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Assessment of Techniques for Teaching School Children with Autism
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Original Article
Assessment of Techniques for Teaching School Children with Autism K. Adalarasu a , M. Jagannath b,∗ , O. James c a b c
School of Electrical and Electronics Engineering, SASTRA Deemed to be University, Thanjavur, Tamil Nadu, India School of Electronics Engineering, Vellore Institute of Technology (VIT) Chennai, Tamil Nadu 600127, India Center for Neuroscience Imaging Research, Institute for Basic Sciences, Sangkyunkwan University, South Korea
h i g h l i g h t s
g r a p h i c a l
a b s t r a c t
• Assessed communication and social interaction of autistic children.
• Horseback riding and yoga improves stereotyped behavior of autistic children.
• Cue cards are seemed to be an effective teaching strategy for autistic children.
a r t i c l e
i n f o
Article history: Received 19 March 2019 Received in revised form 15 September 2019 Accepted 10 October 2019 Available online xxxx Keywords: Autism disorder Stereotyped behavior Communication Social interaction Gilliam autism rating scale (GARS) Horseback riding Cue card teaching Yoga therapy
a b s t r a c t Background: In the modern era, researchers are facing a big challenge in diagnosing autism disorders. According to the Center for Disease Control and Prevention 2014 report, the prevalence of autism among children in the United States is approximately 1 out of 88 children; whereas, in South Korea, the prevalence is 1 out of 38. In India, most of the children with autism are yet to be diagnosed partly due to the lack of self-screening test compared to the other countries. Currently, no data is available for analyzing the prevalence of autism in India. In order to improve the behavior, the social interaction, and the verbal communication of these children, scientists are using various kinds of teaching methods. Objectives: The objectives of this work were to screen the level of autism among school children using Gilliam Autism Rating Scale (GARS-2) questionnaire and evaluate the effects of various teaching methods on social behavior of school children with autism. Methods and results: Ninety children in the age group between 3 – 16 years from three schools (S1 – 30, S2 – 30 and S3 – 30) with autism are participated in this study. In S1, the autistic children are trained with horseback riding and yoga therapy; whereas in the S2, the children are trained with normal teaching using blackboard and in the S3, the children are trained with cue cards. The GARS-2 questionnaire was used for assessing the communication, the stereotype behavior and the social interaction with the help of parents or the caregivers. Conclusion: Results of our study revealed that raw and the standard scores of stereotyped behaviors was notably (p<0.05) low in S1 school children when collated with the other two (S2 and S3) schools. Similarly, the raw and the standard score of communication, the socially interaction sub-score was notably (p<0.05) low for the children in S3 when collated with the children in the other two schools. The study concluded that the horseback riding, the yoga therapy and the cue cards-based teaching methods improve the stereotyped behavior, increase concentration power and also helps in maintaining the children’s mind stability. © 2019 AGBM. Published by Elsevier Masson SAS. All rights reserved.
1. Introduction
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Corresponding author. E-mail addresses: [email protected], [email protected] (M. Jagannath).
https://doi.org/10.1016/j.irbm.2019.10.003 1959-0318/© 2019 AGBM. Published by Elsevier Masson SAS. All rights reserved.
Autism Spectral Disorder (ASD) is a developing disorder that exhibits impairments in the physical, emotional, cognitive and social
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growth among children [1]. Autistic children have a tendency to develop neurological disorders due to highly developmental problems and disabilities starting at the early stages of birth to the age of three years [1]. Autism affects the intelligence and the general behavior of children. Children suffering from autism most commonly lack the ability to communicate verbally, the sense of awareness and to engage in social interactions. The autistic children cannot express their feelings and emotions and they do not have the ability to connect with their peers. Unlike in the normal children, the brain developments of the autistic children are damaged that can be diagnosed only in the later period of life. This may be too late for the intervention. The researchers in autism characterize the autistic people based on three main categories, namely, the repetitive and restrictive behavior, the social interaction impairment and the communication impairment [2]. In the United States, a survey conducted by the Center for Disease Control and Prevention discovered that almost 6% of total children has the problem of autism [3]. ASD is proved to be a booming field of study in child psychiatry. The medical professionals need awareness in autism for rapidly developing countries like India. An article in Times of India (2012) reported that there has been a six-time rise in ASD in India. The worldwide survey predicts that 1 out of the 68 children would be diagnosed with autism compared to the account of 1 in 150 few years ago. In ASD, the genetic information is more important. For example, identical twins are more prone to autism than siblings or fraternal twins. Similarly, a system of abnormality is much more frequent in families with autism and problems are frequent in ASD child. Those mothers who have taken drugs contain with serotonin have more chances of getting autism. The fluid level of amino acid of autistic children has many variations from normal children [4,5]. Other conditions may be due to diet, mercury poisoning, improper usage of vitamins, and minerals and finally, sensitivity towards vaccination. In recent years, people are more interested to know about the autism related information which increased the awareness rate of autism significantly. It is necessary to learn about the details of the diagnosed children that provide vital information to the clinician and the health professionals. Diagnosing the autism in the early childhood and referencing the right intervention may lead to long-life. Höfer et al. [6] conducted a survey that helps parents who are concerned with their autistic children. This survey is a pathway starting from the child’s behavior to the final diagnosis of autism. However, the early diagnosis is difficult because of their phenotype similarity with that of other children having some developmental disorders. The diagnostic stability may be less among large cohorts of toddlers who are as early as 12 months [7]. Now it is noticed and accepted widely that broadest way of treatment experimentally validated with autistic individuals that bring a change in behavior. The numerous diagnostics methods are based on the base level ideas related to emotional as well as the learning of the social behavior. Analyzing behavior type treatment derived from knowledge of experiment makes the scientists to understand the environmental rules that happen due to the environmental behavior. Using laws, the application can be developed to improve their behavior. When scientific principles are behind the improvement of the social behavior is called as applied behavior analysis and yielded positive results in the science. Screening tools play an important role in early diagnosis of autism and identify the risk of autism level (low, medium and severe). If the parent knows that their child has autism, the parent should learn about autism and able to make informed decisions for their child. If parents aware of the autism, they may prevent the cause or provide a better treatment. The autism screening tool is a theoretically derived and interactive measure. This tool can be used to discriminate the autism
