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. Author manuscript; available in PMC: 2020 Jan 1.
Published in final edited form as: J Clin Child Adolesc Psychol. 2018 Jan 31;48(SUP1):S247–S268. doi: 10.1080/15374416.2017.1410826

Usual Care for Youth with Autism Spectrum Disorder (ASD): A Delphi Poll Round 2

Practice Element Definition Example(s)
1. Behavior Contract or Contingency Contracting A written document that describes a desired behavior and the type and amount of reward or reinforcer that the child will receive for performing or increasing that behavior. This may be part of a Behavior Intervention Plan (BIP). Example 1: A written agreement between a teacher and student that, if the student completes 20 math problems every day (at least 80% correct), without tearing up the worksheet, from Monday through Friday, he will receive a get-out-of-homework pass on Friday.
Example 2: A written agreement that, if the child wears her shirt and pants all day at school (i.e., they are still on when she gets home from school), she can have ice cream for dinner.
Example 3: A daily report card.
2. Behavioral Rehearsal/Role Playing Having the child rehearse behavior(s) in treatment before using them in real-life situations. Example 1: Practicing (with a provider) how to take deep breaths to relax before doing so in a real-life, stressful situation.
Example 2: Helping a child brainstorm ways to have a difficult conversation with a classmate. The provider could role-play first as the child, then allow the child to role-play as (him/her)self.
3. Choice Making/Providing Choices Offering a child choices or options in order to accomplish a given task. This could also include following their lead during a task or activity, to ensure it is selected/preferred by them. This may sometimes include “forced choice decision-making.” Example: Asking a child if he would like to do his math or spelling homework first, or whether he wants to use his Star Wars pencil or monkey pencil.
4. Cognitive Restructuring or Using Positive/Coping Self-talk Helping a child to identify negative or unhelpful thoughts (e.g. I can’t do it; I will fail; Others will laugh at me) and challenge these thoughts with more accurate or realistic perspectives. This is often a key part of cognitive-behavioral therapy; conversely, it can sometimes be called “Overt Verbalization Strategies.” Example 1: A child believes that a friend does not like her anymore because they declined an invitation to hang out. The provider probes for evidence for and against this interpretation and helps the child to consider alternatives (e.g. I have said no to her before, even though I liked her; or Just because she said no that does not mean that she is not my friend anymore).
Example 2: Using inner coach vs self-defeater.
5. Positive Reinforcement Providing a reward (e.g. toy, token, praise) following a specific behavior to make the child more likely to engage in that behavior again in the future. This can also be called “contingent reinforcement.” Example: A child receives a reward after appropriately leaving a group conversation. If the child does not appropriately leave the group conversation, he does not get access to the reward.
6. Distance Education, Telehealth or Remote Training Using technology to teach and communicate treatment concepts from two different locations, including remote supervision or video sessions. Example 1: A provider (located at his office) is teaching a child and parent (located in their home) about deep breathing.
Example 2: Used in phone conversations and check ins with parents and clients.
7. Didactic Teaching, Social Scripts, Instructional Learning Offering specific instruction and direction about how to carry out a given task or behavior. This may be done using written scripts or task analysis. Example 1: A child could be taught how to enter, maintain and exit a conversation with a peer through step-by-step instruction.
Example 2: Didactic instruction of social skills in a structured learning curriculum.
8. Exercise, Sensory Breaks, Physical Activity or Gross Motor Movement Physical activity that can be used to reduce or replace problem behavior, serve as an alternative behavior, or increase appropriate behavior. This does not include use of exercise as a punishment (e.g. child must do 10 laps because they broke a rule). Example: A provider may have a child run for 15 minutes each day in efforts to reduce hyperactivity.
9. Graduated, Graded or Habituated Exposure/ Systematic Desensitization Helping a child to reduce a fear or aversion by gradually coming in contact with and learning to tolerate and cope with the fear/aversion in situations that cause him or her small to medium distress (e.g. seeing a dog) and then, as confidence is gained, severe amounts of distress (e.g. petting a dog). Example 1: Fear of dogs. Exposures would gradually progress from easier situations (e.g., videos, pictures, sounds) to medium (e.g. seeing a dog, being in a room with a leashed dog) to harder ones (e.g. petting a dog, feeding a dog).
Example 2: Fear of speaking in front of the class. Exposures would gradually progress from easier situations (e.g., imagining presenting) to medium (e.g. speaking in front of the provider, the teachers, or a few people) to harder ones (e.g. larger crowd, the entire class).
