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Pivotal Areas in Intervention for Autism
Abstract
Discusses several core pivotal areas that appear to be influential in intervention for autism. Literature and outcome data are reviewed with respect to several core areas that appear to be particularly helpful in intervention for autism, including improving motivation, responsivity to multiple cues, self-management, and self-initiation of social interactions. A conceptual framework is described, and outcome data are reviewed suggesting that when children with autism are motivated to initiate complex social interactions, it may reverse a cycle of impairment, resulting in exceptionally favorable intervention outcomes for many children. Because the peripheral features of autism can be numerous and extensive, the concept of intervention for pivotal areas of functioning may be critical if children are to be habilitated in a time- and cost-efficient manner.
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“In fact, in behavioral treatment programs, young children with ASD profit less from the use of social rewards than from non-social reinforcers [42,43]”
From Social “wanting” dysfunction in autism: neurobiological underpinnings and treatment implications (2012) · cites this paper as [42]
In the citing paper
“A weak social ‘wanting’ circuitry suggests that particularly strong social cues, in combination with other strategies to boost attention and engagement [2], might be necessary for individuals with ASD to help them establish motivational salience and initiate desired behaviors [4,42].”
From Social “wanting” dysfunction in autism: neurobiological underpinnings and treatment implications (2012) · cites this paper as [42]
In the citing paper
“The initial behavioral modification programs attempted to create responsiveness to social stimuli through operant conditioning using already powerful reinforcers (for example, food [43,188,189]), but this approach only showed limited generalization effects to daily social function [42].”
From Social “wanting” dysfunction in autism: neurobiological underpinnings and treatment implications (2012) · cites this paper as [42]
In the citing paper
“Later programs focusing on the functional (that is, contextual) analysis of problem behaviors were more successful in addressing core deficits [3,5,6,32,42,190-196].”
From Social “wanting” dysfunction in autism: neurobiological underpinnings and treatment implications (2012) · cites this paper as [42]
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“These child behaviors include ‘‘pivotal responses’’ that provide a child with important ways to learn from others ( Koegel, Koegel, & McNerney, 2001 ) and those eliciting ‘‘boot-strapping operations,’’ that is, that result in positive responses from other people that may lead to learning of other behaviors (Shatz & Eb…”
BackgroundPredictors of Optimal Outcome in Toddlers Diagnosed with Autism Spectrum Disorders
Sutera, S., Pandey, J., Esser, E. L., ROSENTHAL, M. A., Wilson, L. B., Barton, M. L., Green, J., Hodgson, S., Robins, D. L., Dumont-Mathieu, T. M., et al. (2007) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-006-0340-6 · Cited by 341
“2004). Koegel, Koegel, and McNerney (2001) hypothesized that there were pivotal areas that influenced outcome.”
BackgroundHopkins, I. M., Gower, M. W., Perez, T. A., Smith, D. S., Amthor, F. R., Wimsatt, F. C., & Biasini, F. J. (2011) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-011-1179-z · Cited by 371
“Generalization, the ability to transfer a learned behavior acquired during a training activity to another similar or related activity or situation, is considered a difficult task for children with an ASD (Koegel et al. 2001).”
BackgroundThe journal of developmental processes
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“No cure for the disorder exists, although some evidence suggests that early, intensive behavioral treatments may improve functioning.(17-20)”
BackgroundSocial “wanting” dysfunction in autism: neurobiological underpinnings and treatment implications
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“A weak social ‘wanting’ circuitry suggests that particularly strong social cues, in combination with other strategies to boost attention and engagement [2], might be necessary for individuals with ASD to help them establish motivational salience and initiate desired behaviors [4,42].”
BackgroundInfluentialLong-term outcome of social skills intervention based on interactive LEGO© play
LeGoff, D. B., & Sherman, M. (2006) · Autism · doi:10.1177/1362361306064403 · Cited by 184
Robotic animals might aid in the social development of children with autism
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“Autism is a pervasive developmental disorder characterized by three main symptoms [5, 13, 28].”
