Infants and Young Children Vol. 16, No. 4, pp. 296–316 c ... Model article in IYC, 2003.pdf ·...

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Infants and Young ChildrenVol. 16, No. 4, pp. 296–316c© 2003 Lippincott Williams & Wilkins, Inc.

The SCERTS ModelA Transactional, Family-CenteredApproach to EnhancingCommunication and SocioemotionalAbilities of Children With AutismSpectrum Disorder

Barry M. Prizant, PhD; Amy M. Wetherby, PhD;Emily Rubin, MS; Amy C. Laurent, OTR-L

A range of educational/treatment approaches is currently available for young children with autismspectrum disorders (ASD). A recent comprehensive review by an expert panel on ASD (NationalResearch Council, 2001) concluded that a number of approaches have demonstrated positive out-comes, but nonetheless, not all children benefit equally from any one approach. Efforts to increasecommunicative and socioemotional abilities are widely regarded as among the most critical prior-ities, and growth in these areas is closely related to prognosis and long-term positive outcomes.However, some widely disseminated approaches are not based on the most contemporary de-velopmental research on social and communication development in children with and withoutdisabilities, nor do they draw from current understanding of the learning style of children withASD. This article describes the SCERTS Model, which prioritizes Social Communication, EmotionalRegulation, and Transactional Support as the primary developmental dimensions that must be ad-dressed in a comprehensive program designed to support the development of young childrenwith ASD and their families. The SCERTS Model has been derived from a theoretical as well asempirically based foundation and addresses core challenges of children with ASD as they relate tosocial communication, emotional regulation, and transactional support. The SCERTS Model also isconsistent with empirically supported interventions and it reflects current and emerging “recom-mended practices” (National Research Council, 2001). Key words: autistic spectrum disorder,autism, developmental, early intervention, education, communication, emotional regulation,family support, social

AUTISM SPECTRUM DISORDER (ASD) orPervasive Developmental Disorder (PDD)

(APA, 1994) is a category of developmental

From Childhood Communication Services and theCenter for the Study of Human Development, BrownUniversity, Providence, RI (Dr Prizant); theDepartment of Communication Disorders, Center forAutism and Related Disorders, Florida StateUniversity, Tallahassee, Fla (Dr Wetherby); theCommunication Crossroads, Monterey, Calif(Ms Rubin and Laurent); and the Yale UniversityChild Study Center, New Haven, Conn (Ms Rubin).

Corresponding author: Barry M. Prizant, PhD,Childhood Communication Services, 2024 Broad St,Cranston, RI 02905 (e-mail: Barry [email protected]).

disability characterized by qualitative impair-ments in social interaction and social related-ness, difficulties in acquiring and using con-ventional communication and language abili-ties, and a restricted range of interests oftenco-occurring with an extreme need for con-sistency and predictability in daily living rou-tines. Frequently co-occurring and associatedcharacteristics include problems in sensoryprocessing (Anzalone & Williamson, 2000;Greenspan & Wieder, 1997), motor planning(Anzalone & Williamson, 2000; Prizant, 1996),emotional regulation and arousal modulation(Cole, Michel, & Teti, 1994; Dawson andLewy, 1989; Prizant, Schuler, Wetherby, &Rydell, 1997), and behavioral organization

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The SCERTS Model 297

(Ornitz, 1989). The learning profile of chil-dren with ASD is typically uneven and inflex-ible, with relative strengths in “object knowl-edge,”rote memory, and visual-spatial process-ing, and weaknesses in “social knowledge,”se-mantic and conceptual memory, and abstractproblem-solving (Prizant, 1983; Wetherby,Prizant, & Schuler, 1997). ASD is now under-stood to be of neurogenic origin and is gener-ally considered to be a lifelong disability thatcan dramatically impact family members. Ad-vances in research on early identification haveresulted in earlier diagnosis of ASD (Lord &Risi, 2000). As a result, there is a great de-mand for current information on educationand treatment for young children.

A variety of treatment approaches currentlyare available, ranging from educational to clin-ical to biomedical (eg, psychopharmacolog-ical, nutritional) (National Research Council[NRC], 2001). Within the category of edu-cational and clinical strategies, efforts to in-crease communication and socioemotionalabilities are widely regarded as among themost critical priorities (NRC, 2001; Wetherby& Prizant, 2000). These difficulties virtuallydefine ASD, and progress in communicationand socioemotional development is closelyrelated to outcome and independent func-tioning. However, approaches to enhancingthese abilities vary greatly, resulting in con-fusion for caregivers and some professionals.One source of this variability is the extentto which educational/treatment approachesare based (1) on current understanding of thelearning style and the nature of the disabilityof ASD, and (2) on the most contemporaryresearch on communication and socioemo-tional development in children with and with-out disabilities. On the one end of the con-tinuum, approaches that are developmentallybased draw heavily from the knowledge baseon typical child development (eg, Greenspan& Wieder, 1997; Gutstein, 2000; Prizant,Wetherby, & Rydell, 2000; Rogers & Lewis,1989; Wetherby et al., 1997). On the otherend of the continuum are more traditionalABA (applied behavior analysis) approaches,which are based primarily on teaching prac-

tices derived from tenets of learning the-ory and operant conditioning (Lovaas, 1981;Maurice, Green, & Luce, 1996) (see Prizant& Wetherby, 1998, for further discussionof the continuum of educational/treatmentapproaches and the debate on efficacy ofintervention).

Over the past 2 decades, there have been in-creased attempts at “cross-fertilization,” withdevelopmental research and “family-centered”and “child-centered” practice influencing thecontent and teaching practices of traditionalABA approaches (Strain et al., 1992), re-sulting in a clear distinction between con-temporary ABA practice and traditional ABApractice. Similarly, developmental approachesare increasingly infusing tenets of ABA ap-proaches to address the need for consistency,intensity, and accountability, which havebeen strengths of ABA practice (Prizant &Wetherby, 1998). However, in our recent ex-perience, current educational/treatment pro-grams tend to fall into 1 of 2 categories.First, some programs continue to adhere toonly 1 or 2 approaches, with little integra-tion of practices from different perspectives.In contrast, other programs use a “patch-work quilt” strategy borrowing from differentpractices along the continuum, even whensuch practices are not easily integrated, re-sulting in a fragmented approach to program-ming. For example, a young child may re-ceive services in an integrated developmentalpreschool setting focusing on communica-tion, play, and peer interaction, but also re-ceive traditional ABA treatment in additionalhome-based therapy focusing on readinessskills and “compliance training,”with little co-ordination between settings. Such fragmenta-tion may cause confusion for children who areexposed simultaneously to highly structured,directive approaches based on repetitiveteaching drills, as well as more loosely struc-tured, child-centered approaches using morenatural activities for teaching. It may alsoresult in considerable confusion for parentsand frustration for professionals who comefrom different, and sometimes diametricallyopposed, orientations. Thus, there remains


298 INFANTS AND YOUNG CHILDREN/OCTOBER–DECEMBER 2003

a great need for a comprehensive educa-tional/treatment model with the following fea-tures: (1) the model is based on the most cur-rent research in child development and ASD;(2) it is flexible enough to incorporate differ-ent perspectives (ie, developmental and con-temporary ABA); (3) it can be applied in anindividualized manner while addressing the“core deficits” of ASD; and (4) it is family-centered, taking into account critical individ-ual differences across families in reference totheir priorities, and their involvement in criti-cal programmatic decision-making.

