Research in Developmental Disabilities 71 (2017) 200213

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Research in Developmental Disabilities

journal homepage: www.elsevier.com/locate/redevdis

Research Paper

Social skills plus relaxation training with a child with ASD in the MARK
schools

Margaret T. Floressa, , Kim Zoder-Martellb, Rachel Schaubc
a
Eastern Illinois University, 600 Lincoln Avenue, Charleston, IL 61920, USA
b
Ball State University
c
Eastern Illinois University

AR TI CLE I NF O AB S T R A CT

Number of completed reviews is 2 A social skills plus relaxation training (SSRT) program was developed using direct training, re-
Keywords: laxation training, and reinforcement principles. The aim was to examine the eectiveness of SSRT
Social skills training on increasing the frequency of three target behaviors for one 8-year-old, student classied with
Relaxation training autism spectrum disorder (ASD). A multiple-baseline across behaviors design was used to eval-
Autism spectrum disorder uate the eects of SSRT. During baseline, intervention, and maintenance sessions the students
School intervention responses were videotaped and then subsequently viewed and coded after the session. During
intervention, the students correct responses for the targeted social skills increased and were
maintained 17 weeks after SSRT ended. This study adds support for the use of this SSRT program
in a school setting with children who have ASD.

1. Introduction

Autism Spectrum Disorder (ASD) is a disorder characterized by decits in communication and social skills, and the presence of
repetitive behaviors or restricted interests (American Psychiatric Association, 2013). Children with ASD often demonstrate social skill
decits early in life and as they mature social interactions become more challenging. Even children identied as high functioning
due to fewer cognitive and language impairments, face social diculties (Allen, Wallace, Renes, Bowen, & Burke, 2010; DeRosier,
Swick, Davis, McMillen, & Matthews, 2011).
Common social skills decits often present in students with ASD include diculties interpreting others emotions and poor social
pragmatic skills (Bellini, Peters, Benner, & Hopf, 2007; Brooks & Ploog, 2013; Williams-White, Keonig, & Scahill, 2007). For example,
a child with ASD may have diculty interpreting both overt emotions (e.g., someone is in physical pain) and subtle emotions (e.g.,
someone is sad or frustrated). Additionally, students with ASD often have diculty greeting others, giving compliments, and listening
to others (Bauminger, 2002; DeQuinzio et al., 2007; Kamps et al., 1992; Leaf et al., 2012). For example, a child with ASD may have
diculty listening to others as demonstrated by not orienting their eyes and body toward the speaker. Not listening to others may
also be demonstrated by not reciprocating physical mannerisms that communicate paying attention, such as head nodding or vocal
agreements (e.g., yes, I see). A child who has diculty giving compliments may not notice social cues from others that bid for
acknowledgment of accomplishments (e.g., drawing a picture), or praise or admire someone else (e.g., I like your shoes) because they
have diculty taking someone else perspective. These decits can have detrimental eects for the student including withdrawal and
social isolation; peer rejection; an inability to participate in group activities; and diculties developing lasting friendships (Banda,
Hart, & Liu-Gitz, 2010; Bellini et al., 2007). In addition to these decits of ASD, individuals with ASD often present with anxiety,

Corresponding author.
E-mail addresses: moress@eiu.edu (M.T. Floress), kamartell@bsu.edu (K. Zoder-Martell), schaubr@charleston.k12.il.us (R. Schaub).

http://dx.doi.org/10.1016/j.ridd.2017.10.012
Received 24 February 2017; Received in revised form 4 October 2017; Accepted 12 October 2017
0891-4222/ 2017 Elsevier Ltd. All rights reserved.
M.T. Floress et al. Research in Developmental Disabilities 71 (2017) 200213

which can interfere with daily living (Reaven, Blakeley-Smith, Culhane-Shelburne, & Hepburn, 2012; Rotherham-Fuller &
MacMullen, 2011; Wood et al., 2009).
School-based interventions for students with ASD should target the core symptoms and common decits including communication,
social skills decits (Wilezynski, Menousek, Hunter, & Mudgal, 2007), and other underlying symptoms related to tension (White et al.,
2013). To address social skills decits, students with ASD may respond well to social skills training (SST). SST may include Social Stories,
social skills groups, video modeling, computer-based interventions, behavioral skills training, and peer-mediated interventions
(Caballero & Connell, 2010; Reichow & Volkmar, 2010; Walton & Ingersoll, 2013). The school setting is an ideal venue for implementing
SST, because many children with ASD will receive intervention services at school (Brookman-Frazee et al., 2009). There are several
purported benets to school-based intervention services including early intervention, the ability to use peer-mediated interventions and
social skills groups, and multiple opportunities for students to practice newly learned skills in a naturalistic environment (Bass & Mulick,
2007; Dekker, Nauta, Mulder, Timmerman, & de Bildt, 2014; Reichow & Volkmar, 2010; Williams-White et al., 2007).
Although intervention at school is ideal, school personnel often lack training to select and implement eective interventions to
address the complex needs of students with ASD and may benet from highly structured manualized interventions. Unfortunately,
few studies demonstrate the eective implementation of SST within the school setting (Kasari & Smith, 2013), and many of the
available studies rely on pre-and-posttest teacher evaluations of student behavior instead of direct observation of behavior. Since
children with ASD are likely to exhibit decits at school and will receive intervention services at school, it is important to develop
eective and feasible SST programs that can be implemented in a school setting.

1.1. Social skills training and deep breathing

Quality research focusing on interventions for children with ASD is limited due to methodological concerns and that most SST
studies are carried out in clinics or laboratories. Implementing intervention outside of school is often in vain when the goal is to
change the childs behavior within the school setting (DeRosier et al., 2011; Kasari & Smith, 2013; Rao, Beidel, & Murray, 2008). The
teaching interaction procedure (direct training) is an empirically-supported SST model that includes (a) teaching the skill, (b) ex-
plaining its importance and the steps to use the skill, (c) modeling, (d) practicing, and (e) rewarding correct responses (Leaf et al.,
2012). This procedure is similar to behavioral skills training (BST) where instructions, modeling, rehearsal, and feedback are used
(Miltenberger et al., 2004). Phillips, Phillips, Fixsen, and Wolf (1971) and Phillips, Phillips, Fixsen, and Wolf (1974) rst introduced
the teaching interaction procedure as part of the Achievement Place Teaching-Family Model and the eectiveness of this procedure
has been demonstrated in both individual (e.g., Leaf et al., 2009) and group (e.g., Leaf, Dotson, Oppenheim, Sheldon, & Sherman,
2010) settings. Both BST and the teaching interaction procedure use direct training. Evidence suggests that direct training is more
eective than interventions that employ indirect training (e.g., Social Stories). Leaf et al. (2012) found that children who received
direct training (i.e., teacher broke the skills down into smaller components, modeled the skill, had children role-play using the skills,
and praised children for using the skill correctly) successfully learned 18 skills taught, whereas children who were read a Social Story
for 45 min, three to six times a week only learned four of the 18 skills.
Because various studies suggest that children with ASD may experience tension and anxiety symptoms (Reaven et al., 2012;
Rotherham-Fuller & MacMullen, 2011; Wood et al., 2009), incorporating a relaxation component (such as deep breathing) within a
SST program may help teach children with ASD how to appropriately calm. Deep breathing is an empirically-supported relaxation
technique (Silverman, Pina, & Viswesvaran, 2008). Children with ASD are likely to benet from deep breathing not only because
learning to relax is an important adaptive skill, but children with ASD may become increasingly aware of their social decits, and
learning to relax may combat symptoms of tension, anxiety or depression (DeRosier et al., 2011). Wood et al. (2009) demonstrated
that children with ASD, aged 711 and with verbal IQ scores of 70 or higher, eectively decreased their anxiety symptoms after
participating in CBT. Despite the positive ndings of Wood et al., CBT is often time and resource intensive and may not be realistic in
the school setting. Adding a relaxation strategy (i.e., deep breathing) into existing SST programs may be benecial for students with
ASD. Further research is needed to investigate SST with a relaxation component that is delivered within the school setting.

