Procedures and compliance of a video modeling applied behavior analysis intervention for Brazilian parents of children with autism spectrum disorders

Abstract

Video modeling using applied behavior analysis techniques is one of the most promising and cost-effective ways to improve social skills for parents with autism spectrum disorder children. The main objectives were: (1) To elaborate/describe videos to improve eye contact and joint attention, and to decrease disruptive behaviors of autism spectrum disorder children, (2) to describe a low-cost parental training intervention, and (3) to assess participant’s compliance. This is a descriptive study of a clinical trial for autism spectrum disorder children. The parental training intervention was delivered over 22 weeks based on video modeling. Parents with at least 8 years of schooling with an autism spectrum disorder child between 3 and 6 years old with an IQ lower than 70 were invited to participate. A total of 67 parents fulfilled the study criteria and were randomized into two groups: 34 as the intervention and 33 as controls. In all, 14 videos were recorded covering management of disruptive behaviors, prompting hierarchy, preference assessment, and acquisition of better eye contact and joint attention. Compliance varied as follows: good 32.4%, reasonable 38.2%, low 5.9%, and 23.5% with no compliance. Video modeling parental training seems a promising, feasible, and low-cost way to deliver care for children with autism spectrum disorder, particularly for populations with scarce treatment resources.

Keywords

applied behavior analysis autism spectrum disorders parental training video modeling

Autism spectrum disorders (ASDs) are a range of complex developmental lifelong disorders which are usually first diagnosed in childhood. These disorders are characterized by deficits in social communication, and stereotyped/repetitive behaviors and interests (American Psychiatric Association (APA), 2013). In the developed countries, a progressive increase in ASD prevalence has been reported, but the rates vary from 0.67% to 1.13% (Baxter et al., 2015; Center for Disease Control (CDC), 2014; Fombonne, 2009).

Prevalence studies from low- and middle-income countries have less robust data, but they point in the same direction (Elsabbagh et al., 2012). Based on the estimates of the single Brazilian pilot study in this area, 0.3% of the Brazilian population should have ASDs, which can be translated into nearly 40,000 children/adolescents (younger than 20 years of age) living in São Paulo city (Paula et al., 2011, 2012). Thus, ASD is recognized as one of the common neuro developmental dis-orders (Fombonne, 2009), challenging the capability of families, organizations, policy makers, and communities to deliver effective educational and therapeutic programs.

Applied behavior analysis (ABA) is a behavioral science aiming to enhance, reduce, or maintain targeted behaviors. The target behaviors that compose the individualized program should include all the skills a person needs to function successfully, and it should be developmentally sequenced so that easier concepts and skills are taught from the simple to more complex behaviors. This methodology is highly effective in teaching basic communication, play, motor, social, daily living, and self-help skills.

Thus, ABA programs are among the most used (Brookman-Frazee et al., 2006; Matson et al., 2009), but they are expensive and time-consuming (Beaudoin et al., 2014). This is relevant everywhere, but especially in countries like Brazil, where there is a scarcity of specialized human resources; therefore, getting families involved in the training can be a good strategy to maximize resources. Video modeling is one of the most efficient teaching procedures among those used in ABA. Video modeling is a mode of teaching using video recording to provide a visual model of the target behavior or skill (McCoy and Hermansen, 2007). This procedure has been recommended to improve social skills in individuals with ASD (Ayres and Langone, 2005; Bellini and Akullian, 2007; Delano, 2007; McCoy and Hermansen, 2007; Reichow and Volkmar, 2010), with the advantage that is more cost-effective and requires less time for training and implementation than live modeling and can enable its use for parental training on a large scale.

There are few studies showing the effectiveness of video modeling for ASD parental training, and most of the clinical trials focus on high-functioning ASD individuals. In the light of this lack of studies using video modeling for autistic children with intellectual disabilities, our team decided to create a video modeling intervention to train parents of these individuals to develop in their children two behaviors, which are the basis of sociability: eye contact and joint attention. These parents were also trained to prevent disruptive behaviors. Joint attention refers to the shared focus of two individuals on an object and the synchronizing of attention between two or more persons. Joint attention is one of the main prerequisites of verbal behavior and social behavior in general (Bosa, 2002; Landa et al., 2007). Furthermore, when a child with ASD begins to share attention with adults and his pairs, a great positive impact on social relationships is often seen. Improvements in eye contact and joint attention behavior aim to develop social skills. During the intervention, parents were also trained to manage disruptive behaviors, as a support for the child’s learning of the previously described skills. While the ASD individual is engaged in a disruptive behavior, he or she may not be able to pay attention to any other activity, which means that these behaviors compete directly with the child’s readiness to learn new things, and its management is therefore of great importance (Bearss et al., 2015; Maurice et al., 2001; Wong et al., 2015). This methodology may be reproduced at a low cost for the public health system.

