Naturalistic Developmental Behavioral Interventions for AUTISM SPECTRUM DISORDER Yvonne Bruinsma Mendy Minjarez Laura Schreibman Aubyn Stahmer --- FOR MORE, go to bit.ly/BruinsmaNBDI Naturalistic Developmental Behavioral Interventions for Autism Spectrum Disorder edited by Yvonne Bruinsma, Ph.D., BCBA-D In STEPPS and In STEPPS Academy Irvine, CA Mendy B. Minjarez, Ph.D. Seattle Children’s Hospital Autism Center and University of Washington School of Medicine Seattle, WA Laura Schreibman, Ph.D. Baltimore·London·Sydney University of California, San Diego La Jolla, CA and Aubyn C. Stahmer, Ph.D., BCBA-D --- PAUL H BROOKES PUBLISHING C Paul H. Brookes Publishing Co. Post Office Box 10624 Baltimore, Maryland 21285-0624 USA www.brookespublishing.com Copyright © 2020 by Paul H. Brookes Publishing Co., Inc. All rights reserved. “Paul H. Brookes Publishing Co.” is a registered trademark of Paul H. Brookes Publishing Co., Inc. Typeset by Absolute Service, Inc., Towson, Maryland. Manufactured in the United States of America by Sheridan Books, Inc., Chelsea, Michigan. The information provided in this book is in no way meant to substitute for a medical or mental health practitioner’s advice or expert opinion. Readers should consult a health or mental health The individuals described in this book are composites or real people whose situations are masked and are based on the authors’ experiences. In all instances, names and identifying details have been changed to protect confidentiality. Purchasers of Naturalistic Developmental Behavioral Interventions for Autism Spectrum Disorder are granted permission to download, print, and photocopy the forms in the text for clinical and educational purposes. Faculty may download, print, and photocopy the sample syllabi, test bank, and PowerPoint slides for educational use. These materials are available at http://downloads.brookes publishing.com. The forms, sample syllabi, test bank, and PowerPoint slides may not be reproduced to generate revenue for any program or individual. Photocopies may only be made from an original book. Unauthorized use beyond this privilege may be prosecutable under federal law. You will see the copyright protection notice at the bottom of each photocopiable page. copyright protection notice at the bottom of each photocopiable page. Classification: LCC RJ506.A9 (ebook) | LCC RJ506.A9 N38 2019 (print) | DDC 618.92/85882—dc23 Library of Congress Cataloging-in-Publication Data Names: Bruinsma, Yvonne, editor. Title: Naturalistic developmental behavioral interventions for autism spectrum disorder / edited by Yvonne Bruinsma, Ph.D., BCBA-D, In STEPPS Academy, Irvine, CA, Mendy B. Minjarez, Ph.D., Seattle Children’s Hospital Autism Center and spectrum disorder / edited by Yvonne Bruinsma, Ph.D., BCBA-D, In STEPPS Academy, Irvine, CA, Mendy B. Minjarez, Ph.D., Seattle Children’s Hospital Autism Center and University of Washington School of Medicine, Seattle, WA, Laura Schreibman, Ph.D., University of California, San Diego, CA, and Aubyn C. Stahmer, Ph.D., University of California, Davis MIND Subjects: LCSH: Autistic children—Behavior modification. | Autistic children—Education. | BISAC: EDUCATION / Special Education / Mental Disabilities. | EDUCATION / Special Education / Social Disabilities. University of Washington School of Medicine, Seattle, WA, Laura Schreibman, Ph.D., University of California, San Diego, CA, and Aubyn C. Stahmer, Ph.D., University of California, Davis MIND Institute, Sacramento, CA. Description: Baltimore, Maryland: Paul H. Brookes Publishing Co., [2020] | Includes bibliographical references and index. 2023 2022 2021 2020 2019 10 9 8 7 6 5 4 3 2 1 --- Job Name_--**_424760t** FOR MORE, go to bit.ly/BruinsmaNBDI # Contents About the Editors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix About the Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xxiii About the Online Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxv ## SECTION I Overview **Chapter 1 Understanding NDBI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3** *Laura Schreibman, Allison B. Jobin, and* *Geraldine Dawson* ASD Defined . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 History of ASD Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Developmental Science and Its Influence in ASD Early Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Integration of Behavioral and Developmental Sciences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Examples of NDBI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Common Elements of Empirically Validated NDBI . . . . . . . . . . . . . .10 **Chapter 2 Considering NDBI Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21** *Mendy B. Minjarez, Yvonne Bruinsma, and* *Aubyn C. Stahmer* Early Start Denver Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21 Enhanced Milieu Teaching . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Incidental Teaching/Walden Toddler Program . . . . . . . . . . . . . . . . . 25 Joint Attention, Symbolic Play, Engagement, and Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Pivotal Response Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Project ImPACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 iii Excerpted from: Naturalistic Developmental Behavioral Interventions in the Treatment of Children of Autism Spectrum Disorder Edited by: Yvonne E.M. Bruinsma Ph.D., BCBA-D, Mendy B. Minjarez, Laura Schreibman Ph.D., Aubyn C. Stahmer Ph.D., In order to view this proof accurately, the Overprint Preview Option must be set to Always in Acrobat Professional or Adobe Reader. Please contact your Customer Service Representative if you have questions about finding this option. --- FOR MORE, go to bit.ly/BruinsmaNBDI Contents iv FOR MORE, go to bit.ly/BruinsmaNBDI iv Contents SECTION II Core Concepts and Foundational Principles Chapter 3 Selecting Meaningful Skills for Teaching in the Natural Environment . . . . . . . . . . . . . . . . . . . . . . . 45 Grace W. Gengoux, Erin McNerney, and Mendy B. Minjarez Goodness of Fit of NDBI Approaches . . . . . . . . . . . . . . . . . . . . . . . . . 46 Functional Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 The Natural Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Case Example: Jin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Chapter 4 Empowering Parents Through Parent Training and Coaching . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Mendy B. Minjarez, Elizabeth A. Karp, Aubyn C. Stahmer, and Lauren Brookman-Frazee Parent-Mediated Interventions and NDBI . . . . . . . . . . . . . . . . . . . . . 77 Psychological Functioning in Parents of Children With ASD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Effective Parent Coaching Practices . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Case Example: Gabe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91 Chapter 5 Fostering Inclusion With Peers and in the Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Aubyn C. Stahmer, Connie Wong, Matthew J. Segall, and Jennifer Reinehr The Importance of Inclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Inclusion in Practice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .100 Use of NDBI in Inclusive Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . .102 Practical Suggestions for Incorporating NDBI Strategies Into Community Programs . . . . . . . . . . . . . . . . . . .106 Common Challenges to Inclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . .111 Case Example: Preschool Program . . . . . . . . . . . . . . . . . . . . . . . . . . .112 Case Example: Adult Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 SECTION III NDBI Strategies Chapter 6 Implementing Motivational Strategies . . . . . . . . . . . . . . . . . . . . . 123 Mendy B. Minjarez and Yvonne Bruinsma NDBI and Motivation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .124 Measuring Motivation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 Strategies That Enhance Motivation . . . . . . . . . . . . . . . . . . . . . . . . . .126 Chapter 7 Applying Antecedent Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 Jennifer B. Symon, Yvonne Bruinsma, and Erin McNerney Preparing to Teach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .153 --- Job Name_--**_424760t** FOR MORE, go to bit.ly/BruinsmaNBDI Contents v ## Chapter 8 Implementing Instructional Cues and **Prompting Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175** *Kyle M. Frost, Brooke Ingersoll,* *Yvonne Bruinsma, and Mendy B. Minjarez* Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .175 Learning Opportunities Across NDBI Models . . . . . . . . . . . . . . . . .177 Prompting Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .182 Prompt Fading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .187 Examples of Prompts for Specific Skills . . . . . . . . . . . . . . . . . . . . . . .187 Case Example: Leah . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .190 **Chapter 9 Using Consequence Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193** *Allison B. Jobin and Laura Schreibman* Increasing the Strength of a Behavior . . . . . . . . . . . . . . . . . . . . . . . .194 Decreasing the Strength of a Behavior . . . . . . . . . . . . . . . . . . . . . . . .195 Applying the Premack Principle . . . . . . . . . . . . . . . . . . . . . . . . . . . . .196 Promoting Consequence Effectiveness . . . . . . . . . . . . . . . . . . . . . . .196 Using Consequences to Maintain Behavior Change . . . . . . . . . . . .199 Shaping and Chaining . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .201 Using Natural Consequences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202 Reinforcing Attempts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205 Modeling and Expanding on Child’s Response . . . . . . . . . . . . . . . 205 Imitating the Child’s Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206 Troubleshooting NDBI Consequence Strategies . . . . . . . . . . . . . . . 206 **Chapter 10 Guiding Meaningful Goal Development . . . . . . . . . . . . . . . . . . . 213** *Grace W. Gengoux, Erin E. Soares, and* *Yvonne Bruinsma* Formulating Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .214 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .218 Case Example: José. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .221 Considerations for Goal Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . 224 Case Example: Jenna . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226 Case Example: Kaleb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227 Case Example: Ashir . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227 Developmental Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228 Case Example: Alex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229 Case Example: Cole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229 Case Example: Josephine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230 Case Example: Marco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230 --- vi Contents FOR MORE, go to bit.ly/BruinsmaNBDI vi Contents SECTION IV Applications of NDBI Strategies Chapter 11 Targeting Communication Skills . . . . . . . . . . . . . . . . . . . . . . . . . . 237 Mendy B. Minjarez, Rachel K. Earl, Yvonne Bruinsma, and Amy L. Donaldson Communication Profile of Children With ASD . . . . . . . . . . . . . . . .237 Communication Development in Typically Developing Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238 Use of NDBI for Targeting Communication . . . . . . . . . . . . . . . . . . .240 Teaching Communication Across Developmental Levels Using NDBI Strategies . . . . . . . . . . . . . . . . .249 Chapter 12 Improving Social Skills and Play . . . . . . . . . . . . . . . . . . . . . . . . . . 