iPAD modeling Caregivers.pdf

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Teaching caregivers to implement video modeling imitation training

via iPad for their children with autism

Teresa A. Cardon*

Washington State University, United States

Autism is one of the fastest growing disabilities, with an estimated one in 88 children being diagnosed with an

Autism Spectrum Disorder (ASD; Center for Disease Control, 2012). While it is cautioned that these estimates apply to

the 14 sites analyzed in the aforementioned study, with this ever-increasing population, innovative new approaches are

needed to ensure optimal intervention strategies are being implemented for children with ASD (Lord & McGee, 2001). In

addition, it is important that new approaches be cost effective strategies that caregivers can implement in the home

environment to engage their child (Dawson et al., 2010; Koegel & Koegel, 2006). An innovative intervention strategy

with potential for caregiver implementation, specifically VideoModeling Imitation Training (VMIT) via an iPad, was the

focus of this study.

1. Imitation and autism

For over 40 years, researchers have explored how to support skill development in children with ASD (Dawson & Adams,

1984; Lovaas, 1987; Lovaas, Freitas, Nelson, & Whalen, 1967; Rogers, Bennetto, McEvoy, & Pennington, 1996). One skill that

has garnered interest is imitation. Severity of autism is correlated with impaired imitation skills (Rogers, Hepburn,

Stackhouse, & Wehner, 2003). As such, children with autism fail to imitate from an early age and this lack of imitation is a

Research in Autism Spectrum Disorders 6 (2012) 13891400

A R T I C L E I N F O

Article history:

Received 5 April 2012

Received in revised form 11 June 2012

Accepted 12 June 2012

Keywords:

iPad

Caregiver training

Imitation

Video modeling

Autism

A B S T R A C T

Childrenwith autism fail to imitate froman early age and this lack of imitation is a salient

diagnostic marker for the disorder. For children with Autism Spectrum Disorder (ASD),

increased imitationskillsappearto be relatedto increasedskill development ina variety of

areas. Video modeling was recently validated as a technique to support imitation

acquisition inyoung childrenwith autism. Thepurposeof this researchwasto determineif

there is a functional relation between caregiver implemented Video Modeling Imitation

Training (VMIT) via iPad and increased imitation skills in young children with autism. In

addition, a secondary analysis of language development after exposure to VMIT was also

conducted. A multiple baseline design across four caregivers and their children with

autism was implemented. Results indicated that all four caregivers were able to

successfully create video models on an iPad when provided with minimal training and

implementVMITwith fidelity fortheir children.Allfourchildrenmade substantial gains in

their imitation skills during caregiver implementedtreatment. Imitation skillsmaintained

post treatment and, to varying degrees, generalized to imitation of live models. Expressivelanguage skills increased to varying degrees for all participants.

2012 Elsevier Ltd. All rights reserved.

* Tel.: +1 509 358 7590; fax: +1 509 358 7600.

E-mail address: [email protected].

Contents lists available at SciVerse ScienceDirect

Research in Autism Spectrum Disorders

Journa l homepage : http : / / ees .e lsev ier .com/RASD/defau l t .asp

1750-9467/$ see front matter 2012 Elsevier Ltd. All rights reserved.http://dx.doi.org/10.1016/j.rasd.2012.06.002
http://dx.doi.org/10.1016/j.rasd.2012.06.002http://dx.doi.org/10.1016/j.rasd.2012.06.002http://dx.doi.org/10.1016/j.rasd.2012.06.002http://dx.doi.org/10.1016/j.rasd.2012.06.002http://dx.doi.org/10.1016/j.rasd.2012.06.002http://dx.doi.org/10.1016/j.rasd.2012.06.002http://dx.doi.org/10.1016/j.rasd.2012.06.002http://dx.doi.org/10.1016/j.rasd.2012.06.002http://dx.doi.org/10.1016/j.rasd.2012.06.002http://dx.doi.org/10.1016/j.rasd.2012.06.002http://dx.doi.org/10.1016/j.rasd.2012.06.002http://dx.doi.org/10.1016/j.rasd.2012.06.002http://dx.doi.org/10.1016/j.rasd.2012.06.002http://dx.doi.org/10.1016/j.rasd.2012.06.002http://dx.doi.org/10.1016/j.rasd.2012.06.002mailto:[email protected]://www.sciencedirect.com/science/journal/17509467http://www.sciencedirect.com/science/journal/17509467http://www.sciencedirect.com/science/journal/17509467http://dx.doi.org/10.1016/j.rasd.2012.06.002http://dx.doi.org/10.1016/j.rasd.2012.06.002http://www.sciencedirect.com/science/journal/17509467mailto:[email protected]://dx.doi.org/10.1016/j.rasd.2012.06.002


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salient diagnostic marker for the disorder (Lord et al., 2000). For children with ASD, better imitation skills appear to be

related to improved language performance (Stone, Ousley, & Littleford, 1997), play skills (Libby, Powell, Messer, & Jordan,

1997), and social skills (Carpenter, Pennington, & Rogers, 2002; Ingersoll, 2011).

