TEACHING CHILDREN WITH AUTISM TO WAIT PATIENTLY

Clemson University – Romania

BCBA/ BCaBA Course Sequence Applied Behaviour Analysis

Iulia Octavia Mukbel (Nadlacan)

2019
 Abstract

The purpose of the current study is to deliver an accurate aproach, in the area of
teaching children diagnosed with autism spectrum disorder on how to comply by waiting
patiently when instructed so, without engaging in other behaviors. A changing criterion
design was used across a total number of thirthy eight sessions, to evaluate the effects
differential reinforcement of an alternative behavior has, on changing the behavior into
obtaining the compliance of waiting patiently when instructed. Results in this study, clearly
indicate that during the intervention, in all 3 phases, the participant aquires the skill of
waiting patiently upon instruction, meeting in this way the criterion previously set for the
target behavior.

Introduction

Over the past two decades, an increase in access to large and diverse samples has
given researchers the ability to determine that, in many cases, autism spectrum disorder
(ASD) symptoms are best represented in a two-domain model of social-communication
deficits and restricted and repetitive interests/behaviors (RRB) (Rebecca Grzadzinski,
Marisela Huerta and Catherine Lord, 2013). This has scientifical relevance to the subject
discussed in this paper because in both instances, social-comunication deficits and RRB, the
concept of compliance in the form of wait training holds great value in order to overcome
challanges children who have ASD symptoms face in all developmental areas.

David A. Wilder in his article from 2012, argues that, opposed to compliance,
noncompliance is defined as the failure to follow a specific teacher- or caregiver-delivered
instruction (Forehand, Gardner, & Roberts, 1978). Although estimates vary, noncompliance
has been reported to occur in up to half of children between the ages of 15 months and 4 years
and is the most common childhood behavior problem for which treatment is sought (Bernal,
Klinnert, & Schultz, 1980). In addition, noncompliance at a young age is correlated with a
number of psychiatric diagnoses later in life, such as oppositional defiant disorder and
conduct disorder (Keenan, Shaw, Delliquadri, Giovannelli, & Walsh, 1998). He states that,
interventions to increase compliance, and thus address noncompliance, have been organized
into two categories: antecedent-based interventions precede the opportunity for the child to
comply such as advance notice, rationales, and the high-probability (high-p) instructional
sequence, with mixed results efficiency wise and consequence-based interventions that
involve the delivery or removal of a stimulus after compliance or noncompliance which were
more effective than antecedent-based. Common consequence-based interventions include
differential reinforcement and time-out from positive reinforcement (e.g., Bouxsein, Roane, &
Harper, 2011). Differential reinforcement involves the delivery of praise, edible items, or
tangible items contingent on compliance (David A. Wilder et al, 2012).

Some young children exhibit impulsive behavior (i.e., choosing a smaller but
immediate reinforcer over a larger but delayed reinforcer), whereas others exhibit self-control
(i.e., choosing a larger but delayed reinforcer over a smaller but immediate reinforcer). In his
article from 2012, Matthew H. Newquist says that establishing or enhancing self-control
might be important for several reasons. First, self-control may result in access to more
preferred items, activities, and interactions (Hanley, Heal, Tiger, & Ingvars- son, 2007;
Mischel, Ebbesen, & Zeiss, 1972; Schweitzer & Sulzer-Azaroff, 1988). Second, children
often encounter situations throughout the day in which they cannot have immediate access to
certain items, activities, or interactions - these common situations in which reinforcement is
delayed may evoke problem behavior (e.g., inappropriate vocalizations, tantrums). Third,
previous research has shown that self-control in early childhood is correlated with academic,
social, and coping skills in adolescence (Mischel, Shoda, & Peake, 1988; Mischel, Shoda, &
Rodriguez, 1992).

Even though a number of studies have demonstrated the effectiveness of functional

communication training to establish socially acceptable communication for children who have
little or no functional speech it is equally important to aquire self-control in order to master
and mantain a repertoair consisting of a functional relation between those socially accepted
communication skills and the ability to understand and to follow social cues that imply
compliance and more specifically, waiting .

This present study, made it it’s purpose to demonstrate that children can be thought
using a changinng criterion design and can benefit from wait training.
 1. Method

1.1 Participants

The present study was conducted around one participant, Roby, a 5 and a half year old
boy diagnosed with Autism Spectrum Disorder (ASD), who did not undertake any applied
behavior analysis sessions prior to this study taking place. He was involved in other forms of
interventions in the area of pseudo-science such as Sensory Integration Therapy (SIT), also
Speech Therapy and Play Therapy. He was involved in SIT sessions for one and a half years
prior to the experiment and in Play Therapy at a local center since his diagnosis, for two years
before he started SIT. Right now he attends kindergarten 3 days per week for 2 hours, he is
also involved in Speech Therapy at another center and as of 7th of January 2019 his
intervention program consists of daily ABA sessions for 2 hours per day, in the therapy
center.

