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http://ccs.sagepub.com/ Clinical Case Studies http://ccs.sagepub.com/content/13/3/282 The online version of this article can be found at: DOI: 10.1177/1534650113508221 2014 13: 282 originally published online 24 October 2013 Clinical Case Studies Mark F. O'Reilly and Peter B. Marschik Larah van der Meer, Jeff Sigafoos, Dean Sutherland, Laurie McLay, Russell Lang, Giulio E. Lancioni, Communicative Functions in a Child With Autism Spectrum Disorder Preference-Enhanced Communication Intervention and Development of Social Published by: http://www.sagepublications.com can be found at: Clinical Case Studies Additional services and information for http://ccs.sagepub.com/cgi/alerts Email Alerts: http://ccs.sagepub.com/subscriptions Subscriptions: http://www.sagepub.com/journalsReprints.nav Reprints: http://www.sagepub.com/journalsPermissions.nav Permissions: http://ccs.sagepub.com/content/13/3/282.refs.html Citations: What is This? - Oct 24, 2013 OnlineFirst Version of Record - May 8, 2014 Version of Record >> at University of Bucharest on December 7, 2014 ccs.sagepub.com Downloaded from at University of Bucharest on December 7, 2014 ccs.sagepub.com Downloaded from

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  • http://ccs.sagepub.com/Clinical Case Studies

    http://ccs.sagepub.com/content/13/3/282The online version of this article can be found at:

    DOI: 10.1177/1534650113508221

    2014 13: 282 originally published online 24 October 2013Clinical Case StudiesMark F. O'Reilly and Peter B. Marschik

    Larah van der Meer, Jeff Sigafoos, Dean Sutherland, Laurie McLay, Russell Lang, Giulio E. Lancioni,Communicative Functions in a Child With Autism Spectrum Disorder

    Preference-Enhanced Communication Intervention and Development of Social

    Published by:

    http://www.sagepublications.com

    can be found at:Clinical Case StudiesAdditional services and information for

    http://ccs.sagepub.com/cgi/alertsEmail Alerts:

    http://ccs.sagepub.com/subscriptionsSubscriptions:

    http://www.sagepub.com/journalsReprints.navReprints:

    http://www.sagepub.com/journalsPermissions.navPermissions:

    http://ccs.sagepub.com/content/13/3/282.refs.htmlCitations:

    What is This?

    - Oct 24, 2013OnlineFirst Version of Record

    - May 8, 2014Version of Record >>

    at University of Bucharest on December 7, 2014ccs.sagepub.comDownloaded from at University of Bucharest on December 7, 2014ccs.sagepub.comDownloaded from

    http://ccs.sagepub.com/http://ccs.sagepub.com/content/13/3/282http://www.sagepublications.comhttp://ccs.sagepub.com/cgi/alertshttp://ccs.sagepub.com/subscriptionshttp://www.sagepub.com/journalsReprints.navhttp://www.sagepub.com/journalsPermissions.navhttp://ccs.sagepub.com/content/13/3/282.refs.htmlhttp://ccs.sagepub.com/content/13/3/282.full.pdfhttp://ccs.sagepub.com/content/early/2013/10/23/1534650113508221.full.pdfhttp://online.sagepub.com/site/sphelp/vorhelp.xhtmlhttp://ccs.sagepub.com/http://ccs.sagepub.com/

  • Clinical Case Studies2014, Vol. 13(3) 282 295

    The Author(s) 2013 Reprints and permissions:

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    Article

    Preference-Enhanced Communication Intervention and Development of Social Communicative Functions in a Child With Autism Spectrum Disorder

    Larah van der Meer1, Jeff Sigafoos1, Dean Sutherland2, Laurie McLay2, Russell Lang3, Giulio E. Lancioni4, Mark F. OReilly5, and Peter B. Marschik6

    AbstractIndividuals with autism spectrum disorder (ASD) who exhibit limited speech can learn to communicate using augmentative and alternative communication (AAC) systems. We describe the case of Ian, a 10-year-old boy with ASD who had learned to use an Apple iPod- and iPad-based speech-generating device (SGD)Note 1, picture exchange (PE), and manual signing (MS) for functional communication (e.g., requesting), but had difficulty in using these AAC systems for spontaneous and socially oriented functions of communication. His difficulties were originally conceptualized as reflecting the social interaction and communication deficits characteristic of ASD. Alternatively, we suggest that the intervention did not allow for the development of more advanced communication. A preference-enhanced intervention was introduced with Ians chosen AAC system only, that is the iPad-based SGD. Opportunities for communication were created using highly motivating activities and behavioral strategies. Results suggest that the approach facilitated development of spontaneous and socially oriented communication.