1.2. Methodological limitations

SST for children with ASD as well as other groups at-risk for social skills decits has been shown eective (Bellini et al., 2007;
Lsel & Beelmann, 2003; McKenna, Flower, & Adamson, 2016). However, the existing literature presents some methodological lim-
itations, which should be addressed. First, many of the existing studies neglected to include direct observation of student behavior
following SST. Instead, researchers often rely on behavior rating scales as an outcome measure (Goforth, Rennie,
Hammond, & Schoer Closson, 2016; McKenna et al., 2016). In a review of the literature examining social skills development in
children with ASD, Williams-White et al. (2007) found that only 4 of the 14 studies included in the review used direct observation
measures. SST interventions are often implemented in group settings, and collecting in-depth data on all participants can be dicult
(Goforth et al., 2016); however, direct observation of student behavior is an important consideration.
In addition to the lack of direct observation data, studies examining the eectiveness of various social skills interventions often do
not include adequate maintenance and follow-up data (Bellini et al., 2007; Gresham, Sugai, & Horner, 2001; Lsel & Beelmann, 2003;
McKenna et al., 2016). Finally, some researchers have found that the existing SST literature lacks adequate treatment delity data

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(Bellini et al., 2007; Gresham et al., 2001; Lsel & Beelmann, 2003; McKenna et al., 2016), making it dicult to determine whether
the intervention is responsible for any observed changes in behavior. Therefore, further research that uses direct observation and
collects maintenance and treatment delity data to examine the eectiveness of SST in a school setting is needed.

1.3. Summary and purpose

Demonstrating appropriate social skills is an area of diculty for children identied with ASD. Because many children with ASD
will receive intervention services within the school setting, it is important for school personnel to be knowledgeable about empirically
supported SST programs. SST programs that eectively teach students social skills while also addressing adaptive life skills (i.e.,
knowing how to calm), may be especially advantageous because knowing how to calm may assist students in learning new social
skills. In addition, students may be more likely to apply calming strategies to future emotionally distressing situations. To our
knowledge no SST program has combined both direct social skills training with a relaxation strategy.
The purpose of this paper is to evaluate a training program that incorporates social skills plus relaxation (SSRT), implemented in
the school setting, with a child with ASD. Furthermore, this study extends the ndings of earlier studies by including direct ob-
servation of student behavior. The current study had two aims: 1) to examine the eect of a social skills intervention involving direct
training, relaxation training, and reinforcement principles on three target behaviors of a child with high functioning autism 2) and to
probe for social skill maintenance in the school setting. It was hypothesized that once the SSRT program was implemented, increases
in targeted skills would be observed and that these changes would be maintained at follow-up when the program was no longer being
implemented.

2. Method

2.1. Participants & setting

The participants in this study consisted of Sara (an 8-year-old female with an educational classication of ASD) and Saras
general education classroom teacher. Saras individualized education plan (IEP) was reviewed to conrm an educational classi-
cation of ASD. Her IEP revealed the following assessment results (see Table 1): Total score (28) on the Autism Diagnostic Observation
Schedule (ADOS; Lord, Rutter, DiLavore & Risi, 1999), overall score (81) on the Autistic Disorder Evaluation Scale-School Version
(ADES-SV; Arthaud & Duncan, 2008), Full Scale Intelligence Quotient (94) on the Stanford-Binet Intelligence Scale-Fifth Edition (SB5;
Roid & Barram, 2004), and an Adaptive Behavior Composite Score (81) on the Vineland-2 (Sparrow, Cicchetti, & Balla, 2005). Saras
most signicant decit areas on the Vineland were in the Communication (74) and Socialization (81) domains. In addition to meeting
educational criteria for ASD, to be included in the study, Sara needed to demonstrate a low percentage (040%) of target behaviors at
baseline, have good attendance, and have a documented IQ of 70 or higher. All inclusion criteria were met.
There were three other individuals involved in the study, the researcher and two trained undergraduate research assistants (RA).
The researcher, implemented the intervention during her second-year of school psychology graduate school training. Prior to im-
plementing the SSRT program, the researcher completed an independent study and presentation on ASD and empirically-based
interventions for ASD, graduate course work in behavioral therapy, and two supervised practica placements within the public
schools. The researcher did not have a relationship with Sara prior to the study.
The SSRT program took place at Saras elementary school and during the observed sessions, only one assistant was present along

Table 1
Individual Education Plan (IEP) Assessment Results.

Assessment Obtained Score ASD Cut o Scorea Classication

Autism Diagnostic Observation Schedule

Communication 14 5 Autism
Social Interaction 14 6 Autism
Communication & Social Interaction 28 12 Autism

Autistic Disorder Evaluation Scale-School Version

Restricted Range of Interest & Repetitive Behavior 2 Statistically Atypical
Overall Quotient 81 Statistically Atypical

Stanford-Binet Intelligence Scale-5th Ed

Full Scale IQ 94 Average

Vineland Adaptive Behavior Scales-2

Communication 74 Moderately Low
Socialization 81 Moderately Low
Adaptive Behavior Composite 81 Moderately Low

a
Scores above this point are suggestive of Autism.

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with the researcher. A conference room was used three times a week, after school for 3060 min. Included in the conference room
was one table, four chairs, one poster board for the researcher to write on, free play activities, and a token economy system. Sara
received small prizes as part of the intervention and at the end of the study. All intervention and data collection sessions were
videotaped. Saras mother was given copies of the videotaped sessions after the study was completed. No other incentives (monetary
or otherwise) were given to Sara, her mother, or Saras teacher.

2.2. Materials for the teacher

2.2.1. Social skills screener

To target specic social skills for intervention, a social skills screener was created for this study by modifying items from the
Social Skills Rating System (Gresham & Elliot, 1990) and the Autism Social Skills Prole (Bellini, 2006). The social skills screener
included ve questions that were completed by indicating on a Likert scale (1Never, 5Always) how often Sara demonstrated ve
social skills (i.e. greeting others, complimenting others, listening to others, expressing empathy, and joining others in play). The
screener included these specic skills because they were in-line with concerns reported by Saras teacher and were also identied in
the literature as common skill decits for children with ASD (Bauminger, 2002; DeQuinzio et al., 2007; Kamps et al., 1992; Leaf et al.,
2012). This screener was used because it was shorter than the existing screeners and could easily validate Saras teachers concerns
(thereby identifying target behaviors). This screener had both face and content validity (Sattler, 2008) because questions addressed
skill decits common among children with ASD.