Until recently, imitation skills were taught in discrete, analog settings in adult-led exchanges (Cardon & Wilcox, 2011;

Ingersoll & Schreibman, 2006; Lovaas et al., 1967). Although some skill acquisition occurred in these settings, generalization

of skills was extremely limited (Dawson & Adams, 1984). Recently, researchers have found that for children with ASD,

imitation acquisition and generalization improves in naturalistic settings during child-motivated interactions (Cardon &

Wilcox,

2011;

Charlop-Christy,

Le,

&

Freeman,

2000;

Ingersoll,

Lewis,

&

Kroman,

2006;

Ingersoll

&

Schreibman,

2006).

2. Video modeling and autism

Although video modeling (VM) has been described in the literature for over 50 years, it is only over the past decade that

VM has been utilized with children on the autism spectrum (Ayres & Langone, 2005; Bellini & Akullian, 2007; Buggey,

Toombs, Gardener, & Cervetti, 1999; Charlop-Christy et al., 2000). A seminal study designed to teach a variety of skills to

children with autism, compared the effectiveness of VM to live modeling (Charlop-Christy et al., 2000). Participants included

five children with ASD with a chronological age range of 711 years old. Children with varying functioning levels (e.g.,

different mental ages, language ages, play skills) were purposefully selected to determine if VM would be effective in

supporting skill development. Results indicated that children in the VM condition acquired skills faster. Children also

demonstrated generalization of target behaviors after VM, but did not generalize target behaviors after live modeling

(Charlop-Christy

et

al.,

2000).

The

researchers

concluded

that

VM

is

an

effective

technique

that

can

support

the

developmentof a variety of behaviors such as play skills, expressive language, and self-help skills in children with ASD.

Ongoing research has shown video modeling to be an effective intervention tool for teaching preschool and school age

children with ASD a variety of behaviors, including play skills, social skills, and self-help skills (e.g., Ayres & Langone, 2005;

Bellini & Akullian, 2007; Carpenter, Charlop, Dennis, & Greenberg, 2010; DAteno, Mangiapanello, & Taylor, 2003; Nikopoulos

& Keenan, 2003). Both single and multi-step tasks have been successfully taught using video modeling (Tereshko,

MacDonald, & Ahearn, 2010). Previous research has also indicated that personalized video models are more effective than

commercially distributed video models (Palechka & MacDonald, 2010; Rosenberg, Schwartz, & Davis, 2010). The persons

used as models to present the actions in the videos has varied, with adults, children and siblings all being able to support

positive outcomes (DAteno et al., 2003; Reagon, Higbee, & Endicott, 2006). It has been proposed that VM is an effective

method because it capitalizes on characteristics associated with ASD (e.g., over-selectivity, social deficits, preference for

visual stimuli; Corbett & Abdullah, 2005).

Several mediums have been successfully used to present the video model including television, computers, and portable

DVD

players.

Video

modeling

has

been

validated

as

a

technique

to

facilitate

the

four

key

components

(i.e.,

attention,retention, production, and motivation; Bandura, 1977) required for observational learning to occur (Dowrick & Associates,

1991). The monitors (e.g., television, iPad screen, Portable DVD player) offer a restricted field of vision and can therefore

direct childrens attention to relevant stimuli while decreasing their tendency to attend to irrelevant stimuli (e.g., Charlop-

Christy et al., 2000; Corbett, 2003). Retention is also supported via VM because of the consistent repetition of the modeled

behavior. In addition, children are given the opportunity to practice, or produce, the behavior they saw occurring in the

video. Finally, with regard to motivation, television has been found to be particularly motivating for children with autism

(e.g., Charlop-Christy et al., 2000; Corbett, 2003; Nally, Houlton, & Ralph, 2000; Nikopoulos & Keenan, 2003; Shane & Albert,

2008).

While video modeling has been used with children with autism for over a decade (Ayres & Langone, 2005; Bellini &

Akullian, 2007; Charlop-Christy et al., 2000), the use of personal computers (e.g., iPod touch, iPads, tablet computers, smart

phones) to deliver the video model has only recently been studied (Cardon, 2012; Cihak, Fahenkrog, Ayres, & Smith, 2010).

Studies supporting the benefits of personal computers as a medium to deliver video modeling protocols are still emerging;

thus

far,

however,

indicators

suggest

that

iPod

touches,

smart

phones,

and

iPads

are

viable

alternatives

to

televisions,

laptopcomputers, and portable DVD players (Cihak et al., 2010). In addition, use of tablet computers, such as the iPad, to support

intervention has dramatically increased among children with ASD (Dunham, 2011; Sennet & Bowker, 2009). While there has

been reported success anecdotally with iPads, empirical evidence supporting the systematic use of iPads in treatment is

lacking.

3. Video Modeling Imitation Training

Video Modeling Imitation Training is a new imitation protocol designed to teach young children with autism to imitate

using iPads. Conceptually based on video modeling, VMIT supplements video modeling by including specific prompt and

praise procedures, similar to those used in a clinical setting. Developed from a video modeling protocol successfully used to

teach object imitation (Cardon & Wilcox, 2011), VMIT was recently analyzed as a tool to teach young children with autism to

imitate

gestures.