    Keywordsaugmentative and alternative communication, autism spectrum disorder, iPad, preference, speech-generating devices

    1Victoria University of Wellington, New Zealand2University of Canterbury, Christchurch, New Zealand3Texas State University, San Marcos, USA4University of Bari, Italy5The University of Texas at Austin, USA6Medical University of Graz, Austria

    Corresponding Author:Jeff Sigafoos, School of Educational Psychology, Victoria University of Wellington, P.O. Box 17-310, Karori 6147, Wellington 6005, New Zealand. Email: [email protected]

    508221 CCS13310.1177/1534650113508221Van der Meer et al.Clinical Case Studiesresearch-article2013

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    1 Theoretical and Research Basis for Treatment

    Communication impairment is necessary for a diagnosis of autism spectrum disorder (ASD; American Psychiatric Association [APA], 2013; World Health Organization, 1992). Communication impairment in ASD is characterized by the heterogeneity of expressive com-munication skills; with one end of the spectrum presenting as long-winded and talkative and the other end mute (Wilkinson, 1998). Indeed, at least 25% of individuals with ASD fail to develop the ability to speak (Osterling, Dawson, & McPartland, 2001). Although they do not have any spoken language, these individuals might be able to learn to communicate using aug-mentative and alternative communication (AAC) systems (Beukelman & Mirenda, 2013). AAC systems include manual signs (MS), picture exchange (PE), and electronic speech-generating devices (SGDs; Ganz et al., 2012; Mirenda, 2003).

    Because children with ASD have been taught to use each of these AAC systems (MS, PE, and SGDs; Flippin, Reszka, & Watson, 2010; van der Meer & Rispoli, 2010; Wendt, 2009), it can be difficult for clinicians to select the most suitable AAC system for any given individual. Guidelines suggest that a childs choice of, or preference for, different AAC systems should be considered when making such decisions (Beukelman & Mirenda, 2013). Previous research has investigated the effects of assessing childrens preferences for using one AAC system over another on com-munication intervention outcomes (van der Meer et al., 2013; van der Meer, Didden, et al., 2012; van der Meer, Kagohara, et al., 2012; van der Meer, Sutherland, OReilly, Lancioni, & Sigafoos, 2012). Results of this research suggest that children can learn to use each AAC system (MS, PE, and SGD) for functional communication (e.g., requests for preferred items) and indicate a prefer-ence for a specific AAC system. Furthermore, these data suggest that acquisition and mainte-nance of communication skills is best with the childs preferred AAC system. The majority of participants in these studies preferred using an iPod-/iPad-based SGD and exhibited better functional communication skills with this AAC system.

    For the most part, this research is limited to teaching beginning requesting skills. Similarly, various reviews of the literature pertaining to MS, PE, and SGD communication interventions (e.g., Goldstein, 2002; Lancioni et al., 2007) have stressed that children with ASD can be taught to use these AAC systems for functional communication skills, such as requesting and labeling items, but little research has investigated and successfully taught the use of these systems for spontaneous and more socially oriented communication skills. The majority of AAC intervention studies reviewed (e.g., van der Meer & Rispoli, 2010) utilized behavioral intervention involving one-on-one instruction, time delay, response prompting, prompt fading, error correction, and dif-ferential reinforcement. While these procedures appear to be effective in teaching initial com-munication skills, it has been argued that more naturalistic teaching strategies might allow for the development of spontaneous social communication, such as initiations (Drager, Light, & Finke, 2009), although, as Drager and colleagues noted, there is limited research demonstrating that naturalistic approaches are effective in promoting social interaction for children with ASD who use AAC.

    Given that ASD is characterized by persistent deficits in social interaction and social com-munication, including impairments in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, and gestures to regulate social interaction as well as marked impairment in the ability to initiate or sustain a conversation with others (American Psychiatric Association, 2013; World Health Organization, 1992), it is perhaps not surprising that few interventions have been successful in teaching these skills. There are several hypotheses to explain why individuals with ASD struggle to learn spontaneous reciprocal communication. For example, because many individuals with ASD exhibit an indifference or aversion to other people, they may not be intrin-sically motivated to interact with others and obtain new information and perspectives necessary for socially interactive communication (Drager et al., 2009; Sturmey & Fitzer, 2009). This may

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    be the result of a deficit in theory of mind, which relates to an inability to understand other peo-ples cognitive states (Matson, Kozlowski, & Matson, 2012; Tager-Flusberg, 1996; Wilkinson, 1998). Alternatively, it has been hypothesized that children with ASD find the experience of sharing attention with other individuals to be less rewarding (Stone, Ousley, Yoder, Hogan, & Hepburn, 1997), reflecting their usually limited and unusual range of preferences and motiva-tional variables (Sturmey & Fitzer, 2009). This links to the notion that children with ASD are more motivated to communicate wants and needs because they are associated with tangible rein-forcement and therefore of direct benefit to the speaker, while other forms of social communica-tion are commonly of benefit to the listener (Skinner, 1957). Furthermore, communicating wants and needs is typically linked to tangible contextual cues (e.g., the preferred item), thereby serving as a prompt for the communicative behavior, while social communicative functions do not pro-vide these concrete visual cues (Quill, 1997).