2.3. Materials for the researcher

2.3.1. Social skill materials

Social skills materials included poster board with markers, a token economy system, homework assignments, free play activities
(i.e., Legos, coloring books, crayons, 48 piece Disney princess puzzles, blank paper for drawing), and facial expression pictures. A
poster board was used during each session to detail the steps used to teach and review deep breathing as well as each of the social
skills taught. Facial expression pictures were used to teach the social skill expressing empathy. Images were obtained from google
images by searching the following key words: facial expressions and social skills. Five images were selected of female children
with the following facial expressions: happy; sad; mad; excited; and afraid. Images were printed on plain paper. Each image was
approximately 2 inches 2 inches.

2.3.2. Token economy

The token economy included tokens that Sara could earn during the session and a prize bank where Sara could store tokens she
earned during the session. A menu of prizes Sara could buy (e.g., candy could be purchased for 3 tokens; art supplies could be
purchased for 6 tokens; miniature Disney princess dolls could be purchased for 10 tokens) with the tokens she earned was created.
The menu listed how many tokens each prize cost. Prior to the start of the intervention, prizes were purchased based on the
recommendation of Sara's mother.

2.3.3. Homework
Homework assignments were developed specically for this study and included questions for Saras mother to review with Sara at
home regarding the social skill learned and practiced that day. Homework assignments were included to increase home-school
collaboration regarding the SSRT program and to help facilitate the generalization of the social skills Sara to other environments.
Each homework assignment included four questions: 1) What did you learn today?; 2) Why is it important to _____ (listen to others,
express empathy, or give a compliment)?; 3) Show me how you _____ (listen to others, express empathy, or give a compliment); 4)
Show me how you use deep breathing.

2.4. Materials for the research assistants

2.4.1. Video camera

The intervention and data collection sessions were videotaped. To do this, a ip camera was placed on a tripod on a ledge
approximately ve feet in front of Sara. The camera was positioned behind the researcher, who was implementing the intervention, at
a raised height (approximately 4 feet) so that even though the camera was directly across from Sara, it was not in plain sight. The
camera was turned on prior to Sara entering the room to reduce potential reactivity during each session.

2.4.2. Social skills data sheet

Data collection sessions were videotaped and Saras responses to structured bids were viewed and scored after the session using
the social skills data sheet. Bids included verbalizations by the researcher intended to evoke a response from Sara. During the session,
the social skills data sheet (see Appendix A for an example) was used to guide the order of the bids. Leaf et al. (2012) used a similar
method to measure the frequency of targeted behaviors. In their study, an assistant engaged in a behavior that provided an op-
portunity for the participant to display the appropriate social skill (e.g., to measure giving compliments, the assistant showed a

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picture he/she had drawn to the child to see if they would provide a complement). For the current study, a new data sheet was
generated for each data collection session to compensate for order eects. Before each session, the researcher ipped a coin to
randomly assign trial administration to either the researcher or the assistant. Each trial contained three bids, which were delivered in
a specic order and counterbalanced.
After the session was over, the videotaped session was coded by the assistant and the researcher by viewing the tape and then
recording whether or not Sara displayed the correct behavior (see dependent variable for denitions). There were slight variations in
the social skills data sheet across intervention phases (i.e., IR0; IR25; IR20; IR15; see procedure section for more detail; see Appendix
B for an example), which allowed reinforcement during data collection to be thinned. This means that although some data collection
sessions had extra bids (i.e., bids followed by an opportunity to earn praise and a token if the response was correct), the total
number of bids where data were collected remained consistent across all phases (i.e., total of 30 bids, 10 bids for each of the three
target behaviors). Extra bids were never coded for data collection. To calculate the percentage of correct responses, the total number
of correct responses for each target behavior was totaled, divided by 10 and multiplied by 100.

2.5. Dependent variables

The dependent variable in this study were three target behaviors that were selected based on the social skills screener completed
by the teacher. Of the ve social skills screened, the top three most problematic behaviors reported by the teacher were identied for
intervention. These behaviors included complimenting others, listening to others, and expressing empathy. The target behaviors were
measured using the social skills data sheet. The following section provides the bids that were used to evoke target behaviors and the
correct responses. Bids and correct responses were developed based on the existing ASD literature (Blacher & Christensen, 2011;
Boucher, 2012; DeQuinzio et al., 2007; Kamps et al., 1992; Leaf et al., 2012).

2.5.1. Complimenting others

The bid: The researcher or assistant touched Saras shoulder to get her attention, gestured toward the activity, and said look what
I made, Im drawing a big picture, or a similar phrase that functioned in the same way (i.e., to bring attention to what the
researcher or RA wanted Sara to notice/acknowledge and compliment). Correct response: Sara responded by acknowledging the
researcher or RA and complimented them or their activity. Examples included Cool!, Wow!, I like your picture, or a similar
response. To be correct, Saras response also needed to be pragmatically appropriate, given the bid. For instance, if the bid was Look
at my picture and Sara responded by saying I like your shirt, Saras response would be marked incorrect.

2.5.2. Listening to others

The bid: The researcher or assistant said, Sara to obtain Saras attention. Correct response: Sara turned her body to the person
who gave the bid, oriented to their face, and made eye contact.

2.5.3. Expressing empathy

The bid: The researcher or assistant said, Ouch, or Aww man, sighed loudly, or made a similar bid that functioned in the same
way (i.e., to evoke a verbal expression of concern from Sara). Correct response: Sara verbally responded to the person who gave the
bid by expressing concern. Examples included Are you ok?, What happened?. To be correct, Saras response also needed to be
pragmatically appropriate, given the bid. For instance, if the bid was Ouch and Sara responded by saying Do you like pizza?,
Saras response would be marked incorrect.

2.6. Independent variable

The independent variable in this study was the SSRT program. The SSRT program is implemented directly with a child by using
the teaching interaction procedure (Leaf et al., 2012; Miltenberger et al., 2004). Both relaxation training and targeted social skills are
taught. The child is taught to relax via deep breathing, regardless of symptoms of anxiety, because knowing how to calm is an
adaptive skill that all children, but especially children with ASD, are likely to benet from (DeRosier et al., 2011). Skills are taught by
rst teaching the name, why it is important, and the specic steps involved in using the skill. The skill is also modeled for the child
and then the child practices using the skill. Social skills are practiced by approaching the child with a bid that is intended to evoke a
previously taught skill. If the child correctly demonstrates the skill, he/she earns a token and verbal praise. If the child fails to
demonstrate the skill or uses the skill incorrectly, they receive feedback on how to use the skill correctly. After practicing, the child
counts the tokens they earned and given an opportunity to exchange the tokens for small prizes. At the end of the session, the
homework assignment is reviewed with the parent and child and the child is encouraged to return the assignment at the next session.

