Autism Spectrum Disorder in Aotearoa New Zealand, by Jill Bevan-Brown and Vijaya Dharan
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From: Autism Spectrum Disorder in Aotearoa New Zealand, by Jill Bevan-Brown and Vijaya Dharan
Chapter 1 Using an adapted SCERTS framework with a 4-year-old
Autism spectrum disorder (ASD) is a term used to describe a spectrum of developmental disorders involving difficulty in social communication and interaction, and restricted, repetitive patterns of behaviour, interest or activities (American Psychiatric Association, 2013). Interventions for autism typically fall into two categories: those that focus on one specific behaviour or developmental skill, which is targeted for a limited time frame; and those that are comprehensive treatment models covering a broader range of skills over a longer period of time (Odom, Boyd, Hall, & Hume, 2010). The SCERTS framework falls into the latter category.
SCERTS is an intervention framework that was developed in the USA by Barry Prizant, Amy Wetherby, Emily Rubin and Amy Laurent. They describe it as
a comprehensive, multidisciplinary approach to enhancing communication and social-emotional abilities of individuals with Autism Spectrum Disorder (ASD) and related disabilities. (Prizant, Wetherby, Rubin, & Laurent, 2003, p. 298)
This framework has been developed for individuals with ASD—from assessment through to planning goals, implementation and review. SCERTS is an acronym for three distinctive domains:
- social communication (SC)
- emotional regulation (ER)
- transactional supports (TS).
The SCERTS assessment process involves examining the above three domains. Each domain focuses on two key areas: SC examines joint attention and symbol use; ER examines mutual regulation and self-regulation; and TS focuses on interpersonal support and learning support.
SCERTS is based on a combination of research and the clinical practice of the authors since the mid-1970s (Prizant, Wetherby, Rubin, Laurent, & Rydell, 2006). This was also a period during which it came to be realised that autism is a neurological condition, involving differences in brain development. It was a radical shift from one of the previously held beliefs of ‘refrigerated mother’s theory’. In fact it was the publication of the 1980 DSM III (Diagnostic and Statistical Manual of Mental Disorders, 3rd ed.) that allowed a diagnosis of autism for the first time, separating it from the previous diagnostic category of childhood schizophrenia (Baker, 2013).
SCERTS contains elements of both behavioural and developmentally-based interventions. It is based on the understanding that individuals with autism have difficulty generalising skills from one context or task to another, and it therefore focuses on the generalisation of skills across all the natural settings in the child’s environment (Prizant et al., 2006). The intervention is flexible, with a mixture of facilitative (student or child-led) and directive (adult-led) learning and teaching styles, and it is implemented within the natural settings of the child. It takes a family-centred approach, in recognition that family members are the ‘experts’ on their child (or children) and therefore a key part of the team (Prizant et al., 2006).
The first part of the chapter looks at the research behind SCERTS. This is followed by an examination of how the intervention framework was implemented with a child in an early childhood centre (under 5 years) in New Zealand, and the resulting outcomes for the child. Further evaluation of this framework, including adaptations for different cultural groups, is also discussed.
SCERTS is founded on theory and research on child development, clinical data, and practices that have been shown to have positive results for children with autism. The first article about SCERTS was published in 2003 (Prizant et al., 2003), with a comprehensive two-part manual published in 2006 (Prizant et al., 2006). In developing this framework for intervention the authors draw on research from all of the areas in the three domains of social communication, emotional regulation and transactional support (Prizant, Wetherby, Rubin, & Laurent, 2010).