    Further to the social deficits inherent among children with ASD, there are difficulties associ-ated with the task of using AAC systems to teach these skills. Social forms of communication can involve abstract concepts that can be difficult to represent on AAC systems and therefore may be more difficult to teach in communication interventions. Furthermore, representation of these language concepts (e.g., please and thank you) on each AAC system (SGD, PE, and MS) can become even more complex and difficult for children to learn. In an earlier study, we hypothe-sized that this could explain the less favorable results in a communication intervention with two participants (Ian and Hannah) targeting more complex and socially oriented communication using each AAC system (van der Meer et al., 2013). Results suggested that the highly structured behavioral procedures were effective in teaching two-step requesting for both participants, while only moderately successful for three-step requesting and the more social communication skills of (a) initiating greetings, (b) answering questions, and (c) using etiquette with each AAC system for only one of the participants (Ian).

    Given these findings, it is expected that intervention might continue more successfully with the participants preferred AAC system only. In turn, this might allow for more advanced lan-guage and communication skills to be targeted. Still, prompting participants for each interaction could be viewed as contradictory to the way in which children naturally learn language. Instead, natural cues for interaction to indicate opportunities for communication should be provided (Drager et al., 2009; Prizant & Wetherby, 2005). This involves communication opportunities that occur in natural environments, with familiar people, and involve activities that are motivating. The purpose of the present case study was to determine if a modified behavioral intervention with Ians most preferred AAC system would result in more spontaneous, complex, and socially ori-ented communication, which may have been difficult to learn with all four AAC systems (iPod- and iPad-based SGD, PE, and MS). Ians mother and a support worker created natural opportunities for communication related to watching his preferred DVDs. A time-delay (Halle, Marshall, & Spradlin, 1979) procedure was introduced before any communicative initiations/responses with his preferred method, the iPad-based SGD, were prompted by his communica-tion partner.

    2 Case Introduction

    Ian was a 10-year-old boy diagnosed by his pediatrician with ASD, moderate intellectual dis-ability, developmental co-ordination disorder, and epilepsy. Ian participated in an AAC interven-tion where he was taught to use an iPod- and iPad-based SGD, PE, and MS for functional communication, because of his extremely limited communicative skills (van der Meer, Sutherland, et al., 2012). Although Ian tried to sound out some words, these were unintelligible to unfamiliar communication partners. He also used some idiosyncratic gestures, seemingly to depict objects and actions. However, these gestures were largely unintelligible to his communicative partners.

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    Ian would often take peoples hands to direct them to what he wanted and frequently grabbed people in an apparent attempt to get their attention. Ians mother indicated that he engaged in obsessive behavior (e.g., fixation with certain toys) and had difficulty with changes to routines. His vision and hearing were in the normal range and he did not appear to have any major or obvi-ous difficulties with gross or fine motor skills. Ians mother and a support worker taught Ian to use the AAC systems (SGD, PE, and MS) at home. A speech-language pathologist provided input on his communication difficulties.

    3 Presenting Complaints

    With the introduction of the AAC intervention, Ian learned functional communication skills, such as requesting preferred music and toys, with the iPod-based SGD, PE, and MS with compara-ble ease (van der Meer, Sutherland, et al., 2012). In that study, systematic choice assessments were conducted, in which he consistently chose and thereby seemingly demonstrated a prefer-ence for using the iPod-based SGD compared with PE and MS. In a second study, he also learned to use each AAC system for more complex and socially oriented communication skills, such as multi-step requesting, greetings, answering questions, and social etiquette (van der Meer et al., 2013). However, throughout this second intervention, Ian consistently performed better when requesting specific items with each AAC system than he did when opportunities for more social communication were created (e.g., using an AAC system to say Thank you for the requested item or saying Hello to his communicative partner). Furthermore, Ian engaged in such social communicative responses only after a verbal prompt; spontaneous communication was therefore not evident. He had some difficulties in activating the iPod-based SGD. Therefore, follow-up sessions were implemented with an iPad-based SGD to assess whether his ability to use the iPod would generalize to the iPad and whether the larger sized icons and increased sensitivity of the screen on the iPad would make it easier for Ian to activate the SGD. With the introduction of the iPad, correct communicative responding immediately improved and Ian also indicated a preference for using the iPad-based SGD.