The goals of this article were as follows: (1) to elaborate and describe the material of the training model based on videos to improve eye contact and join attention and to decrease disruptive behaviors among children with ASD; (2) to describe a low-cost parental training intervention by video modeling based on ABA, related to these three behaviors; and (3) to assess the compliance of these participants.

Method

The analysis of the clinical trial is underway and was conducted with patients from three specialized clinics for ASD in São Paulo city, Brazil: the Federal University of São Paulo (Social Cognition Clinic—TEAMM), the University of São Paulo (Autism Spectrum Disorders Program—PROTEA), and Mackenzie University (clínica TEA-MACK). Patients were included in the study if they fulfilled the following criteria: (1) presenting an ASD diagnosis according to the Brazilian version of the Autism Diagnostic Interview–Revised (ADI-R; Becker et al., 2012) and a clinical evaluation by a multidisciplinary team of experts based on the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-V; APA, 2013); (2) aged between 3 and 6 years old; (3) to have an IQ between 50 and 70 assessed by the SON-R 2½-7, a non-verbal standardized instrument validated in Brazil (Karino et al., 2011); and (4) their caregivers who would potentially receive the training program having received at least 8 years of schooling. Children with uncontrolled epilepsy (seizure within the last year), or who were receiving a similar intervention, were excluded from the study.

The research had the following stages: development and recording of the videos, sample selection, pre-intervention assessments (3 months before the intervention program), parental training, and reassessment (3 months after the intervention program). The development of videos and their recording started 3 months before the sample selection. The intervention was carried out in 22 weekly sessions lasting 90 min each; the development and recording of the videos, the sample selection, and the pre-intervention assessment took 8 weeks, and the reassessment took 2 weeks.

A clinical assessment was conducted for diagnostic purposes and to record sociodemographic and clinical variables such as medication use. An extensive package of standardized instruments was used to assess the 67 families before and after the intervention. The evaluations of the children were conducted by a multi-professional team using the following measures and instruments: (1) the Brazilian version of the ADI-R: a structured interview conducted with the parents for diagnostic purposes and measures behavior, in the areas of reciprocal social interaction, communication and language, and patterns of behavior (Becker et al., 2012; Le Couteur et al., 1989); (2) SON-R 2½-7 to estimate IQ, which is a non-verbal intelligence test validated in Brazil (Karino et al., 2011); (3) the Brazilian version of the Autism Behavior Checklist (ABC) to evaluate ASD symptoms, which assesses sociability, communication, and stereotyped and restrictive behavior (Krug et al., 1980; Marteleto and Pedrônimo, 2005); and (4) adaptive behavior according to the Vineland Adaptive Behavior Scales (Sparrow et al., 2005). The Vineland has three versions, and in this study we used the Interview Version more Expanded Form, which is based on an interview with parents and lasts about 20 min; and (5) the Child Behavior Checklist (CBCL) to investigate comorbid psychiatric symptoms (Achenbach and Rescorla, 2001) and SNAP-IV Rating Scale to evaluate attention-deficit hyperactivity disorder (ADHD) (Mattos et al., 2006). To evaluate the caregiver profile, we used the Hamilton Depression Rating Scale to assess depression (Hamilton, 1960), Zarit Burden Interview to measure caregiver self-reported stress (Zarit et al., 1980), and the Adult Self-Report Scale (ASRS-18), a self-reported questionnaire used to assist in the diagnosis of adult ADHD (Kessler et al., 2005). The familial socioeconomic status was assessed by a questionnaire developed by the Brazilian Association of Research Companies according to family purchasing power (ABEP). The instrument is one of the most used in Brazil and takes into account, among other factors, the number of home appliances and the education level of the head of the household. Total scores determine the socioeconomic status of families classifying them into five social classes (A, B, C, D, and E). In this study, classes were grouped into three categories: middle-high (A, B), middle-low (C, D), and low (E). To measure the joint attention, eye contact, and disruptive behavior outcome, we used (1) the Structured Observation for Autism Screening-OERA (Observação Estruturada para Rastreamento de Autismo) (Alckmin et al., 2014), a Brazilian instrument with ongoing validation, to evaluate behavior profile and (2) daily records filled by the parents about their child’s progress during the intervention process. Specifically to evaluate joint attention and eye contact outcomes, eye tracking tasks were also used to explore visual contact and the child’s preference for social or non-social images.