277 Yvonne Bruinsma and Grace W. Gengoux Social Initiations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .278 Imitation Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284 Play . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286 Teaching Play With Friends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .297 Chapter 13 Supporting Behavior, Self-Regulation, and Adaptive Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309 Mendy B. Minjarez, Yvonne Bruinsma, and Rosy Matos Bucio NDBI and Challenging Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . .310 Relevant Applied Behavior Analysis Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .311 NDBI Strategies for Teaching Self-Regulation and Adaptive Skills . . . . . . . . . . . . . . . . . . . . . . . . . 322 Promoting Self-Regulation in Individuals With ASD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .326 Teaching Adaptive Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .332 Tips for Teaching Self-Regulation and Adaptive Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339 Case Example: Jonas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341 Chapter 14 Implementing NDBI in Schools . . . . . . . . . . . . . . . . . . . . . . . . . . . 347 Aubyn C. Stahmer, Jessica Suhrheinrich, and Laura J. Hall Including NDBI Components in Group or Academic Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 348 Excerpted from: Naturalistic Developmental Behavioral Interventions in the Treatment of Children of Autism Spectrum Disorder Edited by: Yvonne E.M. Bruinsma Ph.D., BCBA-D, Mendy B. Minjarez, Laura Schreibman Ph.D., Aubyn C. Stahmer Ph.D. --- Job Name_--**_424760t** FOR MORE, go to bit.ly/BruinsmaNBDI Contents vii **Chapter 15 Collecting Data in NDBI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361** *Mendy B. Minjarez, Melina Melgarejo,* *and Yvonne Bruinsma* General Framework for Data Collection . . . . . . . . . . . . . . . . . . . . . .362 Data Collection Across NDBI Models. . . . . . . . . . . . . . . . . . . . . . . . 363 When and Why Data Are Collected . . . . . . . . . . . . . . . . . . . . . . . . . .369 Types of Data and Measurement Systems . . . . . . . . . . . . . . . . . . . . .375 Data Collection in the Natural Environment . . . . . . . . . . . . . . . . . 383 ## Chapter 16 Identifying Quality Indicators of **NDBI Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391** *Aubyn C. Stahmer, Sarah R. Rieth, Brooke Ingersoll,* *Yvonne Bruinsma, and Aritz Aranbarri* Quality Indicators Versus Common Features . . . . . . . . . . . . . . . . . .391 Specific Program Elements to Look for in a Quality NDBI Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .391 **Chapter 17 Considering Future Directions in NDBI . . . . . . . . . . . . . . . . . . . . 407** *Laura Schreibman, Mendy B. Minjarez,* *and Yvonne Bruinsma* Research Future Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 408 Dissemination and Implementation: Future Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .410 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .415 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423 --- About the Editors Yvonne Bruinsma, Ph.D., BCBA-D, In STEPPS and In STEPPS Academy, Irvine, CA. Dr. Bruinsma is CEO and founder of In STEPPS and In STEPPS Academy, a behavioral health agency and a nonprofit private school for children with autism in California. She is a Board Certified Behavior Analyst and received her doctorate in special education, developmental disabilities, and risk studies in 2004. She has been working with families and teaching others how to work with families by over 20 years. Yvonne’s focus is to blend research and reality in the highest quality treatment in a community setting. Mendy B. Minjarez, Ph.D., Seattle Children’s Hospital Autism Center and University of Washington School of Medicine, Seattle, WA. Dr. Minjarez is a licensed psychologist with a background in Applied Behavior Analysis and NDBI. She is an assistant professor in psychiatry and behavioral sciences at the University of Washington, the Clinical Director of the Seattle Children’s Hospital Autism Center, and the Program Director of the Applied Behavior Analysis Early Intervention Program at Seattle Children’s Hospital Autism Center. Dr. Minjarez’s clinical work is focused on diagnosis and treatment of autism spectrum disorder, with a particular interest in NDBI, parent training, and early childhood. Her research is focused on dissemination of parent-mediated NDBI, particularly through innovative models, such as group parent training. Laura Schreibman, Ph.D., Department of Psychology, University of California, San Diego, La Jolla, CA. Dr. Schreibman served as Director and Principal Investigator of the Autism Intervention Research Program at the University of California at San Diego from 1984 until 2012. She is Distinguished Professor Emeritus of Psychology and Research Professor at the University of California, San Diego. Her most recent research interests have focused on the development and dissemination of NDBI strategies, the development of individualized treatment protocols, translation of empirically based treatments into community settings, analysis of language and attentional deficits, generalization of behavior change, parent training, and ix --- FOR MORE, go to bit.ly/BruinsmaNBDI About the Editors FOR MORE, go to bit.ly/BruinsmaNBDI x About the Editors Aubyn C. Stahmer, Ph.D., BCBA-D, University of California, Davis MIND Institute, Sacramento, CA. Dr. Stahmer has been using and studying NDBI strategies with children with autism spectrum disorder and their families in research and community settings for 30 years. She is an expert in the translation of evidencebased autism research to community-based practice and delivery. The main goals of her research include developing ways to help community providers, such as teachers and therapists, and helping children with autism and their families by --- About the Contributors Aritz Aranbarri, Ph.D., The MIND Institute, University of California (UC) Davis Medical Center, Sacramento, CA. Dr. Aranbarri is a clinical licensed psychologist specialized as a developmental neuropsychologist (Early Start Denver Model certified therapist) and holds a Ph.D. in environmental epidemiology and early neurodevelopment. He received postdoctoral training in Autism Early Intervention Community Research at the UC Davis MIND Institute mentored by Dr. Aubyn C. Stahmer and now coordinates autism research at the SJD Barcelona Children’s Hospital. Lauren Brookman-Frazee, Ph.D., San Diego Department of Psychiatry, University of California, La Jolla, CA. Dr. Brookman-Frazee is Professor of Psychiatry at the University of California, San Diego, Associate Director of the Child and Adolescent Services Research Center, and Research Director at the Autism Discovery Institute at Rady Children’s Hospital–San Diego. She specializes in parent-mediated interventions for children with autism spectrum disorder (ASD) and other developmental and mental health problems. Dr. Brookman-Frazee’s research involves partnering with mental health and education system leaders, providers, and families to develop, test, and implement evidence-based interventions in community and school-based settings. Geraldine Dawson, Ph.D., Departments of Psychiatry and Behavioral Sciences, Pediatrics, and Psychology & Neuroscience, Duke University, Durham, NC. Dr. Dawson is Professor in the Departments of Psychiatry and Behavioral Sciences, Pediatrics, and Psychology & Neuroscience at Duke University. She is Past-President of the International Society for Autism Research and a member of the Interagency Autism Coordinating Committee. She is Director of the Duke Center for Autism and Brain Development, an interdisciplinary autism research and treatment center, and Chair of the Faculty Governance Committee for the Duke Institute for Brain Sciences. Dr. Dawson is Director of a National Institutes of Health Autism Center of Excellence Award at Duke focused on understanding early detection, neural bases, and treatment of autism and attention-deficit/hyperactivity disorder. Dr. Dawson has published extensively on early detection, brain function, and treatment of autism. With Sally Rogers, she developed the Early Start Denver Model, a comprehensive early behavioral intervention for young children with autism. She completed a Ph.D. in --- Job Name_--_424760t FOR MORE, go to bit.ly/BruinsmaNBDI xii About the Contributors Amy L. Donaldson, Ph.D., CCC-SLP, Department of Speech and Hearing Sciences, Portland State University, Portland, OR. Dr. Donaldson is an associate professor in the Department of Speech & Hearing Sciences at Portland State University. Her research focuses broadly on social-communication and perception of social competence in individuals on the autism spectrum and neurotypical individuals. Dr. Donaldson examines intervention efficacy, pre- and postprofessional development, the influence of context on performance, and the experiences of neurodivergent individuals in different contexts. Rachel K. Earl, Ph.D., Seattle Children’s Hospital, Seattle, WA. Dr. Earl earned her Ph.D. in school psychology at the University of Washington. She is currently a postdoctoral fellow at Seattle Children’s Hospital–Autism Center, specializing in diagnosis and treatment of ASD. Kyle M. Frost, M.A., Department of Psychology, Michigan State University (MSU), East Lansing, MI. Mrs. Frost is a doctoral candidate in clinical psychology at MSU and a member of the MSU Autism Research Lab. Her research focuses on measuring intervention response and implementation, as well as understanding the common elements of Naturalistic Developmental Behavioral Interventions (NDBI). Erin E. Soares, B.S., Palo Alto University, Palo Alto, CA. Ms. Soares is a third-year Ph.D. student at Palo Alto University (PAU) in the clinical psychology program, with an emphasis in child and family studies. Prior to attending PAU, Ms. Soares graduated from Santa Clara University with a B.S. in psychology and child studies. Grace W. Gengoux, Ph.D., BCBA-D, Division of Child and Adolescent Psychiatry, Department of Psychiatry, Stanford University School of Medicine, Stanford, CA. Dr. Gengoux is a clinical psychologist and Board Certified Behavior Analyst who directs the Autism Intervention Program within the Stanford Autism Center at Lucile Packard Children’s Hospital. Dr. Gengoux received her Ph.D. in Clinical Psychology from the University of California Santa Barbara and completed her clinical internship and postdoctoral fellowship at the Yale Child Study Center. Her research specifically focuses on the development and evaluation of NDBI for young children with ASD. Dr. Gengoux’s previous publications have focused on models for enhancing functional communication and social development and for providing effective parent training. Laura J. Hall, Ph.D., Department of Special Education, San Diego State University, San Diego, CA. Dr. Hall is Professor and Chair of Special Education at San Diego State University. She has been working with individuals with ASD and their families for over 35 years. The focus of her research and teaching has been on the transfer of research into practice, or facilitating the implementation of evidencebased practices by supporting educators and paraeducators. She is the author of the widely used textbook, Autism