    4 History

    Although Ian was initially diagnosed with cerebral palsy at the age of one, this diagnosis changed several times, until diagnoses of ASD, moderate intellectual disability, developmental co-ordination disorder, and epilepsy were given at the age of eight years. Other than a few single and largely unintelligible word approximations, Ian had not developed effective speech. He attempted to communicate by creating his own signs to represent certain items and activities. However, he had no apparent means of easily being understood by his communicative partners. His mother reported spending considerable time deciphering single sign approximations he had created. Because Ian had previous exposure to various AAC systems with limited success, he was selected for a larger research project investigating the feasibility of assessing childrens preferences for using one AAC system over another and whether this would positively influence intervention outcomes. The present case study started approximately one year after this larger research project commenced and directly after the follow-up phase of the second study (van der Meer et al., 2013), in which Ian had demonstrated success in, and a preference for, using the iPad-based SGD.

    5 Assessment

    Before implementation of the communication intervention for the larger research project, an adaptive behavior assessment and a stimulus preference assessment were completed. Using the

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    Vineland Adaptive Behavior Scales, second edition (Vineland-II; Sparrow, Cicchetti, & Balla, 2005), Ian received an adaptive behavior composite standard score of 56, indicating a low adap-tive level with a mild deficit. He received an age equivalency of 1:4 (years:months) on the expressive communication subdomain of the Vineland-II (Sparrow et al.) as well as age equiva-lencies of 2:2 for receptive communication, and 3:10 for written communication. An age equiva-lency of 2:1 on the fine motor skills subdomain of the Vineland-II (Sparrow et al.) suggested that Ian had sufficient motor skills to communicate with each AAC system.

    The stimulus preference assessment was implemented to identify highly preferred activities that could be used to create opportunities to teach Ian various communication skills. The prefer-ence assessment followed a two-stage process (Green et al., 2008). Stage 1 involved an indirect assessment in which Ians mother was asked to provide a list of activities that Ian appeared to enjoy and would be appropriate for the intervention. The six most preferred activities were then selected for a direct stimulus preference assessment, involving the simultaneous presentation of multiple items, without replacement (DeLeon & Iwata, 1996). Ian was offered items for these activities and allowed to select one. A session consisted of repeating such offers six times. Items for each activity were not replaced once they had been selected. Six such sessions were under-taken before his most preferred activity was identified by calculating a rank order of the percent-age of times that an activity was selected. In order to do so, the following formula was used: number of selections / number of offers 100. Watching DVDs was identified as his most pre-ferred activity (selected 100% of the time). We then asked his mother to choose four DVDs that Ian appeared to enjoy watching and could be used for the intervention sessions only (i.e., he was not allowed to watch them in any other context, so as to maintain his motivation to watch the DVDs and participate in the communication intervention sessions). Based on his mothers reports, Ian appeared to have sufficient content knowledge of these DVDs in order to use the iPad for communicative interactions surrounding the content related to the people and activities in the DVDs as well as identifying emotions of characters.

    6 Case Conceptualization

    A case conference was held during the follow-up phase of the second study (van der Meer et al., 2013) to discuss ways in which to promote more naturally occurring social communication. This was based upon data suggesting that social communicative responses with each AAC system were only produced by Ian after a specific prompt (e.g., Its time to do some work, first we are going to play and then we can have a snack. Say hello or We have finished for today. Say thank you and good-bye). It was not known whether Ian would spontaneously demonstrate these social communicative skills. Such naturally occurring social communication may have been inhibited by the complexity of having to learn the responses with each AAC system. For example, to make a request for a cracker, Ian had to learn to select the correct icons on the screen of the SGD to activate the voice-output (I want a cracker, please), select the correct icons from the laminated standard sized sheet of paper and place them onto a separate sentence strip to result in the sen-tence I WANT and A CRACKER and PLEASE for PE, and perform the hand gestures to produce the correct signs for I WANT plus CRACKER plus PLEASE for MS.

    Furthermore, it could be argued that the only part of the communicative interaction Ian gener-ated (and thereby changed the meaning of the utterance) was the single icon for the desired item. It was not known whether Ian could learn more complex communicative skills with any of the AAC systems. The intervention team agreed that such complex language might be more easily learned if intervention continued with Ians preferred AAC system only. The follow-up results indicated that Ian not only demonstrated a preference for the newly implemented iPad-based SGD, but he was also better able to use it. Thus, a decision was made to continue intervention with the iPad-based SGD only. This was paired with a modified behavioral intervention in

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    which a time-delay procedure was introduced before any communicative interactions were prompted. We hypothesized that simplifying the task demands by teaching new communication skills with his preferred AAC system only and utilizing time-delay might allow for the emer-gence of more spontaneous, complex, and social communication.