from other developmental disorders. There are three major sections during the course of screening like play, imitation of motor movements, and nonverbal communication skills [8–10]. The Autism Diagnostic Observation Schedule – Generic (ADOS-G) is an observational calculation that has four criteria that include activities involved directly with the investigators to calculate related reciprocal social interaction, communication skills as well as behavior patterns [11–13]. 1.1. Tools for diagnosing autism The autism disorder can be assessed by evaluating comments from parents, observations and interactions with children, cognitive; adaptive behavior and clinical assessment. For selfassessment, Gilliam autism rating scale (GARS) [14,15] is used to identify and estimate the severity of symptoms with age group between 3 – 22 years. The Parent Interview for Autism (PIA) [16] is used to gather diagnostically relevant information from parents. The Childhood Autism Rating Scale (CARS) [17] is designed to identify the autism and developmental delays or mental retardation in young children. The measure uses the total score as well as the extent of relating, imitation, interactions among peers, imaginative play, understanding language and nonverbal method of communication. Sánchez-García et al. [18] conducted a meta-analysis that aimed to find out the most accurate screening tool for autism disorder. A Bayesian model was used to measure the accuracy of the various screening tools which concluded that Level-1 screening tools are most accurate in detecting autism as early as 14-36 months. Subramanyam et al. [19] framed some important guidelines for ASD diagnosis in clinical practice. The technologies that they had said were not framed anywhere though India has its own indigenous method of assessment. The symptoms related to autism are predicted by the Autism Diagnostic Interview-Revised (ADI-R) scale in the field of social relationship, communication and preservative behaviors [20,21]. It permits DSM-IV (APA, 1994) and ICD-10 [22,23] to impose exhaustive threshold scores to diagnose autistic disorder within the autistic span [24]. A questionnaire, the Pervasive Developmental Disorders Screening Test (PDDST), developed clinically for parents to assess ASD that has three stages. PDDST-Stage 1 includes Level 1 screening. PDDST-Stage 2 is developed for developmental disorders clinic and PDDST-Stage 3 is intended for use within an autism specialty clinic. 1.2. Techniques for teaching autistic children There are several technologies available for quantifying the autism. One of the most demanding applications is in autism related medical conditions and extensive developmental disorders. Children having autism has a tendency to process auditory information slower than visual information [25]. Visual supports like cue cards help build an array of actions that will intensify the understanding ability of school children. Cue Cards are visual cards in which words have been written on them that aims in building certain behaviors in the autistic children [26]. These visual cards help to reinforce an expected behavior in the autistic children. It helps to add more value to verbal guidance, increasing awareness by elucidate the information for the student. Scheduling of various activities is essential for the autistic children as it can be used to prompt the child too busy in certain independent activities such as drawings, stacking and so on [27]. The Picture Exchange Communication System (PECS) motivates the child to initiate the exchange of information during communication skills [28]. Autism children ability to communicate efficiently is developed using Voice Output Communication Aids (VOCAs) system. The VOCAs are a type of augmentative and alternative communication
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system which is self-contained, inexpensive electronic device [29]. This device encourages the use of hand expressions, word plays and verbal communication by the child. The ability to encourage conventional way of inter and intra personal interactions is one of the main benefits of this system. Thus, they socialize through vocal output [30]. The VOCAs consists of System for Augmented Language (SAL) which is an important element in promoting verbal communication in autism. In SAL, the autism children are instructed the way of using the symbols and help to augment their speech in normal communication [31,32]. Chown [33] have written a book entitled “Understanding and Evaluating Autism Theory”. He has adopted philosophies of ‘monotropism’ suggesting that attention, courtesy and inspiration can help differently abled children especially in autism. He provides a detailed correlation of all theoretical aspects and the Asperger syndrome of autism. This book serves as a complete guide for parents having autistic children straddling from conventional and substitute theories. Computer based teachings for autistic children may enhance their attention, proper behavior and cognitive-motor skills [3]. The modern computer technology-based teaching is widely accepted amongst the ASD individuals [34]. The children get to know more about emotions and expressions by the art of mind reading; it acts as an interactive guide to evaluate the child’s progress [35]. An efficient robot that looks like a cartoon character with a basic behavior can be used to indulge in activities for a child with any disorder. Social robots recognize and respond to human social actions with appropriate behaviors [36]. The goal of occupational therapy for autistic children is to improve their prosperity of life in both family and institution. When the research data from initial and intermediate phases are analyzed, there is a decrease in the frequency of slow behavioral activities are exhibited by four children and an increase in the frequency of steady activities are exhibited by three children. There is no significant improvement in the frequency of interaction [37]. Occupational therapy for autistic children includes day to day activities like bathing, eating, combining etc. For holding objects while handwriting or cutting with scissors, autistic children need fine motor skills. Gross motor skills are used for walking, climbing stairs, bicycle riding, balancing posture and other perceptual skills such as differentiating colors, objects and sizes [38]. Autistic children have significant issues with both verbal and nonverbal communication, because of which speech therapy plays a vital role in treating autistic children. Speech therapy techniques might include electronic “talkers”, signing or typing and enhancing clarity of speech by exercising lips or jaw muscles [39]. For autistic children, yoga therapy helps them to balance their healthy, socially integrated, and independent lives. Also, it improves focus attention, sensory information processing, communication, selfregulation, and motor control [40]. Music therapy is an effective form of nonverbal communication for autistic children. Music is used as a therapeutic tool for the autistic children for improving the restoration, psychological, mental and physiological health. It also helps in maintenance of behavioral, developmental, physical and social skills [41]. Horseback riding or therapeutic horseback riding is defined as riding horses by the children in the form of an exercise [42]. This method is used to recover the functionalities in children having physical and psychological disorders. The main aim of this method is to improve cognitive skills among the children in a therapeutic modality. For autistic children, horseback riding therapy is used to improve balancing and propulsive action [43]. Macauley and Guiterrez [44] examined the comparative analysis of animal-assisted therapy and conventional therapy. There is no substantial evidence in research which investigates the best suitable teaching methods for children with autism in Indian scenario. Hence this study aims to conduct research among