Results

were

promising

with

two

out

of

three

participants

making

substantial

gains

in

imitation,

as

well

asreceptive and expressive language skills (Cardon, 2012).

T.A. Cardon/ Research in Autism Spectrum Disorders 6 (2012) 138914001390


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4. Purpose of the current research

While there is evidence that live imitation training can be taught to caregivers to support imitation development in

children with ASD (Ingersoll & Gergans, 2007), currently it is unknown if caregivers can be taught to use VMIT to teach

imitation. Caregiver implemented intervention is increasingly necessary as the number of autism diagnoses continues to rise

and intervention resources are limited. In addition, with the increasing popularity of tablet computers it is important that

research determine how and whether these devices can be used systematically during intervention. The purpose of this

research

was

to

determine

if

there

is

a

functional

relation

between

caregiver

implemented

VMIT

via

iPad

and

increasedimitation skills in young children with autism. In addition, secondary analyses of language development after exposure to

VMIT, was also explored.

5. Method

5.1. Participants

Participants included two boys, ages 24 and 50 months, and two girls ages 26 and 42 months with an autism spectrum

diagnosis and their caregivers. Detailed participant characteristics for children and caregivers are shown in Tables 1 and 2

respectively. Participants were recruited from local autism agencies, school districts, support groups and doctors offices. All

children met the following inclusionary criteria, a) diagnosis of autism from a developmental pediatrician, psychologist, or

psychiatrist and accompanying written report, b) confirmation of diagnosis by the principal investigator (PI) using the

Autism

Diagnostic

Observation

Schedules

(ADOS;

Lord,

Rutter,

DiLavore,

&

Risi,

2001)

and

the

Childhood

Autism

Rating

Scale(CARS; Schopler, Reichler, & Renner, 2002), c) reported television/movie watching for at least one hour per day, and d) no

participation in any outside intervention that specifically taught imitation skills while enrolled in the study.

5.2. Setting and materials

All pre-assessments (i.e., ADOS, Vineland, Motor Imitation Scale, Preschool Language Scale-5) were conducted in a

university autism laboratory. The room contained two child-size tables, three metal cabinets, two file cabinets, a counter top

with wall cabinets, two adult size desks with computers, and a sink. Pre-assessments took place at one child size table that

had been partitioned off from the rest of the lab with cabinets, to minimize distraction and create a more child friendly

atmosphere. Baseline, treatment, post-assessment, and follow-up sessions took place in the participants homes. To protect

participant identity, pseudonyms are used in the following sections. Two participants, Mallory and Tessa, sat at a dining

room table during treatment, Nathan completed the tasks in his bedroom, and Joshua sat on the floor in his living room.

Three

of

the

participants

had

siblings

present

for

part

or

all

of

the

in

home

sessions.

The

fourth

participant

was

an

only

childand only her caregivers were present during her in home sessions.

Materials used during baseline and VMIT sessions supported activities and routines that the caregivers selected for their

children (see Table 3 for a complete list of activities and routines). The others-as-models in the video clips included the

caregivers or siblings (see Table 3) and were created using second generation iPads and the standard video camera software

that is available on an iPad. The video self- model was created with the iPad video camera and manipulated using iMovie on

the iPad. Video clips averaged 13.13 s with a range of 630 s. A Sony HDR-CX550V HD digital camcorder was utilized by

research assistants to record the caregivers creation of the video models for later analysis. The video models created by the

caregivers were uploaded by the PI to a MacBook Pro and saved in case a technical failure of the video clips occurred on any of

the iPads.

5.3. Procedures

5.3.1.

Caregiver

trainingCaregivers attended a 2-h training session. During the training, caregivers were instructed on how to create effective

video models. They received a training manual with instructions and picture descriptions of how to create their own video

Table 1

Child characteristics.

Child Chronological

age

Gender Adaptive Behavior

Composite (Vineland)

(SS)

Preschool Language

Scale Aud. Comp. (SS)

Preschool Language

Scale Expressive (SS)

Autism severity

(CARS)

Mallory 3.8 F 92 97 82 31

Nathan 4.2 M 92 92 86 32.5

Joshua 2.0 M 79 50 77 34.5

Tessa 2.3 F 70 50 66 42

Note:

All

names

are

pseudonyms.

CARS:

Childhood

Autism

Rating

Scale;

SS:

Standard

score.

On

the

CARS,

scores

of

3036.5

indicate

mild-moderate

autism,and scores above 36.5 indicate severe autism.

T.A. Cardon/ Research in Autism Spectrum Disorders 6 (2012) 13891400 1391


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models using an iPad. Caregivers reviewed examples of effective (e.g., limited distractions, clear target behavior, linguistic

mapping) and ineffective video models (e.g., poor lighting, distracting clothing, obstructed views) targeting a variety of

routines and activities. During the 2-h training, caregivers were also shown video examples and given instructions on how to

implement VMIT with their children. Written instructions for VMIT implementation were included in the manuals that were

provided to the caregivers (VMIT manuals are available upon request).