This article provides an overview of theSCERTS Model, a comprehensive, multidisci-plinary approach to enhancing communica-tion and socioemotional abilities of childrenfrom early intervention to the early schoolyears. The SCERTS Model was developed todirectly address the limitations of availableapproaches noted above. The model priori-tizes Social Communication, Emotional Regu-lation, and Transactional Support as the pri-mary developmental dimensions that must beaddressed in a comprehensive program de-signed to support the development of chil-dren with ASD. Because the model addressescore deficits or challenges definitive of ASD,it can be applied flexibly to a range of chil-dren who have varying degrees of disabil-ity (ie, mild to severe) in cognitive, commu-nicative, sensory processing, and regulatorycapacities.

The SCERTS Model is derived from over2 decades of empirical and clinical work,and is consistent with recommended tenetsof “evidence-based” practice espoused by re-searchers and clinical scholars in ASD and re-lated disabilities (NRC, 2001; Prizant & Rubin,1999). More specifically, the developmental,social-pragmatic focus of the model has beenthe hallmark of our work for many years(Prizant, 1982a; Prizant et al., 1997; Prizant& Wetherby, 1985, 1987; Wetherby et al.,1997; Wetherby & Prutting, 1984) and hasbeen influenced by other developmentallybased communication intervention modelsoutside of ASD (Bricker, Pretti-Frontczak, &McComas, 1998; McLean & Snyder-McLean,1978). The model reflects and integrates

our previous empirical research and clini-cal investigation in understanding conven-tional and unconventional communication inASD including communicative functions andintentions of behavior (Prizant & Duchan,1981; Prizant & Rydell, 1984; Prizant &Wetherby, 1987; Rydell & Prizant, 1985;Schuler & Prizant, 1985; Wetherby, 1986;Wetherby & Prutting, 1984) and is philosoph-ically consistent with tenets of recent workin positive behavior supports (Fox, Dunlap,& Buschbacher, 2000; Koegel, Koegel, &Dunlap, 1996; Lucyshyn, Dunlap, & Albin,2002). The model also is built upon our workaddressing the relationships among commu-nication, socioemotional development, andemotional regulation (Prizant, 1999; Prizantet al., 1990; Prizant & Meyer, 1993; Prizant& Wetherby, 1990) and is consistent withthe work of Rogers and Lewis (1989) andGreenspan and Wieder (1998, 2000) ad-dressing socioemotional factors, and DeGangi(2000) and Tronick (1989) addressing arousalmodulation and emotional regulation.

The SCERTS Model also integrates contem-porary understanding of the learning style ofpersons with ASD as addressed in our pre-vious work (Prizant, 1982b, 1983; Prizant &Wetherby, 1998; Wetherby et al., 1997), andas reflected in the current emphasis on theuse of visual supports in educational program-ming (Hodgdon, 1995; Quill, 1998). Finally,the family-centered philosophy espoused inthe model draws from the work of Bailey andcolleagues (Bailey & Simeonsson, 1988) andDunst and colleagues in early intervention(Dunst, Trivette, & Deal, 1988), and has beengreatly influenced by the Hanen Early Lan-guage Centre Model for supporting parents ofchildren with language disabilities (Manolson,1992) and ASD (Sussman, 1999). Our previouswork that addresses our interpretation and ap-plication of family-centered research and prac-tice, both within and outside the ASD litera-ture (Prizant & Bailey, 1992; Prizant & Meyer,1993; Prizant, Meyer, & Lobato, 1997, Prizant& Wetherby, 1993), is infused in all aspects ofthe model.

Thus, the SCERTS Model clearly is consis-tent with, or has been directly influenced



by, contemporary practices and education/treatment approaches noted above. How-ever, we believe it offers an important andnovel contribution to currently available ap-proaches by establishing clear priorities in theareas of social communication, emotional reg-ulation, and transactional support, in a man-ner that addresses the complex interdepen-dencies among these most crucial areas. Inthis manner, the model reflects a new concep-tualization of education/treatment that mostclosely addresses the core deficits observed inASD, and therefore represents an example ofwhat we believe to be the “next generation”oftreatment approaches for ASD. In the follow-ing discussion, we will define the core com-ponents of the SCERTS Model (see Table 1 for

Table 1. SCERTS Model—Summary of education/treatment priority goals

I. Social communicationA. Enhance capacities for joint attention

1. Expression of communicative intent2. Expand range of communicative functions3. Enhance social reciprocity (rate of communication, repair, persistence)4. Enhance communicative gaze, sharing emotional states

B. Enhance capacities for symbol use (symbolic behavior)1. Movement from unconventional to conventional means of communication2. Movement from presymbolic to symbolic behavior in communication and play3. Movement from echolalia to creative language4. Enhance comprehension of language and other symbolic systems

II. Emotional regulationA. Enhance capacities for self-regulation—Ability to independently use sensory motor and/or

cognitive/linguistic strategies to regulate emotional arousal, and support attention andengagement

B. Enhance capacities for mutual regulation—Ability to seek support from others or respondto partners’ efforts to regulation of emotional arousal in the context of social transactionthrough sensory motor and/or cognitive/linguistic strategies

C. Enhance capacity to recover from dysregulation—Ability to recover from extreme states ofdysregulation either independently or with support from partners

III. Transactional supportA. Educational and learning supports—Use of visuals and other organizational supports;

environmental modification; curriculum modificationB. Interpersonal supports—Calibrate partner language and interactive style, and

developmental support to enable child to attend, communicate, engage, and play at moresophisticated levels. Design opportunities for learning with and developing relationshipswith peers

C. Family support—Emotional and educational support provided to parents to enhance theirconfidence and abilities in supporting their child’s development

D. Support among professionals—Provide opportunities for enhancing educational andtherapeutic skills, and for emotional support to cope with work-related challenges

an overview), provide sample goals for eachcomponent, and conclude by considering theoverriding importance of ecological validity inprograms for young children with ASD.

SOCIAL COMMUNICATION

It is now well documented that positivelong-term outcomes for children with ASD arestrongly correlated with the achievement ofcommunicative competence (Garfin & Lord,1986; Koegel, Koegel, Yoshen, & McNerney,1999, NRC, 2001; Venter, Lord, & Schopler,1992). Additionally, those children who dis-play a greater capacity to establish and followthe attentional focus of their communicativepartners are more likely to initiate bids for



communication, use more contingent lan-guage and acquire conversational skills, usemore sophisticated gestures and symbolic lan-guage, recognize and repair communicativebreakdowns, and respond to contextual andinterpersonal cues (Carpenter & Tomasello,2000; Wetherby, Prizant, & Hutchinson,1998). The “SC” component of the SCERTSModel directly addresses the core challengesin social communication faced by childrenwith ASD. Although there is great heterogene-ity in children with ASD, research over thepast 2 decades has identified core challengesthat fall into 2 major areas: (1) the capacityfor joint attention, which underlies a child’sability to coordinate and share attention,share emotions, express intentions, andengage in reciprocal social interactions, and(2) the capacity for symbol use, whichunderlies a child’s understanding of meaningexpressed through conventional gestures,words, and more advanced linguistic forms,and the ability to engage in appropriateuse of objects leading to imaginative play(Wetherby, Prizant, & Schuler, 2000). Theeducational/treatment goals within the social-communication dimension of the SCERTSModel have been derived to enhance thesecore capacities.

Capacity for joint attention

A child’s ability to consider the attentionalfocus of another and to draw another’s at-tention toward objects and events of mu-tual interest is a foundation for the develop-ment of language, social-conversational skills,and social relationships. Moreover, these earlycapacities are strongly related to the abilityto interpret and share emotional states andintentions, and to consider another’s priorexperiences and perspective in relation toevents or conversational topics (Carpenter &Tomasello, 2000; NRC, 2001).