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various existing teaching methods and to draw a conclusion that which one is best suitable for training autistic children. In this study, the Indian autistic children’s data were collected since no paper produced the Indian data for the autistic children. The Indian data may vary in geographical and historical wise. This study was carried out with two objectives. Initially, the autism level of school children has been screened from three different schools using GARS-2 (second edition) questionnaire. Secondly, the techniques such as blackboard teaching, cue cards teaching, horseback riding and yoga therapy were assessed for teaching school children with autism. 2. Methods and materials 2.1. Participants summary In this study, ninety autistic children in the age group of 3–16 years were voluntarily participated. The children were selected from southern part of India. The participants were chosen from three different schools (labeled as S1, S2, and S3) and the teaching methods followed are different among the three schools. The school S1 (30) uses horseback riding and yoga therapy as educational model, whereas in the school S2 (30) uses normal teaching method using blackboard and the school S3 (30) uses cue cards as a teaching tool. The data were collected between 11:00 am to 2:30 pm. The experiment was performed in accordance with the guidelines of the Institution. All parents and caregivers were also informed and signed a consent form before the participation in this experiment. 2.2. GARS-2 questionnaire Gilliam Autism Rating Scale — Second Edition (GARS-2) was used to quantify the level of autism among the school children. The GARS-2 is available in English and Spanish from Pearson at www. pearsonassessments.com/HAIWEB/Cultures/en-us/Productdetail. htm?Pid=076-1602-321&Mode=summary. GARS II gives normalized scores and percentile grades. Patterned behaviors, verbal communication and social interaction are the three main divisions of GARS-2 [15]. Stereotyped behaviors consist of totally 14 questions that describe stereotyped behaviors, motility disorders, unique and atypical behavior such as avoid establishing eye contact, looking away when eye contact is made, whirls, turns in circles, makes high pitch sounds (for example, eee-eee-eee) and other vocalization of self-stimulation. In communication, sub-classes have totally 13 questions that describe verbal and non-verbal behaviors such as repeats words out of context, repeats babble over and over and use cues instead of vocal responses. Social interaction sub-scale consists of 13 questions that are used to assess the ability of the child to relate according to person, actions and gadgets. For example, they cannot replicate other actions when imitation is desirable like in games or some learning problems. They became tensed when regular activities are changed or their order is disturbed. 2.3. Experimental procedure The questions were asked to the parents/caregivers, in which they have to answer the questions in four different measures of frequency (Table 1). Parents/caregivers were asked to describe their children’s behavior and activities before the age of 3 years. The questionnaire consists of 25 questions; first 10 questions deal with delays and next 15 questions deal with abnormal functioning of autistic children. The score is generated based on the sub-scale standard scores (SS) and autism index is used to generate scores when compared with the raw score. Initially the raw scores (RS) for every
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Table 1 Rating scale for the criteria questionnaire administered for Parental – caregivers perceptions. Scale
Criteria
0 1 2 3
Not at all observed (you have not observed that individual behaving in this manner) Rarely observed (you have seen the individual behaving in this manner 1–2 times in a 6-hour period) Occasionally observed (you have seen the individual behaving in this manner 3–4 times in a 6-hour period) Frequently observed (you have seen the individual behaving in this manner 5–6 times in a 6-hour period)
Fig. 1. Mean and one standard error of raw score obtained for stereotyped behavior of autistic children from three different schools (S1 – horseback riding and yoga therapy, S2 – blackboard and the school, S3 – cue cards).
Fig. 3. Mean and one standard error of raw score obtained for communication of autistic children from three different schools (S1 – horseback riding and yoga therapy, S2 – blackboard and the school, S3 – cue cards).
Fig. 2. Mean and one standard error of standard score obtained for stereotyped behavior of autistic children from three different schools (S1 – horseback riding and yoga therapy, S2 – blackboard and the school, S3 – cue cards).
Fig. 4. Mean and one standard error of raw score obtained for communication of autistic children from three different schools (S1 – horseback riding and yoga therapy, S2 – blackboard and the school, S3 – cue cards).
item is summed up. After that, determine the percentile rank and conventional score for each and every sub-scale. If the sub-scale displays a standard score of 7 or higher, then the child has very high possibility of autism (a mean of 10 and a standard deviation of 3). If the sub-scale displays a standard score of 4–6, then the children have mild possibility of autism. If the sub-scale displays a standard score of 0–3, then the child is unlikely to have autism. The sum of all the sub-scale scores gives the autism index. 3. Results 3.1. Statistical test The SPSS 15 for windows is used for statistical analyses (SPSS Inc., Chicago, IL). The analysis of variance (ANOVA) test was performed on the raw and the standard scores (social interaction, communication and stereotype) and on independent variable for different autism school. The Tukey’s Honestly Significant Difference (HSD) test was used to perform Post-hoc analysis. The significant analysis level was set to be p<0.05. Raw score (p<0.05) and standard score (p<0.017) of stereotyped behavior was significantly less for the autistic children in school S1 as compared to the others schools S3 and S2. But there is no significant difference between the raw and standard score of stereotyped behavior (p=0.20) for the autistic children in the school S3 and S2 (Fig. 1 and Fig. 2).
Fig. 5. Mean and one standard error of raw score obtained for social interaction of autistic children from three different schools (S1 – horseback riding and yoga therapy, S2 – blackboard and the school, S3 – cue cards).
For communication, the raw score (p<0.045) and the standard score (p<0.05) was significantly less for the autistic children in school S3 compared to the others school S1 and S2. There is no significant difference between the raw and standard score of stereotyped behavior for the autistic children in the school S1 and S2 (Fig. 3 and Fig. 4). From the inference of Fig. 5 and Fig. 6, the raw score and standard score of social interaction seem significantly different for the three autism schools. The S3 school children have significantly (p<0.05) low socially interaction score when compared to S1 and
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Fig. 6. Mean and one standard error of raw score obtained for social interaction of autistic children from three different schools (S1 – horseback riding and yoga therapy, S2 – blackboard and the school, S3 – cue cards).