2.7. Procedures

Permission to recruit and implement the SSRT program was obtained from elementary school administrators and the Institutional
Review Board (IRB). Once permission was obtained, special education teachers at the school were contacted and informed of the
study. They were encouraged to send home yers advertising the study with students who might be eligible to participate. Saras

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mother expressed interest in having her daughter participate and she and Saras teacher completed informed consent. Sara provided
verbal assent. Next, Saras teacher completed the social skills screener and based on the results complimenting others, expressing
empathy, and listening to others were targeted for intervention.
The study consisted of the researcher, who oversaw the implementation of the SSRT program and data collection, and two trained
research assistants (RAs), who assisted with SSRT implementation, data collection, and inter-observer agreement (IOA). The two RAs
were trained to code data by rst reviewing correct responses (see three of the ve operationalized responses above) for ve target
behaviors (i.e., greeting others, complimenting others, listening to others, expressing empathy, and joining others in play) that
corresponded with the Social Skills Screener. RAs were trained to code all ve behaviors because it was unclear which behaviors
would be targeted for intervention. Next, the researcher met with the RAs to review the correct responses and answer questions.
Finally, the RAs coded a training video independently. The video was made specically for this study and consisted of an adult
delivering a total of 10 bids (two for each of the ve target behaviors) to a young child who either responded correctly or incorrectly.
Prior to collecting data, RAs needed to achieve 80% IOA (percent agreement) with the researcher on the training video. IOA for both
RAs was 100%.
A multiple baseline (MBL) design across behaviors (i.e., complimenting others, expressing empathy, and listening to others) was
used to evaluate the eectiveness of the SSRT program. Baseline and experimental conditions were introduced across target behaviors
after varying the numbers of baseline sessions. Saras responses to structured bids corresponding to the target behaviors were vi-
deotaped and then subsequently viewed and coded after the session.
There are many reasons for using a MBL design to validate social skills interventions. First, MBL design does not require the
intervention to be removed to demonstrate experimental control. A MBL design also does not require the use of a control group and
therefore treatment is not withheld from any of the participants (Kazdin, 2011). MBL design also allows one to observe multiple
behaviors simultaneously while implementing the intervention in an individual, step-wise fashion. Finally, MBL design allows the
researcher to design the intervention for very specic behaviors, thereby individualizing the treatment (Kazdin, 2011), which is
important when working with individuals with ASD.

2.7.1. Baseline
During baseline Sara was seated at the table and told that she could play with the free play activities on the table. Baseline data
were collected by using the social skills data sheet to evoke the three target behaviors (i.e., complimenting others, expressing
empathy, and listening to others). After the session was over, the video was reviewed and coded. Baseline data were collected every
other day (i.e., Monday, Wednesday, Friday) until one of the target behaviors stabilized or there was a decreasing trend in the data,
with a minimum of three data points, as suggested by Kazdin (2011). Once baseline data were stable for one target behavior, the
researcher began the SSRT program beginning with the social skill that corresponded with the baseline target behavior that stabilized
rst. The social skill that corresponded with the next target behavior to have stable baseline data was introduced next. Once baseline
data were stable in the third target behavior, the last social skill was introduced. This ensured that baseline and intervention phases
for each behavior were staggered. No programed reinforcement was provided during baseline sessions.

2.7.2. SSRT program

The SSRT program included a total of 16 sessions. The program used the teaching interaction procedure, but was social skills
instruction was tailored specically to meet the needs of the participant in this study. Sessions lasted 3060 min and were im-
plemented 23 times a week. The following general outline was used for each training session: 1) introduce session 2) teach/review
deep breathing 3) teach/review social skill 4) practice social skills.

2.7.2.1. Step 1: introduce session. Once Sara entered the room, the researcher welcomed her to the session and built rapport by asking
her about her day. Then the researcher gave Sara a brief outline of what would occur during the session (e.g., today we will review
deep breathing and learn how to listen to others).

2.7.2.2. Step 2: teach/review deep breathing. During the rst session, Sara was taught to use deep breathing. During subsequent
sessions, the researcher reviewed the deep breathing exercise. The following steps were used to teach Sara how to deep breath: 1)
Identify the dierence between when your body is tense and relaxed. To do this the researcher discussed common physiological signs
that accompany feelings of being tense (e.g., sweaty palms, butteries in your stomach, tight muscles) and asked Sara if she ever
recognized these sensations. Then the researcher and Sara tensed and relaxed their arm muscles to practice recognizing the dierence
between tense and relaxed. 2) Breathe deeply (e.g., breathing in through your nose for 5 s, holding your breath for 3 s, and then
exhaling through your mouth for 5 s). To do this the researcher demonstrated deep breathing and then had Sara practice deep
breathing three times. 3) Discuss why and when to use deep breathing. The researcher explained or reminded Sara that it is a good
idea to use deep breathing when you feel tense or when you want to calm yourself.

2.7.2.3. Step 3: teach/review social skill. The researcher taught the social skill for that week and reviewed social skills that were taught
previous weeks. The following steps were used to teach social skills: 1) The reason for using the social skill and why it is important
was explained. For example, for teaching listening to others, Sara was told that it is important to listen to others because it show
respect, so you know what is going on, and so you can follow directions. Explanations were kept simple, so no more than three

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reasons were given. 2) The steps to use the social skill were taught. For example, for teaching listening to others, Sara was taught that
listening to others has three steps: rst you need to face the person by turning your shoulders toward the person, second you need to
look the person in the eye, and third you need to nod your head to indicate that you are listening. After the steps were taught or
reviewed the researcher modeled using the social skill with one of the RAs, then modeled using the skill with Sara, and nally had
Sara model the skill. When Sara modeled the skill correctly she was praised. If she did not complete one of the steps, she received
feedback and then asked to model the skill again.

2.7.2.4. Step 4: practice social skill. After teaching/reviewing the social skill, Sara was told to select a free play activity. This was done
so that Sara could practice using the skills (either taught and/or reviewed that day) in a less structured, more naturalistic setting.
Practicing the social skill(s) lasted approximately 5 min. During this time, the researcher and the assistant took turns using bids to
prompt Sara to demonstrate the social skill taught or reviewed that day. The bids used during practice were similar to the bids on the
social skills data sheet, however, they were delivered in an impromptu and naturalistic manner (i.e., the observer and individual
implementing the intervention did not use a data sheet to guide them). When Sara correctly demonstrated the social skill after a bid,
she was praised and earned a token. If Sara responded incorrectly she was given specic feedback of how she should respond in the
future. The number of bids reected the number of social skills taught or reviewed. For example, if only one skill had been taught,
three bids were given, whereas if two skills had been taught or reviewed, six bids were given. Sara had the opportunity to practice
each skill three times. When more than one social skill was practiced, bids for each social skill were mixed so that three similar bids
were never given consecutively. After practicing, the social skills session ended and data collection began. Sara was not cued that the
practice session was ending; however, the researcher signaled the assistant to let her know data collection was starting.