10. Extinction Discontinuing reinforcement of a previously reinforced behavior. Example 1: A mother specifically ignores a child’s whining to sit on her mother’s lap (extinction) but picks her child up when she asks in a “big girl” voice.
Example 2: A child is afraid of his parents driving through a certain intersection and tantrums when they approach that intersection. Normally, his parents respond by avoiding that intersection. With extinction, his parents stop avoiding that intersection and just go through it instead (they no longer reinforce his tantrums).
11. Functional Behavioral Assessment (FBA) A systematic method of assessment to evaluate the function or purpose of problem/challenging behavior(s) in order to inform intervention. An FBA can include indirect methods (e.g., questionnaires, interviews), direct observation (e.g., collecting ABC data) and an experimental functional analysis. Example: A child’s aggressive behavior is assessed using an FBA. It is found that the child is unable to communicate when he is hungry and is usually given food after he becomes aggressive, suggesting that the function of his problem behavior is to get food.
12. Functional Communication Training (FCT) Teaching a child an appropriate communicative behavior that serves the same function or purpose as the inappropriate behavior. This communicative behavior could be verbal/vocal or nonverbal (e.g. sign language, PECS, augmentative communication device, etc). Example: A child is biting people when she wants to go to the bathroom. She is taught to select a picture of a toilet when she needs to use the bathroom instead.
13. Games and Activities that Require Social Interaction such as Cooperative or Facilitated Play Incorporating playful activities that require direct interaction with a peer into treatment. Example 1: In the game “Freeze”, children must follow the lead of another child to maintain an interaction or play scene.
Example 2: In groups of two, children must build an object together. They must plan and build it together using only one hand each, requiring them to interact and problem solve to complete the activity.
14. Computerized Games and Activities that Require Nonverbal Skills Using computer games that incorporate nonverbal communication. Nonverbal skills may include face recognition, emotion recognition, following eye gaze, and perspective taking. Example 1: Child plays a computer game where players are asked to interact with an avatar who displays highly animated facial expressions of emotion. Points are collected when the player accurately guesses the avatar’s feelings and/or intentions.
Example 2: “Secret Agent Society”.
15. Games and Activities (Noncomputerized) that Require Nonverbal Skills Using games or playful activities that explicitly require the participant to examine and interpret the emotions or intentions of others. Example 1: In “Gibberish,” children are required to interpret the tone of voice and body language of another person in order to guess what activity they are doing.
Example 2: In “Follow My Eyes to the Prize,” children are required to use only the adult’s eye gaze and nonverbal cues to locate a hidden prize in the room.
16. Homework Giving the child or parent activities to complete between sessions or classes in order to further practice skills learned during treatment. Example: The provider assigns the child and/or parent homework (skills practice) to do outside of the treatment sessions. Typically, homework is reviewed during the next session.
17. Motivation by Incorporating Special Interests into Activities Teaching therapeutic concepts by incorporating or focusing on the child’s special or circumscribed interests. Example: Using the facial expressions of a child’s favourite cartoon character to teach emotion recognition skills.
18. Mindfulness Exercises Paying attention and focusing on the present moment using mental focus to reduce tension. Example 1: Encouraging a child with anxiety to focus on the present moment rather than worries or future events. A child may be taught to focus on the smell, taste, sight, sound, and feel of an experience (e.g. eating, walking, drinking).
Example 2: Practice Yoga.
19. Meditation Training one’s mind towards relaxation and concentration. It may be used with deep breathing and/or other mindfulness strategies (e.g. increased attention to physical sensations in the body or verbal calming techniques). Example: As part of a treatment for school avoidance, a child may be taught to engage in daily morning meditation.
20. Modeling or Imitation Demonstrating a desired behavior and supporting the child’s imitation of that behavior. Example 1: A provider models a wave and says “do this.” The child imitates this action and waves back.
Example 2: A provider models using coping strategies (e. g., deep breathing) to face and remain calm in a stressful situation (e.g., public speaking).
21. Noncontingent Reinforcement or Built in Breaks Providing the child with a reward at pre-selected times as a preemptive intervention, regardless of whether s/he attains a specified goal. Example: A child frequently engages in escape-maintained problem behaviors. Every 2 minutes, he is given a break (even if he did not ask for or specifically earn the break).