S2 school. But the raw score of social interaction is high for autistic children in the school S2 compared to other schools and the standard score of social interaction is high for autistic children in the school S1 compared to other schools. 4. Discussion Substantial research in the autism field has been directed in the past years, revealing the enormous concentration in studying various techniques for teaching autism children as a therapeutic modality and its possible paybacks for children with ASD. Maximum outcomes show promising results of horseback riding, cue card training and yoga therapy for the ASD population, though; the studies speckled significantly in their sample design, involvement structure, and besieged results [42]. Therefore, the purpose of this study was to discover the best suitable existing method that helps in improving cognitive skills among ASD children. This study collected Indian autistic children’s data and to analyze which type of teaching plays a vital role in social functioning of autism disorder for the children with age group between 3–16 years using GARS-2 self-assessment questionnaire. Children with autism have difficulty in realizing the emotions of people surrounding them. They show difficulty in communicating their own concerns and affections to others [5]. Several results related to stress from the physiological changes can be measured invasively [45]. The children are screen resultant for possible autism, or the high level of worry about autism with the family or clinician recommendation for additional evaluation must do. The diagnosis for this disorder will be the experience and ability of the clinician’s practice to identify the characteristic of the autistic children details history taking from the parent; instruments used for assessment and direct observation. It is imperative to compare the social interaction and the communication skills for the autistic children to their chronological age, not their developmental age factors. The cognitive estimates can also be part of assist in distinguishing the various factors in autistic children. The results of cognitive estimations in a young child or nonverbal child might interpret with attention with the predictive weight is low. The psychological estimation also incorporated measures to estimate the autistic children social stimuli, emotional status, and behavior function. When the autistic children are prone to have impairments in social environment; and they can also present with emotional impairments. The study results suggest that horseback riding and yoga therapy might be the very effective for children with autism. Its shows that social stimulus and sensory sensitivity are improved, inattentiveness and distractibility are reduced by providing the horseback riding. Children with autism exposed to horseback riding demonstrated with better sensory, social motivation, sensory sympathy, not as much of sedentary behaviors. These results provide a clear
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indication that horseback riding may be viable and suitable treatment options for autistic children [42]. More specifically, compared other teaching methods such as cue cards and blackboard teaching method; Cue cards teaching method has provided well-stereotyped behavior compared to another teaching method. Visual cues will help to enhance the verbal instruction and will give clear information for the autistic children will produce the better result as well as increased understanding [25]. The social interaction is high when the normal blackboard teaching method is applied. In this study, the three different teaching methods were compared and identified which teaching method is best and efficient for the autistic children. Many studies have been carried out by applying specific teaching method for the autistic children in different parts of the world and in [43]. They collected the autistic children’s data from Florida (United States) and applied different teaching methods for the autistic children in data and explained the horseback ride one of the effective methods. 5. Conclusions Our study evidently goes into detail the lack of teaching methods amongst teachers who are working with autistic children. Authors suggested that proper training and awareness programs should conduct for teachers in diagnosing autism in children and then determine different teaching methods which are apt to each child. Teacher well-being is an important factor while considering autism and autistic children. The quality of training received by these children is strongly linked to teacher welfare. This study ended that cognitive behavioral methods can be improved by using horseback riding, therapy with yoga and cue cards. These methods help in increasing behavioral patterns and concentration power and to maintain autistic children mind stability. Human and animal rights Not applicable. Informed consent and patient details The authors declare that this report does not contain any personal information that could lead to the identification of the patient(s). Disclosure of interest The authors declare that they have no known competing financial or personal relationships that could be viewed as influencing the work reported in this paper. Funding This work did not receive any grant from funding agencies in the public, commercial, or not-for-profit sectors. Author contributions All authors attest that they meet the current International Committee of Medical Journal Editors (ICMJE) criteria for Authorship. Declaration of competing interest The authors declare that they have no conflict of interest.
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CRediT authorship contribution statement K. Adalarasu: Investigation, Methodology, Visualization, Writing - original draft. M. Jagannath: Conceptualization, Resources, Supervision, Visualization, Writing - review & editing. O. James: Investigation, Visualization, Writing - review & editing. Acknowledgements Authors would like to thank Dr. K. Sasikumar, Associate Professor, School of Electronics Engineering, Vellore Institute of Technology (VIT) Vellore and his team for participant identification for this research study. References [1] Fitzgerald M. In: Hollander E, Kolevzon A, Coyle J, editors. Textbook of autism spectrum disorders. Washington DC: American Psychiatric Press; 2011. [2] Geretsegger M, Holck U, Gold C. Randomised controlled trial of improvisational music therapy’s effectiveness for children with autism spectrum disorders (TIME-A): study protocol. BMC Pediatr 2012;12(1):1–9. [3] Jordan R, Powell S. Understanding and teaching children with autism. Chichester: Wiley; 1995. [4] Baio J. Prevalence of autism spectrum disorders: autism and developmental disabilities monitoring network, centers for disease control and prevention, United States. Morb Mortal Wkly Rep, Surveill Summ 2008;61(3):1–19. [5] Zhang TN, Gao SY, Shen ZQ, Li D, Liu CX, Lv HC, et al. Use of selective serotoninreuptake inhibitors in the first trimester and risk of cardiovascular-related malformations: a meta-analysis of cohort studies. Sci Rep 2017;7:43085. [6] Höfer J, Hoffmann F, Kamp-Becker I, Poustka L, Roessner V, Stroth S, et al. Pathways to a diagnosis of autism spectrum disorder in Germany: a survey of parents. J Child Psychol Psychiatry 2019;13(16):1–10. [7] Pierce K, Gazestani VH, Bacon E, Barnes CC, Cha D, Nalabolu S, et al. Evaluation of the diagnostic stability of the early autism spectrum disorder phenotype in the general population starting at 12 months. JAMA Pediatr 2019;173(6):578–87. [8] Zheng HF, Wang WQ, Li XM, Rauw G, Baker GB. Body fluid levels of neuroactive amino acids in autism spectrum disorders: a review of the literature. Amino Acids 2017;49(1):57–65. [9] Stone WL. Descriptive information about the screening tool for autism in twoyear-olds (STAT). In: Working conference in National Institutes of Health state of the science in autism screening and diagnosis; 1998. p. 15–7. [10] Stone WL, Hogan KL. A structured parent interview for identifying young children with autism. J Autism Dev Disord 1993;23(4):639–52. [11] Khakzanda M, Aghabozorgi K. Achievement to environmenta components of educational spaces for Iranian trainable children with intellectual disability. Proc, Soc Behav Sci 2015;201:9–18. [12] DiLavore PC, Lord C, Rutter M. The pre-linguistic autism diagnostic observation schedule. J Autism Dev Disord 1995;25(4):355–79. [13] Lord C, Rutter M, Goode S, Heemsbergen J, Jordan H, Mawhood L, et al. Autism diagnostic observation schedule: a standardized observation of communicative and social behaviour. J Autism Dev Disord 1989;19(2):185–212. [14] Lord C, Risi S, Lambrecht L, Cook Jr EH, Leventhal BL, DiLavore PC, et al. The autism diagnostic observation schedule—generic: a standard measure of social and communication deficits associated with the spectrum of autism. J Autism Dev Disord 2000;30(3):205–23. [15] Gilliam JE. GARS-2: Gilliam autism rating scale. 2nd ed. Austin Pro-ed; 2006. [16] Gilliam JE. Gilliam autism rating scale: examiner’s manual. Pro-ed; 1995. [17] World Health Organization: the ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. Geneva: World Health Organization; 1992. [18] Sánchez-García AB, Galindo-Villardon P, Nieto-Librero AB, Martin-Rodero H, Robins DL. Toddler screening accuracy for autism spectrum disorder: a metaanalysis of diagnostic accuracy. J Autism Dev Disord 2019;49(5):1837–52. [19] Subramanyam AA, Mukherjee AA, Dave M, Chavda K. Clinical practice guidelines for autism spectrum disorders. Indian J Psychiatry 2019;61(Suppl S2):254–69.
