Research & Practice for Persons wilh Severe Disabilities 20()6. Vol. 31. No. 2.

144-156

copyright 2006 by TASH

Using a Single-Switch Voice Output Communication Aid to Increase Social Access for Children with Severe Disabilities in Inclusive Classrooms
Joanna Evans Cosbey and Susan Johnston Department of Special Education, University of Utah, Salt Lake City
Three young children with severe, mtiltiple disabilities were taught to utilize a voice otttput cotmntmication aid (VOCA) to request access to preferred itents atul/or peers during play activities. Acqidsition of VOCA use resulted from a naturalistic intervention strategy that consisted of creating communication opportunities, prompting the participant to engage in the target behavior via a fidlphysical prompt, and facilitating access to natural consequences for appropriate participant responses. Intervention occurred in the context of naturally occurring free-choice activities in inclusive classrooms. Results showed that the intervention strategy was effective in teaching all three participants to use a VOCA to request access to items and/or peers. The peers generally responded to the participants with either positive or neutral re.\pon.\es. Survey data on the acceptability of the intervention to classroom staff are also discttssed,

DESCRIPTORS: social interaction, severe disabilities, inclusion, augmentative and alternative communication, young children As many school districts across the nation move tod an educational model of inclusion for students with disabilities, children with severe, multiple di.sabilities and social/academic delays are increasingly entering inclusive school environments {Bergert & Burnette, 2001; McLeskey. Henr\. & Hodges. 1999). Although inclusive settings have been found lo promote the social competence of children with severe disabilities (Fisher & Meyer. 2002) and to positively impact their eommunieative interactions (Foreman. Arthur-Kelly. & Pascoe. 2(M)4). these children typically lack the skills to engage in interactions with same-age peers due to poor communication skills, less time engaged in classroom activities that promote development of social skills, the nature of their disabilities, or lack of reinforcement by peers (Arthur. Bochner. & Buttcrfield. 1999; Hestenes &
Address all correspondence and reprini requests to Joanna Evans Cosbcy. I 'niversity of Utah. Department of Special Education. 1705 Campus Ccnier Drive. Room 221. Salt Lake City, Utiih K4112. Email: Susan.Johnston@ed.utah.edu 144

CarroU. 2000; Peterson & McConnell. 1993; Strain & Hoyson. 2IKK1). A variety of intervention strategies have been suggested for promoting social interactions between students with and without disabilities (for a review, see Peterson &. McConnell. 1993). These strategies have included elements such as peer training (e.g.. Brady, Shores, McEvoy. Ellis. & Fox. 1987: Hunt. Alwell. Farron-Davis. & Goetz. 1996; Lilienfeld & Alant. 2(X)5; Odom. Chandler. Ostrosky. McConnell. & Reaney. 1992; Oke & Schreibman. 1990; Pierce & Schreibman, 1995: Weiner. 2005) and time delay (Filla. Wolcry. & Anthony. 1999: Malmskog & McDonnell. 1999)! To date, studies have focused on increasing peer initiations toward children with disabilities (e.g.. Brady. Shores, et al.. 1987; Odom et al.. 1992; Oke & Schreibman, 1990; Pierce & Schreibman. 1995). developing appropriate stKial interactions between children with disabilities and their peers (e.g.. Baker. Koegel. & Koegel. I99: Brady. McEvoy, Wehby. & Ellis. 1987; Malmskog & McDonnell. 1999; Pierce & Schreibman. 1995). and teaching children with disabilities to initiate interactions with peers (e.g.. Davis, Brady. Hamilton. McEvoy. & Williams. 1994; Haring & Lovinger. 1989; Johnston. Nelson. Evans. & Palazolo. 2003; Jolly. Test, & Spooner. 1993; Krantz & McClannahan. 1993; Oke & Schreibman. 1990). Much of the research related to teaching students with disabilities to initiate social interactions with peers has relied on verbal initiation (e.g., Krantz & McClannahan. 1993; Oke & Schreibman, 1990) or the ability of the student with a disability to physically approach and/ or physically participate in activities with peers (e.g., Johnston ei al., 2(K13: Malmskog & McfJonnell. 1999; MeConnell, Sisson. Cort. & Strain. 1991). Due to the significant motor and communication impairments faced by many children with severe, multiple disabilities, it is necessary to examine ways to initiate social interactions that do not require verbalization or physical participation. ITie use of augmentative and allemative communication (AAC) has been examined in a variety of contexts to promote the communication of children with limited

Single-Switch VOCA and Social Access

145

verbal skills (for a discussion, see Romski & Sevcik. 1997). A AC strategies have been used to teach students H) request items or activities (e.g.. Basil, 1992: John.ston et al.. 2(W3: Jolly el al.. 1993; Kravits, Kamps, Kemmerer, & Potucek, 2(K)2: Sigafoos. Didden, & O'Reilly. 2(X)3), as well as to support communicative interactions (Hughes et al.. urn: Hunt et al.. 19%: Hunt, Farron-Davis, Wrenn. Hirose-Hatae, & Goetz, 1997). Mathy-Laikko et al. (1989) and Sehweigert (1989) explored Ihc effectiveness of interventions designed to teach children who are deaf-hlind to activate switches as a means to access social interaction with adults. Sehweigert used a switch paired with either social or nonsocial contingencies and found that the child's rale of switch activation increased when paired with social eonlingencies, but not when paired with nonsoeial contingencies. Mathy-Laikko et al. found that the child demonstrated a higher level of switch activation wben the activation resulted in social attention from her caregiver. These results suggest that social contingencies may promote switch use lor children with severe disabilities. The current study seeks to expand on the work of Mathy-Laikko ct al. and Sehweigert by using social attention from peers and access to preferred items to facilitate switch activation for three young children with severe disabilities. This study furthers the research on teaching children with severe, multiple disabilities to engage in social interactions by integrating current knowledge of effective social skills intervention with the use of a singleswitch voiee output communication aid (VOCA). This sludy examined the effeet of an intervention strategy involving the use of preference testing, a VOCA. and full physical prompting with time delay to promote the social interactions of young students with severe disabilities with their typically developing peers in inclusive settings. In addition, data regarding the sehool personnel's acceptance of the intervention strategy were collected.

