Running head: VISUAL CUES

Are visual schedules or verbal cues more effective in increasing levels of independence in
children with autism?
Sam Burneo and Sara Silverberg
Touro University Nevada

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Introduction

During our fieldwork we observed our fieldwork educator implementing visual cues
during treatment sessions. We wanted to investigate the efficacy of visual cues being used with
children with autism in a pediatric clinic. Our PICO question asked, Are visual schedules or
verbal cues more effective in increasing levels of independence in children with autism.
How does this study relate to your research question?
This study relates to our question because it focuses on the effects of verbal cues versus
pictorial cues with children with autism. The article sought to evaluate two techniques in
assisting children with autism accomplish two specific tasks. These tasks included setting the
table and setting up an art area. Successful completion of these techniques helped a child with
autism become more independent.
What is the purpose of the study?
West sought to evaluate the effects of verbal cues versus pictorial cues with children with
autism in teaching age appropriate skills. They looked at how many errors occurred at each step
of the task when using each specific cue. They also looked at the effects that the two cues had on
the children in regards to maintenance and generalization of doing the activities of setting a table
or setting up an art area.
What are the research questions/hypotheses?
While no hypothesis was specifically stated, it appears that the researcher was trying to
confirm that visual systems are the preferred method for students with autism.
Does the literature review justify the need for this study?
Research has shown that children with autism tend to have things done for them,
therefore, it is important to get them to be more independent. By having children with autism

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become independent, this can decrease their stress and improve their social interactions. The
literature review justifies the need for this study because, according to West, prior studies
comparing the two cues have not been completed. The technique of using picture schedules has
been seen as successful to teach self-management skills. Verbal stimuli has also been shown to
be used as a natural cue to encourage participation in child with autism. However, it is thought
that certain verbal cues may be difficult to comprehend for this population and may lead to
challenging behaviors.
What is the study design/type of study? What is the level of evidence?
The researcher utilized an adapted alternating treatment within a multiple baseline design.
This means that the researcher began by looking at and measuring specific traits to obtain a
baseline. Then the researcher administered the treatment and measured the specific trait to see if
there were any differences in the results. In this study, West administered a baseline phase, a preassessment procedure, a verbal cue phase, and a pictorial cue phase. This research is a level IV
study because it utilized multiple patients that received the same alternating treatment and did
not consist of a control or comparison group.
How many participants?
There were four participants in this study.
How were the participants recruited and selected?
Participants had to meet the following criteria: possess normal visual and auditory inputs,
ability to make eye contact and stay focused on objects for 2 to 3 seconds, and possess the ability
to wait at least 5 seconds to respond to a prompt given by an adult. All of the above information
was conveyed by teachers that directly worked with these four children.
If applicable, how were participants assigned to groups?

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This not applicable to this study because they did not assign the participants into any
groups.
How are the participants described?
Participants were diagnosed with Autism Spectrum Disorder before the age of two years
old and had no other disabilities. The children selected were ages three, four, five, and six. All
four children were males. They were all enrolled in a state-certified special education program
where the children in their classroom either had disabilities or normal development. The article
did not provide any information about ethnicity or race.
What are the variables? Independent and dependent if applicable.
The independent variables were pictorial and verbal cues while the dependent variable
was the child successfully completing each step of the task.
What measures were used?
There were three responses that were recorded during the baseline phase. A correct
response was given if the child responded to the cue within five seconds and then completed the
task within 30 seconds. An incorrect response was given if the child did anything other than what
was intended from the cue. No response was given if the child did not react after five seconds of
the cue being presented. In order to move on to the intervention, the participants had to be 100%
independent in every single task during one session. During the treatment procedures, the
researcher measured whether or not the participant had a correct or incorrect performance. There
were two correct responses for each step of the task which were unprompted corrects and
prompted corrects. This means that the child either responded by doing the task without a prompt
or within 5 seconds of the prompt. There were three incorrect responses for each step in the task
which were unprompted errors, prompted errors, and no response. This means that the child does

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not complete the task correctly within five seconds, does initiate the task but does not complete it
in time, and the child simply does not do the task at all.
If applicable, what is the intervention?
The two interventions presented in an alternating fashion were verbal and pictorial cues.
Each intervention consisted of five steps. Each child was given one on one instruction with a
female instructor. There were two female instructors in this study who were familiar with the
children because they had been assistants in their classrooms. Baseline was done in order to see
where the children were with the pictorial and verbal cues for setting up the table or the art
station until the children were 100% independent in every single task during one session. Next
the children moved on to a pre-assessment procedure to learn what type of prompt would help
evoke a response from the children when they did not respond to the verbal or pictorial cue.
These prompts were given in a hierarchical fashion which were gestural, partial physical, and full
physical assistance. The children then moved to training procedures that occurred daily Monday
through Friday and lasted fifteen minutes each. When a child finally reached a criterion for a task
they moved on to a maintenance probe which consisted of the intervention they found the most
effective with the child and had them do the tasks once again. There were also generalization
probes that were used to have the children practice these tasks in their classroom with unfamiliar
instructors at a natural time.
What statistical analyses were used?
The raw data was based on the performance of each child during each phase of the task.
They added all of the independent responses to determine a score after each session. The higher
the score, the more independent the child was. This was done during each phase of the study.
What are the findings?