The specific study aim of this article was to assess parent compliance with the training of video modeling to manage disruptive behaviors and eye contact/joint attention (both essential in developing adequate social interaction). The entire intervention program was based on 14 videos developed by our clinical team. The main content of these videos was about the three primary outcomes. In addition to that, all videos included a general explanation of which behaviors were being taught and a schedule of reinforcement, as well as a description of the prompting procedures and their use, and how they are gradually reduced until the behavior is produced without prompting (Table 2, in the results section, will present details of the content of the 14 videos). One video per week was delivered to the parents of ASD children to use at home to practice activities. In all, 22 weekly sessions taking 90 min each, in groups of around 11 parents, were conducted at the three specialized clinics to deliver the videos and receive the record sheets (14 sessions) and to discuss doubts related to the video content (8 sessions; embedded in the 14 mentioned sessions). This model will be described in the results section.

The protocol was reviewed and approved by the Ethical Committee of the Federal University of São Paulo and registered at CAAE 19927213.4.1001.5505. This clinical trial was also registered on ClinicalTrials.gov and is identified as NCT02235467.

Parental participation (34 parents of the intervention group) in the weekly sessions of the intervention model was registered through an attendance list. We defined non-adhesion as when the frequency of attendance in the intervention program sessions was between 0% and 24%, low adhesion when it was from 25% to 49%, reasonable adhesion when it was from 50% to 74%, and high adhesion when it was from 75% to 100%.

Results

The sample was composed by 67 parents of children with ASD (mean age, 4.81 ± 1.32), 82.1% boys, mean IQ 58.64 (±8.94), and most of them from middle-low socioeconomic class. These study groups were similar according to age, sex, IQ, and family socioeconomic status (Table 1).

Table 1.

Baseline demographics and clinical characteristics of entire sample and by treatment group.

Sample	Total group (N = 67)	Intervention group (N = 34)	Control group (N = 33)
Age (years)
Mean (SD) Range	4.81 (1.32) 3–7	4.79 (1.25) 3–7	4.82 (1.40) 3–7
p-value (95% CI)	–	0.94 (−0.67 to 0.63)
Sex, male %	82.1	73.5	90.9
p-value (95% CI)	–	0.06 (0.07 to 1.14)
IQ^a
Mean (SD) Range	58.64 (8.94) 49–75	59.90 (9.42) 49–75	57.42 (8.42) 49–75
p-value (95% CI)	–	0.28 (−2.09 to 7.05)
Socioeconomic status %^b
Middle-high Middle-low	17.9 82.1	26.5 73.5	9.1 90.9
p-value (95% CI)	–	0.06 (0.88 to 14.75)

SD: standard deviation; CI: confidence interval.

Six missing.

All individuals in the sample were from social class B or C.

Table 2 summarizes the content and duration of the 14 videos used in the parental intervention program to improve eye contact and join attention and decrease disruptive behavior among children with ASD.

Table 2.

Description, target behaviors, and duration of the 14 videos.