Spectrum Disorders: From Theory to Practice (2009, Pearson). --- FOR MORE, go to bit.ly/BruinsmaNBDI About the Contributors Brooke Ingersoll, Ph.D., BCBA-D, Michigan State University (MSU), East Lansing, MI. Dr. Ingersoll is an associate professor of clinical psychology at MSU, where she is the director of the MSU Autism Research Lab. She is also a licensed psychologist and Board Certified Behavior Analyst. Dr. Ingersoll’s research focuses on the development, evaluation, and dissemination of social-communication interventions for individuals with ASD. She has published multiple peer-reviewed journal articles and book chapters on ASD and is the coauthor of Teaching Social Communication to Children with Autism (with A. Dvortcsak; 2010, Guilford Press), an NDBI parent training curriculum for children with ASD. Allison B. Jobin, Ph.D., BCBA-D, Child and Adolescent Services Research Center, Department of Psychiatry, University of California, San Diego, Rady Children’s Hospital San Diego, San Diego, CA. Dr. Jobin is a licensed clinical psychologist and Board Certified Behavior Analyst at the Autism Discovery Institute of Rady Children’s Hospital San Diego and study manager in the Department of Psychiatry of the University of California, San Diego, and Child and Adolescent Services Research Center. Dr. Jobin has over 15 years of experience in the delivery, supervision, and evaluation of evidence-based interventions for children with ASD and their families. She specializes in parent-mediated treatment models and NDBI. Her re- search focus includes evaluating and improving treatment for children with ASD, as well as methods for effective implementation in community settings. Elizabeth A. Karp, M.S., Department of Psychology, University of Washington, Seattle, WA. Ms. Karp is a doctoral candidate in child psychology at the University of Washington. She is passionate about identifying ways to provide family-centered care for families with a child with ASD. She is particularly interested in caregivers’ experiences as they implement interventions with their young children. Rosy Matos Bucio, Ph.D., BCBA-D, Santa Barbara SELPA, Santa Barbara, CA. Dr. Matos Bucio is a Board Certified Behavior Analyst who completed her doctoral training in 2005 at the University of California, Santa Barbara. For over 20 years, her research and professional practice has focused on using the motivational strat- rently provides psychological assessment and therapy to support the mental health needs of individuals with ASD and their families. egies of NDBI to support individuals with ASD across the life span and disseminate best practices to families and professionals. Erin McNerney, Ph.D., BCBA-D, In STEPPS and McNerney & Associates, Irvine, CA. Dr. McNerney is a licensed clinical psychologist and Board Certified Behavior Analyst Doctoral specializing in ASD, developmental disabilities, and behavior challenges. She has spent the past 2 decades teaching and implementing Pivotal Response Treatment (PRT) and providing behavior-based parent training. She cur- Excerpted from: Naturalistic Developmental Behavioral Interventions in the Treatment of Children of Autism Spectrum Disorder Edited by: Yvonne E.M. Bruinsma Ph.D., BCBA-D, Mendy B. Minjarez, Laura Schreibman Ph D, Aubyn C. Stahmer Ph D xiv FOR MORE, go to bit.ly/BruinsmaNBDI xiv About the Contributors and risk studies from the University of California, Santa Barbara. She is a postdoctoral scholar at San Diego State University and the Child and Adolescent Services Research Center. She is currently involved in research on the multi-level factors affecting the use of evidence-based practices for children with ASD within schools. Jennifer Reinehr, Psy.D., TEACCH Center, University of North Carolina at Chapel Hill, Chapel Hill, NC. Dr. Reinehr is a clinical assistant professor and staff psychologist at the TEACCH Center with the University of North Carolina at Chapel Hill. She is specialized in diagnostic and developmental assessment of young children with ASD. For over 10 years, she has provided clinical oversight for an integrated preschool program for young children with and without ASD. Dr. Reinehr continues to work toward practical application of evidence-based practices in an individual’s natural settings. Sarah R. Rieth, Ph.D., BCBA-D, Child and Adolescent Services Research Center, Department of Child and Family Development, San Diego State University, San Diego, CA. Dr. Rieth is Assistant Professor of Child and Family Development at San Diego State University and an investigator at the Child and Adolescent Services Research Center. She received her Ph.D. from the Psychology Department at UCSD in 2012. Her research focuses on intervention for children with ASD and their families and the delivery of high-quality intervention in community settings. Dr. Rieth is a licensed clinical psychologist and specializes in training others and delivering intervention for children with ASD, ages 12 months to 10 years. Her current work involves training community providers to deliver parent-mediated interventions and examining student outcomes from community-based trials of evidence-based treatment models. Matthew J. Segall, Ph.D., Emory Autism Center, Emory University School of Medicine, Atlanta, GA. Dr. Segall is Program Director for Education and Transition Services at the Emory Autism Center, as well as Assistant Professor of Psychiatry and Behavioral Sciences in the Emory University School of Medicine. He is a licensed psychologist in the State of Georgia. Dr. Segall completed his bachelor’s degree in psychology at the University of Virginia and his doctoral degree in school psychology at the University of Georgia. His predoctoral internship and postdoctoral fellowship were both completed at the Emory Autism Center, while also completing a fellowship at Georgia State University in the Georgia LEND (Leadership Education in Neurodevelopmental Disabilities) program. Dr. Segall’s professional --- FOR MORE, go to bit.ly/BruinsmaNBDI About the Contributors Jennifer B. Symon, Ph.D., BCBA, Special Education and Counseling, California State University Los Angeles, Los Angeles, CA. Dr. Symon is a professor in the Division of Special Education and Counseling at California State University, Los Angeles. She coordinates the programs in ASD and is a Board Certified Behavior Analyst. Her research interests include interventions for parents, teachers, paraprofessionals, and peers who support students with ASD. Connie Wong, Ph.D., Frank Porter Graham Child Development Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC. Dr. Wong is a research scientist at the Frank Porter Graham Development Institute at the University of North Carolina at Chapel Hill and Adjunct Professor in Early Intervention and Early Childhood Special Education at California State University, Los Angeles. Her --- Foreword The outcomes of children with autism spectrum disorder (ASD) may be about to change radically for the better in the next decade. If so, a world of promise, rather than a world of challenges, may open to the approximately 66,000 children who are born every year in the United States alone who will have autism. This possibility is than a world of challenges, may open to the approximately 66,000 children who are born every year in the United States alone who will have autism. This possibility is within the grasp of this coming generation of autism investigators and clinicians to attain, in deep collaboration with parents and community providers. Yet, if we are to succeed in optimizing developmental potential and quality of life of the next generations of children with ASD, three priority goals need to be achieved. We need to identify ASD early; we need to translate early detection into access to evidence-based, effective early treatments; and we need to provide ongo- achieved. We need to identify ASD early; we need to translate early detection into access to evidence-based, effective early treatments; and we need to provide ongoing high-quality supports and solutions to children and families affected by ASD. The challenges in these domains are considerable but not insurmountable. Why is early detection critical? By the time we celebrate a baby’s first birthday, his or her brain has doubled, and synaptic density has quadrupled. Brain maturation guides a baby’s experiences, which in turn deeply influences brain organization and continued specialization. By the end of their second year of life, babies have undergone their period of maximal lifetime neuroplasticity. By 18–24 months, there may be an emergence of autism symptoms, making possible reliable diagnosis by expert clinicians. For treatment to have optimal benefits, there is a need to capitalize on this early brain malleability, before speech-language and communication development is severely derailed and problem behaviors become entrenched. Yet, the median age of autism diagnosis has not changed in consecutive cohorts followed by Centers for Disease Control and Prevention surveillance efforts. Fifty percent of children with autism are diagnosed after the age of 4–5 years, and children from underserved populations—minorities, low income, rural—are diag- believe that populationwide surveillance programs can effectively deploy universal screening for ASD and related developmental delays and that the screening process can be made actionable via increased access to diagnostic services. The promise of early detection can only be delivered if screening programs are shown to increase access to effective early intervention services. Most stud- ies of early treatment in autism have shown major benefits in learning and language acquisition. Yet, it is likely that the potential benefits of early treatment have xvii --- FOR MORE, go to bit.ly/BruinsmaNBDI xviii Foreword FOR MORE, go to bit.ly/BruinsmaNBDI xviii Foreword been grossly underestimated. One reason may be the fact that most investigations have focused on children age 3 years old and older; another reason may be the fact that most studies have reported on relatively small studies conducted by research groups rather than on population trends resulting from federally mandated birth-to-3 services. More studies are needed of early treatment involving toddlers if we are to take neuroplasticity seriously, and more “big data” studies of state-by-state indicators of service access and outcomes are needed if we are to judge the populationwide effects of the Program for Infants and Toddlers with Disabilities (Part C) of the Individuals with Disabilities Education Act (IDEA), and of the now 11-year-old recommendations of the American Academy of Pediatrics. The promise is clear: Optimize development and learning potential by age 3 years, and the child’s lifetime prospects are likely to change dramatically; make highquality early treatment accessible, and the longtime, financial equation burdens are alleviated for individual families and for the entire health care and education systems. Yet, a large number of children with ASD receiving special education in their school years have not benefited from early treatment, and some who receive easily identified, studied, and promoted. This book is a victory of common sense: a consensual framework that will serve as the basis for improvements of treatment efficacy, effectiveness, and community uptake in what is now the highest priority, with potentially the highest gains in the field. Why is the provision of supports and solutions to children and families affected by ASD so critical? Although early detection and