5.3.2. Caregiver measures

Caregiver creation of the video models was analyzed for fidelity using the Video Model Creation: Procedural Checklist

(Fig. 1). In addition, caregiver implementation of VMIT was analyzed for fidelity using the Video Modeling Imitation Training

and Caregivers: Procedural Reliability (Fig. 2).

5.3.3. Child measures

The ADOS and the CARS were administered by the PI, a certified SLP with over 19 years of experience working with

children with autism. The PI received training and met reliability requirements to administer formal autism assessments and

has diagnostic expertise with a variety of tools. Research assistants were trained to administer the outcome measures (i.e.,

Motor Imitation Scale and the Preschool Language Scale-5) and to conduct the interview portion of the Vineland Scales of

Adaptive Behavior (Sparrow, Balla, & Cicchetti, 2005).

5.3.3.1. Vineland Scales of Adaptive Behavior, Second Edition. The Vineland (Sparrow et al., 2005) is a standardized parent

interview that assesses a childs social and personal everyday living skills. The Vineland was used to assess four domains:

social, communication, daily living, and motor skills. The Vineland is recognized as an appropriate assessment tool for

individuals with autism (Perry & Factor, 1989).

5.3.3.2.

Childhood

Autism

Rating

Scale.

The

CARS

(Schopler

et

al.,

2002)

is

a

diagnostic

assessment

tool

used

to

identifychildren who have autism and determine the severity of the diagnosis. The CARS was administered by the PI to confirm the

Table 2

Caregiver characteristics.

Caregiver Age range Gender # of caregivers

in the home

Highest level of

education completed

Annual range

of income

Mallorys mom 4049 F 2 Bachelors $80,001$100,000

Nathans mom 2939 F 2 High School Diploma $60,001$80,000

Joshuas mom 1828 F 2 Bachelors $20,001$40,000

Tessa s mom 1828 F 2 N/P N/P

Note: All names are pseudonyms. N/P: not provided.

Table 3

Caregiver selected actions for Video Modeling Imitation Training.

Participant Actions

Original actions New actions

Mallory 1. wave hi 1. state hi + name

2. pat baby doll 2. pat doll & feed doll bottle

3. wipe her face 3. More _____ please

4. hands up for where gesture 4. No thank you

5. clean up puzzle 5. clean up before finished

Nathan 1. pencil grip

2.

scissor

grasp3. make the bed

4. respond to name

5. clean up

Joshua 1. touch his nose 1. blow kiss

2. hand cup to caregiver 2. hand bib to caregiver

3. allow mom to brush his teeth 3. hold moms hand while walking

4. keep a hat on his head 4. identify dog toy from field of two

5. walk doll up stairs put in bed 5. clean up toys

Tessa 1. doll onto bed

2. sign for book

3. wave bye-bye

4. reach for juice

5. push toy car

Note:

All

actions

were

randomly

presented

to

account

for

possible

order

effects.

Joshuas

video

models

included

his

five-year-old

sibling,

and

Nathans

cleanup video included his twin sister. All other video models were modeled by the childs caregiver.



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reported autism diagnosis and determine the level of autism severity. Concurrent validity between the CARS and the DSM-IV

was shown to be high and the CARS has been deemed a useful instrument in diagnosing and designating autism severity

(Rellini, Tortolani, Trillo, Carbone, & Montecchi, 2004).

5.3.3.3. Autism Diagnostic Observation Schedule. A second measure used to confirm the reported autism diagnosis was the

ADOS (Lord et al., 2001). The ADOS is a semi-structured assessment of communication, socialization, play, and atypical or

repetitive behaviors. The PI met standard requirements for research reliability in administration and scoring of the ADOS.

The following measures were obtained pre- and post-treatment to assess changes associated with treatment.

5.3.3.4. Motor Imitation Scale. The MIS (Stone et al., 1997) is a structured imitation assessment consisting of 16 motor

imitation tasks: eight object imitation and eight body imitation tasks. During the assessment, tasks are presented in a playful

manner and may be modeled up to three times. The assessment instructions state that the examiner is to state, your turn,

after

each

action

is

modeled.

For

the

purposes

of

this

research,

the

your

turn

direction

was

omitted

so

that

spontaneousimitative acts could be assessed. Participants can earn a score of two if they imitate the action immediately, a score of one if

imitation of the action is emerging, and a score of zero if they fail to imitate the action, for a total possible score of 32. Internal

consistency for the MIS revealed sufficient scores (a = .88) with a two week, test-retest reliability score of .80 (Stone et al.,

1997). The MIS was administered to the participants as a generalization probe pre- and post-treatment to assess gains in

imitative abilities.

5.3.3.5. Preschool Language Scale-5th Edition. The PLS-5 (Zimmerman, Steiner, & Pond, 2011) is a diagnostic tool that

evaluates both receptive and expressive language in children up to six years of age. The PLS-5 allows for observation of skills

and/or parent report, and includes materials for dynamic assessment. Raw scores were used to characterize change over

time.