Roby, although verbal, does not mand yet, he has a repertoir of „waiting” consisting of
fidgeting and fussing, running around, lifting his hands up above his head, making
uninteligible noises, taking the tangibles of the table or shelf when in reach, manipulating the
objects placed in front of him on the table or on the floor. In short, he does not master the
ability of waiting patiently without engaging in other behaviors (like the ones listed above)
nevermind the ability of waiting patiently in the waiting room, in line or waiting his turn.

1.2 Materials and settings

In both the baseline and the intervention condition, the sessions were conducted in the
same room of therapy in the center. All the sessions took place in the form of 1:1 with one
single teacher, who is his therapist. The sessions were documented in order to make the data
collection possible. Prior to inception of the study a written consent agreement was signed by
the parents. The room was organized as follows: a round green table, 5 little green chairs, a
shelf consisting in 4 rows and 4 columns with games, books, cars and other toys, a timer and
edible reinforcers (salty corn puffs and sweet wheat cereal) wich were used for the training
sessions.

To conduct the study we used the table, the chairs, salty corn puffs and/or sweet wheat
cereal, as described above and a timer. One to three sessions were conducted each day that
consisted of 5 trials per session.
1.3 Response Definitions and Interobserver Agreement (IOA)

The target behavior pursued in this study is „waiting patiently” and has the following
topography: Roby is sitting on the chair at the table with his hands resting on the table, palms
down, positioned one on top of the other, with the fingers sitting togheter and the tumbs close
to the chest, silently. All other behaviors that occured during the wait time, such as fidgeting
and fussing, getting up and leaving the chair and table area, running around, lifting the hands
up above the head, making uninteligible noises, taking the edibles of the table were in
opposition with the targert behavior, therefore were considered to be in the category of other
behaviors that interacted in an unwanted way with the teaching of the desired topography of
what waiting behavior should look like.

Interobserver Agreement (IOA) was assesed by having the author scorring in

agreement in a number of 32 sessions (160 trials) out of a total of 38 sessions (190 trials)
conducted by Roby’s therapist. The interobserver agreement was calculated using the trial by
trial method, in wich the number of agreements was divided by the total number of the trials
and multiplying it by 100. The agreement score is, in this case, 84%.

1.4 Experimental design and procedures

The effects of the intervention on the subject’s compliance with waiting patiently were
evaluated using a changing-criterion design. Prior to the start of the study, the author
explained the baseline phase and treatment phase procedures to both participant’s parents and
to the therapist conducting the intervention, as well. As stated above, each session consisted
of 5 trials, with a total of 3 sessions per day.

1.5 Baseline

Baseline was held in the first days of Roby entering our facility. The therapist created
a contingency in wich she placed in the middle of the table Roby’s favorite edibles (salty corn
puffs or sweet wheat cereal – acording to his parents testimonies) while Roby was sitting on
the chair at the table and giving the instruction „Wait!”. Baseline was conducted during three
sessions, consisting of five trials for each session, in three consecutive days.
1.6 The dependent and independent variables

The dependent variable consisted of the number of the correct demonstrations of an

waiting behavior (as described in 2.3 Response Definitions) once given the instruction
„Wait!”, for five trails for each session. The independent variable consisted of the
manipulation of the edible reinforcement, manipulating the timer and offering the manual
gesture of „wait”.

1.7 Intervention

Intervention was conducted using intervals at 3 seconds, 5 seconds, 10 seconds and the
crossover criterion at a new interval was 5 consecutive correct sessions per interval. The
author explained and the therapist implemented the following intervention procedure while
using the crossover criterion each time the child succeded in giving 5 consecutive correct
sessions per interval:

• SD: The therapist places the preffered edible on the table (salty corn puffs or
sweet wheat cereal – a quick preference assessment was conducted every time
to see which reinforcer holds the best value, per session).

• Answer: Try to take the object / stretch after it / show the subject / tells its
name/puts his had up.

• SD: The therapist makes the gesture "Wait" (hands up with his palm up facing
the child) and says "Wait" + lets go to timer placed between the child and the
edible reinforcer.

• Answer: It stops from trying to get the item and waits for 3/5/10 seconds

• SD: Ready! You can take (item)

• Consequence: Therapist offers the preffered edible immediately.

A Correct (C) answear - waiting patiently (as defined earlier), was immediately
provided with a contingent concequence, such as social praise and the preffered edible
reinforcer. Every time the child tried to take the item was scored as an Incorrect (I) answer
and the trial ended.

