied by verbal reinforcement, such as saying, “Good job.”
As soon as this task is accomplished, the trainer initiates the next one. The trainer can say “Okay, let’s go on. Now stick your fingers together and place your hands at your sides”, coupled with a physical prompt. Verbal reinforcement is provided when the task is completed successfully. The stage is considered completed once the child is able to successfully complete the tasks with physical and verbal prompting.
The second stage uses gesture-mimic and verbal directed prompts to direct the child’s tasks. The child is provided verbal cues and reinforcement for each step every 5 seconds. For example, the therapist may tell the child to. “Lay back in the water.”, but rather than physically guide the child, he or she can mimic the motion of laying back into the water.
The task is considered successfully completed if the child performs it within the 5 second period after the prompt. Reinforcement is given only if there is a correct response from the child. No physical prompting is provided in this stage, and the stage is considered completed once the child completes the tasks successfully with only verbal and gesture-mimic prompting.
The third stage uses only verbal prompts to induce the child to initiate and complete the tasks. The stage is considered complete when the child is able to complete the tasks successfully after verbal prompts only.
This training method requires diligence and hard work on the part of the therapist, parent or trainer. It is not for everyone.
We will discuss other options for training methods that work with this target population in Section 2 and 3.
This review of the most-to-least prompting method has shown that it can be useful in providing motor skills to children with autism. A quick look through PubMed or Google Scholar will demonstrate many studies where progression was both made and maintained using the most-to-least prompting method.
Section 2: Constant and Progressive Time Delay Techniques
Maria first met Rafaela in a therapeutic pool in Lisbon, Portugal. Maria was visually impaired; Rafaela had been diagnosed with severe autism and she had never spoken. These two little ones crossed paths only because they attended adapted swimming classes back-to-back.
Little Maria loved to question and every week, she would inquire of her swim teacher “Does Rafaela knows how to talk?” to which the reply would follow “Not yet, Maria, not yet.”
Week after week this continued. Until one day Maria asked again “Does Rafaela knows how to talk?” to which the reply came once again “Not yet.” But Maria answered “I know Rafaela can talk. Yes, I know she can talk. Rafaela say ‘Hi’ to me”.
Five seconds later, Rafaela obliged. She said ‘Hi” to her friend Maria. She said ‘Hi’ in a pool in Portugal. For the first time in her life.
Applied Behavior Analysis
As discussed in Section 1, autism is a pervasive developmental disorder that appears during the first three years of life and persists to adulthood. It is characterised by difficulties in communication and social interaction, as well as restricted and repetitive behaviours and interests. Children with autism manifest with symptoms such as failure to develop interests and peer relationships, lack of development in spoken language, persistent preoccupation and stereotypic behaviours.
The theory of applied behaviour analysis (ABA) has been used for generations to decrease inappropriate behaviours while increasing appropriate behaviours, teaching new skills, and maintaining acquired skills. In Section 1, we discussed Most-to-Least Prompting as a way to modify inappropriate or stereotypical behaviours in children on the autistic spectrum. In this section, we will discuss the Constant Time Delay Technique and the Progressive Time Delay Technique as an errorless teaching strategy to train new skills for children with autism.
Prerequisites for Time Delay Training
In order for children to be able to benefit from time delay training, they must have a few skills already well in hand. Before starting a trial of applied behavior training, the therapist should determine if the child can:
- React in response to cues. For instance, the child must be able to look towards the therapist when a cue or other command is used.
- If a child is unable to delay a response (typically starting at 4 seconds), then this technique will not be as beneficial as a technique like Most-to-Least-Prompting which allows the therapist to provide prompting as much and as often as necessary
- Parrott or imitate the therapist’s behaviors. Imitation is at the heart and soul of this technique. If a child is unable to see then mimic (at least in part) a behaviour, this is not an appropriate technique.
- Focus attention (typically in a seated position). This technique becomes more important when time delay techniques are performed as part of small group work, but generally, children must be able to keep focused on a task for 5 minutes or longer.