BackgroundIncreasing Physical Activity in Individuals With Autism
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“during social interactions [1–4].”
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“Federlein et al., 1982). The Parten scale, adapted by Ballard (1981), categorizes children’s free play in accordance with Piaget’s developmental theory, and defines six categories of play:”
MethodParent-implemented natural language paradigm to increase language and play in children with autism
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“Recent studies have incorporated NLP into a broader-scope, multi-component empirically supported intervention referred to a Pivotal Response Training (PRT) without focusing specifically on the effects of NLP as a stand alone intervention (Koegel, Koegel, & Brookman, 2003; Koegel, Koegel, Harrower, & Carter, 1999; Koeg…”
BackgroundLong‐term LEGO therapy with humanoid robot for children with ASD
Barakova, E. I., Bajracharya, P., Willemsen, M., Lourens, T., & Huskens, B. (2014) · Expert Systems · doi:10.1111/exsy.12098 · Cited by 114
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“…and turn taking, (d) varying tasks and interspersing maintenance and acquisition tasks, (e) using contingent and natural reinforcement, and (f) reinforcing attempts at target skills (e.g., Dunlap and Koegel 1980; Koegel et al. 1999a, c, 1987a; Koegel and Koegel 2006; Koegel et al. 2001, 1988).”
Browder, D. M., Wakeman, S. Y., Flowers, C. P., Rickelman, R. J., Pugalee, D., & Karvonen, M. (2007) · The Journal of Special Education · doi:10.1177/00224669070410010101 · Cited by 104
“For example, Kozleski (1991) used time delay to teach individuals with severe cognitive and physical impairments to match objects with pictures on a communication board and then to use these pictures to make requests.”
MethodWehmeyer, M. L., Shogren, K. A., Zager, D., Smith, T. E. C., & Simpson, R. L. (2010) · Education and Training in Autism and Developmental Disabilities · doi:10.1177/215416471004500403 · Cited by 104
“Interventions that seek to improve motivation tend to result in improvements in language, academic, and social functioning, supporting the hypothesis that by increasing student motivation, significant changes in the behavior of students with ASD are observed (Koegel et al., 2001).”
InfluentialGanz, J. B., & Flores, M. M. (2008) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-008-0602-6 · Cited by 99
“Though pivotal response intervention (PRI) was not included as an intervention in this study, Kyle demonstrated a skill often targeted by PRI, learning via initiating to others ( Koegel et al. 2001 ), or selfinitiation.”
MethodDawson, M., Mottron, L., & Gernsbacher, M. A. (2008) · Elsevier eBooks · doi:10.1016/b978-012370509-9.00152-2 · Cited by 95
“…henceforth characterized autistics as being governed by the same laws of learning as all other organisms, while being distinguished by failing to learn from the typical, every-day environment (e.g., Lovaas, 1987; Green, 1996; Smith and Lovaas, 1998; Lovaas and Smith, 2003; Koegel et al., 2001).”
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“[36] report that children with typical development are able to initiate a discussion (asking questions) during their interaction.”
BackgroundDance/Movement Therapy as an Intervention for Children with Autism Spectrum Disorders
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“improving impairment) may in turn facilitate participation (Koegel et al. 2001).”
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“1 3 social communication, (2) responsiveness to multiple cues, (3) self-initiations and (4) self-management [6].”
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“Individuals with ASD often do not independently initiate the completion of steps during classroom activities (L. Koegel, Carter, & Koegel, 2003; R. Koegel et al., 2001).”
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de Korte, M. W. P., Smeekens, I., van Dongen‐Boomsma, M., Oosterling, I. J., den Boer, J. C., Barakova, E. I., Lourens, T., Buitelaar, J. K., Glennon, J. C., & Staal, W. (2020) · Autism · doi:10.1177/1362361320935006 · Cited by 51
“Motivation is considered a pivotal area in treatment (Koegel et al., 2001) Figure 1.”