    7 Course of Treatment and Assessment of Progress

    Communication sessions were implemented by Ians mother or caregiver (the instructors) at the dining room table. Specifically, within a DVD watching activity they taught Ian to use the iPad-based SGD to request, comment, answer questions, and name/label actions, emotions, and peo-ple. Throughout each baseline session, the instructor sat next to Ian, with the iPad, loaded with the software application Proloquo2Go Note 2 to enable synthesized voice-output. The iPad was kept on the table opened to a screen with a folder entitled DVD TIME. Within this folder, the iPad was programmed with five subfolders: ACTIONS, CHOOSING, EMOTIONS, GREETINGS AND ETIQUETTE, and PEOPLE. Within the CHOOSING folder, there were icons to represent each of the DVDs Ian could request to watch, as well as an icon to represent a request to watch MORE and request to STOP watching the DVD. Within the GREETINGS AND ETIQUETTE folder, there were icons to represent social niceties, such as PLEASE and THANK-YOU. Within the ACTIONS, EMOTIONS, and PEOPLE folders, there were icons to represent the various actions, emotions, and people that occurred in each of the targeted DVDs. Ian had to navigate through these folders for each communicative initiation/response.

    All icons comprised of either line drawings selected from the available database in the Proloquo2Go software or photos. Each icon had the word written below and resulted in the corresponding voice-output when the icon was selected. For example, within the CHOOSING folder, selecting the icon with a photo of a DVD and the words BIG RED CAR would result in the voice-output I would like to watch the Big Red Car DVD.

    During baseline sessions, to initiate a communicative interaction, the instructor asked What do you want to do? and waited approximately 10 s for Ian to make a request to watch one of the four DVDs identified in the preference assessment. If a request for a specific DVD was made, that DVD was played. If a request was not made, the instructor randomly selected a DVD for view-ing. After a few minutes the DVD was paused and the instructor waited for approximately 10 s to see if Ian initiated any communication using the iPad. Regardless of any communicative attempts, the movie was then resumed for a few minutes. This process of playing the DVD and then pausing to wait for any communicative interactions was repeated three times per baseline session. To signal the end of the session, the instructor asked Ian: Want to stop?. Regardless of Ians communicative response, the instructor stopped the DVD after 10 s. Because this was a new communicative skill, reinforcing this response was thought to act as an instructional procedure thereby compromising the experimental integrity of the intervention. During these sessions, the instructor recorded whether any communicative acts were independent (i.e., self-initiated), after a verbal cue (prompted), incorrect, or that there was no response. Figure 1 shows the course of treatment. As indicated in this figure, throughout baseline there were no communicative responses for any of the communicative categories programmed to the iPad. In other words, without any instruction on how to use the iPad, Ian did not use it to initiate any communicative interactions surrounding the DVD watching activity.

    During intervention sessions, 10 s after the instructor initiated a communicative interaction by asking What do you want to do?, the instructor also provided a verbal cue by saying You can ask to watch a DVD and, if necessary, used the least amount of guidance necessary (point, model, physical prompt) to teach Ian how to make a request on the iPad for watching one of the DVDs. After Ian had watched the requested DVD for a few minutes, the instructor paused the DVD for approximately 10 s to assess if Ian used the iPad to initiate any communicative interactions. If

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    no communicative initiations were made, the instructor initiated a commenting sequence by ask-ing Who is that? while pointing to one of the characters on the screen of the DVD (PEOPLE category), then What is he/she doing? (ACTION category), and finally How is he/she feeling? (EMOTIONS category). If a response was not made within approximately 10 s, the instructor prompted Ian, using the least amount of guidance necessary, to navigate to the folder on the iPad corresponding to the communicative category for the question asked. As in baseline, this process of playing the DVD and then pausing to wait for any communicative interactions was repeated three times per session. To signal the end of the session, the instructor asked Ian Want to stop or keep going?. Within the CHOOSING folder, Ian could request to watch MORE or STOP. If he requested to watch more, he was able to continue watching the DVD, but the communica-tion intervention session did not continue.

    For each intervention session, the number of communicative acts for each category of com-munication (i.e., ACTIONS, CHOOSING, EMOTIONS, GREETINGS and ETTIQUETTE, PEOPLE) was tallied according to whether the communication was: independent (i.e., self-initiated), after a verbal cue, incorrect, or if no response was made.