At prelinguistic stages of language acquisi-tion, joint attentional capacities are manifestin the ability to orient to a social partner, tocoordinate and shift attention between peo-ple and objects, to share and interpret affector emotional states, and ultimately, to use ges-tures and vocalizations paired with physical

contact or gaze to deliberately affect (ie, com-municate with) another person. A child’s abil-ity to monitor the social environment throughsocial referencing (ie, shifting gaze) and toshare affect typically precedes the develop-mental milestone of intentional communica-tion, which is then followed by an expandedability to express intentions across commu-nicative partners and for a range of commu-nicative functions or purposes. Prior to thedevelopment of language, a child’s capacityfor joint attention also underlies the ability tocommunicate not only for need-based instru-mental purposes (eg, requesting or protestingby using push away or giving gestures), butalso for more social purposes (eg, comment-ing in order to share observations and experi-ences by using showing or pointing gestures).

As a child makes the transition to language,the capacity for joint attention facilitates thedevelopment of a more sophisticated and ex-plicit system of communication. There is arapid expansion of vocabulary and linguisticconcepts, and emergence of more sophisti-cated sentence structures for the purposes ofsharing intentions and emotions (Wetherbyet al., 2000). At more advanced stages of lan-guage acquisition, the emergence of moresophisticated joint attention capacities sup-ports communication about past and futureevents and enables children to consider whatis novel, interesting, and important to their lis-tener based on their listener’s attentional fo-cus, interests, and knowledge of prior events(Carpenter & Tomasello, 2000).

The core challenge in the capacity for jointattention impacts 4 critical developmental ca-pacities in the social-communicative profile ofchildren with ASD, resulting in a number ofsignificant developmental challenges and lim-itations:

1. Limitations in coordinating attentionand affect result in difficulties in (a) ori-enting and attending to a social partner;(b) shifting gaze between people andobjects in order to monitor another’s at-tentional focus and intentions; (c) shar-ing emotional states with another per-son; (d) following and drawing anotherperson’s attention toward objects or



events for the purpose of sharing experi-ences; and (e) participating in reciprocalinteractions over multiple turns in socialexchange.

2. Limitations in sharing intent (Prizant& Wetherby, 1987) result in difficultiesin (a) directing signals to others to ex-press intentions, (b) gaining another’sattention when initiating either gestu-ral, vocal, or linguistic communication,(c) communicating intentionally at a ratenecessary to maintain reciprocal inter-action, and (d) persisting and repairingcommunicative breakdowns when theyoccur.

3. A restricted range of communicativefunctions resulting in a reduced fre-quency of communication for more so-cial purposes (Wetherby, 1986) such asfor social interaction or calling atten-tion to oneself, or for joint attentionsuch as commenting on and sharingexperiences, and expressing emotions;and

4. Difficulties inferring another’s perspec-tive or emotional state—resulting in(a) problems in monitoring the appro-priateness of verbal and nonverbal dis-course; (b) selecting appropriate topics;(c) providing sufficient background in-formation; and (d) reading and respond-ing appropriately to others’ emotionalexpressions.

These difficulties may be manifest differ-ently across children, thus creating a pic-ture of great heterogeneity in the ASD pop-ulation. However, they reflect each child’sstruggle to establish and maintain shared at-tention, and to interpret and express inten-tions at the prelinguistic, emerging language,and advanced language stages (Carpenter &Tomasello, 2000; Wetherby et al., 2000).

Capacity for symbol use

In the SCERTS Model, the basis for under-standing and addressing the symbolic deficitsin children with ASD is derived from the liter-ature on typical developmental processes inlanguage acquisition and play development.Language learning is an active process in

which children “construct” knowledge andshared meanings based on interactions withpeople and experiences in their environment(Bates, 1979; Bloom, 1993; Lifter & Bloom,1998). Children typically progress through 3major transitions en route to developing moresophisticated symbolic language skills to ef-fectively communicate shared meaning withcommunicative partners. First, at the prelin-guistic stage of language acquisition, a childtypically makes a transition to intentionalcommunication, a developmental shift to-ward the systematic use of conventionalgestures (eg, giving, waving, showing, andpointing) and/or vocalizations to deliberatelyaffect another person; second, at the emerg-ing language stage, a child makes the transi-tion to early symbolic communication, a shifttoward the acquisition of single word vocabu-lary (eg, first words, signs, or picture symbols)marked by the acquisition of vocabulary thatserves a variety of communicative functions;and third, a child at more advanced languagestages makes the transition to linguistic com-munication (eg, the construction of multi-word combinations, grammar, and discourse).Parallel development during the transition tosymbolic and linguistic communication is ev-ident in a child’s use of objects, initially forconventional, functional purposes, then insymbolic play, and later in sociodramatic, co-operative play. Capacities in joint attentioncontribute to and interact with the develop-ment of more conventional and sophisticatedlinguistic knowledge, as observed in the abil-ity to modify linguistic structure and style inorder to clarify intent for one’s listener (NRC,2001; Wetherby et al., 2000). In addition toserving important communicative functions,language also comes to serve as an increas-ingly important tool in problem-solving, plan-ning and regulating behavior, and in regulat-ing arousal and emotional state (Prizant et al.,2000) (see next section on Emotional Regula-tion for further discussion).

Challenges in the capacity for symbol useimpact 3 critical developmental capacities inthe social-communicative profile of childrenwith ASD, resulting in a number of significantlimitations:



1. Limitations in the use of conven-tional hand gestures (eg, showing, wav-ing, and pointing) and other nonver-bal conventional communicative means(eg, head nods and headshakes) result-ing in a reliance on primarily concrete,presymbolic motor-based gestures (eg,manipulating a caregiver’s hand, leadinganother toward a desired item, and re-enacting desired actions). Additionally,the use of socially undesirable commu-nicative means or challenging behaviorsfor communication (eg, screaming, ag-gression, tantrums), often observed inchildren with ASD, may be a direct con-sequence of these limitations, as they areused in lieu of more conventional ges-tures for protesting or establishing socialcontrol;

2. Unconventional vocal development,which may be marked by a paucityof vocal communication or the use ofdifficult to read, unconventional sounds;

3. Unconventional verbal behavior suchas the use of immediate or delayed formsof echolalia, perseverative speech, or in-cessant questioning (Rydell & Prizant,1995; Schuler & Prizant, 1985; and

4. Limitations in functional object useand symbolic play, as marked bydifficulties using objects appropriately,which may be due in part to limita-tions in motor planning and in imitat-ing the nonverbal behaviors of others, aswell as limitations in the underlying sym-bolic capacity to represent social events,to “role-play,” and to elaborate on playschemes (Wolfberg, 1999).

Addressing core social-communicationchallenges

A child initially develops communicativecompetence through experiences with differ-ent partners in the social environment overtime and across contexts (Sameroff & Fiese,1990). Newly acquired capacities are prac-ticed as a child learns to share his or herintentions and emotional states with otherswithin natural contexts and recurring activi-

ties. An essential component of the SCERTSModel is to profile a child’s strengths andweaknesses in abilities related to the capac-ity for joint attention, by documenting abili-ties to express a range of intentions, to engagein reciprocal interactions and shared activi-ties with adults and peers, and to use social-affective signals such as gaze shifting for so-cial referencing and affect sharing. Abilitiesrelated to the capacity for symbol use areassessed by documenting presymbolic (e.g,types of gestures), quasi-symbolic (eg, pictureor other nonspeech systems), and symbolicmeans (eg, spoken and signed language) tocommunicate, as well as types and complexityof play. Specific goals and a plan for support-ing social communicative and symbolic ca-pacities across contexts are then formulated.Thus, in the SCERTS Model, a developmentalsequence of social-pragmatic competenciesis addressed within a variety of settings andacross natural environments. Table 2 providessample educational/treatment goals in socialcommunication as children progress throughprelinguistic, emerging language, and moreadvanced language stages.