22. Peer Modeling or Peer Mentoring Using peers, rather than the provider, to model appropriate behaviors. Example: A peer model is helping a child increase play skills. The peer model will demonstrate an action on a toy and the child is rewarded when s/he imitates the peer’s actions.
23. Peer Monitoring and/or Peer Reinforcement Having a typically developing peer observe a child with ASD and either reinforce or reward specific positive behaviors. Example 1: Every time a student with ASD makes a request, a typically developing peer notes this behavior (i.e. monitors the child with ASD) and/or praises the child with ASD afterward (i.e. reinforces the behavior).
Example 2: After a child with ASD engages in a target behavior (e.g., raising his hand), a peer praises him and gives him a sticker.
Example 3: Peers ignore the child with ASD when he is engaging in the target inappropriate behavior and continue interacting with him when he is NOT engaging in the target behavior (i.e., the peers reward or reinforce him for appropriate behavior).
24. Performance Feedback Providing feedback about the specific use (or non-use) of a skill or its components either while the skill is being performed or directly following. Example 1: Providing feedback about the child’s use of eye-contact, facial expressions, or use of gesture and body language during a social interaction in a way that provides information to the child about the use of all, part or even none of the skills learned in order to increase the youth’s knowledge and future use of the skill.
Example 2: Providing feedback to a child after an exposure to help challenge negative thinking (e.g. Identifying that the child used cognitive restructuring to help tolerate the exposure.)
25. Priming Preparing a child for a task or activity by previewing the task or activity briefly in some way before teaching it. May also be called Previewing, Forecasting, Preteaching. Example 1: In order to prepare a child to take turns during a game in class, the child is shown the game and read the rules at home the night before.
Example 2: Showing the child a video of a doctor’s office before a doctor’s appointment.
26. Prompting Presenting a cue to initiate a specific behavior. These cues can be given before or during the performance of the target behavior to assist in the use of a specific skill or increase the likelihood of a target behavior. Example: Prompts, INCLUDE BUT ARE NOT LIMITED TO verbal (e.g., “say hello”), auditory (e.g., setting alarm to remind child to get dressed), tactile (e.g., device that vibrates to remind child to ask a question), visual (e.g., picture of what the child is supposed to do), gestural (e.g., pointing to sink to remind child to brush his teeth), modeling (e.g., demonstrating how to brush your teeth for the child), physical/manual (e.g., physically guiding a child’s hand to pick up the toothbrush), or positional prompts (e.g., placing a target item on the table close to the student).
27. Prompt Fading Gradually reducing prompts until the desired response occurs in the appropriate context without any prompts. Example: To teach a child how to wash his hands, a provider might first move or guide the child’s hands in the correct hand washing motion. Then the provider might model the task and encourage the child to imitate. Once the child is successfully imitating, the provider might provide a verbal instruction for hand-washing steps. Eventually, the child is able to complete the hand washing routine without any prompts or cues from the provider.
28. Reinforcement Schedules Controlling the timing and frequency of rewards in order to increase a desired behavior or decrease an undesired behavior. Example: A child who is inattentive or off-task during class may be rewarded on a variable interval schedule throughout the day to help him maintain attention. The rate of reward averages to approximately one token/30 minutes of on-task behavior.
29. Relaxation Teaching and encouraging the use deep breathing, muscle relaxation, peaceful imagery, or other calming techniques. Example: Teaching a child to relax their muscles when they notice that they are becoming irritable or anxious.
30. Response Cost A type of punishment in which the child loses something rewarding or desired (e.g. a prize, sticker, money, token) following the occurrence of an unwanted or inappropriate behavior. This includes taking away a privilege. Example 1: If a child gets up out of his seat without asking his teacher, he loses tokens that he has gained during the day.
Example 2: If a child yells at his siblings, he loses playtime on his favorite video-game system.
31. Response Prevention or Ritual Prevention Preventing a child from avoiding or escaping a feared or distressing situation or object. Can also be similar in implementation to “response blocking.” Example 1: A child who had an obsession about avoiding contamination is prevented from washing their hands repeatedly or engaging in other rituals (e.g. intensive cleaning) designed to reduce this fear.
Example 2: A child with a dog phobia stands near a dog as opposed to running away from it (his/her usual response.)
32. Self-awareness of Bodily Response Teaching a child to recognize how different emotions feel in their bodies. This can be used as a tool to help children identify and articulate their emotions more quickly. Example: Exploring what areas of the body are active when the child is afraid of or worried about something (e.g. heart racing, fidgety) and helping them to use these physical sensations to recognize anxiety.