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“…potential to explicitly teach students to understand social expectations as well as promote generalization because the skills learned in the intervention foster greater responsivity through more reinforcing interactions across individuals, activities, and environments (R. L. Koegel et al., 2001).”
BackgroundBehavioral Intervention Planning: Increasing Appropriate Behavior of a Socially Withdrawn Student
Christensen, L., Young, K. R., & Marchant, M. (2007) · Education and Treatment of Children · doi:10.1353/etc.2007.0022 · Cited by 41
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“Furthermore PRT is expected to increase parental self-efficacy because of their explicit and pronounced involvement (Koegel et al. 2001), in contrast to DTT that is delivered by therapists.”
BackgroundResultTuchman, R. F. (2003) · Neurologic Clinics · doi:10.1016/s0733-8619(03)00011-2 · Cited by 40
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Effect of Physical Activity on the Stereotypic Behaviors of Children With Autism Spectrum Disorder
Liu, T., Fedak, A. T., & Hamilton, M. (2015) · International Journal of School Health · doi:10.17795/intjsh-28674 · Cited by 36
“Studies show that children with ASD are at risk for many health risks and nutritional deficiencies brought on by lack of exercise because they are not motivated to be physically active and they do not care about their selective diets (25, 26).”
Backgroundvan Otterdijk, M., de Korte, M. W. P., Smeekens, I., Hendrix, J., van Dongen‐Boomsma, M., den Boer, J. C., Buitelaar, J. K., Lourens, T., Glennon, J. C., Staal, W., et al. (2020) · Robotics · doi:10.3390/robotics9040079 · Cited by 37
“PRT is an evidence-based treatment approach [19], which focuses on the social development of the child by training key (pivotal) areas These key areas are motivation, response to multiple cues, self-management, and the initiation of social interaction.”
BackgroundPeer-Mediated Pivotal Response Treatment for Young Children With Autism Spectrum Disorders
Boudreau, A. M., Corkum, P. V., Meko, K., & Smith, I. M. (2015) · Canadian Journal of School Psychology · doi:10.1177/0829573515581156 · Cited by 37
Lin, C. E., & Koegel, R. L. (2018) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-018-3637-3 · Cited by 41
“It emphasizes the pivotal area of child motivation by using strategies to engage and maintain a child’s interest and engagement through a variety of strategies such as following the child’s interests, varying tasks, interspersing difficult and easy tasks, providing contingent reinforcement, and using rewards directly…”
BackgroundMethodSelf-citationWood, J. J., Wood, K. S., Cho, A. C., Rosenau, K. A., Guevara, M. V. C., Galán, C. A., Bazzano, A., Zeldin, A. S., & Hellemann, G. (2021) · Journal of Consulting and Clinical Psychology · doi:10.1037/ccp0000621 · Cited by 36
“…or the therapist’s generally sunny disposition and tendency to use shaping and behavioral momentum instead of demands and requirements, the emphasis on generating positive affective experiences within the sessions coincides with the emphasis on motivation and choice in PRT (Koegel et al., 2001).”
BackgroundRegional Callosal Morphology in Autism and Macrocephaly
Kilian, S., Brown, W. S., Hallam, B. J., McMahon, W., Lu, J. K., Johnson, M., Bigler, E. D., & Lainhart, J. E. (2007) · Developmental Neuropsychology · doi:10.1080/87565640701729821 · Cited by 33
“For example, individuals with autism, as a group, may have more difficulty than RD subjects with emotions ( Dominick et al, 2007 ), motivation, and decision making ( Koegel, Koegel & NcNerney, 2001 ), functions partly controlled by the orbitofrontal cortex.”
BackgroundZhang, Q., Wu, R., Zhu, S., Le, J., Chen, Y., Lan, C., Yao, S., Zhao, W., & Kendrick, K. M. (2021) · Autism Research · doi:10.1002/aur.2565 · Cited by 40
Verschuur, R., Huskens, B., Verhoeven, L. T. W., & Didden, R. (2016) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-016-2966-3 · Cited by 35
“Motivation is often defined as children’s responsiveness to social and environmental stimuli (Koegel et al. 2001).”