In the majority of cases, modifications andadaptations in environments and activitiesare often necessary to support optimal learn-ing (to be discussed in the upcoming sec-tion on Transactional Supports). However, weagree with Strain, McGee, and Kohler (2001)that most children with ASD are capable oflearning in natural activities and inclusiveenvironments as long as the environmentaland interpersonal contexts are modified tomatch the unique learning style and social-communicative needs of the child. There is lit-tle, if any, empirical evidence supporting the“myths” for segregating young children withASD from natural activities and interactions(eg, children with ASD can only learn in 1:1 in-struction, more natural activities and environ-ments are too overly stimulating). However,there is much empirical support for the effi-cacy of educating young children with ASDwith typical peers in well-designed naturalactivities with appropriate transactional sup-ports (Strain et al., 2001).



Table 2. SCERTS Model: Sample social communication goals∗

Goals for joint attention Goals for symbol use

Prelinguistic level• Establish anticipatory behaviors (eg,

orienting to social stimuli, social referencing,following another’s gaze and gestures)

• Establish shared affect (eg, smiling andlooking)

• Establish early intentional behaviors (eg,coordinating gestures/vocalizations withphysical contact or gaze)

• Increase frequency or rate of communicativebids

• Expand range of communicative functionsbeyond instrumental functions (eg,nonverbal attempts to greet, show, and/orrequest social routines)

• Develop strategies to persist and repaircommunicative breakdowns

• Develop ability to communicate intent acrossfamiliar persons, environments, and activities

• Establish a consistent means for expressing intent (eg,conventional gestures, signs, picture communication)

• Replace earlier developing or unacceptablecommunicative means with socially acceptable forms

• Develop a child’s ability to use multiple gestural andvocal means (eg, a give gesture, a contact and distalpoint, a push away, a head nod, a head shake, andadding vocalizations to nonvocal means)

• Develop the use of nonverbal strategies for the purposeof sharing and calling attention to oneself (eg, a wavegesture, a show gesture, and declarative pointing)

• Establish functional use of familiar objects and earlyplay schemes directed toward self

• Develop the use of more formal augmentative/alternative systems to communicate intentions

Emerging language level• Expand ability to communicate intent across

more varied persons, environments, andactivities

• Expand ability to coordinate attention andaffect through shifting gaze and shared affect

• Develop ability to secure attention to one’sself prior to expressing intentions (eg, averbal calling function)

• Expand range of communicative functions toinclude more social purposes (eg, greetings,requesting social games or routines, showingoff, commenting, and requestinginformation)

• Increase reciprocity (ie, turntaking andcontingent use of language) to establish earlyconversational abilities

• Acquire core vocabulary to serve a range ofcommunicative functions (eg, requesting, protesting,greeting, commenting, and expressing emotionalstates)

• Expand vocabulary to express more varied semanticrelations

• Expand ability to combine words/signs/pictures toexpress a fuller range of semantic relationships (eg, 2-and 3-word combinations)

• Generalize unconventional verbal forms (immediate ordelayed echolalia) to express a variety of functions

• Facilitate segmentation of echolalic forms with ruleinduction allowing for greater creativity in languageproduction, and movement to more conventionalforms

• Expand representational play themes that involve basicrole-play in familiar and unfamiliar settings

Advanced language level• Increase ability to communicate about past

and future events• Facilitate awareness of another’s intentions,

preferences, and experiences• Develop ability to modify topic selections

based on a listener’s attentional focus,preferences, and emotional state

• Increase ability to interpret and use languageflexibly depending upon the social contextand the nonverbal cues of one’scommunicative partner (eg, drawinginferences, multiple meaning words,figurative language, and sarcasm)

• Acquire higher level linguistic forms that expressdifferences in meaning (eg, tense markers, pronouns,etc)

• Support the acquisition of verbal conventions forinitiating, exchanging turns, and terminatinginteractions

• Increase ability to use and interpret nonverbal behaviorto support language use and social interaction (eg,body posture and orientation, communicative gaze,facial expressions, gestures, and intonation)

• Acquire ability to use language as a tool for emotionalregulationa. develop vocabulary to express emotions and share

experiences with othersb. use language to prepare for changes in routinec. discuss potentially problematic emotionally

dysregulating situationsd. use language to request assistance and comfort

∗Actual goals will vary depending on child’s needs and family priorities.



In the SCERTS Model, all who interact witha child with ASD on a regular basis (eg,parents, other caregivers, siblings, peers, ed-ucators, and therapists) are viewed as poten-tial developmental facilitators and may bene-fit from guidance and support in enhancingspecific competencies in joint attention andsymbol use. However, a child’s ability and“availability” for social engagement and com-munication, and learning in general, is greatlydetermined by the capacity for maintainingwell-regulated emotional and arousal states.We now turn to this second critical compo-nent, the “ER”of the SCERTS Model.

EMOTIONAL REGULATION

Emotional regulation defined

Emotional regulation is a core process un-derlying attention and social engagement, andis believed to be essential for optimal socioe-motional and communication development,and the development of relationships for chil-dren with and without disabilities (Prizant &Meyer, 1993). Cicchetti, Ganiban, and Barnett(1991) defined emotional regulation as “theintra and extra organismic factors by whichemotional arousal is redirected, controlled,modulated, and modified to enable an indi-vidual to function adaptively”(p. 15). Tronick(1989) distinguished between emotional self-regulatory capacities, and mutual regulatorycapacities, which both serve to aid in modu-lating emotional arousal. Self-regulatory strate-gies are self-initiated and self-directed; mutualregulatory strategies occur in the context ofsocial interaction and involve a child’s abilityto respond to assistance from others in help-ing to maintain a state of optimal arousal. Inearly stages of development, mutual regula-tion is characterized by a caregiver sensitivelyreading and responding to a child’s behaviors,which are not directed purposefully to thecaregiver, but nonetheless signal to the care-giver the child’s emotional state and level ofarousal. A partner must interpret a child’s sig-nals and provide appropriate support if andwhen needed. Therefore, this type of mutual

regulation may be referred to as respondentmutual regulation. For example, a child’s fa-cial expression or bodily tension may signalfear or anxiety, to which a caregiver respondswith verbal or nonverbal comfort. With thedevelopment of greater social awareness andcommunicative abilities, children begin to useinitiated mutual regulation strategies. That is,they are able to intentionally communicatetheir needs (eg, for assistance, comfort) totheir caregivers through verbal and/or non-verbal means. For example, to request com-fort, a preverbal child may purposefully reachout to be held, and a verbal child may requestcomfort by saying “I’m scared.”

Emotional regulation and arousal

Through the process of emotional regu-lation children strive to maintain an opti-mal state of arousal that matches the socialand physical demands of their environmentsand that allows them to respond adaptively(DeGangi, 2000). Arousal has been defined asa continuum of physiological states or biobe-havioral states ranging from sleep to wakeful(Lester, Freier, & LeGasse, 1995). Modulationabilities (ie, the efficient and appropriate tran-sition along the continuum of arousal states)enable children to transition along this contin-uum in accordance with internal and externalfactors. Factors influencing the ability to tran-sition along the continuum include, but arenot limited to, environmental characteristics(eg, types and intensity of environmental stim-ulation), social context, (eg, availability of fa-miliar communicative partners), and internalor constitutional variables (eg, illness, levelof fatigue, and pain). Pert (1997) argued thatphysiological state and emotional state are in-terdependent: “Every change in the physio-logical state is accompanied by an appropriatechange in the mental emotional state, and ev-ery change in the mental emotional state (con-scious or unconscious) is accompanied by achange in the physiological state.”