Methods
Participants Three children (Sonja, Jessiea, and BHanna) partieipated in this investigation. Sonja was a 6-year, 6-monthold girl who was attending a fully inclusive regular education kindergarten classroom. She had ecrebral palsy resulting in right hemiplegia and significant motor, communication, and cognitive delays. Formal test resulu related to Sonja's vision and hearing were not available. However, information from teachers and parents indicated that hearing was within functional limits and that Sonja wore glasses to correct for vision difneulties, She was able to sit independently but required full adult assistance to transition to and from the classroom table, wheelchair, and the floor. Observation of Sonja in the classroom environment revealed that although she demonstrated an interest in the behaviors of other

students in the classroom, she rarely participated in activities with others and primarily engaged in selfstimulatory behaviors. Sonja was nonverbal at school, although her family reported that she occasionally used simple one-word utterances at home to label familiar objects. Her engagement behaviors included eye gazing, reaching, smiling, increased vocalizations, and increased self-stimulatory behaviors (e.g.. hand biting and hand flapping). With one-on-one adult support. Sonja had some prior experience with single-switches to activate toys in settings outside the inclusive classroom. She had minimal exposure to using a VOCA to request singing from an adult but did not have any experience using a VOCA to initiate interaction with peers. Jessica was a 3-year, 6-month-old girl who attended a fully inclusive preschool classroom for 3-year-old children. She had cerebral palsy resulting in significant motor and communication delays. Testing indicated that Jessica's hearing and vision were within normal limits. Jessiea demonstrated globiil motor difficulties related to her cerebral palsy, but her cognitive skills appeared to be within age-appropriate limits. She walked slowly with an adult supporting both hands but erawled or was carried around the room during free-choice activities. As crawling and walking were very effortful activities for her, she generally only interacted with toys that were within her reach or provided by an adult. She was able to sit independently to interact with peers and toys if they were placed in front of her, but was unable to access most materials independently. Jessica used btith of her hands to reach for. point to, and grasp objects with good accuracy. She occasionally initiated play activities with peers but more often interacted with adults or observed others as they engaged in play activities. Jessica provided symbolic, nonverbal responses, sueh as nodding or pointing, to peers and adults when asked questions or given one- or two-step directions. Jessica's engagement behaviors included eye gazing, reaching, and vocalizing. Jessica had no prior exposure to singleswitch use for activation of toys or initiation of communicative interactions. Brianna was a 4-year, 7-month-old giri with cerebral palsy. Pierre-Robin syndrome, and agenesis of the corpus callosum. She attended a fully inclusive preschool classroom for 3- and 4-year-old children. Although formal testing on her vision and hearing was not available, classroom observation and information from her parents and teachers indicate that hearing was a relative strength for her, but that her vision was impaired. Functionally, she was able to focus briefly on lights and brightly colored objects, but it took her increased time to focus and her eyes did not move in unison. In addition. Brianna attended to sounds in her environment, occasionally turning her head toward sounds. Brianna had limited upper extremity movement, consisting primarily of minimal elbow extension and flexion. Brianna was able to hold items placed in her

146

Cosbey and Johnston

hands for a few seconds. Classroom observation revealed that Brianna was dependent on adult support to participate in most classroom activities due to her physical disabilities, y\s Brianna had a traeheostomy and received supplemental oxygen throughout the school day. a nurse monitored her medical needs and positioned Brianna near the other students during activities, providing full physical assistance to help her participate in activities. She was positioned in a tilt-in-space wheelchair for activities outside the preschool classrtKim and used a specialized seating system with a tray lor in-class activities. Brianna's communication behaviors consisted primarily of crying and smiling. When she was presented with visual or auditory stimuli, she rolled her eyes back in her head for approximately 5 s. which her caregivers interpreted as a response to overstimulation. after which she would respond to the stimuli. Her engagement behaviors included increased muscle tone, smiling, and turning her head toward an object. She generally turned away from aversive stimuli. She did not initiate interactions with peers or adults during activities. Brianna had previous experience using a single-switch to activate cause-effect toys in a quiet, isolated setting with two or three adults simultaneously supporting her performance. She did not have any exposure to using a VOCA to initiate communicative interactions. Based upon these observations and interactions with members of Sonja's, Jessica's, and Brianna's teams, an intervention strategy involving the use of a VOCA was developed. This intervention specified that when Ihe participant indicated interest in a previously identified preferred objecfaetivity. the participant would use a VOCA to initiate interactions with peers to request access to objects or social interactions. Setting Sonja attended a half-day, inclusive kindergarten class located in a metropolitan area in Utah. This program incorporated center-based activities with large group instruction. Two adults supported 22 children in the classroom, including two students wilh disabilities. One adult had a ma.ster's degree in educational studies and served as the regular education teacher in the classroom. The second adult provided individualized support for Sonja and had 2 years of college education and training in working with children with disabilities. In addition to these two adults, a special education teacher, a speech-language pathologist, an occupational therapist, a physical therapist, a vision specialist, and a counselor provided consultation services within the classroom. Jessica and Brianna attended a half-day, inclusive preschool program located in a school district in a metroptjiitan area in Utah. This program incorporated free-choice center-based activities with large and small group instruction. Jessica's classroom included three students with disabilities and 22 students without dis-

abilities and was staffed by three adults. One adult had a bachelor's degree in family and human development and was working toward a master's degree in education. The other two adults had high school diplomas and had completed child development associate certification courses. In addition to these three adults, two special education teachers, a speech-language pathok>gist. an occupational therapist, and a physical therapist sePi'ed as classroom consultants. Three adults staffed Brianna's class, which included two students with disabilities and nine students without disabilities. One adult had bachelor's degree in education, another was a licensed practicing nurse, and the third had a high school diploma. In addition to these three adults, two special education teachers, a speech-language pathologist, an oecupational therapist, a physical therapist, and a vision specialist served as classroom consultants, Experimental Design A multiple baseline probe design across subjects was used to examine the effectiveness of the intervention strategy on teaching young children with severe, multiple disabilities to use a VOCA to initiate interactions with peers to request access to preferred objects and* or social interaction during play activities. The u.se of interspersed probes during baseline was implemented to demonstrate stability prior to the introduction of the intervention strategy while minimizing the risk of teaching the target behavior (Kazdin. 1982), Daily intervention probes were used to document the impact of the intervention. Intermittent probes of postintervenlion behavior served as a maintenance check to determine if the effects were durable over time, and generalization probes throughout the investigation served to determine if the effects generalized to other activities. Materials As discussed previously, the intervention plan specified that the participant would request access to a preferred object or social interaction with peers by using a VOCA. The VOCA in this investigation was a singleswitch VOCA programmed with the phrases. "TTial looks fun. Can I play?" The voice of a same age. same gender peer had been recorded onto the VOCA. The VOCA was positioned in a location that allowed for independent activation by each participant using existing functional motor skills. For Sonja and Jessica, the VOCA was placed to either side of midline so that it would not interfere with access to the preferred objects and/or social interaction with peers. Due to Brianna's limited upper extremity function, it was determined that head access would be the most efficient for her. The VOCA was connected to a smaller switch that was mounted on her adapted classroom chair near her right cheek. The VOCA was then placed on her tray, slightly to the right of midline so that her peers could hear it, but it did not interfere with her access to preferred objects or peers.