33. Self-management Teaching the child to monitor, record and/or reward his or her own behaviors. This can include self-monitoring, self-reinforcement, and self-prompting. Example: A student is taught to tally the number of times that she initiates conversations with a peer during the school day. If she reaches a target number of initiations, she earns a reward.
34. Shaping Reinforcing behaviors that are closer and closer “approximations” of a desired behavior until each approximation is mastered. Following the mastery of an approximation, the next closest approximation of the desired behavior is rewarded. This process is repeated until the ultimate desired behavior is achieved. Note: This also includes “reinforcing attempts,” which involves rewarding any attempt to respond, in contrast to traditional shaping in which only correct responses (or responses that are equal or better than the previous response) are reinforced. Example 1: A provider, aiming to elicit the word “cookie” from a child, might initially reward any attempt at making a sound when asked until this is mastered. Then, they may just reward the sound “c” until it is mastered. This process is repeated with the sound “coo.” This process continues until the provider only rewards the full sound “cookie.”
Example 2: A provider wishing to support social initiation with a peer may at first reward simply standing near a peer until this can be done regularly. Then, they may reward look or smiling at the peer. This process continues until full social initiation (as defined by the Provider) is achieved.
Example 3: A provider may reinforce any attempt to employ the target behavior (e.g., engaging with a peer.)
35. Socratic Discussions In this approach, the provider does not give information directly to a child but instead asks a series of leading questions (e.g. What did you do? How did it turn out? What else could have happened?) to help them understand a concept or gather desired knowledge. Example 1: The provider asks a series of leading questions (e.g. What do other kids do? What could you do?) to help the child identify how to initiate conversation on the playground.
Example 2: A provider asks leading questions to help the child understand how they are feeling and thinking after a specific situation.
36. Embedding Special interests in Social Interaction Guiding or structuring a social scenario (with a peer, teacher, counselor, or other) so that the content is focused around the child’s special or perseverative interest. Example: Initiating a conversation about Thomas the Train with a child who has a special interest or preoccupation with Thomas the Train.
37. Stimulus Control Pairing a specific behavior with a specific stimulus/cue in order to control the behavior. Example: When a card says “hands down”, child must keep their hands on table to get a reward. When card says “break time”, the child may engage in repetitive hand motions or other motions with his/her hands.
38. Stories/ Vignettes Using stories or short vignettes to teach children how to problem solve and/or take the perspective of others. This includes Social Stories. Example 1: A provider describes, through story or drawings, a personalized social situation and highlights important cues to attend to for success in the situation.
Example 2: A child has trouble being attentive during story time and engages in many disruptive behaviors. Her provider creates a social story specifically for her that she can read before school each day that describes a child acting appropriately during story time.
39. Suppression Approach Teaching a child to consciously refrain from excessively talking about a special or perseverative interest or engaging in stereotypes so that they can better learn or use skills (i.e. building friendships). Example: Reminding the child that his/her special interest is great and fun but should only be spoken about for a certain amount of time or while others are interested because it can be unexpected or not interesting to peers after a time.
40. Technology-aided Instruction and Intervention The use of technology as a method for teaching or building skills. Also called Augmentative Communication, Assistive technology, Assistive/Augmentative Communication Devices. Example 1: An iPad app that provides speech-generating help for children.
Example 2: A virtual reality program that teaches social skills.
41. Time-out A type of punishment in which all sources of reward or reinforcement (e.g. attention, playing with toys) are removed. The child is moved to a setting that is “less rewarding” and/or stops receiving the reward for a period of time. Example: A teacher removes a student from his friends for 10 minutes when s/he disrupts the class.
42. Token Economy Rewarding a child by giving him tangible symbols (e.g., tokens, points, stickers, poker chips, “catch them being good” coupons) for completing tasks or behaving in desired ways. The child is then able to exchange tokens/points for a desired object (e.g., a toy, candy) or activity (e.g., playing a game). Example: Receiving a sticker for every time a child initiates play with a peer. After earning a certain amount of stickers, he can exchange the stickers for 5 minutes of break time (e.g. running around the soccer field).
43. Use of Song Embedding treatment goals or steps into the context of a song. Example 1: Creating a song that narrates the steps of a social behavior.
Example 2: Making up a song about taking turns.
44. Video/ Audio Modeling Using a video or audio demonstration of the correct performance of a particular task or activity. Children then enact the demonstrated task or activity. Example 1: A video showing two children in a conversation. The child could view this and then try to reenact this later in a real-life conversation.