2.7.3. Intervention + no programed reinforcement

During the rst intervention phase, the researcher implemented the SSRT program as described above. The data collection was
implemented using the social skills data sheet. Thirty bids (10 for each of the three target behaviors) were given and Sara did not
receive any verbal praise or tokens when she responded regardless of correct responses. Providing or withholding tokens would bias
video coding because the coder would observe whether the assistant judged Saras response to be correct. Once all the bids were
given, the data collection session was over. Sara counted her tokens and had an opportunity to spend her tokens. After Sara spent
her tokens, the researcher gave her a homework assignment focusing on the social skill for that week. Sara was encouraged to
complete the assignment at home and told that if she returned the completed assignment she would earn a token. Saras mother was
also informed about the homework assignment.
During data collection, Sara verbally expressed confusion and distress as to why she was no longer receiving tokens for correct
responses (e.g., Sara asked, Where are my tokens? and Why arent you giving me any tokens now?). Saras reaction was likely due
to receiving tokens during the practice session, but not during the data collection session. This also suggested that Sara was unaware
of when practice sessions ended and when data collection began. To maintain rapport with Sara, changes were made to the remaining
data collection sessions so that 25% of the bids included reinforcement opportunities (i.e., extra bids), then 20%, and nally 15%.
These data collection sessions with extra bids are described next.

2.7.4. Intervention + reinforcement

The SSRT program was implemented as described above. The start of the data collection sessions were similar to the intervention
+ no programed reinforcement phase in that the researcher signaled the assistant to indicate that the data collection session was
starting. In addition to the 30 bids on the Social Skills Data Sheet, extra bids (where there were opportunities for reinforcement)
were given in which no data were collected (indicated by two asterisks placed next to the bid on the social skills data sheet; see
Appendix B for an example). When Sara correctly responded to extra bids, she received verbal praise and a token. This allowed her
an opportunity to receive a token for 25% of the bids (10 out of 40 bids); then 20% of the bids (7 out of 37 bids); then 15% of the bids
(5 out of 35 bids) delivered during the data collection session. The reinforcement (extra) bids were randomly intermixed among the
30 data bids. Therefore, the total number of bids given varied, but data was only collected on the 30 data bids. Once all bids were
given Sara had an opportunity to spend her tokens and sent home with a homework assignment covering the social skill for that week.

2.7.5. Maintenance
The maintenance phase was implemented the following school year, approximately 17 weeks after the intervention phase ended
to evaluate whether the SSRT program continued to be eective after the researcher was no longer providing the intervention. The
procedures for the maintenance phase were similar to baseline in that the SSRT program was not implemented. Similarly, to the other
phases, the video camera was turned on prior to Sara entering the room. Sara could play with toys available to her and she was
reminded about potential prizes she could earn with tokens. In addition to the 30 bids on the social skills data sheet, ve additional
extra bids were given in which no data were collected (indicated by two asterisks placed next to the bid on the social skills data
sheet). Therefore, Sara had an opportunity to receive a token for 15% of the bids (5 out of 35 bids). After all the bids were given, Sara
spent her tokens.

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2.8. Reliability

Inter-observer agreement (IOA) data were collected by the researcher and a research assistant for 100% of the baseline sessions,
80% of the intervention sessions, and 100% of the maintenance sessions using the social skills data sheet. IOA was calculated for
baseline, intervention, and maintenance phases to determine the percentage of agreement between observers during the data col-
lection sessions. IOA was calculated by counting the smaller number of correct responses by the larger number of correct responses to
obtain a percentage of discrepancy between observers (Cooper, Heron, & Heward, 2007). Across the data collection sessions, the
average IOA was 95% (range, 80%100%). At baseline IOA was 87%, intervention was 97%, and maintenance was 98%. Cohens
kappa coecient was also calculated to further examine the rate of agreement between observers (Viera & Garrett, 2005). A kappa
value of 0.693 was obtained, indicating substantial agreement between raters and further supports the reliability of the observations
conducted (Viera & Garrett, 2005).

2.9. Procedural integrity

A treatment integrity checklist was used to evaluate whether the SSRT program was implemented accurately and consistently. The
researcher and RA independently answered the six integrity questions while watching the videotaped session after the session had
ended. The checklist items asked: (a) Was calming reviewed? (b) Was the importance of the new social skill explained? (c) Were the
steps needed to use the new skill explained? (d) Was the new skill modeled? (e) Did Sara practice using the skill? (f) Did Sara receive
praise and tokens for using the skill correctly? If the item on the checklist was observed, a checkmark was placed next to that step.
The total number of checkmarks were added together and a percentage was calculated (e.g., if all six items were observed, 100%
treatment integrity was reported). Treatment integrity was collected for all intervention sessions by viewing the videotaped inter-
vention session and completing the treatment integrity checklist. Across all 10 sessions, treatment integrity was 100%. IOA for
treatment integrity was calculated by dividing the smaller number of treatment integrity items endorsed by the larger number of
items endorsed to obtain a percentage of discrepancy between observers (Cooper et al., 2007). IOA for treatment integrity was 100%.
To ensure that treatment was not provided during baseline and maintenance phases, procedural integrity data were collected.
Procedural integrity was collected by using the same treatment integrity checklist; however, if all six items were left unchecked,
100% procedural integrity was reported. During baseline, procedural integrity was 100%. During maintenance procedural integrity
was 83% because Sara did receive praise and tokens when she used the target skills correctly (item 6).

2.10. Data analysis

Visual analysis and eect size calculations were used to determine changes in the percent of correct target behaviors. The per-
centage of correct responses for each target behavior was calculated by dividing the number of correct responses observed, by the
total number of opportunities (10). Data were visually analyzed for level, trend, and variability around level and trend. Several
researchers have recommended analyzing single-subject experimental research (SSER) both visually and by calculating eect sizes
(Maggin et al., 2011; Olive & Smith, 2005). SMD is a benecial calculation in understanding the results of SSER studies due to its easy
calculation and its production of a Cohens d value. To calculate SMD the intervention mean is subtracted from the baseline mean and
divided by the standard deviation of the baseline (Olive & Smith, 2005). Eect sizes between 0 and 0.2 are considered small, 0.21 and
0.5 are medium, and 0.510.8 are large (Cohen, 1988).

3. Results

The percentage of correct responses that occurred across the three target behaviors is presented in Fig. 1 (mean percentages were
rounded to the nearest whole number). When the SSRT program was introduced the percentage of correct responses increased
immediately across all three target behaviors demonstrating a functional relation between the SSRT program and correct responses.
Maintenance data were collected 17 weeks after the SSRT program ended and the percentage of correct responses across each of the
three target behaviors remained high. SMD eect size comparisons for the targeted behaviors reect large eects (see Table 2).

3.1. Target behaviors

3.1.1. Complimenting others

At baseline the mean percentage of correct responses for complimenting others was 0% and remained stable with no variability.
When the SSRT program was introduced the percentage of correct responses immediately increased and stabilized. The average
percentage of correct responses for complimenting others during intervention was 76%. Seventeen weeks after the SSRT program
ended, maintenance data were collected. Complimenting others remained high and stable during maintenance with an average of
97%. SMD for complimenting others was 3.1, which was a large eect.