Single-Switch VOCA and Social Access

147

To the maximum extent possible, we used existing materials to create communication opportunities; however, it was necessary to introduce additional toys to identify preferred objects for the participants. These toys were age-appropriate, commercially available toys that represented a range of sensor\' input, including visual, tactile, and auditory. Table I describes the toys that were used throughout the preference testing and intervention and the preferred items for each participant. Although toys that stimulated other sensory systems, such as vestibular and gustatory, could have been provided, these three sensory systems were selected because they naturally occur in inclusive clussroom environments during existing activities and can naturally tKcur between peers. Also, with the exception of the tactile system, these sensory systems can be stimulated without direct physical contact with the participant. Thas. it was possible for the peers to interact with the objects at a short distance from the participant, requiring the participant to request access to the object. During baseline, intervention, and follow-up sessions, the toys were placed in proximity to ihe participant, but were not physically accessible.
Data Collection

and participant (indirect verbal, direct verbal, tactile, partial physical, and full physical). Data were collected for five opportunilies per participant per session. An opportunity was defined as an instance where the participant demonstrated engagement behaviors in response to a peer approaching the participant and interacting with one of the preferred items. The occurrence of error responses was recorded, with errors txrcurring when the participant reached for the toy or peer instead of activating the VOCA or activated the VOCA when peers were nearby, but not playing with the preferred objects. To obtain five naturally occurring opportunities per session, the length of each session varied, but all sessions occurred within the regularly scheduled free-play time within the classroom, which ranged from 20 to 45 min. Peers were not directed to approach the participant. Due to the high level of interest in the toys selected for this study, the peers willingly approached the participant and the preferred items. Data were also collected on the consequences of the VOCA use in 52 opportunities over 12 data sessions (35 opportunities for Sonja. 12 for Jessica, and 5 for Brianna). Using the same data coding form used to track the participant's behaviors, the interventionist coded the consequence of correct VOCA use (e.g.. access to toy. peer, or adult), the peer's initial response (e.g.. verbal response, rejection, etc.), and the level of support the participant and peers required to facilitate interaction between the children and the toys. This data provided information on the outcomes of VOCA use. In addition, to assess the acceptability and perceived effectiveness of the intervention strategy to the educational staff, a survey was distributed to the teachers who were involved in the education of the participants. This survey was developed by the re.searchers and used an anchored 6-point Likert scale, with possible responses ranging from "strongly agree" to "strongly disagree".

Data to assess the effectiveness of this intervention strategy were collected during baseline, intci^vention, and follow-up sessions. The interventionist used a coding sheet to collect data on the participant's initiation of interactions in response lo peers' engagement with the preferred objects, the interventionist's use of prompts and error corrections, and peer response to the participant's initiation. The coding sheet consisted of columns related to participant response (correct or incorrect). F>eer response (verbal, nonverbal, no response, and positive or negative), consequence (access to toy. peer, adult, other), and consequence support for peer

Table 1 Toys Used During Preference Testing Sensory area

Visual yop Bubbles'^- *P Puppets Mirror^" Auditory
Maracas^'P '"

Toy

Description Brightly colored books with simple pictures Brightly colored egg-shaped spinning top Brightly colored bear thai students could squeeze to access bubbles Brightly colored finger puppets Nonbreakable mirror TXvo plastic noise making toys Plastic lubes ihat made noise when extended and compressed Electronic toy that made animal sounds when activated Electronic toy ihat made siren noises and moved across the floor when activated Small plastic toy thai made a clicking sound when moved Small plu.sh toy ihat vihraied for a short lime when the string was pulled Small, fabric covered ball filled wilh beads Slime-iype material thai was strongly scented Brightly colored bear ihat had soft fur Ball made from rubber strands

Tactile

Noise making See & Sav""- '" Police car"""' '" Click toy Vibrating toy"*'' Stress balH''' ^"

Stuffed Koosh Note: Bp = preferred item for Brianna. Bn = neutral item for Brianna. Jp = preferred item for Jessica, Jn = neutral item for Jessica. Sp = preferred item for Sonja. Sn = neutral item for Sonja.

148

Cosbev and Juhmton conducted prior to initiation of baseline observations using an adaptation of guidelines discussed by Logan and Gast (2(X)1). The adaptations included data collection on the latency of response, presentation of each item once per session over two sessions instead of conducting multiple sessions with portions of the items, and limiting the sensory systems sampled to audilory. visual, and tactile. Data were collected on the latency of response due to information from the teachers that Brianna. in particular, required additional time to respond Ul stimuli. Within each session, items were demonstrated sequentially for 15 s. and the participant's response to each item was d(x:umented. The responses were coded as (a) preferred, (b) neutral, or (c) avoided, based on the participant's reaction to the stimulus, including overt behaviors and the duration of the reaction (see Table 2). This information was used Ihroughout the study to maximize the likelihood that the participant would demonstrate an interesi in the items and have an opportunity to respond independently. In addition to the duration of the participant's response, the time between the presentation of the stimulus and the participant's initiation of a response was measured to determine the participant's response lime. There was a 5- to lO-s delay between the presentations of each stimulus. TTiis preference testing was conducted twice, using the same items, to obtain a more representative sample of the participants' preferences. For each participant, a minimum of five items were identified in each preference category of preferred and neutral. Items that were avoided by Ihe participant were not used in this investigation. Presession Preference Testing A presession assessment occurred prior to every data collection session across baseline and all phases of the intervention to identify items that the participant was most likely to respond tti during that session (Oast et al., 2000). During this assessment, two preferred and two neutral objects were presented individually, and the participant's reaction lo each was recorded. The two items for which the participant demonstrated the longest

Each teacher who responded had the opportunity to observe intervention sessions dispersed across baseline and intervention. Eleven members of the participants' educational teams responded to the survey. Procedures The first author served as the interventionist for all three participants. The first author also served as the (Kcupational therapist for all three participants, as well as other children in the classrooms, so the participants were familiar with her and she was frequently involved in on-going activities in the classrooms. The intervention was implemented in the context of regularly scheduled center-based free-choice activities within the inclusive classrooms. Prior to initiation of the intervention, the intervention strategy was individualized for each participant. Individualization of Intervention Strategy Prior to baseline, the investigator met with members of each participant's IEP team to individualize the intervention strategy. Toys and activities thai were thought to be motivating for the participant were identified, and team members were asked to describe behaviors that the participant used to indicate like or dislike of a particular object or activity. These behaviors, in addition to behaviors identified during preference testing, were used to indicate the participant's preference for particular stimuli. See Table 2 for a description of the engagement and avoidanee behaviors demonstrated by each participant. A full physical prompt was selected to prt)mote errorless learning and to minimize the extent to which the interventionist disrupted the interaction between the participants and their peers. For two of the participants, the full physical prompt consi.sted of using hand-overhand assistance to activate the VOCA. For the third participant. Brianna, the full physical prompt consisted of the investigator using her hand to turn the participant's head to activate the VOCA wilh her cheek. Onee an array of objects or activities and behavioral responses were identified, a preference assessment was