Video	Description and target behaviors	Duration (min)
1. Preparing the setting	In the first video, the parents were instructed in how to organize the therapy room, the place where the skills would be taught. In this video, the guidelines were about what could stay and what should be removed from the setting, seeking greater control of the setting variables. The parents were trained to, for instance, prepare all the stimuli that would be necessary for use during the training trials and as potential reinforcers for the child, while eliminating any other stimulus that might distract the child’s attention	3 min 31 s
2. Management of disruptive behaviors	In the second video, the instructions given were about procedures to control the child’s behaviors, minimizing inappropriate behaviors (leaving the table without permission, self-injury, aggression, etc.) and maximizing appropriate behaviors (sitting, paying attention to what the caregiver said, responding to the request, waiting for the reinforcer, etc.)	22 min 23 s
3. Assessment of preferred items	In this video, the parents were taught to investigate the objects in which the child had greatest interest, and activities and foods that might function as reinforcers. The chosen items were used during the training period to reinforce the behaviors that were being taught (eye contact and joint attention). Immediately after the assessment, the children were allowed to play with the items	6 min 07 s
4. Errorless learning	In this video, the instructions given were related to the prompting of hierarchy, which means that a new skill is taught to the child by preventing his or her exposure to the error. The parents were taught how to use a very high level of support (prompting) to teach the target behavior, and then to systematically reduce this support to a lower level as the child masters the behavior	9 min 12 s
5. Eye contact Level 1—FPP	The child received the following instruction from the parent, “Look at me.” At this first level, the child had to make eye contact with their parent, receiving FPP, until meeting the progression criterion previously described (eight of nine correct answers per block, during three blocks of consecutive training)	6 min 08 s
6. Eye contact Level 2—PPP	The child received the following instruction from the parent, “Look at me.” At this second level, the child had to make eye contact with their parent, receiving PPP, until meeting the progression criterion previously described (eight of nine correct answers per block, during three blocks of consecutive training)	3 min 37 s
7. Eye contact Level 3—GP	The child received the following instruction from the parent, “Look at me.” At this third level, the child had to make eye contact with their parent, receiving GP, until meeting the progression criterion previously described (eight of nine correct answers per block, during three blocks of consecutive training)	3 min 14 s
8. Eye contact Level 4—independence	At this level, the child had to maintain eye contact with their parent without any prompt. The same prompting hierarchy described above in Level 1 was used until the child produced the behavior independently	3 min 17 s
9. Eye contact in a natural setting	Parents learned how to take advantage of daily situations to stimulate eye contact. The child is asked to look into the adults’ eyes	5 min 12 s
10. Joint attention Level 1—FPP	The parent put an object of interest to the child between themselves and the child. The parent then offered prompts to the child to look at them and to look at the object. As already emphasized, to promote errorless learning, all children received FPP at this stage. As soon as the child had met the progression criterion, which meant completing three blocks of consecutive training with at least eight of nine correct responses per block using the PPH, the training passed to Level 2, which used a less intrusive prompt	5 min 34 s
11. Joint attention Level 2—PPP	The child displayed the joint attention behavior when receiving the PPP. After meeting the progression criterion, as described in the previous paragraph, the training was conducted using a less intrusive prompt than in Level 2 (Level 3)	2 min 47 s
12. Joint attention Level 3—GP	The child had to display joint attention behavior after receiving only a GP. After meeting the progression criterion, the training was conducted without the parent’s prompt (Level 4)	2 min 55 s
13. Joint attention Level 4—independence	In the final video, parents learned to stimulate joint attention in a natural setting, such as during play time and daily activities	2 min 52 s
14. Joint attention in a natural setting	In the final video, parents learned to stimulate joint attention in a natural setting, such as during play time and daily activities	6 min 07 s

FPP: full physical prompt; PPP: partial physical prompt; GP: gestural prompt; PPH: programmed prompting hierarchy.

The structure of the 22 training sessions was similar. Each session consisted of (1) watching the video with the parents and (2) delivering the record sheet to them. The record sheet was to be used to record the parents practice with their child during the following week. No instructions or role-playing was conducted during the sessions.

Every week, the parents were given a copy of the video they had watched and asked to watch them at home and continue the training process daily. Thus, parents had the opportunity to practice one topic with their children with ASD for 1 week and to use the record sheet to register those experiences.

Overall, in all sessions, the parents learned to use a teaching strategy with their children called discrete trial teaching—DTT (Lovaas, 1980). As mentioned above, all 14 videos demonstrate the same hierarchy of prompting procedures which are gradually reduced until the child acts independently. Prompting procedures include any help given to the learner in order to assist him or her in using a specific skill. The prompting hierarchy is described below.

Full physical prompt (FPP): the parent holds the child and does the expected movement with her or him.