[20] Schopler E, Reichler RJ, DeVellis RF, Daly K. Toward objective classification of childhood autism: childhood autism rating scale (CARS). J Autism Dev Disord 1980;10(1):91–103. [21] Lord C, Pickles A, McLennan J, Rutter M, Bregman J, Folstein S, et al. Diagnosing autism: analyses of data from the autism diagnostic interview. J Autism Dev Disord 1997;27(5):501–17. [22] Lord C, Rutter M, Le Couteur A. Autism diagnostic interview-revised: a revised version of a diagnostic interview for caregivers of individuals with possible pervasive developmental disorders. J Autism Dev Disord 1994;24(5):659–85. [23] World Health Organization: the ICD-10 classification of mental and behavioral disorders: diagnostic criteria for research. Geneva, Switzerland: World Health Organization; 1993. [24] Paulraj SJPV, Karim RA, Vetrayan J. Evaluation of occupational performance imitation intervention on three imitation learnings among autism: case series. Proc, Soc Behav Sci 2015;202:58–66. [25] Siegel B. Early screening and diagnosis in autism spectrum disorders: the pervasive developmental disorders screening test (PDDST). In: Proceedings of the NIH state of the science in autism: screening and diagnosis working conference; 1998. p. 15–7. [26] Pierce KL, Schreibman L. Teaching daily living skills to children with autism in unsupervised settings through pictorial self-management. J Appl Behav Anal 1994;27(3):471. [27] Quill KA. Visually cued instruction for children with autism and pervasive developmental disorders. Focus Autism Other Dev Disabl 1995;10(3):10–20. [28] McClannahan LE, Krantz PJ. Activity schedules for children with autism. 2nd ed. Bethesda, Maryland: Woodbine House; 1999. [29] Bondy A, Frost L. The picture exchange communication system. Behav Modif 2001;25(5):725–44. [30] Beukelman D, Mirenda P. Augmentative and alternative communication processes: supporting children and adults with complex communication needs. 4th ed. Baltimore: Maryland; 2012. [31] Schepis MM, Reid DH, Behrmann MM, Sutton KA. Increasing communicative interactions of young children with autism using a voice output communication aid and naturalistic teaching. J Appl Behav Anal 1998;31(4):561. [32] Shaw CA, Sheth S, Li D, Tomljenovic L. Etiology of autism spectrum disorders: genes, environment, or both? OA Autism 2014;2(2):11. [33] Chown N. Understanding and evaluating autism theory. London: Jessica Kingsley; 2016. [34] Romski MA, Sevcik RA. Breaking the speech barrier. Baltimore: Paul H. Brookes; 1996. [35] Moore D, McGrath P, Thorpe J. Computer-aided learning for people with autism—a framework for research and development. Innov Educ Teach Int 2000;37(3):218–28. [36] Junek W. Mind reading: the interactive guide to emotions. J Can Acad Child Adolesc Psychiatry 2007;16(4):182–3. [37] Kozima H, Nakagawa C, Yasuda Y. Interactive robots for communication-care: a case-study in autism therapy. In: IEEE international workshop on in robot and human interactive communication; 2005. p. 341–6. [38] Case-Smith J, O’Brien JC. Occupational therapy for children. 6th ed. US: Elsevier Health Sciences; 2013. [39] Schreibman L, Stahmer AC. A randomized trial comparison of the effects of verbal and pictorial naturalistic communication strategies on spoken language for young children with autism. J Autism Dev Disord 2014;44(5):1244–51. [40] Ehleringer J. Yoga for children on the autism spectrum. Int J Yoga Therap 2010;20(1):131–9. [41] Boxill EH, Chase KM. Music therapy for developmental disabilities. 2nd ed. Pro ed; 2007. [42] All AC, Loving GL, Crane LL. Animals horseback riding, and implications for rehabilitation therapy. J Rehabil Res Dev 1999;65(3):49–53. [43] Bass MM, Duchowny CA, Llabre MM. The effect of therapeutic horseback riding on social functioning in children with autism. J Autism Dev Disord 2009;39(9):1261–7. [44] Macauley BL, Gutierrez KM. The effectiveness of hippo therapy for children with language-learning disabilities. Commun Disord Q 2004;25(4):205–17. [45] Kushki A, Drumm E, Mobarak MP, Tanel N, Dupuis A, Chau T, et al. Investigating the autonomic nervous system response to anxiety in children with autism spectrum disorders. PLoS ONE 2013;8(4):1–8.
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Original Article
Assessment of Techniques for Teaching School Children with Autism K. Adalarasu a , M. Jagannath b,∗ , O. James c a b c
School of Electrical and Electronics Engineering, SASTRA Deemed to be University, Thanjavur, Tamil Nadu, India School of Electronics Engineering, Vellore Institute of Technology (VIT) Chennai, Tamil Nadu 600127, India Center for Neuroscience Imaging Research, Institute for Basic Sciences, Sangkyunkwan University, South Korea
h i g h l i g h t s
g r a p h i c a l
a b s t r a c t
• Assessed communication and social interaction of autistic children.
• Horseback riding and yoga improves stereotyped behavior of autistic children.
• Cue cards are seemed to be an effective teaching strategy for autistic children.
a r t i c l e
i n f o
Article history: Received 19 March 2019 Received in revised form 15 September 2019 Accepted 10 October 2019 Available online xxxx Keywords: Autism disorder Stereotyped behavior Communication Social interaction Gilliam autism rating scale (GARS) Horseback riding Cue card teaching Yoga therapy
a b s t r a c t Background: In the modern era, researchers are facing a big challenge in diagnosing autism disorders. According to the Center for Disease Control and Prevention 2014 report, the prevalence of autism among children in the United States is approximately 1 out of 88 children; whereas, in South Korea, the prevalence is 1 out of 38. In India, most of the children with autism are yet to be diagnosed partly due to the lack of self-screening test compared to the other countries. Currently, no data is available for analyzing the prevalence of autism in India. In order to improve the behavior, the social interaction, and the verbal communication of these children, scientists are using various kinds of teaching methods. Objectives: The objectives of this work were to screen the level of autism among school children using Gilliam Autism Rating Scale (GARS-2) questionnaire and evaluate the effects of various teaching methods on social behavior of school children with autism. Methods and results: Ninety children in the age group between 3 – 16 years from three schools (S1 – 30, S2 – 30 and S3 – 30) with autism are participated in this study. In S1, the autistic children are trained with horseback riding and yoga therapy; whereas in the S2, the children are trained with normal teaching using blackboard and in the S3, the children are trained with cue cards. The GARS-2 questionnaire was used for assessing the communication, the stereotype behavior and the social interaction with the help of parents or the caregivers. Conclusion: Results of our study revealed that raw and the standard scores of stereotyped behaviors was notably (p<0.05) low in S1 school children when collated with the other two (S2 and S3) schools. Similarly, the raw and the standard score of communication, the socially interaction sub-score was notably (p<0.05) low for the children in S3 when collated with the children in the other two schools. The study concluded that the horseback riding, the yoga therapy and the cue cards-based teaching methods improve the stereotyped behavior, increase concentration power and also helps in maintaining the children’s mind stability. © 2019 AGBM. Published by Elsevier Masson SAS. All rights reserved.