intervention promise life-changing opportunities for the next generations of children with autism, those affected by ASD now cannot wait. Families, community providers, and schools can deploy treatments that work in fostering communication and adaptive skills and that decrease the risk of problem behavior. Communication skills facilitate meaningful inclusion and make possible friendships and other relationships, as well as a world of vocational opportunities. Adaptive skills promote independence, self-reliance, and self-determination. The management of challenging behavior decreases the risk of isolation, enhances quality of life, and makes it possible for --- Foreword FOR MORE, go to bit.ly/BruinsmaNBDI Foreword xix through the struggles of the day; providers are often overwhelmed at the very sight of the plethora of titles sitting on their book shelves that do not necessarily translate into a concrete plan and approach for their day of therapy and teaching. How are we to distill from this chaotic state the straightforward principles of treatment and supports that work, the roadmap to generate learning that generalizes, and the we to distill from this chaotic state the straightforward principles of treatment and supports that work, the roadmap to generate learning that generalizes, and the strategies to promote communication skills that are self-driven and effective across environments? The solution, again, is in your hands. This book describes ways to leverage children’s daily lives as the stage for their learning. Teach skills in isolation, and the road from skill acquisition to spontaneous skill deployment is a much longer and winding road. The importance of developmental considerations is extended to all ages: Not only are the children with ASD growing up, but so are their peers. And with the passage of developmental stages comes the unfolding of increasingly more challenging environmental demands. Remove therapy and supports from the developmental context in which they need to work, and one may witness further isolation, prompt dependency, and reduced adaptation. Similarly, the reader will learn about environmental controls and reinforcement management techniques that foster habit formation, accelerate skill learning, and promote self-motivation and self-regulation. Fail to consider that, and you may find yourself struggling with continued disruption, lack of engagement, despondency, and heightened anx- and self-regulation. Fail to consider that, and you may find yourself struggling with continued disruption, lack of engagement, despondency, and heightened anxiety. These are principles of treatment and intervention that should guide our work with children of all ages, from infancy through adolescence and beyond. How does this book achieve the sorely needed synthesis? First and foremost, it represents the culmination of some 50 years of science in early treatment of autism, a process that has greatly accelerated in the past 10 years. Facts matter, and science has produced a great body of evidence justifying the integrative approach taken by the authors. In this approach, there is great respect for a clinical principle, enshrined in the language of educational law, that treatments and intervention programs should be individualized to a child’s profile, addressing the child’s needs while capitalizing on the child’s assets. This principle unravels many of the ideological debates. A treatment devised to promote communication skill acquisition in a nonverbal 6-year-old at risk of never speaking is unlikely to be beneficial in the case of a 2-year-old who vocalizes and shows intent to communicate with others, albeit inconsistently, and vice versa. There is no need to train a child to display a complex behavior by chaining discrete and disconnected behaviors if the child has the ability to learn how to learn in more naturalistic settings. In this way, generalization ity to learn how to learn in more naturalistic settings. In this way, generalization challenges are reduced; prompts and consequences are inherent in the real world; and pivotal skills generate more learning, in more settings, and in more contexts. The authors also leverage behavioral science in ways that do not turn it into a stereotype. The science of Applied Behavior Analysis (ABA) has generated some of the most critical advances in the care of individuals with developmental disabilities. Anyone who has worked in a residential facility for individuals with severe disabilities is quick to appreciate this fact. But ABA is not synonymous to narrow applications that may have its place for some children but not for others. ABA is a vast body of science that painstakingly assesses and changes human behavior. At its core is learning theory with its focus on an individual’s behavior acquisition --- XX Foreword FOR MORE, go to bit.ly/BruinsmaNBDI xx Foreword surroundings. Making these connections is central to the acquisition of speech, language, and communication. We fail to follow ABA principles at our peril; indeed, surroundings. Making these connections is central to the acquisition of speech, language, and communication. We fail to follow ABA principles at our peril; indeed, we are all behaviorists in real life, but unfortunately most of us are bad behaviorists, often pre-empting the very result we seek to achieve. By advancing individualized, naturalistic approaches and the basic scientific tenets of learning theory, there should be no surprise that the individual child, his or her style of learning, and his or her perceived environment take center stage in any effective program of treatment and intervention. In between an antecedent and a response, there is a single child with a specific age and stage of development, assets and needs, emotional state, capacity for self-regulation, motivations, social relatedness, interests, fears, and personalized environment. For too long, learning theorists proceeded in their scientific endeavors by pretending to ignore a child’s individualized agency: The brain is no black box! Similarly, for too long, developmental scientists proceeded in their scientific endeavors by focusing on sweeping generalities that were not easily translatable into manualized treatments capable of singling out active ingredients and of achieving greater fidelity. Why these two currents of human ideas forged parallel paths for so many decades is as infuriating as it is counterproductive to any evidence-based synthesis of effective treatment for young vulnerable children. Thankfully, the authors of this book leave this anachronistic notion behind us all. The behaviorists versus developmentalist confronta- young vulnerable children. Thankfully, the authors of this book leave this anachronistic notion behind us all. The behaviorists versus developmentalist confrontation should be relegated to the history of the field, thus erased and eradicated from its future science and its future scientists. By moving the nonsensical aside, and by leveraging the best science from within, this book generates a consensual synthesis, whose name includes the very words that generated this unsatisfactory state of artificial conflagration in our past: Naturalistic Developmental Behavioral Interventions. The very name is our best words that generated this unsatisfactory state of artificial conflagration in our past: Naturalistic Developmental Behavioral Interventions. The very name is our best assurance that research on early treatments will continue to thrive on healthy scientific grounds. This book is more than a compilation of evidence-based treatment principles; it is also a recipe for viability and for increased access. In an early intervention world of scarce resources, to state that a 40-hour regimen of treatment delivered by an expert clinician is aspired standard of care, as we have learned to believe over the past 2 decades, is a recipe for frustration. With few exceptions in the country, most states, where maybe 1–2 hours a week is the reality of treatment, need more viable solutions. Children need to access effective services when they need them and where they are. For that to happen, a number of stakeholders need to be involved. It is the responsibility of investigators and clinicians to use the best implementation science to generate innovations that can be deployed in the real world, advancing quality as well as accessibility. Parents need to be engaged in the most important role in their lives: to promote the development of their children. Parent-mediated interventions are emerging as both viable and effective: Professional interventionists can use their limited availability to train parents to turn every waking moment of the child’s life into a learning moment, using routine daily activities as naturalistic platforms for treatment, with the intensity and emotional engagement needed to achieve lasting results. Similarly, generalist child development providers and teachers can promote similar principles in group settings. In this fashion, a new --- FOR MORE, go to bit.ly/BruinsmaNBDI Foreword FOR MORE, go to bit.ly/BruinsmaNBDI Foreword xxi Most important, the involvement of parents and child care providers allows treatments to be downward extended into toddlerhood and maybe even infancy: There is no reason to wait until a diagnosis is attained to turn surveillance and parent education into strategies that promote development—of all children. All vulnerable children, and certainly those with autism, are likely to benefit from a robust dosage of facilitation of social and communication engagement. This is already the approach taken by those trying to counter the effects of intergenerational poverty on a child’s language acquisition. And therein lies one of the greatest promises in the field: the beneficial effects of child development surveillance and parental engagement on the outcomes of all children. Perhaps if we were to deploy these generalist strategies systemically in a communitywide fashion, chil- deploy these generalist strategies systemically in a communitywide fashion, children would reach the age of more individualized and intensive treatments at a much higher level of readiness to learn. These may seem like lofty aspirations. Yet, after the publication of this book, we, as a field, are closer to these goals than ever before. The authors have made a terrific contribution in our effort to ensure that every child with ASD is afforded what they need in order to fulfill their promise. Ami Klin, Ph.D. --- xxiv Acknowledgments FOR MORE, go to bit.ly/BruinsmaNBDI xxiv Acknowledgments I would like to acknowledge those who have supported me and my career personally, and those who have made this work possible through their contributions to the field. Personally, I could not have asked for a better colleague, coauthor, and friend than Yvonne Bruinsma. I am also grateful to my mentors and colleagues for the knowledge and opportunities they have provided, including Marji Charlop, Ami Klin, Bob and Lynn Koegel, Tara O’Connor, Bryan King, and Maddie Parsons. The body of work that has preceded the NDBI framework must be fully acknowledged because it is the foundation for the content of this book, which we believe will propel the field forward. I have also learned so much from the children and families that I work with, which I anticipate will continue lifelong; however, my greatest teachers are my own children, who have taught me that life is messy and hard but full of humor and joy, which I hope carries over to the rest of my career Mendy B. Minjarez, Ph.D. Over many