Partial physical prompt (PPP): the parent lightly touches the child and does the expected movement with her or him.

Gestural prompt (GP): the parent does not touch the child, but just points to what the child is supposed to do or the body part that will be used in the behavior.

Independent (I): the child performs the behavior without any prompt.

All the work at home to instill visual contact and joint attention behaviors were recorded by the parents on record sheets provided for each training level. These sheets were prepared specifically for this research. In the first 2 weeks, the parents were instructed how to use the training model with the following steps: two training blocks followed by nine trials each, twice a day, from Monday to Sunday at different times of day. After every third trial, the parent gives the child a 2-min break.

Parental adhesion to the full intervention program varied from good (75%–100% frequency) to reasonable (50%–74% frequency) in 70.6% of the participants distributed as follows: good compliance 32.4% of the group (11 families) and reasonable compliance 38.2% of the group (13 families). A total of 29.4% of the sample (10 families) did not achieve good/reasonable compliance, distributed as follows: 5.9% (2 families) low compliance (25%–49% frequency) and 23.5% (8 families) no compliance (0%–24%). All 67 parents and their children participated in the evaluation sessions before and after the intervention.

Discussion and recommendations

As previously emphasized, as children diagnosed with ASD have deficits in symbolic and language abilities, social-cognitive processes, and joint attention (Holth, 2006), the development of intervention models which aim to teach joint attention behavior seems to hold the potential for a significant breakthrough in interventions for this population.

Compliance to the intervention was regarded as favorable (70.6% of the participants good or reasonable), showing the feasibility of using video modeling for parents of ASD children presenting cognitive impairments. Following the recommendation of the literature, this training model started teaching parents of ASD children how to improve basic social behaviors, mainly eye contact and joint attention. Later on, participants were taught how to stimulate more complex behaviors in natural settings with the goal of developing these behaviors independently in the children with ASD. Baer et al. (1968) state that generalization is one of the pillars that supports ABA, and they assert that it should be programmed, rather than expected. Recent studies have shown that one priority of an effective treatment for ASD must be the maintenance of new skills and their generalization to natural settings (Brentani et al., 2013).

In this sense, parental training models have been described as being an effective way to assist ASD children, especially in the social skills domain, since social behavior can be learned and maintained by contingencies within the family context (Beaudoin et al., 2014; Brentani et al., 2013), which can support the generalization of the learned behaviors. In this sort of model, parents learn to modify these contingencies with the aim of promoting and reinforcing appropriate behaviors. When parents do not participate in intervention programs, the behavioral gains for the children are reduced (Wong et al., 2015).

Trying to increase the understanding of “the state of the art” in this field, we conducted a non-systematic literature review using PubMed, focusing on the video modeling procedures used in studies involving participants with an ASD diagnosis. In all, 20 studies were found, which were published between 1987 and 2013. It was noticed that most studies identified in this review are related to social skills training (Bohlander et al., 2012; Kroeger et al., 2007; Walton and Ingersoll, 2012) or involve the training of more specific repertoires such as verbal skills (Baharav and Darling, 2008; Plavnick and Ferreri, 2011), play repertoire (McDonald et al., 2009; Paterson and Arco, 2007), imitation learning (Cardon and Wilcox, 2011), or teaching to share toys/materials with peers (Marzullo-Kerth et al., 2011). Thus, none of the procedures used video modeling to promote the parents’ acquisition of teaching skills.

One of the biggest advantages of using video modeling in intervention programs is to reduce treatment costs. This is particularly relevant because interventions to assist ASD children must be intensive, individualized, and long lasting. Therefore, this type of high-quality face-to-face intervention is almost unobtainable for most Brazilian families as it cannot be provided by the Brazilian Public Health System. For this reason, if the efficacy of this intervention model, based on video modeling parental training, was used and its effectiveness proved, it could have a huge social impact on Brazilian children with ASD as well as for their families and, consequently, for society. In addition, other authors have pointed out several benefits of using video modeling over live interventions, including the following: (1) video modeling leads to acquisition and generalization of target behaviors as well as live interventions and can be used on a larger scales; (2) video modeling allows you to create a variety of natural settings, which would be more difficult than in the in vivo condition; (3) when video modeling is used, the therapist has more control over the modeling procedure, because the video can be recreated until the ideal scene is recorded; (4) it is possible to repeat the observation of the same model many times, because the model does not need to be present at each video presentation; and (5) the videos can be used on a large scale, which means that more clients can be assisted (Charlop-Christy et al., 2000; Luiselli, 2011; Thelen et al., 1979).