Research related to social communication shows there is a link between pre-linguistic skills and language outcomes for children with autism (Watson & Flippin, 2008). These pre-linguistic abilities include social and joint attention, language use, imitation and play. As outlined by Watson and Flippin, research is emerging which shows that specifically targeting these skills (including joint attention) leads to increased communication skills and social interactions. The National Standards Report places joint attention intervention under the ‘established treatments’ list, which has several controlled studies showing the approach to be effective (National Autism Center, 2009).1 In supporting the emotional regulation in children with ASD, focusing on external and internal supports is crucial for developing coping strategies for managing behaviours. External supports will come from the individual’s language partners (for example, a parent giving a child a hug to have them regulate), while internal supports are managed by the individual (for example, a child taking him- or herself to a designated space for time out). Being emotionally regulated has positive effects on a child’s health and emotional wellbeing, and also on their language and interactions (O’Neill et al., 2010).
A couple of published studies also indicate positive progress towards goals set using the SCERTS approach in music therapy. Ayson (2011), an independent music therapist in New Zealand, reported the benefits of using SCERTS with a 3-year-old boy. Walworth, Register and Engel (2009) discuss the progress of 33 individuals with a diagnosis of, or suspected, autism, aged from 18 months to 32 years, through music therapy sessions using the SCERTS framework. There have also been other controlled randomised trials using SCERTS reported for children under the age of 3 years, and also from 5 to 8 years (Hartung, 2010; Wetherby & Lord, n.d.). The latter study is yet to be published at the time of writing this chapter.
SCERTS in New Zealand
When examining the research evidence on interventions for children with ASD, it is clear that no one treatment has been more effective than others, and, more importantly, that not all children with ASD have benefited in the same way from an intervention (Ministries of Health and Education, 2008). To provide a wider range of interventions for children and young people with ASD, the Early Intervention Autism Spectrum Disorder (EI ASD) Development Project2 was set up in 2006 to trial the implementation of SCERTS in New Zealand. This project was part of the Ministry of Education’s initiatives to improve early intervention services for children with ASD and their families. Twelve local project teams were set up around the country in order to explore the use of an adapted SCERTS framework within their local areas. Training was provided to the teams by two of the original authors, Barry Prizant and Amy Laurent, and an adapted SCERTS was created as part of this trial project.
The SCERTS framework was adapted by a national Ministry of Education ASD team for use within New Zealand to ensure the interventions aligned with the key documents that guide practitioners within the early intervention sector. These included the Treaty of Waitangi, Ministry of Education Specialist Service Standards, Te Whāriki (the New Zealand early childhood education curriculum) and the NZASD Guideline (Ministries of Health and Education, 2008). Practitioners across the country were trained to implement the intervention and were provided with ongoing professional learning and development support. These practitioners included Ministry of Education early intervention teachers, psychologists and speech-language therapists.
The adaptations were also designed to make the SCERTS assessments and review easier and faster to use, and to overcome the difficulties of getting the whole team together on a frequent basis. For example, it was easier for a key practitioner (such as the early intervention teacher) to score the assessment and review forms based on information shared and collected from the rest of the team supporting the child, rather than the whole team being involved in all the data gathering. Some practitioners also used only part of the framework (for example, only the emotional regulation section). Recording forms and information handouts were adapted as needed to meet the cultural needs of the student and their family. For example, information handouts about SCERTS provided to families were written in easy-to-understand English, and kaitakawaenga (Māori cultural workers) were available to visit families alongside practitioners to support Māori families.
The adapted framework was clearly laid out to follow a seven-step process:
- determine the communication stage of the student
- gather assessment information to complete the SCERTS assessment process
- collate and score the data
- prioritise goals and objectives
- design and implement the programme
- monitor progress
- review progress through rescoring the assessment forms.
Case study: Max*
The adapted SCERTS framework was used with a child in an early childhood centre. At the time of the intervention Max was 4 years old with a diagnosis of ASD. He was attending his local early childhood centre 3 days a week. When implementation of the SCERTS framework was initially considered, Max was largely non-verbal in his communication. He showed no interest in his peers in the early childhood centre and found it difficult to regulate himself emotionally, even with adult support. For example, when Max entered a new environment he would look around for an escape route and use it often when overwhelmed by noise or people around him. Max had a limited range of activity choices and moved quickly between tasks. He was not toilet trained and ate only a limited range of foods.
