Abstract

Autism Spectrum Disorder Spectrum Disorder is a disorder that often impairs communication and social skills. Individuals with Autism Spectrum Disorder usually prefer to be alone over spending time with others. Engaging in ritualistic and obsessive behaviors is typical.

The key to successful treatment is intervention at an early age. Most children are diagnosed with Autism Spectrum Disorder between the ages of two and three years old. This is when intensive behavioral interventions should begin.

Reciprocal Imitation Training has been shown to be effective in teaching or enhancing both play and social skills in children with Autism Spectrum Disorder. However, some limitations have been noted in the use of Reciprocal Imitation Training when used alone. These include a dependency on the trainer and lack of generalization.

The basis of this dissertation is to  assess whether Reciprocal Imitation Training, when paired with Applied Behavior Analysis, can improve both social and play skills. Children ages 3-5 who are already receiving interventions based on Applied Behavior Analysis, and who demonstrate a lack of both play and social skills, will be asked to participate in this study. Each participant will receive thirty minutes of Reciprocal Imitation Training twice a week, totaling one hour per week. Data will be collected during each session to calculate the percent of independent imitation.  Independence will be calculated based on the number of times a participant independently imitates the researcher.  Data will also be taken to note any instances in which the client plays with a toy or verbally interacts with another person using the skills they were taught during previous RIT sessions.

Literature Review

Introduction

The premise of this section of the research paper is to delve into a broad discussion of literature on the peer-reviewed published material. The bulk of the focus of the study presented evaluates the condition that is known as Autism Spectrum Disorder Spectrum Disorder (ASD) and makes an attempt to understand its causes and effects, as well as intervention mechanisms. Moreover, the literature review section focuses on secondary sources of information that have been published on the topic under research. In regards to that, the particular objective of the literature review is to evaluate the materials for contributions on the core intervention mechanism that the research problem is based. Reciprocal Imitation Training (RIT) is assessed as a viable method for teaching play skills in children with ASD. To that extent, the literature review seeks to decipher evidence in secondary research about the various interventions that have been found for treating ASD mainly based on RIT affiliated interventions.

Autism Spectrum Disorder Spectrum Disorder

Imperative to the understanding of the literature is the evaluation of ASD and its occurrence. Gillis & Butler (2007, p. 533), term ASD as a complex condition where there may exist more than one disorders , hence, the use of the words spectrum and disorders. Equally, Ingresoll (2010, p. 1156) also notes that it is a condition that affects the neural development of the child. Consequently, the condition may appear in varying degrees, in which case, it affects different children in varying ways (White & Keonig, 2006, p. 9).  Ingressoll (2010, p. 1159) adds that ASD can be identified by its level of severity based on the physical symptoms that manifest in the development of the child. As such, signs to watch out for when evaluating the degree  that ASD may have on the brain, range from speech difficulties to motor coordination problems (Ingresoll & Gergans, 2006, p. 8). The myriad of conditions that appear as part of the ASD condition include verbal and non-verbal communication disruptions, difficulty interacting, repetitive behavior, anti-socialness, tendency to wallow in solitude, difficulty sleeping, gastrointestinal problems, and difficulty in motor coordination among other occurring symptoms (Gillis & Butler, 2007, p. 539). Hence, it is not always assured that a given state of conditions qualify as ASD because some could be confused with other conditions and disorders. Nonetheless, the occurrence of the ASD condition is highly likely, with one out of sixty-eight c hildren in America born with ASD every day. Therefore, it is vital to recognize the symptoms early enough so as to commence treatment on time (Ingresoll & Gergans, 2006, p. 8).  Gillis and Butler (2007, p. 534) advise that the age of three to five years proves the most appropriate for beginning ASD intervention and treatment because it is associated with higher rates of improvements in symptoms towards adulthood.