5.3.4. Baseline

Baseline

sessions

occurred three times perweek, with

Mallory

(P1)

attending five sessions, Nathan (P2) attending sixsessions, Joshua (P3) attending seven sessions, and Tessa (P4) attending eight sessions. During baseline, all one-step

ClientCode:_____________________ Clinician:_____________________

Date:_____/_____/_____ Session#:_________

Total Session Time: ________

Instrucons: Remindtheparcipant to picka single acvitythathasa clear beginning, disnct movements, anda clear

endingpoint. They may use theVMITmanualand watchthe video guide as many mes as theyneed to before making

their ownvideomodel using theiPad.Documenttheaccuracy of the steps below for eachrecordedacon.

Imitaon Acon:

Start Time:__________ End

Time:_______

Steps Accuracy(+ or )

Comments

1. Turn on the iPad

2. Slide bar to unlock

3. Press the camera icon

4. Slide to videomode(if camera is

set to faceme modeswitch)

5. hold iPad steady and aim

a. Limited visualdistracons

b. Limited audio distracons

c. Plenty of light

d. Neutral background

6. Press therecord buon

a. Single key word/ phrase said

each me

b. Target acon is clear

c. Appropriate rate

7. Record theenre acon

8. Stop Recording

Fig. 1. Video Model Creation: Procedural Checklist.



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actions (Fig. 3) were presented live by the participants caregiver. After the action was modeled, the caregiver paused

for 10 s to give the child time to imitate the action. All five of the selected actions were modeled during the

2030 min baselines sessions. Imitation was defined as the child copying the target action within 10s with an action

that looked distinctly like the action being modeled. The child was expected to imitate the target action before they

performed a different action and before the adult modeled another action (Cardon & Wilcox, 2011; Ingersoll &

Schreibman, 2006).

5.3.5. Video Modeling Imitation Training

Treatment sessions occurred three times per week for a total of 12 sessions. Each session lasted no longer than 40 min.

During the first treatment session, the caregiver received live coaching and feedback for implementation of VMIT. The

caregiver showed the child pre-recorded clips of the one-step actions on the iPad. One video clip included a video self-model,

as

Nathans

parents

wanted

one

of

his

actions

to

be

responding

to

his

name.

According

to

the

VMIT

protocol,

the

video

clipswere presented and then paused while the caregiver stated a turn cue relevant to the action (e.g., Lets play, Mommy

brush, Lets clean up) and the child was given 10 s to imitate the action they had just viewed. If the child imitated the

action they saw on the clip, they were verbally praised and the next clip was shown. If the child did not imitate the action,

the clip was shown again and then paused. After the third demonstration of the clip in which the child did not imitate, the

caregiver physically prompted the child to perform the action and provided verbal praise before moving on to the next

action. The only action that was not physically prompted was the response-to-name task for Nathan. If Nathan did not

respond after three demonstrations of the video self-model, the caregiver moved on to the next clip. All five actions were

presented twice during each session for a total of 10 actions to imitate each session. The presentation of clips was

randomized across sessions to account for possible order effects.

Criterion was met when imitation of the actions occurred 80% of the time across four consecutive sessions. Both

Mallory and Joshuamet criterion and five new actions were introduced. To increase the level of difficulty, both one-step

and two-step actions were introduced. Mallorys caregivers requested that her second set of videos also include verbal

imitation targets,

such as

stating No thank you

and responding

to

an

introduction using

the

word Hi paired

with

apersons name.

Client Code:_____________________ Clinician:_____________________

Date: _____/_____/_____Session#:_________ Start Time:__________ End Time:_______

Total Session T ime: ________ Rel iabi li ty/Observer____________

Definion of Imitaon: Imitaon has occurred when the child copies the target acon within 10 seconds with

an acon that looks disnctly like the acon being modeled. The child must imitate the target acon before

they perform adifferent acon andbefore the adult models another acon.

Direcons: Place the iPadin front of the child for all tasks. Please record a

(

) if the behavior/task occurs.Record a

(+) or () for the

childs responses.

C=Caregiver, I= Incorrect

Trial Smulus C plays

video

clip

Cgives

turn cue

Cwaits

10 sec.

+ or

VerbalPraise I= Physical

prompt

gesture

VerbalPraise

1

2

3

4

5

6

7

8

9

10

Reliability %

Praise = Good Listening, Nice Sing, Goodjob, Way to go, Nice playing, Good playing, Nice

work, You did it, Yah!

Fig. 2. Video Modeling Imitation Training and Caregivers: Procedural Reliability.



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5.3.6.

Follow-up

sessionsFollow-up sessions occurred in participants homes one and three weeks post-treatment. Follow-up sessions assessed

both maintenance and generalization of skills. To assess generalization of imitation skills, mastery probes conducted under

baseline conditions with live actions were implemented. The caregiver presented a live model of the action and gave the

child 10 s to imitate the action. If the child did not generalize and imitate live models of the actions with greater than 80%

accuracy, the iPad was reintroduced and the video model of the action was presented to assess maintenance of the skill.