It has been well documented that childrenwith ASD have significant difficulties witharousal modulation, and therefore, emotionalregulation, due to neurophysiological factors



(Anzalone & Williamson, 2000; Dawson &Lewy, 1989; DeGangi, 2000; Kientz & Dunn,1997; Ornitz, 1989). This may take the formof a low threshold for physiological and emo-tional reactivity, resulting in being “at risk”forexperiencing heightened states of arousal andemotion (ie, hyperreactivity), causing anxiety,agitation, and a limited ability to be “available”for learning and interacting. In these height-ened states of arousal, children often exhibitflight, fright, and fight reactions, which arefrequently misinterpreted and treated as “be-havior problems.”Thus, when a child exhibitsthese reactions, he or she may be described asbeing aggressive, noncompliant, or intention-ally manipulative. For instance, a child with ahyperreactive response to tactile stimulationmay push or hit other children in a defensivereaction to being inadvertently touched or inanticipation of being touched. A child who ishyperreactive to visual and auditory stimula-tion may attempt to “escape”from overly stim-ulating environments or activities. For otherchildren, persistent states of underarousal (ie,hyporeactivity) secondary to high thresholdsfor physiological and emotional reactivity mayresult in passivity, lethargy, and a similar in-ability to be available for processing socialand environmental experiences. These chil-dren are often described as unmotivated, self-absorbed, nonfocused, or “spacey.”Some chil-dren may experience shifting states of over- orunderarousal that occur cyclically (eg, accord-ing to time of day), or unpredictably, result-ing in a complex pattern that is challenging toboth families and professionals (see Anzalone& Williamson, 2000, for further discussion).

Communication, arousal, and emotionalregulation

Social-communicative and language diffi-culties experienced by children with ASDsignificantly impact their arousal modula-tion abilities and behavioral organization, andtherefore, their emotional regulation, in ref-erence to the development of both self- andmutual regulatory abilities. Regarding self-regulation, difficulties with symbolic capac-ities, as described earlier, may impact nega-

tively on the development of “inner language.”It has long been understood that inner lan-guage (Vygotsky, 1978), or the ability to rep-resent events in memory and problem solvethrough inner symbolic means, serves an im-portant cognitive function of organizing expe-rience and behavior, thinking about and learn-ing from past events, and planning for futureevents. With limited ability to use inner lan-guage for these cognitive functions, it is lesspossible to plan for dysregulating and poten-tially threatening events, or to reflect on pastevents in a manner that supports emotionalregulation when faced with stressful events.These difficulties may contribute to the un-predictable reactions to daily events observedin many children with ASD.

Mutual regulation may be compromisedbecause of difficulties with joint attention,which is considered to underlie the develop-ment of secure relationships (Stern, 1985),and related social-communication difficulties.A caregiver may not be viewed as a poten-tial source for mutual regulation, thus limitingthe strategies a child develops and employs tomaintain a well-regulated emotional state. Forexample, a child may not “know,”that anotherperson can provide comfort through physicalor verbal means, and therefore, does not seekothers out. Even for a child with this “knowl-edge”mutual regulatory strategies may be sig-nificantly compromised or absent at higherlevels of arousal because of a more limitedability to engage in communicative interac-tions in states of high arousal and emotionaldysregulation. In addition to the impact of lim-itations in expressive communication, limita-tions in receptive language and communica-tion may also detrimentally affect the capacityto maintain a well-regulated state. For exam-ple, a child’s emotional reaction to problemsin comprehending gestures or language maycause confusion and/or frustration, resultingin an increase in arousal.

In summary, there is a clear interdepen-dent relationship among the development ofmutual and self-regulatory capacities, commu-nication, language, and other aspects of so-cioemotional development (Prizant & Meyer,



1993; Prizant & Wetherby, 1990). While self-and mutual-regulatory capacities support de-velopment in these related domains, increas-ing abilities in language and communication,in turn, are considered to play an importantrole in the development of more sophisticatedstrategies for emotional regulation.

Addressing emotional regulationchallenges in the SCERTS model

Because of the interdependency betweensocial communication and emotional regula-tion, the SCERTS Model incorporates an inte-grative approach when difficulties are presentin both developmental domains as is com-monly observed in ASD. The SCERTS Modeldirectly addresses emotional regulation bytargeting goals for the development of self-regulatory and mutual-regulatory capacities.In determining individualized goals, these ca-pacities must be understood from a develop-mental perspective. That is, emotional regu-lation may be facilitated through presymbolicsensory-motor means, or through higher levelcognitive-linguistic means, consistent with achild’s developmental profile and skill acquisi-tion (DeGangi, 2000; Prizant & Meyer, 1993).For instance, an infant first develops sensorymotor, self-regulating abilities, such as suck-ing a thumb, averting gaze, or engaging inrepetitive motor activity. Likewise, as a childmatures and develops greater cognitive andlinguistic skills, the ability to employ theseskills for emotional regulatory functions de-velops as well (eg, the ability to use “self talk”to regulate one’s arousal during an anxietyarousing situation). Therefore, while the reg-ulatory abilities of a young child are limitedbased on his or her developmental level (eg, apresymbolic child cannot use language-basedor other symbolic strategies), the abilities ofan older more able child consist of both ear-lier developing sensory-motor strategies andhigher level cognitive-linguistic strategies (eg,a symbolic child can use language as well asengage in repetitive motor activity to remainwell-regulated). State of arousal and environ-mental demands often contribute to whichof these specific types of strategies, or com-

binations of strategies, an individual childemploys.

An essential component of the SCERTSModel is initially to assess a child’s capacitiesto maintain well-regulated states of arousalacross contexts, by documenting the primaryfactors supporting or interfering with emo-tional regulation, and the specific signals thata child gives when he or she needs support.Different behavioral signals are categorizedaccording to different levels of arousal, rang-ing from calm and well-regulated to extremelydysregulated, with gradations in between.Next, specific goals and a plan are developedfor supporting a child in acquiring and apply-ing self-regulatory or mutual-regulatory strate-gies that are indexed to each level of arousal.As emotional regulatory strategies are imple-mented, the efficacy of such strategies aredocumented with adjustments made to theplan as needed.