The use of SCERTS was discussed with Max’s family and team. The team that supported Max included his family, early childhood centre teachers, an early intervention teacher, an education support worker and a speech-language therapist. An occupational therapist had recently come on board to support Max and his family.
*Not his real name
There is a set of criterion-referenced tools in the SCERTS framework to use during the assessment, goal-setting and review process. The assessment process includes a range of data-gathering instruments such as interviews, questionnaires and observation checklists, to be used within different settings. This assessment process was completed in collaboration with Max’s family, and with information from early childhood centre staff and observations. The main priorities identified by Max’s family were related to building his communication and social interactions with adults and peers, toilet training, and increasing his participation in routines and transitions.
There are three stages of communication within SCERTS:
- the social partner stage, in which children intentionally communicate using non-verbal and non-gestural means
- the language partner stage, in which children begin consistently using words, signs and/or gestures to communicate
- the conversational partner stage, in which children use sentences to interact with others (Prizant et al., 2006).
Max was at the social partner (pre-linguistic) stage.
Each stage has a different observational skills checklist to gather data. Max was observed in different settings, with different communication partners and within different routines to gain a broad view of his skills. Each skill from the observation checklist was numbered from 0 to 2 (0 = not yet showing this skill, 1 = using the skill inconsistently and 2 = consistently using the skill across all settings). A profile was then created that showed Max’s strengths and areas that could be developed (see Appendix—the yellow highlighting represents his skills at the time of this initial assessment).
Goals within the SCERTS framework are determined collectively by the family and other professionals involved with the individual, based on functionality, family priorities and developmental appropriateness (Prizant et al., 2006). The goals specifically targeted for Max, as discussed at his individual planning meeting, centred around his participation in routines (eating at the table at home and early childhood centre, hand washing, toileting), learning to manage transitions and changes in routines with adult support, developing an awareness of other children, increasing his reasons for communicating, and his ability to imitate actions and words. Visual supports were used to help achieve a number of the above goals.
These goals were targeted across home and early childhood centre, with a specific focus on building Max’s communication goals at home, supported by regular visits by his speech-language therapist. Ongoing progress was documented through information shared by Max’s early childhood centre teachers, learning stories,3 regular anecdotal notes written by Max’s education support worker, observation by the team (his family, early childhood centre staff, education support worker, early intervention teacher and speech-language therapist), some of these practitioners visiting Max at home and the early childhood centre, and feedback from Max’s family through emails, phone calls and face-to-face meetings.
A range of strategies that align with the guiding principles of SCERTS were used in working towards the goals set by the team. For example, visuals were used as part of the transactional supports to aid Max’s understanding and independence (Prizant et al., 2006). Max’s family and speech-language therapist introduced the use of visual supports (for example, photos of places) to help Max understand upcoming changes or routines at home and the early childhood centre. The use of visuals to build Max’s interest in new or less favoured activities was introduced at the end of this intense intervention time.
Another strategy used in working towards Max’s goals was the use of positive verbal reinforcement by his conversational partners. For example, if Max tipped out a box of toys to obtain one small item, his teacher would praise him for putting a piece or pieces away in working towards tidying up the mess before rewarding him with the desired item. Adaptation of language was also used to aid Max’s understanding and ensure he knew what he needed to do (for example, using shorter three-word sentences such as “Time to eat” rather than longer sentences).
Modelling the desired behaviour for Max was another strategy that worked. For example, Max tended to use the same drum each time the instruments were brought out. After a couple of times modelling how to use a shaker, Max took the instrument when it was handed to him and had a turn. Another strategy involved prompting Max to do something and then allowing him time to try doing the task independently. He enjoyed participating in action songs, so it often worked well to introduce a song to Max and then wait to allow him time to ‘ask’ for the song to be repeated. Max often ‘asked’ by pulling the adult’s hands or vocalising.