Ingresoll and Gergans (2006, p. 6) add that early intervention often leads to independence of Autistic adults who go on to live perfectly normal lives. Such individuals marry, have healthy children, keep a job, and take care of themselves and their families. In contrast, interventions that begin late, especially after the age of six, have recorded less success in the treatment of Autism. As such, adults who begun treatment late would have difficulty in brain functions that impairs their speech and social skills (Durualp & Aral, 2010, p. 163).  According to Wang and Sillane (2009, p. 324), it is difficult to recognize symptoms of Autism in young children because they are in their developmental stages. In addition, ASD occurs alongside a multiplicity of other conditions that make it confusing to recognize whether the child needs ASD based interventions. One such co-occurring condition is a bipolar disorder (Zwaigenbaum, et al., 2015, p. S65). A child with bipolar disorder will display an array of moods at any one given time, and that would make the parent hesitant to suspect ASD due to the hyperactive nature of the child. That is especially true since common symptoms of ASD comprise of antisocial behavior and tendency to seclude oneself (Durualp & Aral, 2010, p. 165). Other symptoms that may be similar to the signs of ASD include depression, Tourette’s syndrome, obsessive-compulsive behaviors, and Attention Deficit Disorder (ADHD) (Cardon & Wilcox, 2011, p. 659). Since there is no single definitive symptom of Autism, it becomes quite difficult to recognize, especially when the child has not developed any speech skills at the ages of one and one and a half years. However, at the onset of the second year, speech skills begin to develop. At that time, the parent can start to take notice of particular issues that arise as a consequence of ADS (Ingresoll & Gergans, 2006, p. 12).

-Wang and Sillane (2009, p. 319) contend that the symptoms of ASD may not manifest until the child is the age of three years when specific observable characteristics can confidently be seen as a cause for worry. Ingresoll & Gergans (2006, p. 5) divide such symptoms into four categories that include behavioral, physical, cognitive, and psychosocial symptoms. Physical symptoms range from poor motor skills to illegible handwriting, unusual postures, heightened sensitivity to loud noises and strong tastes, as well as clumsiness. On the other hand, cognitive signs may include repetitive behavior such as spinning round and round with specific interest in one particular activity such as a strong attachment to a doll. Below average intelligence, poor use of language, and inability to pick up subtle differences in tone, pitch, or voice differences. Psychosocial implications can encompass anxiety, moodiness, loneliness, shyness, depression, and low self-esteem. Behavioral symptoms, on the other hand, include signs of reservedness, avoiding smiling when smiled at, doesn’t make noise to avoid attention, and doesn’t want to play with same aged peers. Also, they do not freely share or talk about feelings, may not like contact or cuddling, obsessed with self-engaged behavior that incorporate finger licking, spinning in circles, scratching, repeated words or noises, and turning the lights on and off, among others (Ingresoll, 2010, p. 1156).  According to Golzari, et al. (2018, p. 5), identifying the symptoms promptly serves crucial in the preparation of the development of intervention mechanisms necessary for the treatment of the ASD. In that respect, it is imperative that between the ages of three to four years parents should look for signs and symptoms of ASD and take measures to access appropriate treatments and interventions for ASD (Eldevik, et al., 2009, p. 442).

Effects of Autism Spectrum Disorder on Social and Play Skills

Autism Spectrum Disorder as a condition is characteristic of affecting young children of all ages. However, early symptoms can be observed in the developmental areas of speech and social skills. In that regard, Durualp and Aral (2010, p. 161) note that children with ASD develop difficulties in cognitive and physical development that can be observed in the social and play skills that they display. To that effect, recognizing the early symptoms of Autism can also assist in evaluating causes and effects that may arise. Gillis and Butler (2007, p. 532) mention that Autism Spectrum Disorder Spectrum Disorder (ASD) can be observed in the symptoms that children display during play time. Further, meaningful interventions during play can help improve play skills that eventually lead to subsidizing the gravity of ASD implications on the child. Equally, recognizing the early signs of ASD can help in the development of appropriate intervention mechanisms that may contribute to improving the child’s cognitive and physical skills (Durualp & Aral, 2010, p. 169). Whereas other conditions tend to co-occur with ASD  they may affect the manner in which Autism Spectrum Disorder as a disease develops, or influence the decisions regarding intervention mechanism that can aid in treatment. As mentioned earlier, such conditions may include but not limited to anxiety disorder, social anxiety disorder, depression, obsessive-compulsive disorders, Tourette’s syndrome, attention-deficit hyperactivity disorder (ADHD), and bipolar disorder, etcetera  (Gillis & Butler, 2007, p. 533).