Table 3 provides sample goals at sensorymotor and cognitive-linguistic levels for self-and mutual regulation. Self-regulatory strate-gies may include helping a child to discoverways to maintain an organized state in whichhe or she is available for active learning. Forinstance, self-regulatory, sensory motor strate-gies for self-soothing when a child is in aheightened state of arousal may include focus-ing on a particular calming activity (eg, listen-ing to music, holding a favorite toy), or, formore able children, taking a break from anactivity. Self-regulatory strategies may also in-clude initiating and engaging in alerting sen-sory motor activities, such as increased phys-ical activity, when a child is in a low stateof arousal and not optimally engaged in ac-tivities and interactions. At a cognitive level,helping children to develop an awareness ofthe activity schedule, steps within activitiesor the duration of activities, transitions be-tween activities, and unexpected changes inroutines may preclude negative reactions dueto confusion or a lack of predictability, andtherefore promote greater self-regulation abil-ities. Helping to develop an awareness oftime concepts as well as the ability to under-stand language about past and future events



Table 3. SCERTS Model: Emotional regulation goals∗

Goals for self-regulation Goals for mutual regulation

Prelinguistic/sensory-motor level goals• Increase child’s ability to acquire and use

sensory-motor strategies to supportengagement and attention to dailyactivities (eg, for a child who is typically ina low state of arousal, expand his/herrepertoire of alerting strategies—jumping,random movement, etc; for a child who istypically in a high state of arousal, expandhis/her repertoire of calmingstrategies—holding favorite object,rhythmic motion, etc

• Expand the child’s use of sensory-motorstrategies to support transitions withindaily routines (eg, use of transitionobjects, embed organizing sensory-motorsupports within transition activities)

• Increase child’s ability to maintain engagementand attention to activities by responding tobehavioral signs of dysregulation (eg, decreasethe amount of environmental stimulationwhen a child exhibits “fright and flight”reactions; increase the amount of stimulationembedded in activities when a child appearshyporesponsive to the environment)

• Increase child’s ability to use sociallyacceptable gestures for social controlfunctions requesting and protesting (eg, headnod, head shake, push away, point, etc)

• Develop strategies through nonspeechtransactional supports to assist the child withexpression of arousal and emotional state (eg,visual supports)

Cognitive-linguistic level goals• Increase the child’s ability to initiate and

utilize cognitive-linguistic strategies tosupport his/her attention to activities anddaily routines (eg, through the use ofrehearsal and self-regulatory language)

• Expand the child’s use ofcognitive-linguistic strategies to supporttransitions throughout daily routines (eg,introduce visual schedules to symbolizeactivity sequence and transitions, increasethe child’s awareness of temporalconcepts, etc)

• Increase the child’s acquisition of vocabularyto be able to request assistance and organizingsupports when he/she experiencesdysregulating events (eg, requesting “help,” abreak from an activity, etc)

• Increase the child’s ability to use specificvocabulary to express emotional state andarousal level

• Increase ability to identify and expressemotional state and arousal level as well as useregulating strategies with and without the useof visual supports

∗Actual goals will vary depending on child’s needs and family priorities.

also contribute to cognitive self-regulationstrategies.

In addition to self-regulatory capacities, theSCERTS Model targets the development ofmutual-regulatory strategies. When a child isexperiencing a high degree of arousal, or isunderaroused, partners need to read those sig-nals indicative of different states, and thensupport mutual regulation by responding inways that promote a child’s ability to focus,engage, and be in a state more conduciveto relating, learning, and processing informa-tion. This is consistent with a respondentform of mutual-regulation discussed earlier.

In the SCERTS Model, capacities for initiatedmutual-regulation strategies are also fosteredin ways that best fit a child’s developmentalprofile and needs. Children may be taught torequest assistance or protest in socially ac-ceptable ways through nonverbal means (eg,acquiring and using early developing gesturesto request, protest, or reject) or verbal means(eg, acquiring and using specific vocabularyfor expressing emotions, or to indicate re-fusal). These abilities have been demonstratedto be effective preventive measures to pre-clude problem behaviors precipitated by emo-tional dysregulation (Carr et al., 1994).



The plan also includes proactive and pre-ventative measures to support emotionl reg-ulation (eg, alternating sedentary activitieswith movement activities, reducing the levelof sensory input), as well as reactive strate-gies when faced with potentially dysregulat-ing experiences (eg, allowing a child accessto a quiet space or calming activity, simplify-ing a task, reducing the duration of an activ-ity). Dysregulating experiences may includeoverwhelming sensory input, changes in rou-tine, inappropriate task demands related todifficulty or duration of an activity, and disor-ganizing social and linguistic input. The useof transactional supports, such as nonspeechcommunication systems and visual supports,play important roles in these efforts, and thus,we now will shift our attention to the “TS” ofthe SCERTS Model.

TRANSACTIONAL SUPPORT

Due in large part to the difficulties in socialcommunication and emotional regulation, themajority of children with ASD require a va-riety of supports to participate optimally ininterpersonal interactions and relationships,and to understand and derive enjoyment fromeveryday activities. Supports are also neededto maximize learning in educational settingsand participation in daily living activities andevents. The notion of transactional supportin the SCERTS Model emphasizes that sup-ports must be flexible and responsive to dif-ferent social contexts and learning environ-ments, and to the changing needs of childrenand families. Most important, however, is thatboth children and family members develop asense of confidence and competence in uti-lizing and responding to supports. Transac-tional support is addressed in 3 major domainsin the SCERTS Model—interpersonal support,educational support, and family support (seeTable 4).

Interpersonal support

The daily experiences of professionals andfamily members (Domingue et al., 2000), aswell as empirical research (Bristol & Schopler,

1984) underscore the challenges experiencedby children with ASD in engaging success-fully in interpersonal interactions, and de-veloping emotionally fulfilling relationships.It is now understood that these challengesare among the core, definitive characteris-tics of ASD. That is, children are not “choos-ing” to be disengaged from social interac-tion and relationships due to a primary lackof interest or desire. Because of challengesin social-communicative, social-cognitive, andemotional-regulatory capacities, they are lim-ited in the requisite abilities and skills to bemore successful, active participants. Addition-ally, some communicative partners who reg-ularly interact with children may also lackthe knowledge and skills to support their ef-forts. Therefore, children with ASD are atrisk for developing a sense of interpersonalinteraction as overwhelming, confusing, andstressful based on a history of repeated un-successful experiences, while others are atrisk for limited engagement and low motiva-tion to participate in social interactions sec-ondary to processing difficulties and hypore-sponsive bias toward interpersonal events. Inthe SCERTS Model, there is a priority placedon supporting children to be as successful aspossible in experiencing a sense of efficacy incommunicating their intentions, and in partic-ipating in affectively charged and emotionallyfulfilling social engagement with a variety ofpartners. We believe an important key to suchsuccess is interpersonal support.

The greater the abilities in social communi-cation and emotional regulation, the greaterthe potential for a youngster to experiencefrequent successful and joyful interactions,which provide the foundation for the de-velopment of emotionally satisfying relation-ships. Interwoven throughout interpersonalexchange and sharing of experiences is thecommunication of emotional states throughthe medium of verbal and nonverbal signals.Sensitive partners attune affectively and cali-brate their emotional tone to that of the lessable partner, in order (1) to acknowledge theirappreciation of the subjective emotional stateof the child, (2) to attempt to motivate further



Table 4. SCERTS Model: Transactional support goals

I. Interpersonal support1. Identify specific features of communicative partners’ interactive styles and language use that

either support or are barriers to successful interactions (eg, expression of emotion, languagecomplexity and style, vocal volume, rate, physical proximity, physical contact, use of visualsupports). An optimal style is one that provides enough structure to support a child’sattentional focus, situational understanding, emotional regulation, and positive emotionalexperience, but that also fosters initiation, spontaneity, flexibility and self-determination

2. Coordinate efforts across different partners in developing strategies to use more thosespecific features that support more successful interaction

3. Design and implement learning experiences with peers so that the child with ASD maybenefit optimally from good language, social, and play models. Design motivating activities,organize supportive environments, and incorporate visual supports. Teach both typicalchildren and children with ASD specific strategies for success in daily interactions

II. Educational and learning supports1. Design and implement visual and organizational supports for

a. expanding and enhancing the development of a child’s expressive communicationsystem, either as a primary modality or as an augmentative system that is one part of achild’s multimodal communication system;

b. supporting a child’s understanding of language as well as others’ nonverbal behavior;c. supporting a child’s sense of organization, activity structure, and understanding of time;

andd. supporting the development and use of cognitive-linguistic emotional regulatory

strategies.e. Adapt and/or modify curriculum goals that are primarily language-based to enable the

child to succeed to the extent possible.2. Design living and learning environments to support social communication and emotional

regulation.III. Family support (ie, support to parents, siblings, extended family members)

1. Provide families with educational support including information, knowledge, and skills tounderstand the nature of their child’s disability and to support their child’s development.Support that is provided, must be based on family priorities, and offered through a variety ofoptions such as educational support activities (eg, lectures, discussion groups), directtraining of skills, observation of educational/treatment programming, and interactiveguidance in natural activities

2. Provide emotional support in one to one and group settings toa. enhance family members abilities to cope with the stresses and challenges of raising a

child with ASDb. help parents to identify their priorities, and develop appropriate expectations and

realistic, achievable goals for their child’s development and for family life

social and emotional engagement, and (3) toattempt to support the child during disorga-nizing and emotionally arousing experiences(Greenspan & Wieder, 1997; Stern, 1985).