Step-by-step models or prompts (similar to forward chaining) showed Max how to complete a task in a way that was easier for him to understand. For example, when washing his hands, taking him through each step: tap on; get some soap; rub your hands under the water; turn the tap off; and dry your hands. A further strategy used was encouraging Max’s peers to interact with him and coaching them how to do this successfully. Sharing toys or resources at the early childhood centre enabled teachers to teach Max’s peers how to interact with him. Teachers would tell the peer/s what Max might want by observing his body language and eye contact, and then prompt the peer/s to help pass the item over to him while facilitating the interaction and ensuring it was successful. Playing people games (hide and seek, for example) was another way peers were encouraged to play with Max.
Review and outcomes
The NZASD Guideline recommends that “interventions should be monitored and evaluated on an ongoing basis” (Ministries of Health and Education, 2008, p. 87). Although progress towards goals was observed and documented following each update or visit, the forms for the SCERTS assessment process provided a framework through which Max’s progress could be more formally recorded and measured. Five months after the initial SCERTS assessment a review of Max’s skills was completed through observation and discussion with Max’s team. His skill levels were again considered in the six areas within SCERTS and his progress over a 5-month period was clearly evident. These data supported the anecdotal stories and observations from Max’s team. The progress recorded through the SCERTS assessment process can be seen highlighted in green in the Appendix.
Evidence of progress made by Max included:
- increased use of eye contact, and engaging more in shared attention during people-based games
- sometimes watching adults speak, and at times attempting to imitate what their mouth was doing or the sounds they were making
- reduced anxiety levels when going out in the car—Max became familiar with the places he went and his mum only needed to verbally tell him where they were going, weaning him off the visuals that were initially used
- becoming more interested in trying new and different toys or activities
- an increased willingness to engage in routines in the early childhood centre, including sometimes joining the group for mat time for a brief time with songs or rhymes he enjoyed (rather than watching out of the corner of his eye from a distance)
- using the toilet during the day with minimal adult support within a few weeks of watching the DVD Tom’s Toilet Triumph (South Australia Department for Families and Communities, 2009)—previously Max had not been able to watch this cartoon as he had appeared fearful of it, hiding whenever his mum put the DVD on.
While it was still relatively early stages with Max at the time of writing this chapter, his progress towards the identified goals was clearly evident. His family and the early childhood centre team started gaining confidence in interacting with Max and knowing how to encourage him to engage in routines and activities. The SCERTS framework enabled the team around Max to try different interventions or strategies, and the assessment process provided a way of recording and measuring progress within a relatively short time. The progress that was seen at home and the early childhood centre for Max, and shared informally through verbal or written updates, was confirmed formally when the SCERTS skills checklist was reviewed.
Advantages of the SCERTS framework
The SCERTS framework has many positive aspects. SCERTS is flexible enough to be adapted to the individual needs of children and families. While the focus is on the child and building their skills, there is also an emphasis on developing the skills of the adults around the child (transactional supports). This is important, considering best practice is that children with ASD should receive interventions within their natural settings and in natural routines (Ministries of Health and Education, 2008). Therefore, the best conversational partners to support a child come from their family, friends and team members involved in supporting the learning of the child.
Although research or reports of SCERTS being used within bicultural or full immersion Māori educational settings have not yet been published, the framework could be adapted for these settings, with a focus on te reo Māori rather than English. Indeed, SCERTS could be adapted to any cultural group within the New Zealand context and internationally, as seen in O’Neill et al.’s (2010) work in a Special School in the UK.
As with all such approaches there are some challenges in implementing SCERTS with a team who have not used this framework before. The comprehensive nature of the intervention means it takes time to understand and implement, particularly in the early assessment phase, when the profile of the child’s strengths and areas of support is being gathered. This need for quality professional time was highlighted in a report following the trials of SCERTS in the New Zealand EI ASD Project (Cognition Education, 2011).