1. Introduction
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Corresponding author. E-mail addresses: [email protected], [email protected] (M. Jagannath).
https://doi.org/10.1016/j.irbm.2019.10.003 1959-0318/© 2019 AGBM. Published by Elsevier Masson SAS. All rights reserved.
Autism Spectral Disorder (ASD) is a developing disorder that exhibits impairments in the physical, emotional, cognitive and social
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growth among children [1]. Autistic children have a tendency to develop neurological disorders due to highly developmental problems and disabilities starting at the early stages of birth to the age of three years [1]. Autism affects the intelligence and the general behavior of children. Children suffering from autism most commonly lack the ability to communicate verbally, the sense of awareness and to engage in social interactions. The autistic children cannot express their feelings and emotions and they do not have the ability to connect with their peers. Unlike in the normal children, the brain developments of the autistic children are damaged that can be diagnosed only in the later period of life. This may be too late for the intervention. The researchers in autism characterize the autistic people based on three main categories, namely, the repetitive and restrictive behavior, the social interaction impairment and the communication impairment [2]. In the United States, a survey conducted by the Center for Disease Control and Prevention discovered that almost 6% of total children has the problem of autism [3]. ASD is proved to be a booming field of study in child psychiatry. The medical professionals need awareness in autism for rapidly developing countries like India. An article in Times of India (2012) reported that there has been a six-time rise in ASD in India. The worldwide survey predicts that 1 out of the 68 children would be diagnosed with autism compared to the account of 1 in 150 few years ago. In ASD, the genetic information is more important. For example, identical twins are more prone to autism than siblings or fraternal twins. Similarly, a system of abnormality is much more frequent in families with autism and problems are frequent in ASD child. Those mothers who have taken drugs contain with serotonin have more chances of getting autism. The fluid level of amino acid of autistic children has many variations from normal children [4,5]. Other conditions may be due to diet, mercury poisoning, improper usage of vitamins, and minerals and finally, sensitivity towards vaccination. In recent years, people are more interested to know about the autism related information which increased the awareness rate of autism significantly. It is necessary to learn about the details of the diagnosed children that provide vital information to the clinician and the health professionals. Diagnosing the autism in the early childhood and referencing the right intervention may lead to long-life. Höfer et al. [6] conducted a survey that helps parents who are concerned with their autistic children. This survey is a pathway starting from the child’s behavior to the final diagnosis of autism. However, the early diagnosis is difficult because of their phenotype similarity with that of other children having some developmental disorders. The diagnostic stability may be less among large cohorts of toddlers who are as early as 12 months [7]. Now it is noticed and accepted widely that broadest way of treatment experimentally validated with autistic individuals that bring a change in behavior. The numerous diagnostics methods are based on the base level ideas related to emotional as well as the learning of the social behavior. Analyzing behavior type treatment derived from knowledge of experiment makes the scientists to understand the environmental rules that happen due to the environmental behavior. Using laws, the application can be developed to improve their behavior. When scientific principles are behind the improvement of the social behavior is called as applied behavior analysis and yielded positive results in the science. Screening tools play an important role in early diagnosis of autism and identify the risk of autism level (low, medium and severe). If the parent knows that their child has autism, the parent should learn about autism and able to make informed decisions for their child. If parents aware of the autism, they may prevent the cause or provide a better treatment. The autism screening tool is a theoretically derived and interactive measure. This tool can be used to discriminate the autism
from other developmental disorders. There are three major sections during the course of screening like play, imitation of motor movements, and nonverbal communication skills [8–10]. The Autism Diagnostic Observation Schedule – Generic (ADOS-G) is an observational calculation that has four criteria that include activities involved directly with the investigators to calculate related reciprocal social interaction, communication skills as well as behavior patterns [11–13]. 1.1. Tools for diagnosing autism The autism disorder can be assessed by evaluating comments from parents, observations and interactions with children, cognitive; adaptive behavior and clinical assessment. For selfassessment, Gilliam autism rating scale (GARS) [14,15] is used to identify and estimate the severity of symptoms with age group between 3 – 22 years. The Parent Interview for Autism (PIA) [16] is used to gather diagnostically relevant information from parents. The Childhood Autism Rating Scale (CARS) [17] is designed to identify the autism and developmental delays or mental retardation in young children. The measure uses the total score as well as the extent of relating, imitation, interactions among peers, imaginative play, understanding language and nonverbal method of communication. Sánchez-García et al. [18] conducted a meta-analysis that aimed to find out the most accurate screening tool for autism disorder. A Bayesian model was used to measure the accuracy of the various screening tools which concluded that Level-1 screening tools are most accurate in detecting autism as early as 14-36 months. Subramanyam et al. [19] framed some important guidelines for ASD diagnosis in clinical practice. The technologies that they had said were not framed anywhere though India has its own indigenous method of assessment. The symptoms related to autism are predicted by the Autism Diagnostic Interview-Revised (ADI-R) scale in the field of social relationship, communication and preservative behaviors [20,21]. It permits DSM-IV (APA, 1994) and ICD-10 [22,23] to impose exhaustive threshold scores to diagnose autistic disorder within the autistic span [24]. A questionnaire, the Pervasive Developmental Disorders Screening Test (PDDST), developed clinically for parents to assess ASD that has three stages. PDDST-Stage 1 includes Level 1 screening. PDDST-Stage 2 is developed for developmental disorders clinic and PDDST-Stage 3 is intended for use within an autism specialty clinic. 1.2. Techniques for teaching autistic children There are several technologies available for quantifying the autism. One of the most demanding applications is in autism related medical conditions and extensive developmental disorders. Children having autism has a tendency to process auditory information slower than visual information [25]. Visual supports like cue cards help build an array of actions that will intensify the understanding ability of school children. Cue Cards are visual cards in which words have been written on them that aims in building certain behaviors in the autistic children [26]. These visual cards help to reinforce an expected behavior in the autistic children. It helps to add more value to verbal guidance, increasing awareness by elucidate the information for the student. Scheduling of various activities is essential for the autistic children as it can be used to prompt the child too busy in certain independent activities such as drawings, stacking and so on [27]. The Picture Exchange Communication System (PECS) motivates the child to initiate the exchange of information during communication skills [28]. Autism children ability to communicate efficiently is developed using Voice Output Communication Aids (VOCAs) system. The VOCAs are a type of augmentative and alternative communication