Another important point to consider in the use of video modeling in ASD is the lack of trained professionals in this approach in Brazil, which is even more pronounced if we consider only the public health system. Moreover, these professionals are concentrated in the South and Southeast regions and in bigger cities. This model will facilitate the provision of the training process at a low cost to a greater number of providers, particularly those in remote regions. In addition, the coming together of three major Brazilian universities with specialized services for ASD is a first in the country and will help to create a platform to promote future research projects. The development of an integrated database in this research, for instance, has already been a product of this partnership. It would establish São Paulo as the major research center in this area in the country and would make it possible for this group to become an international reference. Future research that uses the method described in this study, with the same audience but with bigger samples, could contribute to the improvement of this type of intervention and its implementation on a large scale.

This study does have some limitations, such as (1) small sample size; (2) the absence of Autism Diagnostic Observation Schedule (ADOS), the gold-standard observation schedule for diagnosing ASD, in the package of standardized evaluation instruments; and (3) this type of intervention is restricted to families who have DVD player, but most of Brazilian families would be able to participate since more than 70% of them have this type of device (Instituto Brasileiro de Geografia e Estatistica (IBGE), 2013).

In conclusion, video modeling using ABA techniques is one of the most promising procedures to improve social skills in the ASD population (Bellini and Akullian, 2007; Reichow and Volkmar, 2010). This method is cost-effective and requires less time for training and implementation than live modeling, which can enable its use on a large scale. These aspects are particularly relevant in low-and-middle-income countries like Brazil, where there is a lack of specialized, trained professionals. However, there are only a few studies using video modeling specifically for ASD parental training (Beaudoin et al., 2014). In addition, most of the clinical trials in the ASD field focus on high-functioning individuals, so there is a need for evidence with respect to individuals with ASD and cognitive problems.

It is important to mention that the participants live in one of the biggest cities in the world, with a wide range of access problems, such as an inefficient public transportation system. Thus, the level of adhesion obtained in this study can be considered successful. At the same time, these obstacles must be taken into consideration in future initiatives to improve intervention compliance. Therefore, offering this training model by distance learning can be a viable alternative to scale up this intervention at national and international levels.

Thus, the intervention model presented in this article is a promising, feasible, and an inexpensive way to offer assistance to children with ASD and low IQ. However, its efficacy was not attested yet, since future studies showing the clinical trial results are still in process. After proving its efficacy, this model can be replicated in bigger samples and populations which currently lack access to treatment services, making a major impact on ASD treatment in Brazil and potentially in other Portuguese-speaking countries.

Footnotes

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the State of São Paulo Funding Agency—FAPESP under a special agreement with Maria Cecília Souto Vidigal Foundation (grant number 2012/51584-0). The NGO Autismo & Realidade gave a support for the administration of the grant.

References

Achenbach

Rescorla

(2001) Manual for the ASEBA School-Age Forms & Profiles. Burlington: University of Vermont, Research Center for Children, Youth & Families.

Alckmin

Teixeira

MCTV

Brunoni

. (2014) Identificação de sinais precoces de autismo segundo um protocolo de observação estruturada: um estudo de seguimento. Psico (PUCRS. Impresso) 45: 502–512.

American Psychiatric Association (APA) (2013) Diagnostic and Statistic Manual of Mental Disorders (DSM-V). 5th ed. Washington, DC: APA.

Ayres

Langone

(2005) Intervention and instruction with video for students with autism: a review of the literature. Education and Training in Developmental Disabilities 40(2): 183–196.

Baer

Wolf

Risley

(1968) Some current dimensions of applied behavior analysis. Journal of Applied Behavior Analysis 1: 91–97.

Baharav

Darling

(2008) Case report: using an auditory trainer with caregiver video modeling to enhance communication and socialization behaviors in autism. Journal of Autism and Developmental Disorders 38: 771–775.