Interpersonal support is addressed in a va-riety of ways in the SCERTS Model. First, theinteractive styles and language use of commu-

nicative partners are assessed for the quali-ties that enhance or inhibit successful inter-actions. Interaction style variables that war-rant assessment are those that may influencea child’s response to others’ attempts to en-gage in social exchange. These include, butare not limited to, expression of emotion,



language complexity and style, volume andrate of speech, physical proximity, and phys-ical contact. For example, a well-intentionedpartner may use too loud a voice and exag-gerated facial expression to express delightto a hyperreactive child, or another partnermay use language that is too complex, result-ing in confusion or nonresponsiveness. An in-teractive style that is too directive and con-trolling (eg, excessive physical prompting orcorrecting) may result in a hyporeactive childdeveloping an even more passive and respon-dent style of relating or communicating. Con-versely, a child with a bias toward sensoryhyperreactivity may respond by frequent at-tempts to protest or escape from a highlydirective partner. On the other end of thecontinuum, a partner who provides too littleconsistency, structure, or clarity of expecta-tions through language or other means maynot be able to support a child who needsa greater degree of external scaffolding foremotional regulation and social participation.Based on an assessment of partners’ stylesacross contexts, and a child’s reaction to dif-ferent styles, educational/treatment goals mayinclude determining the features of commu-nicative and interactive styles most support-ive for a child in different settings. In theSCERTS Model, an optimal style is one thatprovides enough structure to support a child’sattentional focus, situational understanding,emotional regulation, and positive emotionalexperience, but that also fosters initiation,spontaneity, flexibility, problem-solving, andself-determination. With the important prior-ities of building self-determination and initia-tion, a predominant behavioral pattern of pas-sive compliance in a child is as undesirableas “difficult to control” behavior. Efforts mustbe coordinated across different partners in de-veloping strategies to use more optimal stylesof interaction, to support children’s indepen-dence and development of a sense of self. Al-though some degree of variability across part-ners is natural and is to be expected, too greata discrepancy may result in confusion for achild trying to learn the very rudiments of so-cial engagement, and social expectations.

Second, opportunities for play interactionswith other children (including siblings) areassessed, with the goal of designing and im-plementing learning experiences so that thechild with ASD may benefit optimally fromgood language, social, and play models. Thegoal is to develop a history of successful ex-periences for a child with ASD to further moti-vate a child to seek out other children, leadingto the development of positive relationshipsand increased social motivation. Because chil-dren tend to be less predictable than adults, itis commonly observed that interactions withother children may be avoided by childrenwith ASD. Supporting successful peer inter-actions involves designing motivating activi-ties, organizing supportive environments, andteaching both typical children and childrenwith ASD specific strategies for success.

Educational and environmentalsupports

Because of the nature of learning differ-ences in ASD and the complexity of learningenvironments, a variety of educational sup-ports are typically needed to optimize successin school, and other learning environments.Although it is acknowledged some childrenwith the most extreme challenges may re-quire significant modifications to support ac-tive learning, the SCERTS Model prioritizeslearning in a variety of settings from the out-set. The justification is that generalization ofabilities is best accomplished when childrenlearn skills in settings that occur naturally aspart of their daily routine. Additionally, differ-ent social settings provide more varied learn-ing opportunities that cannot be replicatedin highly repetitive one-to-one drill practice.For example, treatment limited primarily toadult-child 1:1 interaction cannot address thegoal of enhancing a child’s capacity to shiftattention to follow the flow of interaction ina small group, to tolerate proximity to otherchildren, and/or to anticipate one’s turn inongoing reciprocal interactions. These goalsnot only require well-designed, semistruc-tured activities, but also more varied socialcontexts.



In the SCERTS Model, educational and en-vironmental supports are developed and uti-lized to enable children to be more actively en-gaged by supporting social communication,emotional regulation, and learning. First, it isnecessary to assess the barriers to active en-gagement in reference to the learning style ofchildren with ASD. For example, it is well ac-cepted that most children with ASD are moreeffective at processing and retrieving visual in-formation than auditory information (Prizant,1983; Wetherby et al., 1997). Therefore, visualsupports may be helpful in

1. expanding and enhancing a child’s ex-pressive communication system, eitheras a primary modality or as an augmen-tative system comprising one compo-nent of a child’s multimodal communica-tion system (eg, pictures, gestures, signs,speech);

2. supporting children’s understanding oflanguage as well as others’ nonverbal be-havior through the use of topic boards,cue cards, etc;

3. supporting a child’s sense of organiza-tion, activity structure, and understand-ing of time through the use of pictureschedules and activity sequences; and

4. supporting the development and use ofcognitive-linguistic emotional regulatorystrategies through the use of picture se-quences, break cards, personal organiz-ers, and so forth (Groden & LeVasseur,1995; Quill, 1998; Schuler, Wetherby, &Prizant, 1997).

In the SCERTS Model it is essential to specifi-cally identify the types of visual and organiza-tional supports that may be helpful based ona child’s developmental capacities and needs,and relative to activities and social contexts ina child’s life. Furthermore, efforts are made tomodify and calibrate supports as a child de-velops, with the goal of greater efficiency andfunctionality in the use of supports over time.

In educational environments, another es-sential transactional support is curriculummodification. Although this is not as cru-cial for children in the preschool and earlychildhood years as it is for older children,

curriculum modification also is often neces-sary to support a preschool child’s success.For preschool children with more significantlanguage processing limitations, curriculumgoals that are primarily language-based mayhave to be adjusted and or modified, withappropriate supports (eg, visual supports)added to enable the child to succeed to theextent possible in the preschool curriculum.

Support to families

Support to families can be conceptual-ized in reference to educational support (ie,providing families with the information,knowledge, and skills to support their child’sdevelopment) and emotional support (ie, en-hancing family members abilities to cope withthe inevitable stresses and challenges of rais-ing a child with ASD). In the SCERTS Model, italso is recognized that many stresses and chal-lenges experienced by family members maynot be attributed directly to the child’s behav-ior or needs. Great stress may be induced bysystems of service delivery that parents ex-perience as nonsupportive, disorganized, andin general, not helpful (Domingue, Cutler, &McTarnaghan, 2000).