Example 2: The child or another person puts together a train set that the child will enact later in order to expand play.
45. Visual Tools or Supports The use of visual tools (e.g. pictures, written words, videos, maps, timelines, calendars or diagrams) to teach skills, behaviors, or concepts, or to increase the predictability of a situation. Also called Visual Prompts. Example 1: Using cartoon drawings to assist the child in understanding skill development (e.g. cartoons of people interacting to teach social skills).
Example 2: Using a visual indictor to show how much time is left in the treatment session (e.g. a visual timer or “running man” that takes a few steps forward periodically as the session progresses).
Example 3: Using a visual schedule to inform a child about the upcoming sequence of events or activities (e. g., picture of home, dry cleaner, bank, and back home).
Example 4: A student is presented with an Activity Schedule - a photo album containing photos that depict the sequence of steps necessary to engage in a leisure activity.
New items added in Round 2 of DPQ (based on feedback from Round 1)
46. Task Analysis/Chaining Task Analysis: Breaking a complex task or behavior (such as putting on your coat) into smaller discrete steps (e.g., pick up coat, put left hand in left sleeve, put right hand in right sleeve, zip). The components of the task analysis form a behavioral chain, or a sequence of related behaviors that make up a skill. Example: Shoe Tying: 1. Place left lace across the top of the shoe, 2. Cross right lace over left lace and pull it under the left lace, 3. Make a bow with the lace on right side, 4. Wrap left lace around bow, 5. Pull through hole under bow, 6. Grab both bows and pull tight.
Chaining: Teaching one step of the behavioral chain at a time until the entire chain of steps is mastered. Forward Chaining: Teaching the first step in the behavioral chain to mastery first and adding each subsequent component one at a time. Backward chaining: Teaching the last step in the behavioral chain first and adding each previous component one at a time.
47. Differential Reinforcement Providing reinforcement for an appropriate behavior (DRA), physically incompatible behavior (DRI), the absence of problem behavior (DRO), or a lower rate of problem behavior (DRL), while withholding reinforcement for problem behavior. Example 1: If a student calls out in class to get attention from the teacher, DRA would involve his teacher calling on him (reinforcing him) when he raises his hand, but ignoring him when he calls out.
Example 2: An individual is reinforced every 5 minutes he goes without yelling (DRO).
Example 3: If a student raises his hand only 3 times or less per class, then he can be line leader (DRL).
Example 4: A parent provides relatively more reinforcement for approaching a feared stimulus than for running away (i.e., DRI) or more reinforcement for “brave” behaviors (e.g., coping self-talk) than anxious behaviors (e.g., reassurance-seeking) (i.e., DRA).
48. Motivational Interviewing Facilitating and engaging intrinsic motivation within the patient in order to change the behavior. Example: Motivating the child to change social behaviors in order to make friends.
49. Parent Coaching Modeling the technique for the parents, then having the parents attempt the technique while offering corrective feedback. Example: Modeling positive reinforcement for a parent, then allowing the parent to try this strategy and then providing the parents with feedback to better use the strategy.
50. Imitating the child Mirroring the child’s actions. Example: While a child is playing with a toy truck on the floor, the therapist also plays with a toy truck on the floor at the same time, perhaps using similar or identical movements.
51. Communicative temptations Attempting to get a verbally delayed child to talk by enticing them with various temptations. Example 1: Eating the child’s favorite food in front of them.
Example 2: Putting a desired object in the child’s sight but out of reach so that the child has to make a social initiation to get the object.
52. Environmental Structuring Modifying the environment to be optimal for reaching desired therapy goal. Example: Removing distracting objects from a room. Limiting access to preferred objects.
53. Social Context Structuring: (Lunch bunch) Having a group of children meet together during a specified time with a specific goal in mind. Example: Having 3 children with ASD sit at lunch together and discuss a common area of interest.
54. Psychoeducation The stage of training in which an individual is provided with concrete information about their condition and the way it is usually manifests, with the aim of normalizing and helping the individual (or family) to become familiar with the condition more broadly. Example 1: Written material provided to members of a support group for parents with kids with ASD.
Example 2: A book offered to a client that describes their disorder in accessible terms.
55. Acceptance strategies Recognizing and accepting the existence of painful thoughts and emotions. Example: Noticing and describing painful thoughts and feelings instead of trying to change them.