Participant Sonja

Table 2 Engagement and Avoidance Behaviors Identified During Preference Testing Engagement behaviors Avoidance behaviors Eye gaze for more than 2 s and one of the following: o Reaching o Leaning toward item/peer o Vocalizing Eye gaze for more than 2 s and one of the following: o Reaching o Smiling o 'Riming toward item/child Eye gaze for 2 s (after rolling eyes back for 1-5 s) Increased movement Smiling Turning toward item/child Lack of eye contact Turning head away Pushing item/peer away Shaking head 'no' Turning head away Pushing item/peer away Reucliing for i>thcr item Crying Roiling eyes backwards >S s Sustained inerease in muscle tone lurning head away

Jessica

Brianna

Smglc-Switch VOCA and Social Access

149

duration of engagement behaviors were used during thai intervention session as the preferred objects. Reactions were coded as preferred, neutral, or avoided, as during the preliminary preference testing. The participant's response time was again measured, and during the sceond phase of the intervention, the longest response time was used as the time delay provided before the lull physical prompt was introduced. This response time was individualized across participants and across intervention sessions to provide the participants with an opportunity to perform the target behaviors independently while acknowledging potential differences in reaction times. Baseline with VOCA Baseline observations occurred during free-choice activities in the classroom. During baseline sessions, the interventionist positioned the participant in an area of the classroom that contained two toys that were determined during presession assessment to be of high interest to the participant. The toys were placed within visual range for each participant but were out of reach {within 18 in. for all participants). Although Jessica had the motor ability to move through her environment to access toys and peers, it was observed that she seldom did, presumably because of the effort that mobility required. As a result, even when the toys were placed within 18 in. of her. she did not move to get to them. During this phase of the study, teachers were asked to engage in routine interactions with the participant. To increase the similarity to intervention conditions, the interventionist maintained close proximity to the participant (within arm's reach) bul did not provide instructional support. The location of the other adults varied, depending on the activities they were supporting in the classroom, with the exception of Brianna's nurse, vk'ho was always sealed in proximity to her to attend to any medical needs that arose. A single-switch VOCA was posilioned for optima! access by the participant, as discussed previously. No instruction on use of the switch was provided to the participant or the peers. Intervention During the intervention phase of the study, the peers in the classroom received incidental training immediately preceding the intervention session. The teacher and/or investigator told the peers Ihat their friends may ask to play with their toys while they are playing with them. They were instructed to share the toys with other students, if asked. Peers were not specifically directed to approaeh the participant, in an attempt to increase the similarity to natural Interactions in the classroom. The inter\'ention was implemented each day that the participant was in school during regularly scheduled, center-based free-choice activities in the classroom. The intervention consisted of a three-step instructional strategy. In the first step, opportunities for social interaction were created by identifying high interest objects.

arranging the environment, and establishing physical proximity (e.g., the participant and preferred items were placed in an area of the classroom that was frequented by peers, increasing the chanees that a peer would approach Ihe participant). The toys identified during that day's presession preference assessment were placed within visual and/or auditory range of the participant, but out of reach (within IS in. for all participants), in a location that increased the likelihood that peers would see and interact with the toys. The second step of the intervention involved the activation of a VOCA to request access to peer and/or toy. An opportunity to unplement the second step of the intervention strategy was defined as instances where the participant demonstrated engagement behaviors in response to a peer approaching the participant and interacting with one of the preferred items. The peers were generally within 18 in. of the participant while playing with the toys. The second step of the intervention was presented in two phases. During the first phase, immediately following the demonstration of engagement behaviors by the participant in response to a peer interacting with a preferred toy. the interventionist provided full physical assistance to activate the singleswitch VOCA to ensure initiation of peer interaction. That is, a 0-s delay was used to facilitate high rates of correct responding. After the participant experienced the target behavior during at least 80% of opportunities aeross three consecutive intervention sessions (with full physieal assistance), the interventionist progressed to the next phase. This level of 80% of opportunities was selected to account for the possibility that the participants mighl engage in responses that were defined as errors for the purposeof this study, such as activating the switch when peers were not interacting with the toys. In the second phase, the interventionist followed the same procedure, but a time delay was inserted prior to the administration of the full physieal prompt (for a discussion of the time delay strategy, see Schuster. 1998). This time delay was individualized for each participant as determined by the presession preference test (Daugherty, Grisham-Brown, & Hemmeter. 2001; Filla et al., 1999: Malmskog & McDonnell. 1999; Wolery, Anthony. Caldwell. Snyder, & Morgante, 2(K)2). If the participant engaged in the target response independently within the allotted interval, the natural consequences were facilitated. If the participant did not engage in the target response within the interval, the interventionist provided the full physical prompt, followed by facilitation of natural consequences. This second phase was designed to transfer stimulus control of the prompt to the naturally occurring opportunity for peer interaction. In the third step, the interventionist facilitated provi.sion of natural consequences (i.e.. access to toy and/or sodal interaction with the peer) contingent on the emission of the target response. The interventionist modeled and supported appropriate interactions between

150

Cosbev and Johaston

I he peers and the participant. For example, if the participant initiated interaction with a peer to request a musical toy. the interventionist provided the peer with strategies to allow the participant to access the toy, such as handing it lo her. placing it on her wheelchair tray, or holding it within her visual field, depending on the participant. After the peer and/or participant demonstrated disengagement behaviors, such as putting the toy down, showing engagement in another toy, or if the peer walked away, it was possible for a new opportunity to occur. The interactions between peer and participant were not intemjpted to provide more opportunities. Maintenance and Generalization Generalization data were collected across activities and settings for two of the participants throughout baseline and intervention. The data were collected on Sonja and Jessica in activities other than the intervention setting (e.g., outside play and music). Generalization data were collected during baseline to examine the frequency of unprompted behavior during these activities. Prese.ssion preference testing was conducted using the same toys that were used during the intervention sessions. These toys were available for the participants and their peers during ihe generalization and maintenance probes. The VOCA was positioned to provide optimal access by the participant, but no reinforcement or correction to the participant or peers was provided by the interventionist. The peers were provided with a general prompt prior to the data collection sessions, reminding them that their friends might ask to play with their toys and that they should share if asked. Generalization data were collected across 33% and 25% of ba.seline sessions and 29% and 22% of intervention sessions for Sonja and Jessiea, respectively. Due to scheduling conflicts, it was not possible to collect generalization data on Brianna. Follow-up maintenance probes began approximately 1 week after the completion of the intervention for Sonja and Jessica. Limited maintenance data were collected, but intermittent probes continued until the end of the school year, resulting in two data points for Sonja and one data point for Jessica. Maintenance probes were conducted in the context of the same activity as the intervention sessions, with presession preference testing occurring prior to the data collection session. An independent data collector was present during the maintenance probes, and the interventionist was not present. No prompting was provided to the peers or participant, other than a general classroom prompt to share toys with friends. Maintenance data were not collected on Brianna because the school year ended as she completed the second phase of intervention. Reliability Intcrobserver agreement was obtained to evaluate biJth procedural fidelity and dependent variable reli-