years, I have had the good fortune to work with amazing students, colleagues, researchers, teachers, and community members of all kinds. Most important, I have had the good fortune to work with wonderful children and families who have taught me so much and have showed me the real power of what we do and what we can accomplish. I want to acknowledge the efforts of all these people who have worked so hard at getting us to where we are today. I see the develop- ment of NDBI as the fruit of these efforts. Laura Schreibman, Ph.D. Many people have devoted their time and expertise to make this project a reality. First, thank you to all the amazing NDBI developers willing to support the integration of their individual evidence-based interventions into a coherent model. Each reviewed the descriptions of their respective interventions in this book and supported the concept of NDBI through the original article. Second, thank you to all my colleagues who helped shape my understanding of NDBI across contexts. Third, thanks to my research and treatment teams in San Diego and Sacramento, who bring it all to life. Finally, thank you to all the children, families, teachers, therapists, and advocates who have supported this work. --- FOR MORE, go to bit.ly/BruinsmaNBDI Overview Excerpted from: Naturalistic Developmental Behavioral Interventions in the Treatment of Children of Autism Spectrum Disorder Edited by: Yvonne E.M. Bruinsma Ph.D., BCBA-D, Mendy B. Minjarez Laura Schreibman Ph.D., Aubyn C. Stahmer Ph.D., --- Understanding NDBI Understanding NDBI utism spectrum disorder (ASD) affects as many as 1 in 59 children (Baio et al., 2018). Although this statistic certainly has an impact across ser- Avice systems, the impact is far greater for those individuals and families affected. While ASD may have been considered a dire prognosis for these children and families from the 1950s through the 1980s and beyond, the state of affairs is much brighter today. Research since the 1960s conducted across multiple academic disciplines has led to the identification and development of treatments for ASD that are both highly effective and efficient. The development of these effective intervention strategies, coupled with an ability to diagnose ASD at earlier ages, has broadened and strengthened the positive effect of treatment efforts. Early intervention by using empirically based treatments has proven to have a substantial impact on the future functioning of children with ASD, changing the outlook for these individuals and their families (e.g., Dawson, 2008; Dawson et al., 2012; Rogers & Dawson, 2010). Although early intervention using these newer strategies has certainly improved the prognosis for young children with ASD, treatments based on these same principles have also proven to be effective for individuals throughout the life span, as well as for individuals with related disorders that share some of these same principles have also proven to be effective for individuals throughout the life span, as well as for individuals with related disorders that share some of the same features of ASD (e.g., language acquisition delays, behavior problems, cognitive impairment). Our goal in writing this book was to describe a scientifically validated set of interventions, derived primarily from the fields of Applied Behavior Analysis (ABA) and developmental psychology. These interventions are called Naturalistic Developmental Behavioral Interventions (NDBI) to reflect the essential combined contributions of these two disciplines. As described in later chapters, there are several established NDBI utilized with children with ASD and related disorders; although --- Overview FOR MORE, go to bit.ly/BruinsmaNBDI 4 Overview the concepts and procedures that unite them, and provides an implementation guide for practitioners and others who wish to use NDBI with children with ASD. Section I introduces NDBI and key NDBI models. Section II explains core concepts and foundational principles common to all NDBI, highlighting topics such as the selection of meaningful skills, parent empowerment, and inclusion. Section III and foundational principles common to all NDBI, highlighting topics such as the selection of meaningful skills, parent empowerment, and inclusion. Section III dives deeper into specific NDBI strategies, and Section IV offers an implementation- focused look at NDBI in practice. This book is a resource for practitioners, educators, and other professionals who make treatment decisions for children with ASD. Those searching for ASD treatment are often confused and overwhelmed because there is so much information available. Much of what is available via the web or other sources is not likely to be helpful and can even be harmful. Some proposed treatments have proven to be dangerous (e.g., certain drug regimens or chelation). Other treatment approaches elevated through celebrity advocacy, although perhaps the most visible, often lack evidence for effectiveness. Furthermore, even if a child receives a relatively benign but not scientifically validated treatment (e.g., equine or dolphin therapy), it still evidence for effectiveness. Furthermore, even if a child receives a relatively benign but not scientifically validated treatment (e.g., equine or dolphin therapy), it still can be harmful if it is costly or results in the child spending less time in effective treatment. There are so many treatments and claims of effectiveness (often patently false) that the process of identifying effective interventions for a child with ASD too often becomes a burden for parents and treatment providers. This book offers a solution by not only identifying proven treatments but also by describing the basic, important concepts that characterize such treatments to help parents, teachers, and practitioners decide if interventions meet the standards of established NDBI. Although specific NDBI may have different names, such as Pivotal Response Treatment (or Training) (PRT), Early Start Denver Model, and Project ImPACT, they all involve the same important core concepts discussed in this book. Our hope is that by helping parents, teachers, and practitioners determine ASD DEFINED Before diving in to the more complicated topics that follow in this book, perhaps it is best to establish a common understanding of what we mean by autism spectrum disorder (ASD). Autism was first identified as a specific disorder by Leo Kanner in 1943. Kanner described a group of children who exhibited a set of features unlike those of any other known pediatric disorder. These features included severe social deficits, such as failure to bond with parents, social avoidance of others, failure to establish eye contact, failure to acquire language or particular pathological features of language if it did develop, lack of appropriate interaction or interest in toys or other features of the environment, and the presence of repetitive, nonpurposeful behaviors. He also believed that these children possessed normal or above-normal intelligence. Kanner named this disorder early infantile autism to describe the fact that the symptoms were exhibited very early in life and involved a severe withdrawal. Since 1943, much has changed in whether a treatment meets the standard of research-based practice, we will make the initially unmanageable, manageable. --- FOR MORE, go to bit.ly/BruinsmaNBDI Understanding NDBI According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association, 2013), the following diagnostic criteria for ASD have been established: 1. Persistent deficits in social-communication and social interaction such as 1. Persistent deficits in social-communication and social interaction such as abnormal social approach, reduced sharing of emotions or affect, and failure to initiate or respond to the social initiations of others 2. Persistent deficits in verbal and nonverbal behaviors used for social interaction, such as failure to develop speech, inadequate eye contact, failure to use or tion, such as failure to develop speech, inadequate eye contact, failure to use or understand gestures for social purposes, failure to develop and maintain social relationships, and absence of interest in, or sharing with, peers 3. Presence of restricted, repetitive patterns of behavior, interest, or activities (including stereotyped or repetitive motor movements or use of objects; inflex- (including stereotyped or repetitive motor movements or use of objects; inflexibility to changes in routines; and highly restricted, fixated interests that are ibility to changes in routines; and highly restricted, fixated interests that are abnormal in intensity of focus) 4. Hyper- or hyporeactivity of the sensory environment Also, whereas Kanner did not associate autism with cognitive impairment, a significant number of these individuals do experience cognitive impairment. (See the nificant number of these individuals do experience cognitive impairment. (See the DSM-5 and Autism Speaks at http://www.autismspeaks.org for a more detailed and comprehensive description of ASD.) and comprehensive description of ASD.) HISTORY OF ASD INTERVENTION To fully appreciate where the field of ASD intervention is now, it is important to look back at where the field began and how it has progressed. Prior to the early 1960s, educators widely assumed that children with ASD could not learn. The early work of Charles Ferster and Marian DeMyer (1961, 1962) demonstrated that children with ASD could learn a simple task if their responses reliably resulted in a positive effect. The task was pressing a lever for candy in the presence of a stimulus, and the positive effect was delivery of candy. Although this was not a particularly functional curriculum, it did demonstrate that the principles of learning could be used effectively to teach children with ASD. This early work was followed by a substantial increase in the study of operant learning approaches to teach a variety of skills. Examples of these skills include language (Lovaas, Berberich, Perloff, & Schaeffer, 1996; Risley & Wolf, 1967), social skills (Ragland, Kerr, & Strain, 1978; Strain, Kerr, & Ragland, 1979), play (Koegel, Firestone, Kramme, & Dunlap, 1974; Lifter, Sulzer- Azaroff, Anderson, & Cowdery, 1993; Stahmer, 1999; Stahmer & Schreibman, 1992), adaptive skills (Ayllon & Azrin, 1968; Baker, 2004), and academic skills (McGee, Krantz, & McClannahan, 1986; McGee & McCoy, 1981), as well as skills to reduce is used by everyone (e.g., saying “please” to request a treat will become a stronger --- FOR MORE, go to bit.ly/BruinsmaNBDI 6 Overview response if the treat follows saying the word). The field of ABA has established many of these laws and continues to refine understanding of how to improve the response if the treat follows saying the word). The field of ABA has established many of these laws and continues to refine understanding of how to improve the life of others. It offers specific experimental methodologies to investigate and prove the effects of procedures aimed at changing behavior. The application of behavioral principles to teach new skills and reduce behavioral challenges for children with ASD took a huge leap forward through the work of Ivar Lovaas; Lovaas and his colleagues developed an intensive and comprehensive intervention program that focused on many of these skills (Lovaas, 1987, 2002). Although Lovaas’s successes, and those of other behavioral researchers, propelled behavioral treatment into the forefront, his 1987 treatment study had the most profound impact. In that study, Lovaas provided intensive (i.e., up to 40 hours per week) behavioral intervention to a group of young children with ASD. In contrast to a control group of children who did not receive the treatment at such intensity, the children in the experimental group showed significant gains in IQ score and success in typical school placements. This work greatly altered the expectations of treatment, especially early treatment, for ASD. The field began to realize that tremendous progress, potentially leading to limited ongoing need for services and supports, might be possible for almost half of children with ASD if they receive excellent treatment early enough and with enough intensity. This work, and subse- supports, might be possible for almost half of children with ASD if they receive excellent treatment early enough and with enough intensity. This work, and subsequent studies demonstrating efficacy of early intervention, led to two main trends in ASD treatment. First, parents, understandably very encouraged by these findings, began advocating for their children to receive early intensive behavioral intervention, which led to changes in educational practices and policies. Second, discrete trial training (DTT), the behavioral approach used in Lovaas’s (1987) study, became increasingly popular. In brief, DTT involves one system of implementation of operant methodology. In this type of intervention, teaching is conducted via successive discrete trials, with each trial consisting of an antecedent (a cue to indicate when a response als, with each trial consisting of an antecedent (a cue to indicate when a response should be emitted), a response or behavior, and a consequence (an event following the response). We call this the three-term contingency and abbreviate it A-B-C. In DTT, educators break skills down into smaller, separate components and teach them one at a time using discrete training trials until the complete skill is acquired. For example, if a teacher wanted to teach a child to put on a pair of pants when told to put on pants, he or she might first teach the child to point to a pair of pants when told to put on pants. Once the child reliably points to the pants, the teacher would teach the next component of the skill by requiring the child to point to and then pick up the pants. Once that is mastered, the child would be required to put one leg in the pants and so forth until the child could perform the entire skill --- FOR MORE, go to bit.ly/BruinsmaNBDI Understanding NDBI limitations and otherwise improving and expanding treatment effectiveness. Advances in the developmental sciences—particularly those in the area of promoting early communication skills, social engagement, and affective engagement—set the stage for advancing early intervention methods beyond the highly structured format of DTT. The marriage of ABA principles and principles derived from developmental science has proven to be particularly important and relevant because the ability to diagnose ASD in children at earlier ages has led to an increased number of children receiving early intervention. DEVELOPMENTAL SCIENCE AND ITS INFLUENCE IN ASD EARLY INTERVENTION In the late 1980s and 1990s, researchers started to think that ASD could be best understood by explaining how the developmental trajectory of children with the diagnosis deviated from that of typically developing children. This perspective was fueled by the emergence of the field of developmental psychopathology (Cicchetti, 1989), which allowed for the scientific study of atypical development. Researchers realized that typical and atypical development are mutually informative and that their understanding of ASD would be enhanced by studying the basic processes that caused development to diverge from typical pathways. This led to a search for the earliest fundamental developmental processes that could explain the core symptoms of ASD. At this time, there was also greater emphasis on longitudinal tional cues (Sigman, Kasari, Kwon, & Yirmiya, 1992). Studies of home videotapes showed that young infants who later developed ASD did not orient to name, point, show, or make eye contact, demonstrating the earliest symptoms of ASD by 10–12 months of age (Werner, Dawson, Osterling, & Dinno, 2000). These findings began to shape both the strategies used in early intervention and the targets of intervention. For example, theories of typical development emphasized the active role of the child in constructing both the social and nonsocial world. Researchers found that even young infants learn by forming ideas or hypotheses and then testing these ideas through playing with objects, interacting with people, and using social interaction to test those hypotheses (Saffran, Aslin, & Newport, 1996). Thus, researchers focused intervention methods more on children’s initiation and spontaneity rather than on their response to cues and prompts. Likewise, research on typically developing infants and young children showed that learning is promoted when that learning occurs in the context of an affectively rich social environment, such as social play involving smiling and eye --- Overview FOR MORE, go to bit.ly/BruinsmaNBDI 8 Overview (Dawson et al., 1990). Thus, ASD treatments began using strategies to promote affective engagement (e.g., Prizant et al., 2003; Rogers & DiLalla, 1991), or using social emotion to act on and respond to the world. Studies of typically developing infants found that early emerging skills, such as joint attention and imitation, were critical for setting the stage for a wide range of later skills. As a result, early inter- critical for setting the stage for a wide range of later skills. As a result, early intervention began targeting skills that were fundamental precursors to the development of language, including joint attention (Mundy, Sigman, & Kasari, 1990). As the theoretical frameworks and research findings from the fields of developmental psychology and developmental psychopathology were incorporated into early intervention models, it became clear that they could be readily integrated with the strategies of ABA. This integrated approach improved children’s motivation to learn, speed of acquisition of skills, and ability to generalize newly acquired skills to novel environments. NDBI were the result of this integration of developmental and ABA principles. mental and ABA principles. INTEGRATION OF BEHAVIORAL AND DEVELOPMENTAL SCIENCES Despite their distinct theoretical foundations, methodologies, and implications for intervention, the fields of behavioral and developmental science came together with the emergence of NDBI (see Schreibman et al., 2015). These interventions incorporated components of both fields, demonstrating that integrating behavioral and developmental sciences had a profound effect. The merging of these two fields led to interventions that are informed by the strengths of each perspective and that better serve the younger ASD population in particular. NDBI essentially are research-based interventions that incorporate well-established behavioral interventions to affect developmentally important and appropriate behavior change. ventions to affect developmentally important and appropriate behavior change. Thus, NDBI ensure that the treatment strategies employed remain guided by understanding of child development. ing targets, contexts in which the interventions are delivered, and instructional strategies (see Schreibman et al., 2015). strategies (see Schreibman et al., 2015). Nature of Teaching Targets The teaching targets selected in NDBI typically come from a broad range of developmental domains, including language and communication, play, social interaction, cognition, and motor skills. The skills are selected based on the cascading effect (i.e., flow or progression from lower level skills toward higher level skills) and the foundational role they play in later development, especially in regard to the core social deficits of ASD. These skills include imitation; shared and reciprocal engagement; joint attention; and functional communication via the use of gestures, facial expressions, and words, among others. Moreover, various domains are targeted concurrently during learning episodes, in contrast to more highly structured methods that may teach each domain separately. This distinction reflects a developmental systems approach, whereby different skills are integrated from the start to promote generalization. Generalization is the use of skills across various people, places, and materials with the ultimate goal of promoting long-lasting and func- --- Understanding NDBI FOR MORE, go to bit.ly/BruinsmaNBDI Understanding NDBI same words during dinnertime at home or during another daily routine. During these activities, the therapist or parent would also incorporate other developmental skills, such as gesture use, imitation, shared engagement, or joint attention. skills, such as gesture use, imitation, shared engagement, or joint attention. Contexts of Treatment Delivery The empirical literature has provided evidence that children’s experiences affect neurobiological development (Dawson et al., 2012; Knudsen, 2004) and that experiences have a cascading effect on development (e.g., Thelen & Smith, 1994). The contexts in which early learning occurs need to allow children to experience the natural contingencies of their own behavior (Gibson, 1973). For example, asking an adult for help reaching a toy leads to acquiring the toy. Increasing evidence is emerging that learning is enhanced when it is embedded in activities that contain emotionally meaningful social interactions, compared to situations in which instruction occurs without meaningful social engagement (Topál, Gergely, Miklósi, Erdohegyi, & Csibra, 2008). Spelke, Bernier, and Skerry (2013) argued that providing children the opportunity to learn within a socially engaged context sets the stage for them to learn about the social landscape around them. For example, an educator can teach a child about different pieces of furniture by teaching the labels chair or table separately, but learning is improved if a social partner teaches the chair or table separately, but learning is improved if a social partner teaches the child while playing house. The child could sit a doll in the chair or put a dish on the table for his or her mother so that the child learns the pieces of furniture within the context of the natural environment. In NDBI, these concepts are brought to fruition through child-initiated and motivation-based (i.e., following the child’s preferences) interactions. These interventions take place during enjoyable play routines and familiar daily routines using a variety of materials. Teaching usually looks and feels like the everyday interactions that are central to toddler experiences. In fact, first-time observers of these approaches have said they do not look like therapy. Parent and family involvement is also common to NDBI because it broadens the context in which teaching occurs and increases the frequency of learning opportunities. Learning opportunities include imitating facial expressions and actions, identifying body parts during bath time with mom or dad, or building shared engagement and social initiations during a game of Peekaboo or chase with the child’s therapist. Skill acquisition has been shown to be more effective in engaged contexts such as these (Dawson et al., 2010; Delprato, 2001). Thus, specific characteristics of learning contexts, including the activities, materials, and quality and emotional valence of the adult–child interaction, contribute