3.1.2. Expressing empathy

At baseline the percentage of correct responses for expressing empathy demonstrated a downward trend. The mean percentage of

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Fig. 1. Saras percentage of correct responses across target behaviors, with phase means. Note: Phase percentages (i.e., 0%, 25%, 20%, 15%) indicate the percentage of
extra bids delivered during data collection for which Sara could earn a token for responding correctly. Data was not collected on Saras responses to extra bids.

Table 2
Eect size and classication categories for Target Behaviors from Baseline Phase to Intervention Phase.

Target Behavior Eect Size Eect Size Classication

Complimenting Others 3.1 Large

Expressing Empathy 3.3 Large
Listening to Others 6.0 Large

correct responses was 28%. When the SSRT program was introduced the percentage of correct responses immediately increased,
although data were somewhat variable compared to the percentage of correct responses for giving compliments. The average per-
centage of correct responses during intervention was 71%. During maintenance, the percentage of correct responses declined to 63%
on average, but remained stable SMD for expressing empathy was 3.3, which was a large eect.

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3.1.3. Listening to others

At baseline the percentage of correct responses for listening to others was variable. The mean percentage of correct responses was
16%. When the SSRT program was introduced the percentage of correct responses immediately increased and remained high and
stable. The average percentage of correct responses during intervention was 92%. During maintenance, the percentage of correct
responses slightly increased to 97% on average and remained stable SMD for listening to others was 6.0, which was a large eect.

4. Discussion

The purpose of the current study was to examine the eects of the SSRT program on increasing three target behaviors (i.e.,
complimenting others, expressing empathy, and listening to others). Results demonstrated that the SSRT program had a direct and
lasting eect. Once the SSRT program was introduced correct responses for the three targeted behaviors increased and remained high
during the following school year. These results are promising because they provide preliminary support for the use of the SSRT
program as an eective method to increase socially-appropriate behaviors and maintain these behaviors over time. In addition, the
SSRT program was implemented within the school environment, which is key because children identied with ASD are likely to
receive the majority of their intervention at school. Results from this study also demonstrate direct and observable changes, which is
important considering that most SST programs are evaluated using indirect methods.
The results from the current study were consistent with previous research (Leaf et al., 2010, 2012), suggesting that direct training
using a teaching interaction procedure is eective for teaching social skills to children with ASD. However, one dierence is that in
the current study the participants correct responses to target behaviors remained high for all three target behaviors, even during
maintenance. In the Leaf et al. (2010) study, maintenance data for several target behaviors decreased and were variable. In the
current study, there were approximately four months in between the last data collection session and the rst maintenance session,
during which students were out of school for three months for summer break. The fact that each target behavior continued to be high
(two of which exceeded intervention percentages) and stable prior to and following summer break is likely a testament to the robust
nature and ecacy of the individualized SSRT program.
Maintenance results may have also remained high because the SSRT program taught a coping strategy. It is unclear to what extent
Sara beneted from deep breathing, however it is possible that learning this skill may have also accounted for dierences in the
results between the current study and previous research (Leaf et al., 2010, 2012). Teaching children with ASD coping skills (such as
deep breathing) may be particularly benecial considering that many higher functioning youth with ASD, also have anxiety (deBruin
et al., 2007; Joshi et al., 2010). Coping techniques are useful tools for all children when faced with uncomfortable or stressful
situations. Therefore, teaching coping strategies to children with ASD, who are more likely to experience discomfort when there are
changes in their environment (i.e., an unexpected change in routine), seems more than logical.
Although the current study found positive results during the maintenance phase, there were subtle dierences between the three
target behaviors. The percentage of correct responses for giving compliments and listening to others increased from intervention and
remained stable. The percentage of correct responses for expressing empathy decreased slightly from intervention, but remained
much higher than baseline. A slight decrease in expressing empathy during maintenance may have occurred because expressing
empathy tends to be a more dicult skill for children with ASD to master (Baron-Cohen, 2009), as it requires higher level thinking
skills and multiple steps. For instance, to express empathy, the child must listen to the words the other person says, look at their facial
expression to determine what emotion they are feeling, and gure out an appropriate response. In addition, expressing empathy
requires the child with ASD to be aware of the perceptions and emotions of others, which is not a skill that comes naturally for
children with ASD (Gould, Tarbox, OHora, Noone, & Bergstrom, 2011).

4.1. Limitations

Despite the positive ndings from this study, there are some limitations that warrant discussion. Although both RAs were never
explicitly made aware of the study phases, they may have known or assumed which phase was being conducted because of their
assistance with the SSRT program. To help prevent possible observer-expectancy eects (Rosenthal, 1976), the second assistant was
primarily involved in coding video from the data collection sessions. In addition, a high level of IOA was achieved (i.e., 95%) and the
majority of data points were coded identically between the researcher and the assistant. In addition, disagreements were decided
among the RAs to protect against possible observer-expectancy eects. The researcher informed the RAs there was a disagreement,
then both RAs individually reviewed the tape until a coding consensus was made. There were approximately two instances in which
IOA fell below 100% (i.e., 80%89%), which required the observer and the researcher to review the tape a second time. Although
80% IOA or higher is satisfactory, if IOA was less than 90% the video was re-reviewed and coded a second time.
A second limitation to the current study was the absence of a typical peer. Recruiting a typical peer to participate in the social
skills intervention was unsuccessful. Having a typical peer participate in the social skills group is benecial for various reasons
including increasing generalization of the skills taught to other settings (i.e., the classroom, playground). In addition, including a
typical peer in the social skills intervention increases the number of opportunities for children with ASD to engage with other children
in a positive and safe environment. Lastly, including a typical peer promotes individual dierences and diversity among typically
developing peers, which would hopefully make them more likely to demonstrate compassion and understanding for children with
disabilities.

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Finally, although this study was conducted in a school setting, it may not mimic naturalistic conditions. The SSRT sessions were
conducted after school by a trained graduate student, therefore it is unclear whether similar results would be obtained if sessions
were implemented during the school day by school sta.