ability during the baseline and intervention phases of the investigation. The independent observer was a licensed special education teacher who was currently serving as the special education consultant for Jessica and Brianna and had served as the primary teacher for Sonja before she transitioned into kindergarten. Reliability agreement data were collected for 33%. 25%, and 29% of baseline sessions and 29%, 22%. and 25% of intervention sessions for Sonja, Jessica, and Brianna, respectively. To assess procedural fidelity, the observer independently recorded the interventionist's implementation of a task-analyzed list of procedures, including environmental arrangement and the delivery of appropriate prompts and consequences. Procedural fidelity was calculated by dividing the number of correct interventionist behaviors by the number of planned interventionist behaviors and multiplying the result by l(X). To compute dependent variable reliability, the observer independently collected data on the participants' responses during the intervention session. That record of response was compared to the interventionist's data as entered on a data sheet. As was done to compute procedural fidelity, a point-by-point agreement was calculated. The number of agreements was divided by the number of agreements plus disagreements and the result was multiplied by 100. To be considered an agreement, the observer and interventionist must have both coded a I'whavior as either correci or incorrect.

Results
Child Outcomes Figure I displays percent correct use of the VOCA during baseline, intervention, and maintenance for each participant. The participant's behaviors were coded as "unprompted" if the participant activated the VOCA in the presence of peers during the intervention session without the provision of a full physical prompt from the interventionist. These unprompted behaviors generally occurred during the second phase of the intervention (after the implementation of the time delay). However, they (Kcasionally also occurred during the first phase, when the participant simultaneously demonstrated engagement behaviors and aetivated the VOCA, preventing the interventionist from providing the full physical prompt, Sonja and Jessica showed stable baseline levels at 0% mean correct unprompted use of the VOCA to iniUate social interactions with peers across sessions, with five opportunities per session. Brianna dem<jnstrated a mean baseline level of 2.9% (range = 0-20%). with five opportunities per session. Intervention data reflect consistent use of five opportunities per session for each participant. Visual inspecfion of the intervention data demonstrates that there was an increase in all three participants' correct unprompted use of the VOCA. During

Single-Switch VOCA and Social Access Baseline Intervention Maintenance

151

Unprompted Prompted Generalization (unprompted)

10

15

20

25

30

35

45

50

Session Number
Figure I. Frequency of independent VOCA use across participants.

the first phase of intervention, Sonja and Brianna demonstrated 0% correct, unprompted use of the VOCA for initiation of interaction, which is to be expected given Ihe use of a 0-s delay before provision of the full physical prompt. Jessica, however, on several occasions exhibited engagement behaviors while simultaneously activating the VOCA. resulting in a mean level 33% (range = 0-80%) correct, unprompted use of the VOCA. In the seeond phase of the intervention, when the full physical prompt was being faded by the insertion of a time delay that was individualized for each participant, Sonja averaged 84% correct unprompted use of the VOCA, Jessica averaged 87% correct unprompted use of the VOCA, and Brianna averaged 70% correct unprompted use of the VOCA to initiate interactions. Maintenance data reflect a consistent use of five opportunities per session for each participant, with Sonja participating in two maintenance sessions and Jessica

participaUng in one maintenance session. During maintenance, Sonja demonstrated an average of 90% correct, unprompted use of the VOCA for initiating interactions over two data points. For her one maintenance data point. Jes.sica displayed HH)% correct, unprompted use of the VOCA. This data must be interpreted with caution due to the very limited maintenance opportunities. The generalization data collected were also limited, with Sonja and Jessica participating in five and three generaliziition sessions, respectively. Generalization data were collected for Sonja and Jessica during baseline and intervention phases, with consistent use of five opportunities per session for each participant. The generalization data were aillected in settings and/or activities that were different than the intervention setting and activities, such as during recess or different small group activities. Sonja and Jessica both demonstrated 0% correct unprompted use of the VOCA to initiate interaction

152

Cosbey and Johnston

during the baseline phase, and an average of 55% (11/20) and 20% (2/10) correct, unprompted use of the VOCA. respectively, during the generalization phase. Although these levels of VOCA use are lower than during intervention sessions, they are higher than the level t)bserved during baseline sessions. As discussed previously, although the provision of lull physical prompts was used to minimize the likelihood of error responses, error responses did occasionally occur. For example, on some occasions, peers were not interacting with the toys when the VOCA was activated by the piinicipant. Although it may have been an attempt to gain attention from adults or peers, when such behaviors occurred, these responses were eonsidered to be error responses. The other error response observed occurred when the participant gestured toward the toy instead of activating the VOCA. Although an appropriate communication strategy, for the purposes of this study, it was considered an error response becaase ihe data being collected related to the use of the VOCA to gain access to peers and toys, lliese responses cKcasionally occuned during Ihe zero-delay phase of the intervention. Although every attempt was made to provide the prompt immediately upon identification of an opportunity, there were times that the participant demonstrated engagement behaviors while simultaneously gesturing toward a toy and/or peer, preventing the interventionist from providing the prompt before an error could be made. Sonja had no error responses during the no-delay phase of intervention and demonstrated error responses for 16% (8/50) of opportunities during the delay phase of intervention. Jessica had no error responses during the no-delay phase of intervention and had error responses for 13% (4/30) of opportunities during the delay phase. Brianna demonstrated error responses for 25% (5/20) of opportunities during the no-delay phase and 5% (1/20) of opportunities during the delay phase. Consequences of VOCA Use Data were collected on the consequences of the VOCA use in 52 opportunities over 12 data sessions (35 opportunities for Sonja. 12 for Jessica, and 5 for Brianna). Data were only collected for the opportunities during which Ihe participant engaged in correct use of the VOCA, either prompted or unprompted. The participants obtained access to the toy in all of the opportunities. The participants obtained access to social interaction with peers, either verbal or nonverbal in 50 of the opportunities (96%). as discussed below. Finally, there was only one opportunity where the participant gained access to social interaction with an adult. Tliis txrcurred with Brianna when she initiated interaction with the interventionist, although peers were present. When this occurred, the interventionist engaged with Brianna to reinforce her initiation of interaction.