Baxter

Brugha

Erskine

. (2015) The epidemiology and global burden of autism spectrum disorders. Psychological Medicine 45(3): 601–613.

Bearss

Johnson

Smith

. (2015) Effect of parent training vs parent education on behavioral problems in children with autism spectrum disorder: a randomized clinical trial. The Journal of the American Medical Association 313(15): 1524–1533.

Beaudoin

Sébire

Couture

(2014) Review article: parent training interventions for toddlers with autism spectrum disorder. Autism Research and Treatment 2014: 839890. Available at: dx-doi-org.web.bisu.edu.cn/10.1155/2014/839890 (accessed 4 November 2015).

10.

Becker

Wagner

Bosa

. (2012) Translation and validation of Autism Diagnostic Interview-Revised (ADI-R) for autism diagnosis in Brazil. Arquivos de Neuro-Psiquiatria 70(3): 185–190.

11.

Bellini

Akullian

(2007) A meta-analysis of video modeling and video self-modeling interventions for children and adolescents with autism spectrum disorders. Exceptional Children 73(3): 264–287.

12.

Bohlander

Orlich

Varley

(2012) Social skills training for children with autism. Pediatric Clinics of North America 59(1): 165–174.

13.

Bosa

(2002) Atenção compartilhada e Identificação precoce do autismo. Psicologia: Reflexão e Crítica 15(1): 77–88.

14.

Brentani

Paula

Bordini

. (2013) Autism spectrum disorders: an overview on diagnosis and treatment. Revista Brasileira de Psiquiatria 35: 62–72.

15.

Brookman-Frazee

Stahmer

Baker-Ericzén

. (2006) Parenting interventions for children with autism spectrum and disruptive behavior disorders: opportunities for cross-fertilization. Clinical Child and Family Psychology Review 9(3–4): 181–200.

16.

Cardon

Wilcox

(2011) Promoting imitation in young children with autism: a comparison of reciprocal imitation training and video modeling. Journal of Autism and Developmental Disorder 41(5): 654–666.

17.

Center for Disease Control (CDC) (2014) Autism and Developmental Disabilities Monitoring Network Surveil-lance Year 2010 Principal Investigators. Prevalence of autism spectrum disorder among children aged 8 years. Autism and Developmental Disabilities Monitoring Network 63(2): 1–21. Available at: http://www.cdc.gov/mmwr/volumes/65/ss/ss6503a1.htm (accessed 28 October 2015).

18.

Charlop-Christy

Freeman

KAA

(2000) A comparison of video modeling with in vivo modeling for teaching children with autism. Journal of Autism and Developmental Disorders 30(6): 537–552.

19.

Delano

(2007) Video modeling interventions for individuals with autism. Remedial and Special Education 28(1): 33–42.

20.

Elsabbagh

Divan

Koh

. (2012) Global prevalence of autism and other pervasive developmental disorders. Autism Research 5(3): 160–179.

21.

Fombonne

(2009) Epidemiology of pervasive developmental disorders. Pediatric Research 65(9): 591–598.

22.

Hamilton

(1960) A rating scale for depression. Journal of Neurology, Neurosurgery & Psychiatry 23: 56–62.

23.

Holth

(2006) An operant analysis of joint attention skills. European Journal of Behavior Analysis 7: 77–91.

24.

Instituto Brasileiro de Geografia e Estatistica (IBGE) (2013) Pesquisa nacional por amostra de domicílios : síntese de indicadores 2013/IBGE, Coordenação de Trabalho e Rendimento. - 2. ed. - Rio de Janeiro : IBGE, 2015. 296 p. Available at: biblioteca.ibge.gov.br/visualizacao/livros/liv94414.pdf, p. 78.

25.

Karino

Laros

Jesus

(2011) Evidências de Validade Convergente do SON-R 2½-7[a] com o WPPSI-III e WISC-III. Psicologia: Reflexão e Crítica 24(4): 621–629.

26.

Kessler

Adler

Ames

. (2005) The World Health Organization Adult ADHD Self-Report Scale (ASRS): a short screening scale for use in the general population. Psychological Medicine 35(2): 245–256.

27.

Kroeger

Schultz

Newsom

(2007) A comparison of two group-delivered social skills programs for young children with autism. Journal of Autism and Developmental Disorder 37(5): 808–817.