- Respond to reinforcers with positive change. Children who do not have a history of altering their behaviours in response to cues or prompts may not benefit from this method.
- Follow 1-step commands. This skill can be in response to an auditory command (“Catch the ball”) or in response to written or pictoral cues.
Constant Time Delay
Time delay is a form of response-prompting, errorless learning approach that provides frequent opportunities for the child to respond and for the therapist or support personnel to provide immediate feedback or consequences to child responses. The term “time delay” refers to the amount of time between the therapist’s cue for the child to initiate the behaviour (e.g. “Throw the ball”) and the delivery of another prompt (e.g. the teacher gestures towards the ball).
Typically, a time delay procedure begins with 0 s (second) delay trials. This means that the verbal task request and the prompting are given simultaneously. During these trials, the student receives both prompting and assistance from the teacher to complete the desired task.
In Constant Time Delay Training, if the student is successful in completing the task with the 0 s interval, then a predetermined interval of time is set between the task request and the prompt. The delay interval provides the child the opportunity to perform the task independently, while at the same time allowing the teacher opportunities to give feedback. Put simply, the initial 0 s delay trials are for skill acquisition, while the delay intervals are for skill maintenance.
The constant time delay (CTD) technique uses a fixed amount of time between the verbal task cue and the controlling prompt throughout the entire training procedure. The most frequent time delay interval used in CTD is 4 seconds. This time delay strategy allows the student to progressively transfer stimulus control from the prompt (i.e. a correct response after the prompt) to the stimulus (i.e. correct response before the prompt).
A systematic review of CTD has found it useful and effective in teaching children with developmental disabilities. The use of CTD in teaching chained tasks has been associated with positive outcomes for most of its participants.
CTD’s fixed interval between task cue and controlling prompt is in contrast to the progressive time delay technique, which varies the length of delay with the student’s responsiveness.
Progressive Time Delay
With progressive time delay, teachers and other practitioners gradually increase the waiting time between an instruction and any prompts that might be used to elicit a response from a learner with ASD.
Both procedures use two types of trials: 0-second trials and delay trials. In both types of training, the 0-second trials look the same. The therapist performs or presents the stimulus and task direction and then (with no delay) presents the controlling prompt. This occurs before the child has had a chance to respond. The 0-second trials are used in order to allow skill acquisition and to overcome the training curve.
After the child has mastered the 0-second trial, the therapist has a choice whether to use the Constant Time Delay Technique (which typically delays the controlling prompt for 3, 4 or 5 seconds) or to use the Progressive Time Delay Procedure which increases the delay by 1 second increments until reaching a final level (typically a delay of 5 or 6 seconds).
Both Time Delay Procedures are very useful for teaching behaviours and new skills to children on the autism spectrum. Both techniques include a cue and a target stimulus, both include a desirable response (a skill or behaviour) and both give feedback. The choice of whether to use a constant delay or a progressive one should be made on a case by case basis, although there is some evidence that the Progressive Delay technique allows fewer errors.
Individuals looking for a step-by-step guide to creating a useful Time Delay Method of training are directed to this excellent resource through the National Professional Development Centre on Autism Spectrum Disorders. And for those looking for a list of evidence-based practices that can be viewed in whole, this online guide provides more than enough techniques to keep even the most eclectic trainer or therapist busy.
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Andrea Salzman, MS, PT graduated from the University of Alabama at Birmingham with a Master’s degree in physical therapy in 1992. Over the last two decades, she has held numerous prominent leadership roles in the physical therapy field, with a heavy emphasis on academic writing and administrative functions. Between 1995 and 1998, Salzman served as the Editor-in-Chief of an American Physical Therapy Association (APTA) journal. In 2010, Salzman received one of the highest honors given to a physical therapist from the American Physical Therapy Association, the Judy Cirullo Leadership Award. Between 2012 and the present, Salzman has written 12 physical therapy courses for Care2Learn, Relias Learning and reviewed over 100 other course offerings. Currently, Salzman continues in her writing, leadership and administrative roles at Aquatic Therapy University and 10K Health.