Peer Responses

Data on peer responses were collected on 52 opportunities over 12 data days (35 opportunities for Sonja. 12 for Jessica, and 5 for Brianna). Peer responses to the participant's activation of the VOCA were coded as no response, verbal or nonverbal, and positive, neutral, or negative. Peer responses were not collected on any opportunity during which the participant engaged in an error response- There were no occurrences of negative responses, such as rejection or refusal to share preferred item and there were only two occurrences (4%) of the peer not responding (one each for Sonja and Jessica). In general (63'i^o of opportunities), the peers tended to respond nonverbally and neutrally (e.g.. handing the participant the toy without actively interacting with them for 33 of 52 opportunities). In 8 of these 33 opportunities (15% of the total opportunities), the peer handed the toy to the participant and walked away, but in the 25 other opportunities (4K% of the total opportunities), the peer stayed with the participant for multiple turns with the toys. The second most common response was a positive, nonverbal response (e.g.. smiling and handing them the toy, 12 out of 52 opportunities or 23% of the total opportunities). Finally, there were 5 occurrences (10%) of positive verbal respon.ses, (e.g., "She likes that" or "I'll help you fix that!"). The level of support that the peers required to interact with the participants was also recorded for those 52 opportunities. This level of support was documented after the peers" initial response.s. which were described above. The peers were able to independently interact with the participant in 25 (48%) of the opportunities. They required direct verbal prompts, such as, "Hand it to her," in 17 (33%) of the opportunities, indirect verbal prompts (e.g.. "I think she wants to play.") in 4 (8%) of the opportunities, and physical prompts in 6 (12%) of the opportunities. Educalional Staff Perceptions Members of each participant's educational team were also asked to complete a survey related to their perceptions of the interventitin components (e.g., preference testing, environmental arrangement, and prompting strategies) and the impact of the intervention on the classroom environment. Sonja's respondents included her general education kindergarten teacher and the paraprofessional assigned to her classroom. Jessica's respondents included her general education preschool teacher, her special education teacher, and two paraprofessionals assigned to her classroom. Brianna's respondents included her general education preschool teacher, her two special education teachers, the paraprofessional assigned to her classroom, and her nurse. All of the respondents had the opportunity to observe data collection sessi(jns across baseline and the intervention phases of ihe study.

Singte-Switch VOCA and Sodal Access Table 3 Summary of Teacher Chccklisi Ratings Across Intervention Components Importance Component Vse of preference testing Placement of preferred items Use of VOCA LLsc of full physical prompis High 11 S 11 II Moderate 0 2 0 0
No

15.1

DifficuUy of implementation High 0 0 Moderate 1 1 I t)

No

Appropriateness High 11 10 10 11 Moderate 0 0 1 0

No
I)

0 1 0 0

1 0

10 10 9 11

1 0 0

Note: Summary based on 11 respondents. Teacher responses selected from anchored ft-poinl Liki.Tt scale. In tliis table, the six scale eategories were collapsed into three categories.

Table 3 provides a summary of the results of the sections of the teacher survey that address specific intervention components. As indicated by Table 3, the educational staff generally responded that the intervention components, including preference testing, environmental arrangement, and prompting strategies were important aspects of the intervention and would not be difficult to implement. Table 4 provides a summar>^ of the results of the sections of the teacher survey that address perceptions regarding the impact of the intervention on the educational environment. As reported in Table 4, most of the educational staff reported that it would not be difficult to implement this intervention in an inclusive classroom. In addition, all of the respondent.s indicated that the intervention was not disruptive to classroom routines and activities and that the observed outcomes were worth the time required to implement the intervention. Reliability Procedural ndeUty for all three participants was 100% across both baseline and intervention sessions. Dependent variable reliability was UX)% for all three participants across baseline and averaged 95% across
Table 4 Summary of Teaeher Checklist Ratings Across Environmental Variables
n Environmental variable Response option 1 Participant displayed new Agree (3-5) 10 inappropriate behaviors Disagree (0-2) that may be assudated with this intervention 0 Intervention was disruptive Agree (3-5) 11 to classroom activities Disagree (0-2) and/or routines 11 TimL' required for Agree (3-5) 0 intervention was worth Disagree (0-2) benefits to participants 1 It would be difftcult to Agree (3-5) 10 implement ihis Disagree (0-2) intervention Note: Summon h;tscii nn 11 respondents. Teacher responses selected from anchored d-pttint Likert scale. In this table, the six scale categories were collapsed into two categories.

the participants during intervention (range = 80-100%). TTie dependent variable reliability was 1(H)% during intervention for Jessica and Brianna. During one reliability data collection session with Sonja. there were four agreements and one disagreement between the interventionist and the reliabihty data collector, resulting in a reliability of 80% for thai one session (four of five trials).

Discussion
The purpose of this study was to examine (a) the effectiveness of an intervention strategy in teaching young children with severe disabilities to initiate interaction with peers using a VOCA and (b) how preschool staff rated the acceptability and perceived effectiveness of the intervention. Although this study was limited in its scope, results of this study suggest that the intervention was effective in teaching three young children with severe multiple disabilities to initiate interaction with peers using a VOCA. These findings add to the literature on the stJcial interactions of students with severe multiple disabilities in inclusive settings (Hunt et al., 1996: Logan et al.. 199S). In addition, these findings supplement existing research that supports the impact of social contingencies on single-switch use (Mathy-Laikko et al.. 1989; Sehweigert. 1989). The data indicate aequisition of the target skill for all three participants, which is noteworthy given the wide range of cognitive abilities of the participants. The three children who participated in this study all demonstrate severe developmental disabilities involving their communication and motor abilities; however, they demonstrate a range of cognitive abilities, suggesting that this strategy may be effective with a wide range of children with physical and/or cognitive disabilities. The participants all learned to use the VOCA to request access to preferred items from peers during naturalistic play activities. However, due to time constraints, limited data on the maintenance of the skills were available. Both of the participants who entered the maintenance stage of the study demonstrated an ability to engage in the skill at least I week after intervention. The data demonstrate that both of ihese participants showed some generalization of the target skill to activities other than