Persons with Autism Spectrum Disorder present a variety of symptoms that are differentiated in degree. Nonetheless, the characteristics are common alongside other conditions that occur in children and adults diagnosed with ASD. Therefore, looking out for the similarities helps in the identification of the mechanisms that can be taken for intervention. Moreover, taking notice of the conventional signs will help to correctly diagnose an individual. Such characteristics include the child giggling a lot or laughing inappropriately and uncontrollably. Apparently, the laughing is not in reaction to anything funny, and it is not natural. Instead, it occurs without the child’s awareness or consciousness of the inappropriateness of the laughter (Wang & Sillane, 2009, p. 318). White and Keonig (2006, p. 9) advise that once a parent notices odd behavior in the child’s speech such as uncontrolled screaming, crying, yelling or laughing, there is a high likelihood that the child is Autistic. It is also advantageous to take note of the developmental stage of the child by gauging their age to know whether they are supposed to have developed appropriate speech skills. In that respect, children between the ages of three and six years who show difficulties in speech development are most likely to be Autistic (Golzari, et al., 2018, p. 6). Additionally, it is important to evaluate whether the child has the potential to respond to social reciprocity, in which case, it is important that the child takes notice of directions given by the adult. For example, on noticing uncontrollable inappropriate laughing, the parent can instruct the child to stop. When the child responds by complying it is assumed that the degree of autistic development is not as high. Moreover, an appropriate intervention for the same can be sought (White & Keonig, 2006, p. 9).

Another core characteristic of the effect of ASD manifests in the sensual responses of the child to situations of danger. According to Wang & Sillane (2009, p. 340), children with ASD lack a logical sense of danger and may not show signs of fear even when faced with the extremes of dangerous situations. White & Keonig (2006, p. 9) add that an Autistic child is not aware of the dangers that lurk in their environment, and as such pose a risk to themselves. To that extent, it would not be surprising to see an Autistic child placing their hand on a burning stove or rushing into oncoming traffic on the road without any fear of getting hit (Wang & Sillane, 2009, p. 332). Such children may lack the cognitive ability  for self-awareness and also may not have the capacity to recognize the dangers that surround them. This knowledge serves as a warning sign on the interventions that should be taken to avert a situation that may result in harming the child without their knowledge (Durualp & Aral, 2010, p. 164).

Closely associated with a lack of a sense of danger, as White & Keonig (2006, p. 9) explain, is the child’s insensitivity to pain. In that esteem, it is extremely likely that the child would be in pain, yet not show any signs. In that respect, the child poses a danger to themselves since they can cut themselves or break their limbs, while not showing any signs of physical distress. As such, it is imperative to have Autistic children under surveillance at all times to ensure that they get the care they need (Wang & Sillane, 2009, p. 322). Parents can take precautions by keeping rooms free of sharp objects or things that they can easily swallow (White & Keonig, 2006, p. 10). Children diagnosed with ASD have also been found to have inappropriate attachments to objects that may include toys. In that respect, such children cannot go to sleep or leave the house without the subject matter in their hands. They become inseparable with the object and would prefer being left alone with the object rather than spending time in the company of peers or even with a parent (Durualp & Aral, 2010, p. 169).

When engaged in speech, the Autistic child may echo words or phrases instead of responding appropriately as required (Gillis & Butler, 2007, p. 535). Further, such children may display a lot of difficulty in expressing themselves particularly in regards to their needs. As such, it would be difficult for them to maintain eye contact, and may avoid affection such as hugging or cuddling. Autistic children would rather spend time in solitude than enjoy the company of others (White & Keonig, 2006, p. 8). Golzari, et al. (2018, p. 5) indicate that the effects of Autism serve as warning signs and symptoms of what is to come rather a degree of the graduation of ASD. It is imperative to take notice of the small changes in the behavioral characteristics of the child so as to seek appropriate intervention. In that respect, evaluating effects can serve as signs that help in identifying the intervention needed to slow down the development of ASD (Gillis & Butler, 2007, p. 539).