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system which is self-contained, inexpensive electronic device [29]. This device encourages the use of hand expressions, word plays and verbal communication by the child. The ability to encourage conventional way of inter and intra personal interactions is one of the main benefits of this system. Thus, they socialize through vocal output [30]. The VOCAs consists of System for Augmented Language (SAL) which is an important element in promoting verbal communication in autism. In SAL, the autism children are instructed the way of using the symbols and help to augment their speech in normal communication [31,32]. Chown [33] have written a book entitled “Understanding and Evaluating Autism Theory”. He has adopted philosophies of ‘monotropism’ suggesting that attention, courtesy and inspiration can help differently abled children especially in autism. He provides a detailed correlation of all theoretical aspects and the Asperger syndrome of autism. This book serves as a complete guide for parents having autistic children straddling from conventional and substitute theories. Computer based teachings for autistic children may enhance their attention, proper behavior and cognitive-motor skills [3]. The modern computer technology-based teaching is widely accepted amongst the ASD individuals [34]. The children get to know more about emotions and expressions by the art of mind reading; it acts as an interactive guide to evaluate the child’s progress [35]. An efficient robot that looks like a cartoon character with a basic behavior can be used to indulge in activities for a child with any disorder. Social robots recognize and respond to human social actions with appropriate behaviors [36]. The goal of occupational therapy for autistic children is to improve their prosperity of life in both family and institution. When the research data from initial and intermediate phases are analyzed, there is a decrease in the frequency of slow behavioral activities are exhibited by four children and an increase in the frequency of steady activities are exhibited by three children. There is no significant improvement in the frequency of interaction [37]. Occupational therapy for autistic children includes day to day activities like bathing, eating, combining etc. For holding objects while handwriting or cutting with scissors, autistic children need fine motor skills. Gross motor skills are used for walking, climbing stairs, bicycle riding, balancing posture and other perceptual skills such as differentiating colors, objects and sizes [38]. Autistic children have significant issues with both verbal and nonverbal communication, because of which speech therapy plays a vital role in treating autistic children. Speech therapy techniques might include electronic “talkers”, signing or typing and enhancing clarity of speech by exercising lips or jaw muscles [39]. For autistic children, yoga therapy helps them to balance their healthy, socially integrated, and independent lives. Also, it improves focus attention, sensory information processing, communication, selfregulation, and motor control [40]. Music therapy is an effective form of nonverbal communication for autistic children. Music is used as a therapeutic tool for the autistic children for improving the restoration, psychological, mental and physiological health. It also helps in maintenance of behavioral, developmental, physical and social skills [41]. Horseback riding or therapeutic horseback riding is defined as riding horses by the children in the form of an exercise [42]. This method is used to recover the functionalities in children having physical and psychological disorders. The main aim of this method is to improve cognitive skills among the children in a therapeutic modality. For autistic children, horseback riding therapy is used to improve balancing and propulsive action [43]. Macauley and Guiterrez [44] examined the comparative analysis of animal-assisted therapy and conventional therapy. There is no substantial evidence in research which investigates the best suitable teaching methods for children with autism in Indian scenario. Hence this study aims to conduct research among
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various existing teaching methods and to draw a conclusion that which one is best suitable for training autistic children. In this study, the Indian autistic children’s data were collected since no paper produced the Indian data for the autistic children. The Indian data may vary in geographical and historical wise. This study was carried out with two objectives. Initially, the autism level of school children has been screened from three different schools using GARS-2 (second edition) questionnaire. Secondly, the techniques such as blackboard teaching, cue cards teaching, horseback riding and yoga therapy were assessed for teaching school children with autism. 2. Methods and materials 2.1. Participants summary In this study, ninety autistic children in the age group of 3–16 years were voluntarily participated. The children were selected from southern part of India. The participants were chosen from three different schools (labeled as S1, S2, and S3) and the teaching methods followed are different among the three schools. The school S1 (30) uses horseback riding and yoga therapy as educational model, whereas in the school S2 (30) uses normal teaching method using blackboard and the school S3 (30) uses cue cards as a teaching tool. The data were collected between 11:00 am to 2:30 pm. The experiment was performed in accordance with the guidelines of the Institution. All parents and caregivers were also informed and signed a consent form before the participation in this experiment. 2.2. GARS-2 questionnaire Gilliam Autism Rating Scale — Second Edition (GARS-2) was used to quantify the level of autism among the school children. The GARS-2 is available in English and Spanish from Pearson at www. pearsonassessments.com/HAIWEB/Cultures/en-us/Productdetail. htm?Pid=076-1602-321&Mode=summary. GARS II gives normalized scores and percentile grades. Patterned behaviors, verbal communication and social interaction are the three main divisions of GARS-2 [15]. Stereotyped behaviors consist of totally 14 questions that describe stereotyped behaviors, motility disorders, unique and atypical behavior such as avoid establishing eye contact, looking away when eye contact is made, whirls, turns in circles, makes high pitch sounds (for example, eee-eee-eee) and other vocalization of self-stimulation. In communication, sub-classes have totally 13 questions that describe verbal and non-verbal behaviors such as repeats words out of context, repeats babble over and over and use cues instead of vocal responses. Social interaction sub-scale consists of 13 questions that are used to assess the ability of the child to relate according to person, actions and gadgets. For example, they cannot replicate other actions when imitation is desirable like in games or some learning problems. They became tensed when regular activities are changed or their order is disturbed. 2.3. Experimental procedure The questions were asked to the parents/caregivers, in which they have to answer the questions in four different measures of frequency (Table 1). Parents/caregivers were asked to describe their children’s behavior and activities before the age of 3 years. The questionnaire consists of 25 questions; first 10 questions deal with delays and next 15 questions deal with abnormal functioning of autistic children. The score is generated based on the sub-scale standard scores (SS) and autism index is used to generate scores when compared with the raw score. Initially the raw scores (RS) for every
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Table 1 Rating scale for the criteria questionnaire administered for Parental – caregivers perceptions. Scale
Criteria
0 1 2 3
Not at all observed (you have not observed that individual behaving in this manner) Rarely observed (you have seen the individual behaving in this manner 1–2 times in a 6-hour period) Occasionally observed (you have seen the individual behaving in this manner 3–4 times in a 6-hour period) Frequently observed (you have seen the individual behaving in this manner 5–6 times in a 6-hour period)
Fig. 1. Mean and one standard error of raw score obtained for stereotyped behavior of autistic children from three different schools (S1 – horseback riding and yoga therapy, S2 – blackboard and the school, S3 – cue cards).