154

Cosbey and Johnston

the free-choiee sessions used during the intervention, although these data too are limited. Sonja demonstrated an upward trend in her unprompted VOCA use, and Jessica's use of the VOCA was slightly higher than during baseline, suggesting that with further time and intervention, generalization to other settings may be possible. Further investigation into the generalization of the target skill to other activities is recommended. In addition, this study was limited by its focus on the acquisition of VOCA use for the target children. As a result, although other forms of communication were prompted and reinforced within the children's classrooms (e.g., pointing or reaching), they were not specifically encouraged as part of this study. Instead, the data collected was limited to assessing the VOCA use for the target students, so future studies should examine the development of other forms of AAC The findings of this study suggest that service providers found this intervention strategy, including the use of the VOCA in inclusive settings, to be socially valid. Although a variety of service providers, including general and special educators, paraeducators, and a nurse, observed the intervention and were generally positive regarding acceptability, effectiveness, ease of use, and outcomes for the participant, it is important to note that none of them directly provided the intervention. For this study, it was decided that the researcher would first determine the feasibility of the intervention strategy before other members of the classroom staff would engage in the implementation. Future research should explore the efficacy of this strategy when classroom teachers and paraeducators are the interventionists. The results of this study suggest that it is possible to use VOCAs to teach students with severe multiple disabilities to initiate social interaction with peers. However, the data on peer responses suggest that it may be necessary to provide more explicit instruction to peers on strategies lor interacting with students with severe multiple disabilities. It is encouraging that the peers did not demonstrate rejection or negative responses toward the participants, but further studies focusing on strategies to promote positive social interactions between typically developing peers and children who use singleswitch VOCAs is warranted. Implications for Practice and Future Research The results obtained in this study offer several potential areas ftir future research. It was not possible to determine which elements of the intervention strategy were most effective in teaching the participants the target skill. Future investigations could examine the effects of each of these components in isolation. The focus of this study was on teaching students to use a single-switch voice output communication device to initiate social interaction with their peers. Given that students with severe multiple disabilities have signifieant aimmunication needs, research examining the

efficacy and feasibility of using more complex AAC systems that allow for greater variability in the form and function of communication interactions would provide valuable information regarding the use of AAC for this population of students. During this study, the intervention was implemented by an interventionist who was not a regular member of the teaching staff, it is possible that the social validity of the intervention strategy may be different when implemented by the classroom siaff. Future studies involving the classroom personnel as interventionists should be conducted. These studies should examine both the empirical effectiveness and the perceived acceptance and effectiveness of the intervention strategy. Finally, it is unclear whether the participant was motivated to use the VOCA to access to a desired toy or because it resulted in Increased attention from and interaction with peers. Future studies should examine whether the consequences provided contingent on VOCA use (e-g., access to desired toy paired with sixrial attention vs. social attention only) influence acquisition of the skill. The three participants in the study demonstrated a variety of functional skill levels in the areas of communication, cognition, and motor skills. Future research might examine the roles that AAC has in promoting the skills of students with complex communication needs at a nonsymbolic level and for students who have some symbolic communication skills and may be transitioning into verbal language. Research in this area would provide information about the most effective and efficient ways to promote social interaction skills using AAC to support the changing needs of students, including the use of gestures and VOCAs. The collateral effect.s of AAC use and the use of strategies to promote social interaction on peers with and without disabilities warrant further investigation. Anecdotal evidence from this study suggests that peers were motivated to participate in the activities and act as models and communication partners during the study. These peers had the opportunity to learn and potentially benefit from this interaction. Empirical evidence examining the effect of the intervention on the peers may suggest that implementation of the intervention strategy in the natural environment may be an efficient use of the interventionist's time and benefit multiple students in the classroom. ln addition to the potential areas of future research highlighted by the current study, implications for current practice can be inferred. Results suggest that the use of a VOCA may be an effective way to promote social interaction between students with severe disabilities and their peers in inclusive classrooms. Full physical prompts, which have previously been used to teach specific academic skills, can be used to teach students to initiate social interaction and can be effective when paired with time delay and other naturalistic teaching strategies. Ilie use of a VOCA can be an effective tool

and Social Access

155

for increasing the social interactions of students with severe disabilities when (a) the skills arc taught in the natural contexts, (b) preference testing is used to increase the likelihood of reinforcing stimuli, (c) validated intervention strategies are used, and (d) acquisition, maintenance, and generalization of skills are monitored. The results of Ihis study also indicate that early childhood educators view the intervention strategies as practical for use in inclusive classrooms. ITiese strategies may provide an effective and socially valid way for educators to meet some of the social interaction needs of students with severe disabilities in their classrooms.

References
Arthur, M.. BtK:hner. S., & Butterfield. N. (I9*W). Enhancing peer interactions within the context of play. Inwrnationai Journul of Disabililv. Devehprneni ami Education, 46. .%7 381. Baker, M. J.. Koegel. R. L., & Koegel. L. K. (1998). Increasing the social behavior of young children with autism using their obsessive behaviors. Journal of the Association for Persons wiih Severe Handicaps. 23, 300 3t)M. Basil. C. (1992). Social interaction and learned helplessness in severely disabled children. Augmentative and Alternative Communiaition. S. IS8-199, Bergert, S., & Burneue, J, (2001). Educating ejtceptional children: A siatistUai profile. ERIC Clearinghouse on Disabilities and Gifted Education, Arlington, VA. Brady, M, P.. McEvoy, M, A.. Wehby, J.. & Ellis. D. (1987). Using peers as trainers to increase an autistic child's sodal interactions. Exceptional Child. 34. 213-219, Brady, M. P.. Shores. R. E., McEvoy. M. A., Ellis, D.. ^ Fox, J. (1987). Increasing social interactions of severely handicapped autistic children. Journal of Autism and i)evelopmental Disonkrs. 17. 375-390. Daugherty. S.. GHsham-Brown. J., & Hemmeter. M. L. (2001). Tile eftects ol' embedded skill instruction on the acquisition of target and non-target skills in preschoolers *ith developmental delays. Topics in Early Chiidhood Special Education, 2/. 213-221. Davis. C A.. Brady, M. P., Hamilton. R.. McEvoy, M. A., & Williams, R. E. (1994). Effects of high-probability requests on Ihe social interactions of young children with severe disabilities. Jottmid of Applied Behavior Analv.sis. 27. (il9-637. Filla, A., Wolery. M.. & Anthony, L. J. (1999). Prompliiig children's conversations during play with adult prompts. Journal of Early huervention. 22, 93-l(W. Fisher, M.. & Meyer, L. H. (2002). Development and stK'ial competence iifier two years for students enrolled in inclusive and self-contained educational programs. Research and Practice for Person.^ with Severe Disahiliiies. 27. 165-174. Foreman. P.. Arthur-Kelly. M., & Pascoe. S. (2004). Evaluating the educational experiences of students with protdund and multiple disabilities in inclusive and segregated ctas.sroom settings; An Australian perspective. Research and Practice for Persons with Severe Disabilities, 2^. 183-193. Cast, D. L., Jacobs, H, A., Logan, K. R., Streu Murray. A., Holioway, A., & Long. L. (2iK)0). Pre session assessment of preferences for studenLs with profound multiple disabilities. Educaiion and Training in Menial Retardation and Developmental Dmihilities. 35, 393-405. HaHng. T. G.. & Lovinger, L. (1989). Promoting sodal interaction through teaching generalised play initiation responses to preschool children with autism. Journal of the A,\sodaiion for Persons with Severe Handicaps. 14, 58-67.