toward optimal learning and generalization of newly developing skills. of newly developing skills. Instructional Strategies Finally, NDBI have in common the use of development-enhancing strategies, which are described in more detail in other chapters. These strategies promote learning and motivation within ecologically valid contexts and routines. At first, the child may learn through highly predictable and salient response–reinforcer sequences. For example, he or she may get to push a car down a steep ramp after making --- Overview FOR MORE, go to bit.ly/BruinsmaNBDI 10 Overview enjoyment around that theme with the therapist. By incorporating behavioral strategies, such as modeling, shaping, chaining, prompting, and differential reinforcement, the therapist, teacher, or parent supports the child throughout these activities in the development of expressive communication, receptive language understanding, early cooperative play, and shared engagement. The rewarding value of these child-centered, everyday activities maximizes motivation. Research has of these child-centered, everyday activities maximizes motivation. Research has also demonstrated a decrease in maladaptive behaviors as they are replaced with more functional, adaptive skills (e.g., Carr & Durand, 1985). These skills are relevant for older individuals as well. Although this feature of NDBI is most commonly utilized in early intervention, researchers and practitioners realize the importance of skills such as imitation and joint attention as foundations for many more advanced skills. For example, joint attention skills are an important component of successful social interaction. Thus, they are good skills for older individuals learning social skills. These skills need to be taught at any age if the individual has not already acquired them. Another key feature of NDBI is that the components can be adapted for any age and any skill area. that the components can be adapted for any age and any skill area. EXAMPLES OF NDBI While developing interventions for ASD, several clinical research laboratories independently realized the need for more naturalistic treatments that would greatly expand on the earlier work of Hart and Risley (1968) and increased focus on strategies that would enhance child motivation and improve generalization of learned skills. Thus, these laboratories established distinct NDBI that had several commonalities. Examples include incidental teaching (IT; Hart & Risley, 1968, 1975; McGee, Morrier, & Daly, 1999), Pivotal Response Treatment (Koegel & Koegel, 2006; Koegel et al., 1989; Schreibman & Koegel, 2005), the Early Start Denver Model (ESDM; Dawson et al., 2012; Dawson et al., 2010; Rogers & Dawson, 2010; Rogers, Dawson, & Vismara, 2012), Enhanced Milieu Teaching (EMT; Kaiser & Hester, 1994), Project ImPACT (Improving Parents as Communication Teachers; Ingersoll & Wainer, 2013a, 2013b), and Joint Attention, Symbolic Play, Engagement, and Regulation (JASPER; Kaale, Fagerland, Martinsen, & Smith, 2014; Kaale, Smith, & Sponheim, 2012; Kasari, Gulsrud, Wong, Kwon, & Locke, 2010; Kasari, Kaiser, et al., 2014; Kasari, Lawton, et al., 2014; Kasari, Paparella, Freeman, & Jahromi, 2008). Although this list is not exhaustive, it includes many of the models with the most research, each of which is discussed in greater detail in Chapter 2. Some of the intervention models are comprehensive (i.e., they target a broad range of functioning across multiple developmental domains), whereas others are focused interventions that address specific areas of behavior or development (e.g., social-communication only). The emphasis throughout this book, however, is on the commonalities among these NDBI. --- Ready, Set, Implement! Ready, Set, Implement! Ready, Set, Implement! BOX 1.1: What are the common elements of empirically validated NDBI? Core Components Core Components • Are based on the well-established principles developed via the science of ABA of ABA • Use developmentally based intervention strategies and sequences to • Use developmentally based intervention strategies and sequences to guide goal development that is individualized to each child Common Procedural Elements Common Procedural Elements • Have an intervention manual or manuals that clearly specify the • Have an intervention manual or manuals that clearly specify the procedures of the intervention procedures of the intervention • Include procedures for assessing treatment fidelity • Include procedures for assessing treatment fidelity • Involve ongoing measurement of progress during treatment Common Instructional Strategies • Specify how the environment should be arranged to ensure that the child • Specify how the environment should be arranged to ensure that the child must initiate or interact with an adult in order to gain access to desired must initiate or interact with an adult in order to gain access to desired materials, favored activities, or familiar routines materials, favored activities, or familiar routines • Utilize natural reinforcement and other motivation-enhancing procedures • Utilize natural reinforcement and other motivation-enhancing procedures • Use prompting and prompt fading during acquisition of new skills • Use prompting and prompt fading during acquisition of new skills • Use balanced turns within teaching routines • Use balanced turns within teaching routines • Use modeling Core Components of NDBI continuum of emphasis/degree across NDBI. • All evidence-based NDBI are based on the well-established principles developed via the science of ABA. As might be expected from ABA-based strategies, NDBI all involve the threepart contingency of antecedent → behavior (response) → consequence, which helps the child understand when to respond and ensures that the intervention provides feedback to the child. Although more recent strategies for ASD intervention, such as NDBI, differ in various forms from earlier behavioral interventions, the basic tenets of NDBI are the same as those of their original ABA roots. For example, Skinner’s (1953) work on motivation and Stokes and Baer’s (1977) seminal work on enhancing generalization of intervention effects are • Use modeling • Utilize adult imitation of the child’s language, play, or body movements Core Components of NDBI This section discusses foundational tenets underlying all NDBI, presented along a continuum of emphasis/degree across NDBI. --- Overview FOR MORE, go to bit.ly/BruinsmaNBDI 12 Overview Motivation to respond is enhanced when rewarding events can be anticipated. NDBI utilize strategies that promise these rewards (reinforcers) for responding and thus increase the child’s motivation to respond. Stokes and Baer (1977) described how generalization of acquired behaviors may be enhanced by utilizing a specific set of teaching strategies. To illustrate, a generalization-enhancing strategy is to use multiple examples of materials during training. Thus, when teaching a child the concept of a car, the teacher would utilize cars of various colors, shapes, and sizes to ensure the child learns the general concept of car instead of learning car means a red object of medium size on a specific table. instead of learning car means a red object of medium size on a specific table. NDBI employ strategies to ensure that the child’s teaching environment contains a variety of stimuli. • Having a base in developmental science, NDBI use developmentally based • Having a base in developmental science, NDBI use developmentally based intervention strategies and sequences to guide goal development that is individualized to each child. Some NDBI are associated with a specific developmental assessment and curriculum (e.g., ESDM; Rogers & Dawson, 2010). In almost all NDBI, goals are developed with the use of standardized assessment, observation, and developmental checklists, which serve to guide the clinician in determining individu- alized treatment targets across behavior domains. Strategies for assessment and goal development are outlined in detail in later chapters. and goal development are outlined in detail in later chapters. Common Procedural Elements Common procedural elements are procedures that consistently accompany use of of implementation, but manuals alone are unlikely to lead to proficiency. Additional training, including coaching and feedback, will be required (Bush, 1984; Common procedural elements are procedures that consistently accompany use of NDBI and should be incorporated throughout implementation of the intervention approaches. Those elements are as follows: approaches. Those elements are as follows: • NDBI have an intervention manual or manuals that clearly specify the procedures of the intervention. Research has shown that accurate implementation of an intervention requires adherence to clearly stated procedures (Durlak & DuPre, 2008; Fixsen, Naoom, Blasé, Friedman, & Wallace, 2005; Greenberg, Domitrovich, Graczyk, & Zins, 2005). Manualization helps with consistency of implementation and with training of treatment providers (e.g., clinicians, parents). Some manuals for NDBI are published and thus readily available to the public, whereas others are available primarily in research settings. Of course, clearly described procedures and manualization of intervention are important in ensuring accuracy of implementation, but manuals alone are unlikely to lead to proficiency. Addi- cording to the manual, but it is unknown how effective the intervention might --- FOR MORE, go to bit.ly/BruinsmaNBDI Understanding NDBI be if it is not accurately applied. Thus, the accuracy of treatment implementation is likely a mediating factor in child outcome, with better outcome likely associated with more accurate treatment implementation (Durlak & DuPre, 2008; Gresham, MacMillan, Beebe-Frankenberger, & Bocian, 2000; Stahmer & Gist, Gresham, MacMillan, Beebe-Frankenberger, & Bocian, 2000; Stahmer & Gist, 2001). NDBI provide specific assessment procedures and mastery criteria to allow trainers to assess the level of implementation accuracy by practitioners. allow trainers to assess the level of implementation accuracy by practitioners. • Ongoing measurement of progress during treatment is an essential feature of good treatment and thus a feature of all NDBI. Effective practice must be systematically and objectively verified through appropriate data collection (Simpson, 2005a, 2005b). Data must be collected to track child progress not only to ensure overall treatment effectiveness but also to allow for alterations in treatment procedures or treatment targets if necessary. Although all NDBI have specified procedures for tracking treatment progress, different NDBI emphasize different methods appropriate for their intervention. Data collection methods may include trial-by-trial recording of child responses to each learning opportunity, interval recording of progress during a treatment session, probes of specific behavior, or the use of curriculum-based assessments to examine progress at specific time periods (e.g., monthly, quarterly). Data collection is an essential feature of any intervention based on ABA and should be linked to the child’s treatment goals. If necessary, it should be used to alter intervention to better serve the child’s needs. NDBI share common instructional strategies that comprise the intervention application itself. These strategies are the individual component parts that make up the interventions. • NDBI specify how the environment should be arranged to ensure that the • NDBI specify how the environment should be arranged to ensure that the