BackgroundMcLay, L., France, K. G., Blampied, N., Hunter, J. E., van Deurs, J. R., Woodford, E., Gibbs, R., & Lang, R. (2021) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-021-05116-3 · Cited by 19
McPartland, J. C., Law, K. C. Y., & Dawson, G. (2015) · Elsevier eBooks · doi:10.1016/b978-0-12-397045-9.00230-5 · Cited by 33
Hong, E. R., Ganz, J. B., Gilliland, W. D., & Ninci, J. (2014) · Research in Autism · doi:10.1016/j.rasd.2014.01.012 · Cited by 30
Systematic Review of Matrix Training for Individuals With Autism Spectrum Disorder
Curiel, E. S. L., Axe, J. B., Sainato, D. M., & Goldstein, H. (2019) · Focus on Autism and Other Developmental Disabilities · doi:10.1177/1088357619881216 · Cited by 30
Gillis, J. L., Callahan, E. H., & Romanczyk, R. G. (2010) · Research in Autism · doi:10.1016/j.rasd.2010.04.019 · Cited by 30
Hume, K., & Reynolds, B. (2010) · Preventing School Failure Alternative Education for Children and Youth · doi:10.1080/10459881003744701 · Cited by 35
“THE AMOUNT OF TIME THAT A STUDENT with autism is actively engaged in or attending to activities and interactions has been cited as one of the best predictors of long-term student outcomes ( Iovannone, Dunlap, Huber, & Kincaid, 2003 ; Koegel, Koegel, & McNerney, 2001 ).”
BackgroundLedbetter‐Cho, K., Lang, R. B., Watkins, L., O’Reilly, M. F., & Zamora, C. (2017) · Autism & Developmental Language Impairments · doi:10.1177/2396941517737536 · Cited by 29
Huskens, B., Reijers, H., & Didden, R. (2012) · Developmental Neurorehabilitation · doi:10.3109/17518423.2012.705910 · Cited by 26
“[11] identified five pivotal areas: motivation, selfinitiations of communication, responsiveness to multiple cues, empathy and self-management.”
BackgroundYerys, B. E., Wallace, G. L., Jankowski, K. F., Bollich, A. M., & Kenworthy, L. E. (2011) · Child Neuropsychology · doi:10.1080/09297049.2010.547462 · Cited by 27
“Finally, divided attention may serve as a lab-based index of poor “responsivity to multiple cues,” a targeted area of intervention in several ASD treatments, such as pivotal response training ( Koegel, Koegel, & McNerney, 2001 ).”
Responsivity to familiar versus unfamiliar social reward in children with autism
Pankert, A., Pankert, K., Herpertz‐Dahlmann, B., Konrad, K., & Kohls, G. (2014) · Journal of Neural Transmission · doi:10.1007/s00702-014-1210-6 · Cited by 30
“Evidence from behavioral treatment programs suggests that children with ASD profit less from the use of social rewards than from nonsocial rewards, such as candy, tokens, and stickers (Koegel et al., 2001; Matson et al., 1996).”
BackgroundMeta-Analysis of Pivotal Response Training for Children with Autism Spectrum Disorder
Bozkuş-Genç, G., & Özkan, Ş. Y. (2016) · Education and Training in Autism and Developmental Disabilities · doi:10.1177/215416471605100103 · Cited by 26
“The basic premise of PRT is that changes in certain pivotal areas of behavior will trigger changes in other behavioral areas (Koegel et al., 2001).”
Tabeshian, R., Alhosseini, M. N., Movahedi, A., Zehr, E. P., & Faramarzi, S. (2021) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-021-05090-w · Cited by 28
Tilmont, E., Saint-Georges-Chaumet, Y., Favrot, C., Tanet, A., Cohen, D., & Saint‐Georges, C. (2018) · BMC Pediatrics · doi:10.1186/s12887-018-1126-7 · Cited by 26
“forms of attempts to respond, alternating between acquisition and maintenance, and using intrinsic reinforcers [10].”