Follow-up sessions were held in order to evaluate the stability of the target behavior.
 2. Results

Figure 1, represented below, shows the number of seconds Roby succeeded to wait as
part of his training intervals on waiting patiently. In the baseline section, as seen below, Roby
did not stop and wait at the hearing of the instruction given by his therapist „Wait” and
proceeded in taking the edible from the table, on a number of 3 sessions each consisting of 5
trials in 3 consecutive day (1 session per day), after which he engaged in self-stimulatory
behaviors.

The intervention phase had 3 criterions on which the waiting skill was built. First, in
the „wait 3 sec” phase that the child, when given the SD with the timer and the hand gesture
that simbolizes „wait”, gives an answer consisting in waiting, but not to meet criterion of 3
seconds. He follows the first Incorrect session by 3 more sessions in which, again he does not
comply with the SD. Eventualy, given the intervetion he understands what the task is and
complies with the verbal and non-verbal SD and as a result he meets the criterion of 3 second
(5 consecutive sessions of Correct answer). This phase took 9 sessions (45 trials) to complete.

Fig. 1 Distribution of waiting behavior across baseline and intervention phases and follow-up
 Given the fact that the criterion in the first phase was reached, the therapist proceeded
with the next phase, changing the criterion to „wait 5 sec”. Here we can observe that 4
Incorrect attempts where performed, during which Roby engaged in other behaviors than the
target behavior when given the verbal and non-verbal SD’s after which he starts to
demonstrate the target behavior, once again reaching criterion. This phase took 9 sessions (45
trials) to reach criterion.

Phase 3 changed the criterion to „wait 10 sec” when given the verbal SD („Wait”) and
the non-verbal SD (timer and hand gesture). As we can see in the graph above, at the
beginning of the phase, there is an increased variability while at the end of the intervention the
trend is stabilizing with the intervention being cosidered a success due to the fact that the 10
seconds wait criterion is reached. This phase took 12 sessions (60 trials) to reach criterion.

The follow-up phase shows that the target behavior aquired using DRA procedure has
been matained for 5 consecutive sessions, a total of 25 trials, after the intervention ended.

As seen in Fig. 1, the behavior demonstrated in all three phases and in the baseline as
well, was at first a noncompliant behavior regarding the instruction given, with the major
diference that in the intervention phases with the use of differential reinforcement, the child
demonstrates a compliant behavior in the form of waiting for the desired item, a preffered
edible in this case.

3. Discussions

As seen above, the use of differential reinforcement of an alternativ behavior in a

changing criterion designed setting, delivered the expected results, meaning an autism
spectrum disorder (ASD) diagnosed child, with limited verbal skills learned compliance in the
form of waiting patiently, without engaging in other behaviors.

In the words of Michael Passage (2012), demonstration of self-control with

qualitatively different reinforcers mirrors more naturalistic choice and may make
reinforcement interventions more effective. Preferences are rarely stable and vary for any
given individual, both for this population (Zhou, Iwata, Goff, & Shore, 2001) and for
typically developed individuals (Wine, Gilroy, & Hantula, 2012). These findings suggest that
individuals with intellectual disabilities can be taught self- control by progressively increasing
the duration of task-related behavior required to produce a more preferred reinforcer.
Furthermore, self- control may generalize to tasks for which no self-control training occurred.

Further exploration of qualitatively different reinforcers and their effects on acquisition and
generalization of selfcontrol skills is warranted (Michael Passage, Matt Tincani and Donald
A. Hantula, 2012).

The curent study has met it’s purpose, that of teaching Roby how to wait patiently
without engaging in other behaviors. Across the intervention phases, at first, Roby starts by
demonstrating the incapacity of self-control in the form of waiting, but eventualy, as the DRA
is conducted, Roby begins to master the target behavior by being compliant with the
instruction given. Although being unstable at the begining, phase three becomes stable after 7
sessions (35 trials) with the follow-up being a complete succes.

Although meeting it’s purpose, the study has a few limitations that need to be
addressed. One of the limitation is that generalization was not assessed in other rooms of the
center, with other therapist nor outside the center with other people. Further research may
address generalization across other settings and with different people (family members, other
teachers/therapists).

One other limitation of the current study is the fact that it requires criterion for a
maximum of 10 seconds. Further study should extend to teach waiting for longer periods of
time (for example 30 sec, 1 minute, 2 minutes and so on). From here on, further study should
take in consideration all other instances where waiting is required: waiting in line, waiting
one’s turn, waiting patiently and listening what others say or waiting patiently in the waiting
room at one’s doctor, without engaging in other behaviors.

Waiting is a very important skill that is part of everyday life sometimes in a direct way
but often times in a subtle, more private way but with great potential of compliance and
therefor a better life quality, or noncompliance and therefor greater challanges in achieving
one’s goals.
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