Hestencs. L. L.. & Carroll. D. E. (2000). The play interactions of young children with and without disabilities: individual and environmental influences. Early Childhood Research Qmrierly, 15. 229-246. Hughes, C., Rung, L. L., Wehmeyer, M. L., Agran. M., Copeland. S. R.. &. Hwang, B. (2(XX)). Self-prompted communication book use to increase sodal interaction among high school students. Journal of the Association for Persons with Severe Handicaps. 25, 153-166. Hunt. P., Alwell, M.. Farron-Davis, F., & Goetz. L. (1996). Creating socially supportive environments for fully included students who experience multiple disabilities. Journal of the Assoviaiion for Persons with Severe Handicaps, 21. 53-71. Hunt, P. Farron-Davis, F.. Wrenn, M., Hirose-Hatae. A,. & Goetz. L. (1997). Promoting interactive partnerships in inclusive educational settings. Journal of the Association for Persons with Severe Handicaps. 22, 127-137. Johnston, S. S., Nelson. C. Evans, J., & Palazolo. K. (2003). The use of visual supports in teaching young children with autism spectrum disorder to initiate interactions. Augmentative and Alternative Communication. 19, 86-103. Jolly, A. C , Test, D. W., & Spooner, F. (1993). Using badges to increase initiations ot children with severe disabilities in a play setting. Journal of the Association for Persons with Severe Handicaps. 18, 46-51. Kazdin, A. E. (1982). Single-case research designs: Methods for clinical and applied settings. New York: Oxford University Press. Krantz, P J., & McClannahan, L. E. (1993). Teaching children with autism to initiate to peers: Effects of a script-hiding procedure. Journal of Applied Behavior Analysis, 26. 121-1.32. Kravits. T. R.. Kamps. D. M.. Kemmerer, K.. & Potucuk. J. (2{H)2). Brief report: Inereasing communication skills tor an elementary-aged student with autism using the Picture Exchange Communication System. Journal of Auiism and Developnienial Disorders, 32, 22.'i-230. Lilienfcld, M., & Alant, E. (2{K)5). The sodal interaction of an adolescent who uses AAC: The evaluation of a peer-training program. Augmeniafive and Alternative Comnnmicatitm, 21. 278-294. Logan, K., & Gast, D. L. (2001). Conducting preference assessments and reinforccr testing for individuals with profound multiple disabilities: Issues and procedures. Exceptionality. 9, 12.3-134. Logan, K.. Jacobs. H. A., Gast. D. L , Streu Murray. A., Daino. K., & Skala, C. (1998). The impact of typiciil peers on the perceived happiness of students with profound multiple disabilities. Journal of the Association for Persons yvith Severe Handicaps. 23. 309-318. Malmskog. S.. & McDonnell, A. P (1999). Teacher-mediated facilitation of engagement by children with developmental delays in inclusive preschools. Topics in Early Childhood Special Education, IV. 203 216. Mathy-Laikko. P, lacono. T. Ratcliff. A., VillarT\iel, F . Yoder, D.. & Vanderheidcn. G. (1989). Teaching a child with multiple disabilities to use a tactile augmentative communication device. Augmentative and Aliernaiive Communication. 5. 249-256. McConneU. S. R., Sisson. L. A., Cort.C. A., & Strain, P S. (19*^1). Eftects ot sodal skills training and contingency management on reciprocal interaction of presch(X>l children with behavioral handicaps. Journal of Special Education, 24, 473-495. McUskey. J., Henr>. D , & Htxlges. D. (1999). Inclusion: What progress is being made across disability categories? Teaching Exceptional Children. 60-64. Odom. S. L., Chandler, L. K.. Ostrosky, M., McConneU, S. R., & Reuney, S. (1992). Fading teacher prompts from peerinitiated inter\'entions for young children with disabilities. Journal of Applied Behavior Analysis, 25. 307-317.

156

Cosbey and Johaiton communication skills. Augmentative and Alternative Communication, 5. 192-198. Sigafoos. 1. Didden, R.. & O Reilly. M. (2(X)3). Effects of speech output im maintenance of requesting and frequency of vtjcalizations in three children with developmental disabilities. Augmentative and Alternative Conunimication, 19, Strain. F S,, & Hoyson, M. (2000), The need for longitudinal, intensive social skill intervention: LEAP follow-up outcomes for children with autism. Topics in Early Childhood Special Education. 20. 116-122. Weiner, J. S. (2005). Peer-mediated conversalional repair in students with moderate and severe disabilities. Re.\earch and Practice for Person.^ with Severe DLsnhilines. 30, 26-37. Woler>, M,. Anthony, L. J.. Caldwell. N. K,, Snyder, E. D . & Morgante, J. D. (2IH)2). Embedding and distributing constant time delay in drcle time and transitions. Topics in Early ChikUtood Special Education. 22. 14-26. Received: January 23. 2006 Final Acceptance: May 19. 21X16 Editor in Charge: June Downing

Okc. N. J., & Schreihman, L. (1990). Training stK-ia! initiations to a high-functioning autistic child: Assessment of collateral behavior change and generalization in a case study. Journal of Autism anil Developmental Disorders, 20. 47')-497. Peterson, C. A., & McConneU. S. R. (1993). Factoi-s affecting Ihe impact of sodal interaction skills interventions in early childhtKid special educaiion. Topics in Early Childhood Spe(iai Educaiion, 13. 38-56. Pierce, K.. & Schreibman, L. (1995). lncrcfising complex social behaviors in children with autism: Effects of peer-implemented pivotal response training. Journal of Applied Behavior Anahsis, 2H. 285-295. Romski. M. A., & .Sevcik. R. A. (1997). Augmentative and alternative communication for children with developmental disabilities. Mental Retardation and Developmental Disabilities Research Reviews, 3. 363 368, Schuster. J. W., Mor^ie, T. E.. Jones Ault, M.. Crawford, M. R., & Wolery, M. (1998). Constant time delay with chained tasks: A review of Ihe literature. Education and Treatment of Children, 21. 74-H)6. Sehweigert, P (1989). Use of microswitch technology to facilitate social contingency awareness as a basis for early