4.2. Future research

In the future, this study should be replicated to provide more support to the preliminary ndings. To improve eciency, future
studies should evaluate whether the SSRT training is eective with fewer (i.e., two sessions) per week. In addition, future research
should evaluate whether the percentage of correct responses remains high if reinforcement were faded out completely (i.e., 0%
reinforcement rate). While the rate of reinforcement was faded as sessions progressed, it was not entirely removed. Future researchers
should consider eliminating the rate of reinforcement during the maintenance phase of the study, if not nearing the end of the
intervention phase.
Future studies should also examine whether increases in correct responding generalize to the classroom and home settings. The
homework assignments used in the current study were intended to assist with generalizing skills to other environments, however
whether these skills generalized to other environments was not measured. Although the assignments were reviewed with Saras mom,
the completed homework was never returned. Future studies might examine whether using videotaped sessions increases general-
ization. It was speculated that giving Sara the videos may have helped her maintain the social skills she learned. Giving children
videos of themselves correctly using social skills may be a generalization tool they can use independently, compared to homework
assignments that require parent participation.
Lastly, future studies should replicate SSRT with additional children with ASD, as well as train school personnel to implement the
program. One of the unique and benecial aspects of this study is the fact that the SSRT program was created to address individual
childrens social decit needs. Future studies should continue to match the SSRT program to the individual child by using a screener
to target specic areas of need and then formatting the SSRT program to teach the needed skills. Obtaining the childs perspective
regarding areas of improvement compared to teacher report would also be interesting. Finally, continuing to nd ways to implement
this program at school is key. Future researchers might consider implementing an SSRT program as part of a small pull-out group,
embedded within after school care. Many children participate in after-school care, located at their elementary school. Providing an
option for both targeted students (who would benet from SSRT) as well as peer models to participate in a social skills pull-out group
may also have a positive eect on overall school climate.

4.3. Implications

The Social Skills Intervention implemented in this study was an individualized approach that included various components. It is
unclear which components had an impact on the target behaviors because the current study examined all the components together
and are therefore interconnected. Consequently, if an individual uses the SSRT program with other students with ASD, it is important
that each component is included and implemented with integrity. Future research might attempt to examine each of the components
(i.e., direct training, deep breathing, verbal praise, token reinforcement, rate of reinforcement) separately to determine their in-
dividual impact on increasing target behaviors.
It is also important to investigate additional methods for teaching specic target behaviors (i.e., expressing empathy). Some skills
are likely to be more dicult for children to master. It is important to continually evaluate and examine the way in which social skills
are taught to maximize learning. Expressing empathy is reportedly a more challenging skill to master for many children with ASD, so
developing more eective strategies to teach children with ASD how to identify emotions in others and determine what others might
be feeling would be benecial to the eld.
Furthermore, persons reading the results of this study should be informed that the intervention and therefore the results are
limited to the participant involved in the study or others with similar characteristics to the participant in this study. This information
is useful when planning interventions for Sara or when considering interventions for individuals with similar characteristics to Sara.
It would be inappropriate to implement a district-wide social skills intervention like the one developed for the current study, because
the intervention was tailored specically to Saras concerns and characteristics.
Overall this study adds valuable information to the literature surrounding social skills intervention plus anxiety reduction with
children with ASD. It provides promising preliminary results in support of a cost-eective strategy that can be implemented to
increase the occurrence of socially-appropriate behaviors.

Acknowledgements

The authors would like to thank Morgan Nesbitt and Taylor Sauerwein for their assistance with this project and the participating
school for their support.

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Appendix A. Social Skills Data Sheet

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Appendix B. Social Skills Data Sheet

References

Allen, K. D., Wallace, D. P., Renes, D., Bowen, S. L., & Burke, R. V. (2010). Use of video modeling to teach vocational skills to adolescents and young adults with autism
spectrum disorders. Education and Treatment of Children, 33, 339349.
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: APA.
Arthaud, T. J., & Duncan, K. (2008). Autistic disorder evaluation scale (ADES). Hawthorn Educational Services Inc.
Banda, D. R., Hart, S. L., & Liu-Gitz, L. (2010). Impact of training peers and children with autism on social skills during center time activities in inclusive classrooms.
Autism Spectrum Disorders, 4, 619625. http://dx.doi.org/10.1016/j.rasd.2009.12.005.
Baron-Cohen, S. (2009). Autism: The empathizing-systemizing (E-S) theory. Annals of the New York Academy of Sciences, 1156, 6880. http://dx.doi.org/10.1111/j.
1749-6632.2009.04467.x.
Bass, J. D., & Mulick, J. A. (2007). Social play skill enhancement of children with autism using peers and siblings as therapists. Psychology in the Schools, 44(7),