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The findings found that three out of the four children had greater success when using
pictorial cues versus verbal cues. Only one child had more success using verbal cues over
pictorial cues. Pictorial cues only worked during one task for this one child, Mateo, but once it
was transferred to other tasks the pictorial cue did not work.
Do these findings support the hypothesis?
The results supports what the researcher thought which was again that pictorial cues are
more effective in children with autism over verbal cues.
How do the findings relate to previous research as described in the literature review?
West discovered in her extensive literature review that children with autism are visual
learners. Her findings indicate that children with autism have the cognitive and visual ability to
support communication and, further, assists with managing behavior. Prompts and prompt
fading have successfully been utilized as techniques to teach self-management and foster
independence. Prompts include a variety of modalities including pictorial, verbal and/or tactile
cues. Wests research indicates that while visual cues have been found most effective, verbal
cues may in fact be unbeneficial. Wests research reaffirmed the efficacy of visual stimuli when
working with children with autism.
Does the author state any clinical implications for the findings?
Clinical implications of this study suggest benefits for the child and parent. Visual cues
increase child independence and decrease dependence on parents and other adults which ease
stress and improve interactions. Increased independence and self-management skills have a
positive effect on behavior management. Ultimately, increased independence and selfmanagement skills allow the child to participate in a wider variety of occupations.
What are the limitations that the author identifies?

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The author identifies several limitations within her study. First, the study was conducted
outside of a clinic, which may have affected methodological rigor. The study was designed
around two varying tasks, each with five components. While it appears the author went to
lengths to choose tasks that were similar in nature, the author has no control over which tasks
may be more motivating for the participants. Level of difficulty and degree of exposure may
have impacted participants motivation to participate in the activity.
The author sought to assess the acceptability of the focus and outcome of intervention
without interviewing the examiners. The author notes information obtained from this data could
have been useful in creating program changes for consumers.
Lastly, while the research sought to increase levels of independence for children with
autism, it focused solely on the school environment. Family incorporation, maintenance and
generalization across environments were not addressed.
Does the author discuss implications for future research?
West suggests implementing more research to study whether the frequency and type of
cue influences outcomes when addressing challenging behavior. West suggests that
advancements in technology may impact the type of visual cues available for use and studies
should follow this trend. West indicates a broader study encompassing a larger sample, older age
group, and a wider range of task would be beneficial. Lastly, a study focusing on the
generalization of skill acquisition in the home setting would be beneficial.
What would you say about the sample size? Do you think it is adequate?
This was a very small sample size. While children with autism have general similar
characteristics, they are not a homogenous population. Implementation of this intervention needs
to thoroughly evaluate the individual client to determine if these strategies are appropriate.

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If the researcher did not find a significant difference between the groups, is it possible that
this is due to a Type II error? If so, why do you think so?
There were no group placements within this study, however, intervention methods
demonstrated a more positive outcome for three out the four participants with regards to pictorial
cues.
Is there a control or comparison group? If so, is the control or comparison group
comparable to the experimental group on key features?
There was no control group.
Are those administering the outcome measures blind to group assignment?
There were no group assignments in this research. Administrators were knowledgeable
of the outcome measures. The experiment was designed to include adapted alternating treatment
based on the reactions of participants. If administrators determined one intervention was more
effective over the other, then they were instructed to conclude with a final phase. In the final
phase, administrators administered the less effective and efficient method to assess if skill
acquisition improved with the least effective and efficient intervention approach when the more
effective and efficient approach was applied.
Are the participants blind to group assignment?
There were not group assignments in this research.
Does the researcher account for drop-outs in the study? Could drop outs have influenced
the outcomes?
There were no drop outs in the study.
Does the researcher report reliability and validity of the outcome measures? Are there
questions about the outcome measures chosen?

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While validity was not addressed, reliability was addressed. The author notes two types
of reliability were assessed: interobserver and procedural reliability. The author indicates that
data collection was conducted during each session. Interobserver reliability was collected for
each phase of treatment by using a point-by-point method. This method required the researcher
to divide the number of agreements by the number of agreements plus disagreements and
multiplied by 100.
Procedural reliability was conducted simultaneously with data collection across each
phase of intervention. Assessments measured across sessions included material arrangement and
accessibility, presenting task direction, waiting the appropriate time for responses, and providing
the appropriate prompt. To obtain the procedural reliability, the researcher divided the number of
correct instructor behaviors by the number of expected behaviors and multiplied by 100.
No concerns were presented about the outcome measures selected.
What confounding factors could contribute to or influence the study outcomes?
The author has no control over which tasks may be more motivating for the participants.
Level of difficulty and degree of exposure may have impacted participants motivation to
participate in the activity.
What are the major strengths of this study?
One of the major strengths of this study is that it confirms the efficacy of pictorial cue use
with children with autism. The alternating multiple baseline design catered to the participants in
that it was flexible and responded to their needs. If one cue was not effective in engaging the
child, the alternate cue was implemented. Lastly, participants were assessed prior to initiation of
treatment to assess preferred activity. This was important in motivating and encouraging
participation in the tasks.

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What are the major weaknesses of the study?

Three major weakness of this study are the small sample size, the lack of generalizability
across environments, and lack of instructor involvement when designing the study.
How would you use this article as a therapist?
I would incorporate the visual cue technique within my treatment sessions. It would
encourage participation, increase receptive and expressive language, ease transitions, and
establish expectations.
How does this article support/not support participation in occupation and the field of
occupational therapy?
This article supports participation in occupations. Too often children with autism have
things done for them, limiting their exposure and participation in occupations. Enabling and
encouraging independence has a positive lifelong effect on children with autism.

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Reference

West, E. (2008). Effects of verbal cues versus pictorial cues on the transfer of stimulus control
for children with autism. Focus On Autism & Other Developmental Disabilities, 23(4),
229-241.