    As shown in Figure 1, with the introduction of systematic instruction (the least amount of guidance necessary) to teach Ian to navigate through the iPad for communicative interactions, he did learn to request the DVDs and comment on what was happening in the DVD, who was in the DVD, and how particular people in the DVD were feeling. Requesting was self-initiated 53% of the time, while commenting on the DVDs primarily only occurred after the instructor provided a verbal cue (e.g., What is he/she doing?). Naming of the characters in the DVD was initiated by Ian 10% of the time, while labeling actions and feelings independently only occurred 3% and 2% of the time, respectively. Requests to continue or stop the DVD only occurred after a verbal cue. Across all communicative categories, Ian only made incorrect responses 3% to 7% of the time.

    Figure 1. Percentage of response types across communicative categories and each phase of the study for Ian.

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    Throughout the intervention he did not communicate any social niceties. However, a verbal cue for this category of communication (GREETINGS AND ETIQUETTE) was not provided.

    To assess reliability of the instructors data collection, an independent observer simultane-ously and independently collected the same data (i.e., whether communicative interactions were independent, after a verbal cue, incorrect, or if there was no response). A percentage of agreement between the instructor and the independent observer was calculated using the formula: [Agreement / (Agreements + Disagreements)] 100. The data can be seen as highly reliable in that inter-observer agreement on Ians performance was checked on 24% of all baseline, intervention, and follow-up sessions with agreement ranging from 80% to 100% (M = 95%). To assess procedural integrity, the independent observer had a checklist of the procedural steps (e.g., 1. Child sits at table with iPad in reach and DVD player in view; 2. Instructor asks What do you want to do?; 3. Wait 10 s, then prompt request to watch DVD as necessary, etc.) and recorded whether or not the instructor had correctly implemented each procedural step in its proper sequence. Procedural integrity checks collected on 24% of all baseline, intervention, and follow-up sessions showed that correct implementation of procedural steps ranged from 83% to 100% (M = 94%). Inter-observer agreement on the procedural checks was collected on 5% of sessions (1 session) with 100% agreement. Unfortunately, the video-camera malfunctioned during the long-term follow-up meaning inter-observer agreement and procedural integrity data could not be collected.

    8 Complicating Factors

    While an appropriate AAC system was selected for Ian (his preferred iPad-based SGD) and intervention strategies were modified in an attempt to elicit spontaneous social communication, these skills may also have been inhibited because he only had access to the iPad-based SGD in the specified intervention sessions, thereby limiting opportunities for naturalistic communicative exchanges. Future research could examine ways in which the use of such structured procedures might allow for more spontaneous and complex communication in AAC interventions or whether a more qualitative and naturalistic approach is better suited to achieving this aim. This follows a recent finding that suggests discrete trial (structured behavioral) intervention is better suited to children with lower receptive language levels, while milieu (naturalistic) models appear to be more effective for children with higher levels of receptive language (Paul, Campbell, Gilbert, & Tsiouri, 2013).

    More generally, there may be several complicating factors to AAC intervention that might need to be considered with future cases. Specifically, successful adoption of AAC systems involves using a particular system/s (SGD, PE, MS) not only for expressing basic wants and needs when prompted to do so but also for spontaneous use of the system and for more complex and socially oriented communicative purposes. While intervention studies have demonstrated children with ASD can learn to use SGD, PE, and MS (Flippin et al., 2010; van der Meer & Rispoli, 2010; Wendt, 2009) for functional communication in structured environments, less empirical research has been undertaken to guide clinicians in facilitating self-initiated social communication (Drager et al., 2009). Drager and colleagues explained that there are two essen-tial components in AAC interventions to promote social communication for children with ASD: the AAC system itself and the AAC intervention/instructional techniques. AAC technologies alone will not allow for the development of social communication, they must be paired with appropriate intervention strategies to encourage spontaneous social communicative interactions.

    One reason for the dearth of empirical research in this field is that highly structured proce-dures are needed for data collection and to ensure experimental control, limiting the type, com-plexity, and spontaneity of communication skills targeted (van der Meer et al., 2013).

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    9 Access and Barriers to Care

    This clinical case study was carried out in New Zealand. By law, all children in New Zealand, regardless of their disability, are allowed access to public education. Children identified as high needs are provided with extra education funding to support their development and are required to have an individual education plan (IEP). The IEP commonly includes a number of related ser-vices, such as speech-language therapy. However, the speech-pathologist typically works within a consultancy model of practice by providing advice and guidance to the childs teachers, teach-ing assistants, and parents on how to implement the plan. Similarly, little direct intervention was being provided by a speech-language pathologist, which led to Ians identification as a suitable participant for a research project involving AAC intervention.