BackgroundPsychotherapie des Asperger-Syndroms im Erwachsenenalter
Fangmeier, T., Lichtblau, A., Peters, J., Biscaldi-Schäfer, M., Ebert, D., & van Elst, L. T. (2010) · Der Nervenarzt · doi:10.1007/s00115-010-3121-6 · Cited by 24
Graetz, J. E., Mastropieri, M. A., & Scruggs, T. E. (2009) · Education and training in developmental disabilities · doi:10.1177/215416470904400109 · Cited by 24
“…Johnston, Crompton, & Nelson, 2007; DiSalvo & Oswald, 2002; Gil-berts, Agran, Hughes, & Wehmeyer, 2001; Laushey & Heflin, 2000), self-management (Koegel, Koegel, & McNerney, 2001; New-man, Reinecke & Meinberg, 2000), and the use of visual supports (Charlop-Christy, Car-penter, Le, LeBlanc, &…”
Pujol, C., Pellissier, L. P., Clément, C., Becker, J. A. J., & Merrer, J. L. (2018) · Translational Psychiatry · doi:10.1038/s41398-018-0247-y · Cited by 22
Sevin, J. A., Rieske, R. D., & Matson, J. L. (2015) · Review Journal of Autism and Developmental Disorders · doi:10.1007/s40489-015-0056-7 · Cited by 32
“However, with the possible exception of Koegel et al. (2006b) in which choice regarding order of assignments and material selection was used to assist 8-year-old”
BackgroundMethodReynolds, B. M., Gast, D. L., & Luscre, D. (2013) · Journal of Positive Behavior Interventions · doi:10.1177/1098300713483176 · Cited by 23
Training Issues Unique to Autism Spectrum Disorders
LeBlanc, L. A., Gravina, N., & Carr, J. E. (2009) · Applied Behavior Analysis for Children with Autism Spectrum Disorders · doi:10.1007/978-1-4419-0088-3_13 · Cited by 30
“When possible, teach pivotal skills that will allow the client to manage more of their environment and individual needs (e.g., self-management, requesting assistance or attention) ( Koegel, Koegel, & McNerney, 2001; Lee, Simpson, & Shogren, 2007; Reichle, Dropik, Alden-Anderson, & Haley, 2008).”
BackgroundHolzer, L., Mihailescu, R., Rodrigues-Dagaeff, C., Junier, L., Müller‐Nix, C., Halfon, O., & Ansermet, F. (2006) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-005-0053-2 · Cited by 21
“evidence to support a multidisciplinary therapeutic approach (Danion-Grilliat, 1996; Gilman & Tuchman, 1995; Ozonoff & Cathcart, 1998; Reid, Balis, & Sutton, 1997; Rutter, 1999) and the effectiveness of educational interventions ( Koegel, Koegel, & McNerney, 2001; Ozonoff & Cathcart, 1998).”
Empirisch überprüfte Frühfördermethoden bei autistischen Störungen
Freitag, C. M. (2010) · Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie · doi:10.1024/1422-4917/a000043 · Cited by 19
Bradshaw, J. L., Trumbull, A., Stapel‐Wax, J. L., Gillespie, S. E., George, N. A., Saulnier, C. A., Klaiman, C., Woods, J. J., Call, N. A., Klin, A., et al. (2020) · Autism · doi:10.1177/1362361320928829 · Cited by 22
“Further, interventions delivered by caregivers in the child’s natural environment during normal routines promote generalization of learned skills (Coolican, Smith, & Bryson, 2010; Koegel, Koegel, & McNerney, 2001).”
BackgroundEsteve, T. V., Salvador-García, C., Gil-Gómez, J., & Maravé-Vivas, M. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph18105216 · Cited by 18
“Specifically, they show hypo or hyperreactivity or unusual interest in sensory aspects of movement [19], poor motor coordination and motivation [20], difficulty self-monitoring [21] and altered postural control in bipedal stance compared to their typically developing (TD) peers [22].”