child must initiate or interact with an adult in order to gain access to desired materials, favored activities, or familiar routines. Environmental arrangement refers to how the adult structures the environment to facilitate and encourage child initiation of skills and learning of new target skills. Preferred materials may be visible but placed out of reach to encourage the child to initiate a request for the material (e.g., incidental teaching); in other interventions, a variety of toys or activities are placed in a room and the child is asked what he or she wants (e.g., PRT). Other types of environmental arrangement 1) control access to materials until the child initiates; 2) playfully obstruct where the child initiates to continue the activity; 3) introduce materials that require assistance so that the child must interact with the adult; 4) create expectant waiting, in which the adult looks at the child and waits for an initiative response; or 5) violate a routine, in which the adult changes a familiar sequence of events so that the child must correct the sequence. Some NDBI are quite specific on methods to structure the environment to promote child initiation, whereas others are less specific, dictating that the adult simply must gain the --- FOR MORE, go to bit.ly/BruinsmaNBDI 14 Overview interaction with the child can be used extensively in the child’s natural environment. Thus, if the child is playing in a community park where different objects ment. Thus, if the child is playing in a community park where different objects are present, the treatment provider can use NDBI to promote initiation and in- are present, the treatment provider can use NDBI to promote initiation and interaction, allowing all of the child’s environments to be potentially therapeutic. • NDBI utilize natural reinforcement and other motivation-enhancing procedures. NDBI give the child a good deal of control over a teaching episode, and the child’s choice of stimuli or activities allows for the use of natural reinforcement as a consequence. Reinforcement refers to the strengthening of a behavior and making that behavior more likely to occur, as a result of what happens immediately following that behavior. A natural reinforcer is one that is directly related to the child’s response. For example, if the child wishes to play with a car, access to the car would be contingent on a related response from the child, such as saying “car.” This is in contrast to an indirect or unrelated reinforcer, which is not related to the response. The previous example would exhibit an indirect reinforcer if the child says “car” and the adult reinforces the child with a piece of candy. Candy and saying “car” are not related, whereas saying “car” and gaining access to a car are related. A related motivation-enhancing procedure involves the use of loose reinforcement contingencies, also referred to as reinforcing attempts or loose shaping. This strategy involves allowing for more variability around a correct response such that the child may receive reinforcement for reasonable attempts to respond correctly. Thus, the child receives reinforcement for trying. Overall this procedure typically leads to more reinforcement and thus higher cally require this strategy, whereas others achieve this effect via loose shaping by reinforcing a mastered or maintenance task as an attempt. Some NDBI also attempts to respond correctly. Thus, the child receives reinforcement for trying. Overall this procedure typically leads to more reinforcement and thus higher motivation. Different NDBI vary in terms of how closely the child’s response must be to the target response in order for a reinforcer to be delivered. Another strategy used to keep the overall reinforcement level, and thus the child’s motivation, high is interspersal of maintenance tasks. A maintenance task is a skill the child has already mastered (i.e., an easy task). When teaching a new skill, the adult will expect some maintenance (i.e., easier) tasks among acquisition (i.e., new, more difficult) tasks. To illustrate, a child is learning to say the phrase “I want the ball” (i.e., acquisition task). It is new, so it may be challenging at times. To increase the child’s motivation while decreasing frustration, the adult would intersperse trials where the child is asked only to label the ball, a skill already mastered (i.e., maintenance task). This practice also serves to maintain learned skills through presentation of mastered skills while helping the child acquire more advanced skills. Several NDBI specifically require this strategy, whereas others achieve this effect via loose shaping require the systematic use of adult prompts to promote new skills. --- FOR MORE, Understanding NDBI Understanding NDBI • NDBI use balanced turns within teaching routines. This strategy (also known as turn taking, shared control, or reciprocal interactions) involves back-and-forth exchanges in activities or with objects between the child and the adult. Such interactions serve to increase and support the social reciprocity found in many typical social interactions. In addition, this strategy increases maintenance of social interactions as well as allows the adult to control access to materials. Because turn taking involves the back-andforth structure that has been associated with early learning (Harris & Waugh, 2002), its inclusion in NDBI has intuitive merit. However, despite its inclusion in NDBI, its empirical validation as an individual component awaits more research. Not all NDBI emphasize turn taking to the same degree. Some require it as a specific, programmed component of their NDBI, and others emphasize it as a specific, programmed component of their NDBI, and others emphasize that turn taking occurs within the context of building longer interactions and that turn taking occurs within the context of building longer interactions and thus is not specifically programmed. • NDBI use modeling. In modeling, the adult demonstrates a behavior that follows the child’s focus of interest and typically demonstrates the target skill the child should perform. Modeling is often used as a prompt strategy, specifically by the adult to evoke and support the child’s imitation of a modeled action or language. Across NDBI, modeling is used in various ways. Some NDBI use it primarily as a prompt strategy, and others also incorporate it as a general strategy for as a prompt strategy, and others also incorporate it as a general strategy for promoting engagement and enhancing the learning environment outside of specific embedded teaching trials. • NDBI utilize adult imitation of the child’s language, play, or body movements. This strategy is used to increase the child’s responsivity to, and imitation of, an adult, as well as to promote continuation of the interaction. Research indicates that children with or without ASD respond with increased attentiveness when being systematically imitated by the adult (Dawson & Adams, 1984; Ingersoll 2010; Ingersoll & Schreibman, 2006). Again, different NDBI place different emphasis on reciprocal imitation as a specific component strategy, with some models using this strategy to systematically generate a context for embedding teaching trials (as in reciprocal imitation training) and others using it as a general strategy to enhance engagement and enrich the learning environment. • NDBI work to broaden the attentional focus of the child. Early research identified an attentional deficit in many children with ASD, wherein a child’s behavior might only be affected by a small portion of a compound stimulus (e.g., Lovaas, Schreibman, Koegel, & Rehm, 1971). This attention phenomenon is called stimulus overselectivity to denote that the level of selective attention is excessive. For example, one child whose father wore glasses could not identify his father when the father removed the glasses. The child used only a very small portion (glasses) of the compound stimulus (father, made up of many component features) to identify him. It is easy to see how such restricted stimulus control might interfere with learning. More re- models using this strategy to systematically generate a context for embedding teaching trials (as in reciprocal imitation training) and others using it as a gen- --- Overview FOR MORE, go to bit.ly/BruinsmaNBDI 16 Overview Schreibman, 2013). In many cases, it can be modified (e.g., Koegel & Schreibman, 1977), and teaching with multiple examples seems to be key. Because NDBI emphasize teaching in natural and varied contexts with a variety of materials, this natural occurrence of multiple examples may likely help broaden, or als, this natural occurrence of multiple examples may likely help broaden, or normalize, the child’s attentional focus (Dawson et al., 2012; Rieth, Stahmer, Suhrheinrich, & Schreibman, 2014). Suhrheinrich, & Schreibman, 2014). • One of the most critical features of NDBI is that all NDBI involve some form of child-initiated teaching episodes. This strategy may be called child choice or following the child’s lead. It seeks to take advantage of increased motivation by presenting something highly desired to a child or providing an instruction or opportunity to respond within the context of a child-preferred activity or familiar routine. The child indicates interest in an object or activity by speaking, pointing to, reaching for, or spontaneously engaging in the desired activity, and the clinician provides a teaching opportunity within the activity. Because the child chooses the object or activity involved in the teaching interaction, the child’s successful achievement of his or her goal is the positive consequence for the child’s use of the target skill set up by the adult. The degree to which the child must initiate a teaching episode varies across NDBI, with some models focusing primarily on child initiations (e.g., incidental teaching) and other models balancing child initiations with adultinitiated teaching episodes (e.g., PRT, Project ImPACT). nosed and the importance of developmental science became apparent when early social and other behavioral deficits became the focus of treatment. Thus, the fields of behavioral psychology and developmental psychology have joined to inform a set of interventions called NDBI. NDBI are composed of a number of specific interventions that include required components and procedures. Thus, the concept of NDBI provides for parsimony of distinct intervention models (e.g., PRT, ESDM, JASPER) and allows for a clearer appreciation and understanding by families, professionals, insurance carriers, and others. It is essential that researchers and clinicians self-identify their particular intervention as one of the NDBI. To be identified as such, however, requires that --- FOR MORE, go to bit.ly/BruinsmaNBDI Understanding NDBI Chapter 2 provides a short overview of NDBI models. Sections II–IV offer more specifics of NDBI concepts, requirements, and intervention procedures. This more specifics of NDBI concepts, requirements, and intervention procedures. This book focuses in detail on how NDBI are implemented and evaluated as treatment strategies for individuals with ASD and other developmental disabilities. REFERENCES American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Ayllon, T., & Azrin, N. (1968). The token economy: A motivational system for therapy and rehabilitation. New York, NY: Appleton Century-Crofts. Baio, J., Wiggins, L., Christensen, D. L., Maenner, M. J., Daniels, J., Warren, Z., . . . Dowling, N. F. (2018). 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