The great majority of caregivers of chil-dren with ASD have had little formal train-ing in child development. However, the mostcritical social-communicative and socioemo-tional experiences for most children occurin their interactions with family members,when youngsters are developing the founda-tions of relationships, are learning the basicelements of communicative exchange, and,eventually, are acquiring more sophisticatedsocioemotional and communicative abilities.Daily routines and family events provide theexperiential opportunities in which childrenlearn and practice these abilities and developsecure and trusting relationships (Prizant &Meyer, 1993). As noted, however, childrenwith ASD are greatly challenged in socioe-motional and communicative development,despite the best efforts of loving and well-intentioned family members. Thus, familymembers are likely to experience frustrationand confusion as they try their intuitive best to



engage their children. In the SCERTS Model,efforts are made to mitigate these challengesto family members by addressing causal fac-tors related to limitations in social commu-nication and emotional regulation directlythrough supportive education/treatment andsharing of resources with families.

In the SCERTS Model, it is emphasized thatclinicians and educators must be cognizantof the whole range of possible reactions thatfamily members may experience in raisinga child with ASD, in order to best supporttheir efforts. The SCERTS Model is a devel-opmental model for caregivers as well as forchildren, as it is recognized that the natureand types of emotional support will need tochange as caregivers progress in their under-standing of and ability to support their child.Parents and caregivers are encouraged to dis-cuss their child’s strengths and difficulties,and to articulate the primary concerns andexpectations regarding their child’s develop-ment. When appropriate, caregivers may beasked to share their sense of competence aswell as limitations in fostering communicativeand socioemotional development. Successfuland unsuccessful strategies that family mem-bers may have employed to promote socialand communicative interactions must also beexplored. Information about a child and fam-ily’s strengths and needs, and family priori-ties, as gathered in assessment, form the ba-sis from which specific educational/treatmentgoals are derived. Caregivers are supportedin reference to communicative and interactivestyles that are most appropriate in enhancingtheir child’s development. Issues discussedearlier such as degree of directiveness and de-velopmentally appropriate language and com-municative modeling in everyday routines areimportant considerations in ongoing supportof caregivers. In addition to assistance ad-dressing social communication skills, care-givers are supported in helping their childrento develop emotional regulation capabilities.Ongoing assessment of and dialogue withcaregivers about a child’s reactive style tophysiological and emotional factors is crucial.Strategies for the development of self- and

mutual-regulatory capacities within the con-text of the family structure and routine arealso addressed.

In the SCERTS Model, it also is emphasizedthat clinicians and educators understand vari-ous family structures and functions, and howthese can be influenced by economic, ethnic,and cultural factors. For example, becauseof cultural and pragmatic factors, biologi-cal parents may not necessarily be the pri-mary caregivers in some families, and thus,other family members such as grandparentsor older siblings may play a more active rolein education/treatment. When designing ed-ucational/treatment strategies to be utilizedby family members and integrated into dailyfamily routines, it is critical that recommenda-tions must be compatible with the family’s be-lief systems and sociocultural characteristics(Lynch & Hanson, 1998).

Another important dimension of transac-tional support in the SCERTS Model is help-ing parents to think clearly about their pri-orities, and develop appropriate expectationsand realistic, achievable goals for their child’sdevelopment. Parents are not dictated to,they are respected as having ultimate “own-ership” of the decisions that must be madefor both the child and family. Professionalshave the responsibility of “keeping hope alive”by emphasizing a child’s strengths as wellas needs, highlighting the potential for pos-itive development and change, and helpingto identify developmentally appropriate “nextsteps.” This involves helping parents to learnto recognize and celebrate even the smallestmeaningful gains in social-communicative andsocioemotional development. The more care-givers are attuned to positive change, themore they are likely to become invested in be-ing actively involved in educational/treatmentefforts.

In summary, transactional supports ad-dressed in the SCERTS Model are designedto enhance children’s communication and so-cioemotional abilities in everyday social con-texts that a child experiences. Supports mayinclude interpersonal supports, educationalsupports, and support to family members,



who play such an important role in fosteringa child’s development. Because of the trans-actional nature of development (Sameroff& Fiese, 1990), the crucial role played byall caregivers and partners is recognized,with specific efforts directed to developmentof mutually satisfying and effective social-emotional experiences based on an under-standing of a child’s and family’s needs.

ASSURING ECOLOGICAL VALIDITYIN SERVICE DELIVERY

In the SCERTS Model, it is recognizedthat a primary challenge for service deliveryproviders is to address the complex relation-ships among the acquisition of communica-tive abilities, socioemotional factors (eg,emotional regulation, development of rela-tionships), and types of transactional supportsthat predict better social-communicative out-comes for children with ASD. On the ba-sis of a comprehensive review of interven-tion research on children with ASD, theNRC (2001) concluded that research hasdemonstrated substantial changes in largenumbers of children receiving a varietyof educational/treatment approaches, rang-ing from behavioral to developmental. How-ever, even in treatment studies with thestrongest gains, children’s outcomes werevariable. Service providers are thus facedwith the need to determine which educa-tional/treatment approaches or combinationsof educational/treatment strategies may bemost effective for particular children and fam-ilies (Prizant & Wetherby, 1998).

The most common reported outcome mea-sures for children with ASD are changes inIQ scores and postintervention placement(NRC, 2001). These measures may not beecologically valid, because they do not mea-sure changes within natural environments, donot address the core “deficits” in ASD, andare particularly problematic for infants andyoung children. In determining if an educa-tional/treatment approach is effective, it is im-portant to go beyond traditional “static” mea-sures such as improvement on standardized

tests or school placement, to include broaderand more dynamic measures, such as degreeof success in communicative exchange, re-lated dimensions of emotional expression andregulation, social-communicative motivation,social competence, peer relationships, andthe child’s competence and active participa-tion in natural activities and environments.Therefore, assessment cannot be limited tothe evaluation of child variables only; it shouldbe extended to contextual and interactionalvariables (see Prizant & Wetherby, 1998, forfurther discussion). Service providers need togather meaningful measures of a child’s abil-ities in order to guide educational/treatmentdecisions and to determine whether educa-tional/treatment effects are being achieved.This need for more meaningful outcome mea-sures in research on children with ASD wasrecently recognized by the NRC (2001). Itrecommended that as priorities, such mea-sures should include (1) gains in initiation ofspontaneous communication in functional ac-tivities and (2) generalization of gains acrossactivities, interactants, and environments. Inother words, enhancing communication andsocioemotional abilities for children with ASDentails not only increasing vocal and verbalrepertoires, but also increasing many of thedynamic aspects of social communication andsocial relationships that are targeted as highpriorities in the SCERTS Model, so that chil-dren are able to participate more success-fully in developmentally appropriate activi-ties with caregivers and peers in a variety ofcontexts.

In summary, the SCERTS Model offersa framework to directly address the corechallenges of ASD, focusing on building achild’s capacity to initiate communicationwith a conventional, symbolic system, andto develop self- and mutual-regulatory ca-pacities to regulate attention, arousal, andemotional state. The model provides indi-vidualized education/treatment based on achild’s strengths and weaknesses guided by re-search on the development of children withand without disabilities. It incorporates ed-ucational/treatment strategies derived from



evidence-based practice of contemporary be-havioral and developmental social-pragmaticapproaches. Transactional supports are iden-tified and implemented to support young chil-dren and their caregivers and to promote gen-eralization of acquired abilities. Progress ismeasured in functional activities with a vari-ety of partners in the SCERTS Model; thus,the broader context of a child’s developmentis recognized, including family involvement,

and the absolute necessity for supportingcommunication and socioemotional develop-ment in everyday activities and routines. Itis hoped that the SCERTS Model will pro-vide a vehicle to motivate professionals tofocus efforts on the core challenges facedby children with ASD and their caregivers,and to help to move the field to a new gen-eration of more integrated, comprehensiveprograms.

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