Gillis and Butler (2007, p. 541) advance that it is imperative to recognize the warning signs of ASD development so as to evaluate whether or not it is necessary to seek immediate intervention. For that reason, analyzing the behavior of the child serves as the best approach to identifying effects, and in the same line the symptoms of Autism Spectrum Disorder. For instance, the repetitive or ritualistic behavior of spinning or rocking back and forth is a sign of ASD. Once a parent has observed repeated behavior on the same, it is necessary to see a physician for a definite diagnosis (Gillis & Butler, 2007, p. 542). Other signs to look out for according to White & Keonig (2006, p. 8) include an evaluation of the deterioration of physical and cognitive skills that the child once had acquired before. In that respect, the reduction in the skills will make the child redundant in attributes such as speech and play skills. To that end, the parent should seek further advice from a physician on whether the skills can be improved based on interventions that can possibly be applied (Durualp & Aral, 2010, p. 165). Similar advice by Wang & Sillane (2009, p. 322) is such that on taking notice of the child’s lack of interest in interaction with peers as well as with others, coupled with a persistent insistence of solitude, is a serious warning signal. In that respect, it is necessary to seek advice from a physician on the appropriate intervention mechanisms that can improve social skills (Gillis & Butler, 2007, p. 544). Equally, a lack of interest in social interaction is coupled with the child’s disinterest in communication, in which case, it becomes necessary to note whether or not the intervention used can improve both communication and social interaction outcomes (Wang & Sillane, 2009, p. 322).

Importance of ASD Diagnosis in Children Aged 3-5 Years

ASD presents adverse ramifications for the physical and mental development of individuals. For that reason, it is imperative to recognize the symptoms of the graduation of ASD early enough for the intervention mechanisms to take place. Giving the children the attention that they require based on the particular conditions is necessary to ensure that children suffering from ASD are treated with the appropriate medical care that would lead to the improvement of their symptoms. According to Kern and Humpal (2012, p. 48), there is a need to recognize that children suffering from ASD are not any different from other kids their age and, therefore, should first and foremost be treated as children. That is, however, not to imply that one should ignore the obvious fact that an Autistic child is special. In retrospect, it means that treating them differently would further emotionally scathe such children (Kern & Humpal, 2012, p. 49). Landa (2008, p. 138) observes that diagnosis of ASD in children is often common or possible between the ages of three and six years. However, there are individual cases in which diagnosis can occur within the first two years of the child’s life. The same sentiments are shared by Shattuck et al., (2009, p. 474) who also note that early diagnosis of ASD can lead to timely interventions that serve to improve social and communication skills of the child. The identification of symptoms in a timely fashion will allow for clinical interventions that are geared towards improving the mental health of the child while at the same time serving to mitigate any deterioration in social and play skills that results from the development of ASD (Shattuck, et al., 2009, p. 476). Landa also notes that early diagnosis in some children has very promising results in communication and social interventions taken. Hence, identifying the existence of ASD at the beginning of the child’s life ensures that the child will receive the adequate interventions that may lead to the eradication of neurological deterioration (Landa, 2008, p. 140).

Alvi (2010, p. 344) adds another twist to the importance of early diagnosis of ASD; he observes that children with ASD, who are diagnosed early need to be placed in groups of their peers. The collective placement of the child with peers will assist in mitigating the effects of ASD by enhancing their capacity to interact with one another and socialize. In that regard, it is imperative to ensure that such children are in the company of others to help them develop their social and communication skills (Stahmer, et al., 2005, p. 67). Play time proves essential in improving communication and learning where interactions become the avenue to which the child relates to others in their environment. Such a child becomes aware of the need to reciprocate feelings which ultimately leads to the reduction of the effects of ASD on their cognitive development (Alvi, 2010, p. 346).  Stahmer et al., (2005, p. 69) in their study to evaluate the various approaches that can be utilized for interventions revealed that most interventions that were utilized more included focus group discussion. In that respect, developing a community of interest where the focus of the group is in the improvement of the cognitive skills of the child is a necessary step towards improving their mental health (Zwaigenbaum, et al., 2015, p. S79). In this case, the development of the child requires that social surroundings engage the child with peers so the child can relate to others like himself.

