Developing Rapport and Sustaining Motivation in Autism Treatment: Session 325 with Alice...

Summary

The episode examines how rapport-building (“pairing”) can prepare children with autism for effective therapy and learning. Dr. Alice Shillingsburg emphasizes that rapport is more than having fun or being liked: therapeutic rapport means developing trust and motivation so a child is more willing to engage when instruction becomes challenging.

Why pairing matters

• People are often more willing to put effort into difficult tasks when they trust and feel positively toward the person guiding them.
• Therapy can involve tasks that are unfamiliar, effortful, or not immediately preferred. A positive relationship can help make those tasks more tolerable.
• Pairing helps therapists learn what a child prefers and gives the child ways to show interest, disengagement, or refusal.
• Pairing is one approach to building a relationship, not the only possible approach.

The nine-stage pairing and instructional-fading approach

Shillingsburg describes the protocol as a flexible set of guidelines, rather than a rigid script. The child’s behavior and readiness determine the pace.

Stages 1–3: Intensive pairing without instruction

• Create frequent positive interactions in a new or potentially unfamiliar setting.
• Make preferred activities and reinforcers available.
• Watch for approach and initiation behaviors, such as moving closer, reaching, pointing, looking toward an item, or standing beside an activity.
• Respond to these signals so the therapist becomes associated with access to enjoyable things.

Stages 4–9: Gradually introduce instruction

• Begin with easy, brief tasks, ideally skills the child has already mastered; use errorless prompting when needed.
• Increase the number and frequency of instructions gradually, rather than moving abruptly into intensive teaching.
• In clinical practice, also adjust task difficulty and duration. The published protocol discussed primarily faded the amount and sequence of instruction.
• Continue monitoring the child’s approach, engagement, and signs of discomfort. Advance only when the child appears ready; slow down or adjust if signs suggest the demands have become too difficult or aversive.

Across all stages: Follow the child’s signals

• Treat approach and initiation behaviors as useful information about what the child wants and whether they are willing to interact.
• Make room for the child to move away or decline an activity. Shillingsburg describes this as important for allowing the child to communicate refusal and for helping the therapist respond appropriately.
• The aim is not to force participation, but to build a history in which the therapist provides positive experiences and respects the child’s signals.

What effective pairing involves

• Pairing is not simply free access to toys, being nearby, or “just playing.” The therapist should actively connect their presence and interaction with access to preferred activities.
• Choose reinforcers that the therapist can deliver or make available without coercively blocking the child. Bubbles or Play-Doh tools are examples: the therapist can provide more as the child signals interest. A playground slide is less suitable if controlling access would require physically preventing the child from using it.
• Pairing is an operant process: the therapist reinforces approach, initiation, and interaction, helping make the therapist a valuable social partner and potentially a cue for positive activity.
• Shillingsburg notes that the procedure is not intended to continue indefinitely. In the study discussed, pairing took approximately 5–13 hours in total across participants, though the appropriate pace depends on the child and treatment schedule.

Monitoring progress in practice

Shillingsburg recommends collecting enough information to guide decisions without allowing measurement to interfere with therapy.

• In practice, engagement can be assessed in 10-minute intervals by recording how much time the child chooses to spend near or with the therapist.
• Approach and time spent with the therapist are important indicators of readiness and growing engagement.
• Also watch for signs of discomfort or avoidance, such as pushing materials away, self-injury, negative vocalizations, crying, or complaining.
• Simply getting up or moving around is not automatically treated as a problem; the child’s choice to leave and return can itself provide useful information.
• These measures help clinicians decide whether to continue pairing, introduce more instruction, or adjust what they are doing.

Addressing concerns that “the child is just playing”

Shillingsburg says caregivers’ concerns about time and progress are understandable. Clinicians should explain the rationale, what they are measuring, and how the approach supports treatment goals. Pairing can also serve meaningful clinical objectives, including:

• Increasing communication and social initiations, such as reaching, pointing, or requesting.
• Supporting participation and transitions into a work setting.
• Increasing the time a child chooses to remain engaged.
• Reducing escape or avoidance behavior by keeping demands manageable and responding to signs of distress.

If a procedure labeled “pairing” is only unrestricted access to activities, lacks active therapist-child interaction, or continues without measurement or progress, it may not include the elements intended to make pairing effective.

Maintaining rapport and limitations

• Rapport is not secured once and then left alone. Clinicians should continue considering the child’s motivation and avoid unintentionally making therapy aversive.
• As tasks become more demanding, the therapist should maintain a history of positive reinforcement and avoid forcing participation when a child resists or moves away.
• Shillingsburg reports that the approach has been durable in her clinical experience, but it is not effective in every case. She estimates that it has not been sufficient for roughly 15% of children she has worked with.
• Pairing may be more difficult when a child has very few effective reinforcers or can access equally reinforcing activities independently. If progress stalls or the procedure becomes aversive, clinicians should reassess and make adjustments.

Research directions

The discussion notes that pairing is a multi-part intervention, which can make its effects harder to isolate experimentally. Areas for further study include:

• Comparing different ways to fade instruction, including changes in task difficulty, duration, and preference—not only the number of instructions.
• Studying whether staff can be trained to implement pairing reliably.
• Tracking whether pairing increases gestures, especially pointing, as a form of communication.
• Examining how pairing affects attention to social partners and opportunities for incidental learning.

The episode also includes brief promotional material for the Verbal Behavior Conference, continuing-education offerings, and a school behavior conference.

Speakers and sources featured

Speakers heard

• Matt Cicoria — host of the Behavioral Observations podcast; his name is rendered inconsistently in the auto-generated subtitles.
• Dr. Alice Shillingsburg — guest and researcher on pairing and rapport-building procedures.
• Dr. Paul Gavoni — speaker in promotional material for the school behavior conference and Behavioral Toolbox.

Research and professional sources discussed

• Shillingsburg and colleagues’ 2014 work on pairing.
• Shillingsburg, Bethany Hanson, and Melinda Wright’s 2019 article on rapport-building and instructional fading before discrete-trial instruction.
• Tom Cariveau’s follow-up article in the Journal of Behavioral Education.
• The work of Vince Carbone and the Sundberg and Partington (1998) manual, cited as influences on the development of this line of work.