BackgroundBarrie, E. S., Pinsonneault, J. K., Sadée, W., Hollway, J. A., Handen, B. L., Smith, T. H., Arnold, L. E., Butter, E. M., Hansen‐Kiss, E., Herman, G. E., et al. (2018) · Journal of Developmental and Physical Disabilities · doi:10.1007/s10882-018-9590-4 · Cited by 16
Intensive verhaltenstherapeutische Interventionsprogramme bei Autismus-Spektrum-Störungen
Poustka, L., Rothermel, B., Banaschewski, T., & Kamp‐Becker, I. (2012) · Kindheit und Entwicklung · doi:10.1026/0942-5403/a000074 · Cited by 15
Development of a tool to assess visual attention in Rett syndrome: a pilot study
Wandin, H., Lindberg, P., & Sonnander, K. (2020) · Augmentative and Alternative Communication · doi:10.1080/07434618.2020.1798507 · Cited by 15
Bölte, S., & Poustka, F. (2002) · Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie · doi:10.1024//1422-4917.30.4.271 · Cited by 15
Herbrecht, E., & Poustka, F. (2007) · Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie · doi:10.1024/1422-4917.35.1.33 · Cited by 14
Examination of Studies Targeting Social Skills with Pivotal Response Treatment.
Bozkuş-Genç, G., & Vuran, S. (2013) · Educational Sciences Theory & Practice · Cited by 13
McIlvane, W. J., Gerard, C. J., Kledaras, J. B., Mackay, H. A., & Lionello‐Denolf, K. M. (2016) · European Journal of Behavior Analysis · doi:10.1080/15021149.2016.1139363 · Cited by 13
Das Asperger-Syndrom - eine Autismus-Spektrum-Störung
Remschmidt, H., & Kamp‐Becker, I. (2007) · Cited by 13
¿Podemos curar el autismo? Del desenlace clínico a la intervención
Alessandri, M., Thorp, D. M., Mundy, P. C., & Tuchman, R. F. (2005) · Revista de Neurología · doi:10.33588/rn.40s01.2004648 · Cited by 12
Attar, N. M. A., Al‐Hroub, A., & Zein, F. E. (2022) · Frontiers in Psychology · doi:10.3389/fpsyg.2022.819473 · Cited by 14
Metadata
- Authors
- Koegel, R. L., Koegel, L. K., & McNerney, E. K.
- Affiliations
- University of California, Santa Barbara (US)
- Venue
- Journal of Clinical Child & Adolescent Psychology
- Publisher
- Informa UK Limited
- Published
- 2001-02-01
- Volume
- 30
- Issue
- 1
- Pages
- 19-32
- ISSN
- 1537-4416 (ISSN-L)
- 1537-4424
- OpenAlex
- W2015957449
- Cited by
- 243
- References
- 150
- Citations by year
- 2026: 1 · 2025: 15 · 2024: 3 · 2023: 6 · 2022: 5 · 2021: 14 · 2020: 15 · 2019: 6 · 2018: 9 · 2017: 9 · 2016: 9 · 2015: 11 · 2014: 18 · 2013: 12 · 2012: 13
- FWCI
- 1.57
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of Clinical Child & Adolescent Psychology (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Institute of Mental Health (MH 28210)
- Topics
- Life Sciences › Neuroscience › Cognitive Neuroscience › Autism Spectrum Disorder Research
- Social Sciences › Psychology › Developmental and Educational Psychology › Behavioral and Psychological Studies
- Health Sciences › Medicine › Psychiatry and Mental health › Child Nutrition and Feeding Issues
- Keywords
- autism spectrum disorder, autism intervention, motivation, self-management, social initiation, social interaction, intervention outcomes, conceptual framework
- MeSH terms
- Autistic Disorder, Child, Cues, Humans, Models, Psychological, Motivation, Physical Stimulation, Reinforcement, Psychology, Self Care, Social Behavior, Treatment Outcome
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