Zwaigenbaum et al., (2015, p. S60) add that it is important to recognize that toddlers, unlike adults, learn faster and better in groups. In that respect, it is imperative to ensure that enhancing the learning outcomes of Autistic children requires placing them in an environment where they can gain the most benefit in regards to ramifications of learning outcomes (Gillis & Butler, 2007, p. 541). It is, however, not always straightforward to generalize that group interventions  are the most necessary and practical approaches to the treatment of children with ASD. As a matter of fact, ASD treatment often requires specialized attention that does not always align with group dynamics. In that respect, practitioners are increasingly finding it difficult to seclude interventions that are successful in each case. On that note, it is not surprising to conclude that intervention that may prove satisfactory for one child diagnosed with ASD can be utterly useless when applied to another (Kern & Humpal, 2012, p. 49). Alvi (2010, p. 346) concurs with the sentiments presented by Kern and Humpal (2012, p. 49) noting that each Autistic child is special. In that regard, it is imperative that every intervention mechanism taken towards the treatment of an Autistic child is tailor-made to suit the needs and expectations of the Autistic child and his family respectively (Durualp & Aral, 2010, p. 163). Moreover, the degree to which Autism affects children of different ages is dependent on factors that may vary from one case to the other (Alvi, 2010, p. 348). Therefore, recognizing that each Autistic child is special will require that specialized attention is given to the child to ensure that they can develop the necessary social and communication skills to improve their mental health (Kern & Humpal, 2012, p. 51). Questions then linger on when is the appropriate time to begin intervention or treatment. According to Kern & Humpal (2012, p. 48), intervention should start immediately after a diagnosis has been made. Children aged between three and six years are at the height of discovery where much of their speech, language, and social skills are learned. Therefore, it is necessary to educate children at the ages of between three to five years on fundamental social skills (Landa, 2008, p. 143).

Kern and Humpal (2012, p. 48) recommend that the ages of three and five years recommend that children between the ages of three and five years of age require additional parental assistance with social skills. Such support will require systemic engagement in social activities such as in the identification of objects as well as knowledge of events (Wang & Sillane, 2009, p. 332). Following the diagnosis of a child with Autism Spectrum Disorder condition, it is necessary to begin intervention immediately (Kern & Humpal, 2012, p. 48). That fact is reiterated by Golzari, et al., (2018, p. 6) who note that it is necessary to begin a schedule that can be meticulously planned towards age-based developmental activities. Such events can run throughout the course of the year in a periodic manner that ensures an Autistic child is exposed to all the support that they require (Wang & Sillane, 2009, p. 332). Kern and Humpal (2012, p. 48) advise that developing a schedule that meets the daily routine of the child rather  is central to the child’s successful recovery. Further, setting individual short-term goals that are meant to achieve minuscule gains is essential during the intervention (Wang & Sillane, 2009, p. 335). Hence, gradually changing and customizing interventions to the ones that suit the needs of a particular Autistic child will ensure that they enhance their chances on the road to recovery (Kern & Humpal, 2012, p. 49). Intervention requires that the minimal gains that can be achieved in behavioral training are the most fundamental towards generating the possibility of successful outcomes (Golzari, et al., 2018, p. 6). Family members’ participation in the intervention sessions also proves central to the facilitation of successful outcomes. In other words, it is necessary to ensure that all family members are aware of the unique needs of the child with ASD and that all should focus on helping the child towards recovery (Landa, 2008, p. 145). Given that family members are the ones who would likely have the highest rate of interaction with the child, each of them should have knowledge of the interventions that seem to work best and that the Autistic child would respond to most appropriately (Kern & Humpal, 2012, p. 49). Kern and Humpal (2012, p. 49) add that it is also necessary to bring the family members on board regarding the various adjustments that are made in the treatment of the Autistic child (Wang & Sillane, 2009, p. 322). Moreover, the family should create global opportunities and activities where all members participate jointly in support of the efforts of the Autistic child. The importance of group’s social dynamics cannot be overstated since they prove essential to the treatment of the child with ASD (Landa, 2008, p. 144).