212
M.T. Floress et al. Research in Developmental Disabilities 71 (2017) 200213

727735.
Bauminger, N. (2002). The facilitation of social-emotional understanding and social interaction in high-functioning children with ASD: Intervention outcomes. Journal
of ASD and Developmental Disorders, 32, 283298.
Bellini, S., Peters, J. K., Benner, L., & Hopf, A. (2007). A meta-analysis of school-based social skills interventions for children with autism spectrum disorders. Remedial
and Special Education, 28(3), 153162. http://dx.doi.org/10.1177/07419325070280030401.
Bellini, S. (2006). Autism social skills prole. Retrieved on line from http:www.ocali.org/up_doc/Autism_Social_Skills_Prole.pdf on October 2012.
Boucher, J. (2012). Putting theory of mind in its place: Psychological explanations of the socio-emotional-communicative impairments in autistic spectrum disorder.
ASD, 16, 226246.
Brookman-Frazee, L., Baker-Ericzen, M., Stahmer, A., Mandell, D., Haine, R. A., & Hough, R. L. (2009). Involvement of youths with autism spectrum disorders or
intellectual disabilities in multiple public service systems. Journal of Mental Health Research in Intellectual Disabilities, 2, 201219. http://dx.doi.org/10.1080/
19315860902741542.
Brooks, P. J., & Ploog, B. O. (2013). Attention to emotional tone of voice in speech perception in children with autism. Research in Autism Spectrum Disorders, 7,
845857.
Caballero, A., & Connell, J. E. (2010). Evaluation of the eects of social cue cars for preschool age children with autism spectrum disorders (ASD). Journal of Behavior
Assessment and Intervention in Children, 1(1), 2542.
Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, New Jersey: Erlbaum.
Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). Applied behavior analysis (2nd ed.). New Jersey: Pearson Prentice Hall.
deBruin, E. I., Ferdinand, R. F., Meester, S., De Nijs, F. A., & Verheij, F. (2007). High rates of psychiatric co-morbidity in PDD-NOS. Journal of Autism and Developmental
Disorders, 37, 877886.
DeQuinzio, J. A., Townsend, D. B., Sturmey, P., & Poulson, C. L. (2007). Generalized imitation of facial models by children with ASD. Journal of Applied Behavior
Analysis, 40, 755759.
DeRosier, M. E., Swick, D. C., Davis, N. O., McMillen, J. S., & Matthews, R. (2011). The ecacy of a social skills group intervention for improving social behaviors in
children with high functioning ASD spectrum disorders. Journal of ASD and Developmental Disorders, 41, 10331043.
Dekker, V., Nauta, M. H., Mulder, E. J., Timmerman, M. E., & de Bildt, A. (2014). A randomized controlled study of a social skills training for preadolescent children
with autism spectrum disorders: Generalization of skills by training parents and teachers? BMC Psychiatry, 14, 189. http://dx.doi.org/10.1186/1471-244X-14-189.
Goforth, A. N., Rennie, B. J., Hammond, J., & Schoer Closson, J. K. (2016). Strategies for data collection in social skills group interventions: A case study. Intervention
in School and Clinic, 51(3), 170177. http://dx.doi.org/10.1177/1053451215585806.
Gould, E., Tarbox, J., OHora, D., Noone, S., & Bergstrom, R. (2011). Teaching children with autism a basic component skill of perspective-taking. Behavioral
Interventions, 26, 5066.
Gresham, F. M., & Elliot, S. N. (1990). Social skills rating system (SSRS). Circle Pines, MN: American Guidance Service.
Gresham, F. M., Sugai, G., & Horner, R. H. (2001). Interpreting outcomes of social skills training for students with high-incidence disabilities? Exceptional Children,
67(3), 331344.
Joshi, G., Petty, C., Wozniak, J., Henin, A., Fried, R., Galdo, M., et al. (2010). The heavy burden of psychiatric comorbidity in youth with autism spectrum disorders: A
large comparative study of a psychiatrically referred population. Journal of Autism & Developmental Disorders, 13611370. http://dx.doi.org/10.1007/s10803-010-
0996-9.
Kamps, D. M., Leonard, B. R., Vernon, S., Dugan, E. P., & DelQuadri, J. C. (1992). Teaching social skills to students with ASD to increase peer interactions in an
integrated rst-grade classroom. Journal of Applied Behavior Analysis, 25, 281288.
Kasari, C., & Smith, T. (2013). Interventions in schools for children with autism spectrum disorder: Methods and recommendations. Autism, 17, 254267. http://dx.doi.
org/10.1177/136236131247-496.
Kazdin, A. E. (2011). Single-Case research designs (2nd ed.): Methods for clinical and applied settings. New York: Oxford University Press.
Lsel, F., & Beelmann, A. (2003). Eects of child skills training in preventing antisocial behavior: A systematic review of randomized evaluations. The Annals of the
American Academy of Political and Social Science, 587, 84109.
Leaf, J. B., Taubman, M., Bloomeld, S., Palos-Rafuse, L. I., McEachin, J. J., Leaf, R. B., et al. (2009). Increasing social skills and prosocial behavior for three children
diagnosed with ASD through the use of a teaching package. Research in ASD Spectrum Disorders, 3, 275289.
Leaf, J. B., Dotson, W., Oppenheim, M. L., Sheldon, J. B., & Sherman, J. A. (2010). The eectiveness of group teaching interactions for young children with a pervasive
developmental disorder. Research in ASD Spectrum Disorders, 4, 186198.
Leaf, J. B., Oppenheim-Leaf, M. L., Call, N. A., Sheldon, J. B., Sherman, J. A., Taubman, M., et al. (2012). Comparing the teaching interaction procedure to social stories
for people with ASD. Journal of Applied Behavior Analysis, 45, 281298.
Lord, C., Rutter, M., DiLavore, P. C., & Risi, S. (1999). Autism diagnostic observation schedule (ADOS). Los Angeles, CA: Western Psychological Services.
Maggin, D. M., Swaminathan, H., Rogers, H. J., OKeee, B. V., Sugai, G., & Horner, R. (2011). A generalized least squares regression approach for computing eect
sizes in single-case research: Application examples. Journal of School Psychology, 49, 301321.
McKenna, J. W., Flower, A., & Adamson, R. (2016). A systematic review of function-based replacement behavior interventions for students with and at risk for
emotional and behavioral disorders? Behavior Modication, 40(5), 678712.
Miltenberger, R. G., Flessner, C., Gatheridge, B., Johnson, B., Satterlund, M., & Egemo, K. (2004). Evaluation of behavioral skills training to prevent gun play in
children. Journal of Applied Behavior Analysis, 37, 513516.
Olive, M. L., & Smith, B. W. (2005). Eect size calculations and single subject designs. Educational Psychology, 25, 313324.
Phillips, E. L., Phillips, E. A., Fixsen, D. L., & Wolf, M. M. (1971). Achievement place: Modication of the behaviors of pre-delinquent boys within a token economy.
Journal of Applied Behavior Analysis, 4, 4559.
Phillips, E. L., Phillips, E. A., Fixsen, D. L., & Wolf, M. M. (1974). The teaching-family handbook (2nd ed.). Lawrence: University Press of Kansas.
Rao, P. A., Beidel, D. C., & Murray, M. J. (2008). Social skills interventions for children with Aspergers Syndrome or high functioning ASD: A review and re-
commendations. Journal of ASD and Developmental Disorders, 38, 353361.
Reaven, J., Blakeley-Smith, A., Culhane-Shelburne, K., & Hepburn, S. (2012). Group cognitive behavior therapy for children with high functioning ASD spectrum
disorders and anxiety: A randomized trial. Journal of Child Psychology and Psychiatry, 53, 410419.
Reichow, B., & Volkmar, F. R. (2010). Social skills interventions for individuals with autism: Evaluation for evidence-based practices within a best evidence synthesis
framework. Journal of Autism and Developmental Disorders, 40(2), 149166.
Roid, G., & Barram, R. (2004). Essentials of Stanford-Binet intelligence scales (SB5) assessment. Hoboken, New Jersey: John Wiley & Sons, Inc.
Rosenthal, R. (1976). Experimenter eects in behavioral research. New York: Irvington.
Rotherham-Fuller, E., & MacMullen, L. (2011). Cognitive-behavioral therapy for children with ASD spectrum disorders. Psychology in the Schools, 48, 263271.
Sattler, J. M. (2008). Assessment of children: Cognitive foundations. San Diego: J.M. Sattler.
Silverman, W. K., Pina, A. A., & Viswesvaran, C. (2008). Evidence-based psychological treatments for phobic and anxiety disorders in children and adolescents. Journal
of Clinical Child and Adolescent Psychology, 37, 105130. http://dx.doi.org/10.1080/15374410701817907.
Sparrow, S., Cicchetti, S., & Balla, V. D. (2005). Vineland adaptive behavior scales (2nd ed.). Circle Pines, MN: American Guidance Service.
Viera, A. J., & Garrett, J. M. (2005). Understanding interobserver agreement: The kappa statistic. Family Medicine, 37, 360363.
Walton, K. M., & Ingersoll, B. R. (2013). Improving social skills in adolescents and adults with autism and severe to profound intellectual disability: A review of the
literature. Journal of Autism and Developmental Disorders, 34(3), 594615.
White, S. W., Ollendick, T., Albano, A. M., Oswald, D., Johnson, C., Southam-Gerow, M., et al. (2013). Randomized control trial: Multimodal anxiety and social skill
intervention for adolescents with autism spectrum disorder. Journal of Autism and Developmental Disorders, 43, 382394.
Wilezynski, S. M., Menousek, K., Hunter, M., & Mudgal, D. (2007). Individualized education programs for youth with autism spectrum disorders. Psychology in the
Schools, 44, 653666. http://dx.doi.org/10.1002/pits.20255.
Williams-White, S., Keonig, K., & Scahill, L. (2007). Social skills development in children with autism spectrum disorders: A review of the intervention research.
Journal of Autism and Developmental Disorders, 37, 18581868.
Wood, J. J., Drahota, A., Sze, K., Har, K., Chiu, A., & Langer, D. A. (2009). Cognitive behavioral therapy for anxiety in children with ASD spectrum disorders: A
randomized controlled trial. Journal of Child Psychology and Psychiatry, 50, 224234.

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