28.

Krug

Arick

Almond

(1980) Behavior checklist for identifying severely handicapped individuals with high levels of autistic behavior. Journal of Child Psychology and Psychiatry 21(3): 221–229.

29.

Landa

Holamn

Garrett-Mayer

(2007) Social and communication development in toddlers with early and later diagnosis of autism spectrum disorders. Archives of General Psychiatry 64(7): 853–864.

30.

Le Couteur

Rutter

Lord

(1989) Autism diagnostic interview: a standardized investigator-based instrument. Journal of Autism and Developmental Disorders 19: 363–387.

31.

Lovaas

(1980) Teaching Developmentally Disabled Children: The “ME” Book. Austin, TX: Pro-Ed: An International Publisher.

32.

Luiselli

(2011) Teaching and Behavior Support for Children and Adults with Autism. Spectrum Disorder: A Practioner’s Guide. Oxford: Oxford University Press.

33.

McCoy

Hermansen

(2007) Video modeling for individuals with autism: a review of models types and effects. Education and Treatment of Children 30: 183–213.

34.

McDonald

Sacramone

Mansfield

. (2009) Using video modeling to teach reciprocal pretend play to children with autism. Journal of Applied Behavior Analysis 42(1): 43–55.

35.

Marteleto

Pedrônimo

(2005) Validity of autism behavior checklist (ABC): preliminary study. Revista Brasileira de Psiquiatria 27(4): 295–301.

36.

Marzullo-Kerth

Reeve

. (2011) Using multiple-exemplar training to teach a generalized repertoire of sharing to children with autism. Journal of Applied Behavior Analysis 44(2): 279–294.

37.

Matson

Mahan

Matson

(2009) Parent training: a review of methods for children with autism spectrum disorders. Research in Autism Spectrum Disorders 3(4): 868–875.

38.

Mattos

Serra-Pinheiro

Rohde

. (2006) A Brazilian version of the MTA-SNAP-IV for evaluation of symptoms of attention deficit/hyperactivity disorder and oppositional-defiant disorder. Revista de Psiquiatria do Rio Grande do Sul 28: 290–297.

39.

Maurice

Green

Fozz

(2001) Making a Difference: Behavioral Intervention for Autism. Pro-Ed, Inc. Austin, TX: Pro-Ed: An International Publisher.

40.

Paterson

Arco

(2007) Using video modeling for generalizing toy play in children with autism. Behavior Modification 31(5): 660–681.

41.

Paula

Lauridsen-Ribeiro

Wissow

. (2012) How to improve mental health care of children and adolescentes in Brazil: Actions needed in the public setor. Revista Brasileira de Psiquiatria 34(3): 334–351.

42.

Paula

Ribeiros

Fombone

. (2011) Brief report: Prevalence of pervasive develpomental disorder in Brazil: A pilot study. Journal of Autism and Developmental Disorder 41(12): 1738–1742.

43.

Plavnick

Ferreri

(2011) Establishing verbal repertoires in children with autism using function-based video modeling. Journal of Applied Behavior Analysis 44(4): 747–766.

44.

Reichow

Volkmar

(2010) Social skills interventions for individuals with autism: evaluation for evidence-based practices within a best evidence synthesis framework. Journal of Autism and Developmental Disorders 40(2): 149–166.

45.

Sparrow

Cicchetti

Balla

(2005) Vineland Adaptive Behavior Scales, Second Edition. Circle Pines, MN: AGS Publishing.

46.

Thelen

Fry

Fehrenbach

. (1979) Therapeutic videotape and film modeling: a review. Psychological Bulletin 86: 701–720.

47.

Walton

Ingersoll

(2012) Improving social skills in adolescents and adults with autism and severe to profound intellectual disability: a review of the literature. Journal of Autism and Developmental Disorder 43(3): 594–615.

48.

Wong

Odom

Hume

. (2015) Evidence-based practices for children, youth, and young adults with autism spectrum disorder: a comprehensive review. Journal of the Autism Developmental Disorder 45(7): 1951–1966.

49.

Zarit

Reever

Back-Peterson

(1980) Relatives of the impaired elderly: correlates of feelings of burden. The Gerontologist 20: 649–655.