Intervention: Applied Behavior Analysis

There is a myriad of interventions that can be utilized in the treatment of children with ASD. However, most of the approaches aim at lessening the associated deficit in physical and cognitive skills. The ultimate goal is to ensure that the intervention results in enhancing the social skills of the child. More often than not, children diagnosed with Autism have a higher chance of recovery if their intelligence quotient is high. Thus, lower IQs tend to be associated with diminished chances of recovery (Smith & Ladarola, 2015, p. 901). The ASD condition consists of a variety of conditions that are thought to be hereditary. Nonetheless, there are environmental factors that are as well associated with its occurrence.  The others include Pervasive Developmental Disorder, not otherwise specified (PDD-NOS), in which case, the criteria for Autism or Asperger Syndrome occur in variations that do not qualify for either. The challenge that physicians, parents, and the families of the children diagnosed with ASD have to contend with is the unique condition of the child which they need or have to bear with. To physicians, it is a daunting task to develop the intervention that is most appropriate for treatment. On the other hand, parents and family members must provide the support and help necessary to ensure that the child recovers. In the end, it requires a joint and collaborative initiative that brings together all the efforts of persons involved. The most challenging aspect is, therefore, aligning the efforts of all individuals to ensure that all parties involved are working towards the realization of the same objectives (Myers & Johnson, 2007, p. 1166). Myers and Johnson (2007, p. 1162) content that no single treatment approach proves sufficient as an intervention for the treatment of Autism. Instead, different options require evaluation to seek the best alternative. In the same respect, physicians are warned against using a blend of interventions concurrently since that has been proven to have a boomerang effect on the treatment of the Autistic child (Eldevik, et al., 2009, p. 442).

The family unit and the education curriculum qualify as the most influential structures or units that serve to impact the development of the child towards recovery. To that extent, it is necessary that the child receives adequate attention at home and at school to ensure that their path to recovery is well on the course (Levy, et al., 2009, p. 1628). Another attribute of evaluating the needs for treatment of Autistic children is to assess whether or not they are making progress through the treatment interventions. To ensure that progress is achieved, it is imperative to take note of changes and improvements. Moreover, small improvements serve as a guideline on which adjustments to the intervention can be made in an attempt to make them better suited to the condition of the ASD diagnosed child. Despite there being a lack of evidence of a definitive treatment mechanism that can be applied in any case of ASD, studies show that specific intensive maladaptive behavioral interventions prove to develop progressive results. Further, behavioral therapy serves as a psychosocial intervention through which development of behavioral characteristics or traits are used as a mechanism to trigger the enhancement of cognitive functions (Seida, et al., 2009, p. 98). Among the most common approaches that are used include speech and language therapy, social skills therapy, occupational therapy, applied behavior analysis , structured teaching, among other developmental models. (Eldevik, et al., 2009, p. 446) Levy et al., (2009, p. 629) propose reciprocal imitation training as one of the models that can be useful in the treatment of ASDs. The same sentiments are shared by Seida et al., (2009, p. 99) who also believe that reciprocal imitation training can prove useful in the development and implementation of social and language skills in children diagnosed with ASD.

Therefore, the importance of the use of reciprocal imitation training (RIT) as an intervention mechanism towards the treatment of ASD proves a viable option. Ingersoll and Gergans (2006, p. 11) argue that RIT interventions lead to the enhancement of speech skills and ensures that children are in a position to learn developmental skills that encompass language and social skills. In the same line, the ability to grasp language is associated with cognitive development in regards to following instructions. In that respect, children diagnosed with ASD, who have been put in interventions that draw from treatment associated with RIT models have recorded better motor skills, good memory, and improved social skills (Ingresoll & Gergans, 2006, p. 12). However, contrary opinion by Cardon and Wilcox (2011, p. 654) is that that such treatment interventions for children diagnosed with ASD that apply RIT methodology do not show adequate acquisition of developmental skills. Instead, RIT models were found to be too much dependent on the instructor to the extent that in the absence of the instructor the child with ASD remains helpless. Nonetheless, the RIT intervention proves essential in gauging the attention of the child and using that to make them achieve minuscule gains in cognitive development (Ingresoll & Gergans, 2006, p. 11). However, it is also imperative that the independence of the Autistic child in taking actions that lead to social interactions as well as communication are pursued. In that regard, the ultimate intention of improving the social and communication skills of the child is to ensure that the child can independently communicate and socialize without being prompted to do so by the instructor.

Similar concerns by Paparella and Freeman (2015, p. 65) advise that in the past it has not been possible to seclude the gains made in RIT intervention models towards the development of speech and language skills of children diagnosed with ASD. The challenge according to Paparella and Freeman was in the fact that with RIT models it is hardly easy to recognize the Autistic child’s willingness to participate in the interaction. Instead, the child needs prompting from the instructor to respond. In other words, RIT models are thought to be as effective as teaching a pet to do tricks, therefore, do not offer adequate treatment options that would make the child independent of the instructor in the future (Paparella & Freeman, 2015, p. 71). Cardon and Wilcox (2011, p. 658) also note that while RIT proves successful in depicting attentiv