5.3.7. Fidelity and reliability

To determine fidelity of implementation, the Video Model Creation: Procedural Checklist (Fig. 1) was analyzed by six

trained research assistants to determine if caregivers were able to accurately choose target actions and create the video

models to be used during treatment after attending one 2-h training session. Point by point comparisons across six trained

observers were made for 56% of the caregiver created video models (n = 50). Fidelity of implementation>80% was met by all

four caregivers in every category (Table 4).

To

ensure

the

caregivers

fidelity

of

VMIT,

point

by

point

comparisons

were

made

across

participants.

Of

the

26

baselinesessions, 42% (n = 11) of them were scored by four trained research assistants in their entirety from video tape. Reliability

0%

20%

40%

60%

80%

100%

987654321 10 11 12 13 14 15 16 17 18 19

0%

20%

40%

60%

80%

100%

987654321 10 11 12 13 14 15 16 17 18

0%

20%

40%

60%

80%

100%

987654321 10 11 12 13 14 15 16 17 18 19 20 21

0%

20%

40%

60%

80%

100%

87654321 109 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Baseline Treatment Follow Up

iPad acons

Mallory

Nathan

Joshua

Tessa

Criterion met,

new acons

on iPad

%

ofAconsImitated

# of Sessions

Live acons

Fig. 3. Multiple baseline graph of child imitated actions after caregiver implemented VMIT.



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standards greater than 80% were easily met during baseline, with actions being modeled correctly by caregivers 100% of the

time, caregivers waiting 10 s 98%, and imitation rated as correct/incorrect 96% of the time.

During treatment, 58% of the sessions (n = 28) were scored in their entirety from video tape using the Video Modeling

Imitation Training and Caregivers: Procedural Reliability Checklist (Fig. 2).The following percentages for caregiver treatment

fidelity

were

obtained:

presentation

of

the

clip

98.8%,

providing

a

turn

cue

98.4%,

waiting

10

s

97.5%,

verbal

praise

for

correctimitation 95.7%, physical prompts 99.2%, and verbal praise after physical prompt 98.2%. To calculate scoring reliability for

imitation, the definition remained consistent across baseline, treatment and follow-up. Four trained research assistants

scored 58% of the sessions from video tape. Reliability for imitation was 95% during treatment.

5.4. Experimental design

The first objective was to determine whether caregivers could be trained to create effective video models to teach their

children imitation skills using VMIT (Cardon & Wilcox, 2011). Caregivers attended one, 2 h training session, and received a

training manual and video guide with step-by-step instructions recorded on the iPad. The training manual and video guide

provided examples of actions/gestures that could be targeted during VMIT. Caregivers then identified five specific actions/

gestures (e.g., teeth brushing) or play schemes (e.g., pushing a car) that they wanted to teach their child to imitate (Table 3).

Caregivers recorded the five target actions/gestures that they identified as being important for their children on iPads that

were

provided

by

the

PI.

Caregivers

provided

linguistic

mapping

during

each

video

model

(e.g.,

wipe

my

face;

up,

up,

up;hat on). Caregivers agreed that video models on the iPad would be shown to their child exclusively when the PI or a

graduate research assistant was present.

A multiple baseline design across the four participants was conducted. Participants attended baseline sessions until

stable trends were established. Mallory attended five baseline sessions, Nathan six baseline sessions,Joshua seven baseline

sessions, and Tessa eight baseline sessions. At the completion of her baseline sessions, Mallory entered the treatment phase

for four weeks. When a positive trend was identified for Mallory, Nathan entered the treatment phase for four weeks and so

on forJoshua and Tessa. Treatment sessions occurred three times a week for up to 40 min/session depending on the number

of presentations required per session. Maintenance and generalization probes were conducted at one and three weeks post

treatment for all participants. The Motor Imitation Scale (Stone et al., 1997) and the Preschool Language Scale-5

(Zimmerman et al., 2011) were obtained pre- and post-treatment to assess changes over time associated with treatment.

6. Results

Caregivers used iPads to create video models and implement VMIT with their children on the autism spectrum. Analysis

of caregiver created video models indicated that all caregivers created personalized video models on the iPads with greater

than 90% fidelity across all categories (Table 4). In addition, caregivers implemented VMIT with high fidelity across sessions

(95.799.2%).

6.1. Visual analysis of multiple baseline design

A visual analysis was conducted to determine if there was a functional relation between caregiver implemented VMIT and

increased child imitation skills. When analyzing single case designs, such as the multiple baseline design used in this study,

the preferred method of analysis is a visual inspection of the data as this method does not require specific assumptions to be

met and participants act as their own control (Gast, 2010; Kratochwill et al., 2010; Kromrey & Foster-Johnson, 1996). One

aspect of visual analysis is identifying data levels and trends across and between phases of each participant.