    Ethical approval from the relevant university committee and informed consent from Ians parents were gained before the intervention program was undertaken. Ians assent to participate was implied by his willingness to cooperate in the intervention. Ian always readily took part in the intervention sessions. The initial objective was to teach Ian to use three common forms of AAC (SGD, PE, and MS) and assess his preference for using one system over the others. Ian demonstrated a preference for using the iPad-based SGD and the intervention team decided that he would be motivated to continue communication intervention targeting more complex language with this AAC system only. His parents were consulted in the process and agreed that continued intervention with the iPad was the best option for Ian. This treatment, while home-based, was consistent with objectives in his IEP, where the school was starting to use iPads for academic activities.

    While students with severe communication impairment are usually provided with a SGD on the recommendation of speech-language pathologists, this can often be a lengthy and difficult process. Fortunately, an iPad Mini-based SGD was donated to Ian upon completion of the first follow-up of this case study. Ians parents, speech-language pathologist, teacher, and teaching assistants consulted with the intervention team to develop a communication plan using the iPad Mini to meet Ians on-going and increasing communication needs.

    10 Follow-Up

    Four follow-up sessions were conducted 10 weeks after the final session of the intervention phase. During the 10-week break, Ian did not have access to the iPad. The follow-up proce-dures were the same as those described for intervention, except that prompting (using the least amount of guidance necessary) was not given. As shown in Figure 1, Ians self-initiated requests for watching a DVD increased to 75%. He did not independently comment on aspects of the DVD (people, actions, emotions), but did respond correctly 75% to 88% of the time for these communicative categories. Incorrect responses did increase slightly (12% to 25%) from interven-tion for these communicative categories. Again, Ian did not communicate any greetings or other social etiquette using the iPad. Never the less, these follow-up data suggest good maintenance of the treatment effect for increasing the number of communicative interactions.

    Two long-term follow-up sessions were implemented one year after the first follow-up phase. During this year, Ian had been using the iPad Mini as his primary mode of communication. Procedures were identical to those outlined for the first follow-up. As indicated in Figure 1, Ians self-initiated requests for watching the DVD were 100% and self-initiated commenting about the people in the DVD, what they were doing, and how they were feeling increased to between 38% and 70%. He even independently initiated use of the GREETINGS AND ETIQUETTE category, although needed a verbal cue to then use the iPad for the greeting resulting in the voice-output: hello.

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    Anecdotally, Ians mother reported that since Ian received his own iPad Mini-based SGD, he began using it to initiate interactions for a range of communicative functions. For example, he will persist in using the iPad Mini to request to visit his caregiver by selecting an icon with the voice-output: Can I go to . . . house? He has even learned to use various social niceties, such as repeatedly using the iPad Mini to select an icon with the voice-output: please when his mother does not allow him to visit his caregiver.

    11 Treatment Implications of the Case

    The introduction of the iPad utilizing applications such as Proloquo2Go to serve as commu-nication systems with speech-output has offered many potential benefits to individuals with ASD who require AAC. Benefits include a device that is low cost, easy to obtain and transport, readily available, and socially acceptable (Shane et al., 2012). However, McNaughton and Light (2013) also highlight potential challenges in the adoption of these new technologies. Namely, the mere use of the technology itself is not enough to enhance the communicative interactions of individu-als with ASD. The focus must remain on appropriate assessment and intervention to support a wide variety of communicative functions. Furthermore, with research suggesting individuals with ASD may only focus their attention to stimuli, which are of interest and highly motivating to them (Casanova, 2007; Casanova, Buxhoeveden, & Brown, 2002; Geschwind, 2009), the intervention should generate opportunities for communication within preferred activities and using highly reinforcing items.

    Still, teaching more abstract and socially oriented communication skills may be too difficult for some children with ASD (as was the case with Hannah; van der Meer et al., 2013) and is typi-cally attributed to deficits in social interaction and social communication characteristic of ASD (Drager et al., 2009). However, it is also well documented in the AAC field that individuals require intensive intervention to learn a range of communicative functions (Beukelman & Mirenda, 2013). For cases such as Ian, structured intervention can be used to explicitly teach some social communicative functions. We propose that a combination of factors led to Ians com-municative competence: (a) using his preferred AAC system (iPad-based SGD) only, (b) creat-ing opportunities for communication within highly motivating activities (watching DVDs), (c) one-on-one intervention with behavioral procedures (prompts) to teach specific communicative functions, and (d) introduction of time delay before communication was prompted to allow for initiations. With such reductions to instructional control (Sigafoos, OReilly, Schlosser, & Lancioni, 2007) and as Ian became familiar with the new communicative functions, he indicated the ability to take part in these social communicative interchanges (e.g., commenting on who certain people in the DVDs were, what they were doing, and how they were feeling). Furthermore, after this initial structured behavioral intervention, long-term follow-up data suggest that inte-grating iPad use into everyday communication exchanges across contexts allowed for further development of spontaneous, creative, and socially oriented communication.