SCERTS is a flexible, family-centred, holistic intervention for a child with ASD. The framework has been adapted for use within New Zealand, and this adapted version was shown to be useful in guiding the intervention and recording the progress made by Max, in an early childhood centre in New Zealand, over a period of 5 months. Research in the use of this framework is ongoing, but the studies available and the trial of this approach with Max show this to be a promising intervention framework for teams supporting children with ASD. Because the framework uses a child’s strengths and interests to build the necessary skills in familiar everyday environments with known conversational partners (Prizant et al., 2006), it can be used with any child who has difficulties engaging and communicating with others socially, and with those who struggle to emotionally regulate themselves, whether or not they have the diagnosis of autism.
I wish to acknowledge Max, his family and his education support worker and educators for allowing me to work alongside them in the implementation of SCERTS. I would also like to acknowledge the support of colleagues, and the Ministry of Education, who were my employers during this intervention period.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Ayson, C. (2011). The use of music therapy to support the SCERTS model objectives for a three year old boy with autism spectrum disorder in New Zealand. New Zealand Journal of Music Therapy, 9, 7-31.
Baker, J. P. (2013). Autism at 70: Redrawing the boundaries. The New England Journal of Medicine, 369(12), 1089-1091.
Cognition Education. (2011). Evaluation of the use of the Social Communication, Emotional Regulation and Transactional Support (SCERTS) framework in New Zealand. Wellington: Author.
Hartung. (2010). FSU researchers awarded $3M grant to study autism curriculum. The Florida State University News. Retrieved from http://www.scerts.com/docs/May%202010%20SCERTS%20Grant.pdf
Ministries of Health and Education. (2008). New Zealand autism spectrum disorder guideline. Wellington: Ministry of Health.
National Autism Center. (2009). National standards report. Randolf, MA: Author. Retrieved from http://www.nationalautismcenter.org/pdf/NAC%20Standards%20Report.pdf
O’Neill, J., Bergstrand, L., Bowman, K., Elliott, K., Stephenson, S., & Wayman, C. (2010). The SCERTS model: Implementation and evaluation in a primary special school. Good Autism Practice, 11(1), 7-15.
Odom, S. L., Boyd, B. A., Hall, L. J., & Hume, K. (2010). Evaluation of comprehensive treatment models for individuals with autism spectrum disorders. Journal of Autism and Developmental Disorders, 40, 425-436. Retrieved from http://web.a.ebscohost.com.ezproxy.massey.ac.nz/ehost/pdfviewer/pdfviewer?vid=3&sid=4a5c903a-7a20-49c1-ac6d-e9774cf5ffb8%40sessionmgr4004&hid=4207
Prizant, B. M., Wetherby, A. M., Rubin, E., & Laurent, A. C. (2003). The SCERTS model: A transactional, family-centered approach to enhancing communication and socioemotional abilities of children with autism spectrum disorder. Infants and Young Children, 16(4), 296-316.
Prizant, B. M., Wetherby, A. M., Rubin, E., & Laurent, A. C. (2010). The SCERTS model and evidence-based practice. Retrieved from http://www.scerts.com/docs/SCERTS_EBP%20090810%20v1.pdf
Prizant, B. M., Wetherby, A. M., Rubin, E., Laurent, A. C., & Rydell, P. J. (2006). The SCERTS model: A comprehensive educational approach for children with autism spectrum disorders. Michigan, MI: Paul H. Brookes Publishing Co.
South Australia Department for Families and Communities. (2009). Are you ready? Tom’s toilet triumph [DVD]. Government of SA: Author.
Walworth, D. D., Register, D., & Engel, J. N. (2009). Using the SCERTS model assessment tool to identify music therapy goals for clients with autism spectrum disorder. Journal of Music Therapy, XLVI (3), 204-216.
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1 The National Autism Center is a non-profit organisation that promotes evidence-based practice for individuals with ASD and their families, and those practitioners working alongside them. http://www.nationalautismcenter.org/
3 In New Zealand, many early childhood centres use learning stories as a way of showing a child’s progress by recording, through text, photos and sometimes videos, what was observed in the natural learning contexts of the child.