All

four

participants

exhibited

no

imitation

(0%)

to

minimal

levels

(average

20%)

of

imitation

during

baseline,

and

stabletrends were established before staggered treatment sessions were implemented across all four participants (Fig. 3). Percent

Table 4

Caregiver fidelity of video model creation via iPad.

Category Percent correct

1. Hold iPad steady and aim at target 98%

2. Limit visual distractions 98%

3. Limit auditory distractions 96%

4. Plenty of light 100%

5. Neutral background 98%

6. Press record button 98%7. Single work/key phrase stated 92%

8. Target action clear 96%

9. Appropriate rate 100%

10. Record entire action 100%

11. Stop recording 100%



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imitated was calculated as the total number of actions imitated divided by the total number of actions presented (# of

actions imitated/total # of actions). All four participants demonstrated an increased level of imitation once treatment was

implemented (Fig. 3) and maintained higher than baseline levels of imitation during treatment. Three of the four participants

demonstrated immediate increases by the second treatment session. After immediate increases early on, data for three

participants remained stable, with two participants meeting a priori criteria (>80% imitation over four consecutive sessions)

for the introduction of new target actions (Table 3). New target actions for Mallory andJoshua consisted of expanded targets

(i.e., one step to two step actions, action with verbal imitation) or generalization of target actions (e.g., give me cup to give

me

bib).Nathan did not meet a priori criteria for the introduction of new actions because he exhibited problem behaviors during

the sessions with his caregiver (e.g., refusals to participate, demands for specific video clips, tantrums). A token economy

system, a sticker received for each video watched, was implemented during the last two treatment sessions to address

Nathans problem behaviors. With the external sticker reward system, Nathans problem behaviors decreased and his video

watching and imitation increased.

Tessa gradually increased her imitation skills after the onset of VMIT; however, during ongoing visual analysis of the data

it was noted that her progress was limited. A decision was made to increase the number of sessions she received during the

last two weeks of treatment from three sessions per week to four sessions per week. With the increased number of sessions,

Tessa demonstrated an increased positive response to treatment.

6.2. Pre- and post-treatment assessments

All

four

participants

made

positive

gains

in

expressive

communication

as

measured

by

increases

in

raw

scores

on

the

PLS-5 post treatment (see Fig. 4). Three out of four participants also demonstrated gains in auditory comprehension. All four

children made gains on the Motor Imitation Scale (Stone et al., 1997) post-treatment (see Fig. 5). Consistent with past

research, participants with lower scores on the CARS indicating less autism severity (i.e., Mallory and Nathan) demonstrated

larger gains on the Motor Imitation Scale, while participants with higher scores on the CARS (i.e., Joshua and Tessa)

demonstrated fewer imitation gains. While some improvement in language and imitation skills could be attributed to

maturation, there was a limited amount of time between pre- and post-assessment sessions (maximum of 8 weeks).

6.3. Maintenance and generalization

Mastery probes, a return to baseline conditions, were conducted at one and three weeks post-treatment in participants

homes to determine if imitation skills had maintained and/or generalized. All four participants demonstrated mastery of the

imitation skills to varying degrees at the initial one week follow-up session. Mallory imitated 80% of her target actions when

presented

with

a

mastery

probe.

Nathan

imitated

100%,

Joshua

90%,

and

Tessa

40%

of

her

target

actions.

Because

Tessasimitation of the mastery probes was below 80%, she was given an opportunity to view the actions she did not imitate on the

iPad to determine if the ability to imitate the video models had maintained. With the iPad, Tessa was able to imitate 40% of

the target actions.

At the second follow-up session, three weeks post-treatment, Mallory refused to imitate the mastery probe actions and, in

fact, stated, no and requested the iPad. With the iPad, her imitation skills of previously viewed target actions maintained at

100%. Nathan continued to generalize his skills and imitated 100% of his target actions in response to a mastery probe. Given

a mastery probe during his second follow-up session,Joshua imitated 70% of his target actions. Because his imitation during

the second follow-up was below 80%, the iPad was reintroduced and he demonstrated maintenance of imitation skills at 90%.

0

5

10

15

20

25

30

3540

45

50

TreatmentPre

Post Treatment

Auditory Comprehension Expressive Communicaon

Fig. 4. Preschool Language Scale-5 raw scores pre- and post-treatment.



10/12

Tessa did not imitate any mastery probes during her second follow-up; however, she did maintain the ability to imitate the

video models presented on the iPad at 40%.

7. Discussion

This study investigated caregivers abilities to create effective video models with iPads and examined the functional

relation between caregiver implemented VMIT and imitation gains in their young children with autism. Caregivers created

effective video models on an iPad with the training provided and use those video models to teach their children with ASD to

imitate a variety of actions/gestures. Treatment fidelity was high and caregivers proved to be effective implementers of the

intervention approach. In addition, all four children generalized imitation skills to mastery probes to varying degrees after

discontinuation of treatment. Expressive and receptive language skills also increased as reported on the PLS. While language

skills were not explicitly targeted, these findings add support to existing research indicating a possible relationship between

imitation skills and language development (Cardon, 2012; Ingersoll & Schreibman, 2006; Stone et al., 1997).