    12 Recommendations to Clinicians and Students

    A key issue for research and practice in designing effective communication interventions for individuals with ASD is the selection of an appropriate AAC system (Sigafoos, Drasgow, & Schlosser, 2003). Because there does not appear to be one single mode of AAC that is most read-ily taught to, and learned by, these children, we suggest that decisions regarding which AAC system to implement can be based upon an assessment of the individuals preferences for using one AAC system above the others. It is recognized that with heavy caseloads, a wide range of assessment considerations, and short timeframes for service delivery, clinicians often find it dif-ficult to assess client preferences (Ruggero, McCabe, Ballard, & Munro, 2012; Verdon, Wilson,

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    Smith-Tamaray, & McAllister, 2011). Results of our preference-enhanced communication inter-vention provide an efficient method for clinicians to assess choice and indicate that giving stu-dents the opportunity to select their most preferred AAC system positively influences progress in learning to communicate and maintain these newly acquired AAC skills (van der Meer, Didden, et al., 2012; van der Meer, Kagohara, et al., 2012; van der Meer et al., 2013; van der Meer, Sutherland, et al., 2012). Furthermore, we expect that by using the childs preferred AAC system there will be less chance of device abandonment at the conclusion of initial interventions, a com-mon issue in the field of AAC (Abbott, Brown, Evett, Standen, & Wright, 2011; Johnson, Inglebret, Jones, & Ray, 2006). However, if new technologies, such as the iPad-based SGD, are indicated as preferred by students, then parents, teachers, and clinicians need to gain confidence in programming and maintaining the hardware and software to meet each individuals increasing communication demands (McNaughton & Light, 2013).

    The present case study emphasizes the need for systematic selection of an appropriate AAC system based on the clients preference combined with appropriate use of intervention strategies to allow for the development of a range of communicative functions beyond expressing basic wants and needs. Results provide evidence to suggest that a structured behavioral intervention enabled Ian to learn to use an iPad-based SGD for specific communicative skills and as he developed an understanding of the meaning and purpose of these communicative interactions, they gradually became spontaneous and generalized to a wider range of communicative functions used within naturally occurring communicative exchanges.

    Declaration of Conflicting Interests

    The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

    Funding

    The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publi-cation of this article: Preparation of this chapter was supported by a grant from the New Zealand Government through the Marsden Fund Council, administered by the Royal Society of New Zealand; and by Victoria University of Wellington, The University of Canterbury, and The New Zealand Institute of Language, Brain & Behaviour.

    Notes

    1. Apple iPod/iPad/iPad Mini are a registered trademark of the Apple Corporation, Cupertino California, www.apple.com

    2. Proloquo2Go is a registered trademark of AssistiveWare B.V., Amsterdam, the Netherlands, www.assistiveware.com

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    Author Biographies

    Larah van der Meer, PhD, is a post-doctoral research fellow in the School of Educational Psychology at Victoria University of Wellington, New Zealand. Her research focuses on preference-enhanced communi-cation intervention for children with autism spectrum disorders.

    Jeff Sigafoos, PhD, is a professor in the School of Educational Psychology at Victoria University of Wellington, New Zealand. His research focuses on communication intervention for individuals with devel-opmental and physical disabilities.

    Dean Sutherland, PhD, is a senior lecturer in the School of Health Sciences at the University of Canterbury, New Zealand. His research focuses on communication, augmentative and alternative communication and children with autism spectrum disorder.

    Laurie McLay, PhD, is a lecturer in the School of Health Sciences at the University of Canterbury, New Zealand. Her research interests include evidence-based practice for children with developmental disabili-ties, applied behavior analysis, functional behavior assessment, and AAC.

    Russell Lang, PhD, BCBA-D, is an assistant professor in the Department of Curriculum and Instruction at Texas State University in San Marcos. He is the executive director of the Clinic for Autism Research

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    Evaluation and Support (CARES) where he conducts research on the treatment of challenging behavior in children with neurodevelopmental disabilities.

    Giulio E. Lancioni, PhD, is a professor in the Department of Neuroscience and Sense Organs, University of Bari, Italy. His research focuses on assistive technology interventions for individuals with multiple disabilities.

    Mark F. OReilly, PhD, is the Audrey Rogers Myers Centennial Professor in Education, College of Education and professor and chair of the Department of Special Education at The University of Texas at Austin. His research focuses on assessment and treatment of challenging behavior and use of assistive tech-nologies with individuals with severe disabilities.

    Peter B. Marschik, DPhil, PhD, DMsc, is an associate professor at the Institute of Physiology at Medical University of Graz, Austria. His interdisciplinary research focuses inter alia on typical and atypical speech-language and communicative development.

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