Previous research has shown that caregivers can be successful implementers of autism intervention (Dawson et al., 2010;

Ingersoll & Gergans, 2007; Koegel & Koegel, 2006; Yoder & Warren, 1998) and results from this study support the use of

caregiver implemented VMIT for autism intervention. Further, while iPad use among children with autism has been

anecdotally reported, this study among the first to provide empirical evidence to support the use of iPads as intervention

agents

in

the

home

environment.

In

addition,

this

research

furthered

support

for

VMIT

as

an

effective

tool

to

teach

bothobject and gestural imitation to children with ASD, and suggests that verbal imitation is a viable target behavior for VMIT.

Three of four participants in the current study showed immediate gains once their caregivers introduced the video model,

confirming that video modeling is an effective method for teaching a variety of skills (Cardon & Wilcox, 2011; Charlop-

Christy et al., 2000). This immediacy effect is a relative strength of video modeling in general and was confirmed with these

results. Participants were highly motivated to attend to the iPads, thereby increasing their attention to the learning

opportunity. The use of electronic mediums, such as the iPad, to focus childrens attention on relevant stimuli supports the

use of VMIT as an intervention tool (Cardon & Azuma, 2012; Corbett & Abdullah, 2005). Participants were able to learn five

individual target behaviors concurrently. Participants abilities to attend to, retain, and produce actions viewed on an iPad

with caregiver support is an important component of this research.

The results of this work have important clinical implications with regard to the use of iPads in intervention settings. The

demonstrated effectiveness of iPads to deliver VMIT, and the relative ease with which the caregivers were taught to create

their own video models and implement VMIT, provides tentative evidence for clinicians considering iPad use with children

on

the

autism

spectrum.

Caregiver

implemented

programs

(e.g.,

Pivotal

Response

Treatment,

Early

Start

Denver

Model,Reciprocal Imitation Training) typically require extensive training by highly skilled professionals and are very expensive. In

contrast, VMIT required one, 2-h training session and a one hour coaching session for an estimated cost of $300 per child. The

need for a highly skilled professional was limited once the initial training was complete. Future research should examine the

extent to which VMIT could be implemented in rural settings via telemedicine with pre-recorded, training sessions and

online coaching.

While VMIT is not meant to replace intervention with trained clinicians, the present results suggest that it may enhance

existing interventions. For example, Nathans parents chose two fine motor tasks, pencil grip and scissor grasp, which he had

been struggling with in traditional occupational therapy. While Nathans occupational therapist was concerned, she agreed

to defer continued training of these tasks while Nathan completed the study. After VMIT, Nathan was able to produce both

actions when presented with a live model 100% of the time at follow-up and his occupational therapist was reportedly

thrilled with the results. Similarly,Joshua had been working on identifying body parts in speech therapy for over 8 months

with limited success. His mother wanted him to imitate touching his nose as one of his target behaviors. After three sessions,

he

was

able

to

imitate

the

action

after

watching

the

video

of

his

sister

touching

her

nose.

In

addition,

teaching

verbalimitation through VMIT had not previously been addressed until Mallorys mother requested that it be included in her

0

5

10

15

20

25

30

35

Mallory Nathan Joshua Tessa

Pre Treatment

Post Treatment

Fig. 5. Motor Imitation Scale pre- and post-treatment.



11/12

second set of target behaviors. While previous research with video modeling has demonstrated that adults and adolescents

can learn verbal targets through video modeling (Charlop & Milstein, 1989; Taylor, Levin, & Jasper, 1999), given Mallorys

success, teaching verbal imitation via VMIT to young children should be explored further in future studies. These results

strongly suggest that focused attention on relevant stimuli through VMIT can help some children with autism learn target

behaviors that had previously been resistant to training using traditional methods.

While the overall results of this study are promising, there are some limitations. The four participants in the current study

are appropriate for the single-case design methodology employed in this research; replication with a larger group in a

randomized

control

trial

is

warranted.

Physical

prompts

were

used

as

part

of

the

VMIT

protocol;

however,

this

is

a

limitationof the study as the increase in imitative behaviors may have been influenced by the physical prompts. In addition, the

introduction of a token economy system to address Nathans problem behaviors during his last two sessions could be

considered a limitation because of its impact on Nathans increased response to VMIT. Tessas need for additional training is a

limitation of this study and it would be beneficial for future research to determine the extent to which autism severity

influences a childs response to video modeling in general and VMIT specifically (Cardon & Wilcox, 2011; Rogers et al., 2003).

Future research might also ask if children with certain prerequisite skills (e.g., increased interest in play, increased verbal

language, etc.) respond more consistently to VMIT.

This study offers important contributions to the growing field of autism intervention research. Results indicate that

caregivers of children with autism can be taught to utilize iPads to record effective video models. Caregivers require only

minimal training to implement VMIT effectively with their children in the home environment. Finally, iPads can be effective

tools to support imitation development in very young children with autism.

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