Fig. 3. Mean and one standard error of raw score obtained for communication of autistic children from three different schools (S1 – horseback riding and yoga therapy, S2 – blackboard and the school, S3 – cue cards).
Fig. 2. Mean and one standard error of standard score obtained for stereotyped behavior of autistic children from three different schools (S1 – horseback riding and yoga therapy, S2 – blackboard and the school, S3 – cue cards).
Fig. 4. Mean and one standard error of raw score obtained for communication of autistic children from three different schools (S1 – horseback riding and yoga therapy, S2 – blackboard and the school, S3 – cue cards).
item is summed up. After that, determine the percentile rank and conventional score for each and every sub-scale. If the sub-scale displays a standard score of 7 or higher, then the child has very high possibility of autism (a mean of 10 and a standard deviation of 3). If the sub-scale displays a standard score of 4–6, then the children have mild possibility of autism. If the sub-scale displays a standard score of 0–3, then the child is unlikely to have autism. The sum of all the sub-scale scores gives the autism index. 3. Results 3.1. Statistical test The SPSS 15 for windows is used for statistical analyses (SPSS Inc., Chicago, IL). The analysis of variance (ANOVA) test was performed on the raw and the standard scores (social interaction, communication and stereotype) and on independent variable for different autism school. The Tukey’s Honestly Significant Difference (HSD) test was used to perform Post-hoc analysis. The significant analysis level was set to be p<0.05. Raw score (p<0.05) and standard score (p<0.017) of stereotyped behavior was significantly less for the autistic children in school S1 as compared to the others schools S3 and S2. But there is no significant difference between the raw and standard score of stereotyped behavior (p=0.20) for the autistic children in the school S3 and S2 (Fig. 1 and Fig. 2).
Fig. 5. Mean and one standard error of raw score obtained for social interaction of autistic children from three different schools (S1 – horseback riding and yoga therapy, S2 – blackboard and the school, S3 – cue cards).
For communication, the raw score (p<0.045) and the standard score (p<0.05) was significantly less for the autistic children in school S3 compared to the others school S1 and S2. There is no significant difference between the raw and standard score of stereotyped behavior for the autistic children in the school S1 and S2 (Fig. 3 and Fig. 4). From the inference of Fig. 5 and Fig. 6, the raw score and standard score of social interaction seem significantly different for the three autism schools. The S3 school children have significantly (p<0.05) low socially interaction score when compared to S1 and
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Fig. 6. Mean and one standard error of raw score obtained for social interaction of autistic children from three different schools (S1 – horseback riding and yoga therapy, S2 – blackboard and the school, S3 – cue cards).
S2 school. But the raw score of social interaction is high for autistic children in the school S2 compared to other schools and the standard score of social interaction is high for autistic children in the school S1 compared to other schools. 4. Discussion Substantial research in the autism field has been directed in the past years, revealing the enormous concentration in studying various techniques for teaching autism children as a therapeutic modality and its possible paybacks for children with ASD. Maximum outcomes show promising results of horseback riding, cue card training and yoga therapy for the ASD population, though; the studies speckled significantly in their sample design, involvement structure, and besieged results [42]. Therefore, the purpose of this study was to discover the best suitable existing method that helps in improving cognitive skills among ASD children. This study collected Indian autistic children’s data and to analyze which type of teaching plays a vital role in social functioning of autism disorder for the children with age group between 3–16 years using GARS-2 self-assessment questionnaire. Children with autism have difficulty in realizing the emotions of people surrounding them. They show difficulty in communicating their own concerns and affections to others [5]. Several results related to stress from the physiological changes can be measured invasively [45]. The children are screen resultant for possible autism, or the high level of worry about autism with the family or clinician recommendation for additional evaluation must do. The diagnosis for this disorder will be the experience and ability of the clinician’s practice to identify the characteristic of the autistic children details history taking from the parent; instruments used for assessment and direct observation. It is imperative to compare the social interaction and the communication skills for the autistic children to their chronological age, not their developmental age factors. The cognitive estimates can also be part of assist in distinguishing the various factors in autistic children. The results of cognitive estimations in a young child or nonverbal child might interpret with attention with the predictive weight is low. The psychological estimation also incorporated measures to estimate the autistic children social stimuli, emotional status, and behavior function. When the autistic children are prone to have impairments in social environment; and they can also present with emotional impairments. The study results suggest that horseback riding and yoga therapy might be the very effective for children with autism. Its shows that social stimulus and sensory sensitivity are improved, inattentiveness and distractibility are reduced by providing the horseback riding. Children with autism exposed to horseback riding demonstrated with better sensory, social motivation, sensory sympathy, not as much of sedentary behaviors. These results provide a clear
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indication that horseback riding may be viable and suitable treatment options for autistic children [42]. More specifically, compared other teaching methods such as cue cards and blackboard teaching method; Cue cards teaching method has provided well-stereotyped behavior compared to another teaching method. Visual cues will help to enhance the verbal instruction and will give clear information for the autistic children will produce the better result as well as increased understanding [25]. The social interaction is high when the normal blackboard teaching method is applied. In this study, the three different teaching methods were compared and identified which teaching method is best and efficient for the autistic children. Many studies have been carried out by applying specific teaching method for the autistic children in different parts of the world and in [43]. They collected the autistic children’s data from Florida (United States) and applied different teaching methods for the autistic children in data and explained the horseback ride one of the effective methods. 5. Conclusions Our study evidently goes into detail the lack of teaching methods amongst teachers who are working with autistic children. Authors suggested that proper training and awareness programs should conduct for teachers in diagnosing autism in children and then determine different teaching methods which are apt to each child. Teacher well-being is an important factor while considering autism and autistic children. The quality of training received by these children is strongly linked to teacher welfare. This study ended that cognitive behavioral methods can be improved by using horseback riding, therapy with yoga and cue cards. These methods help in increasing behavioral patterns and concentration power and to maintain autistic children mind stability. Human and animal rights Not applicable. Informed consent and patient details The authors declare that this report does not contain any personal information that could lead to the identification of the patient(s). Disclosure of interest The authors declare that they have no known competing financial or personal relationships that could be viewed as influencing the work reported in this paper. Funding This work did not receive any grant from funding agencies in the public, commercial, or not-for-profit sectors. Author contributions All authors attest that they meet the current International Committee of Medical Journal Editors (ICMJE) criteria for Authorship. Declaration of competing interest The authors declare that they have no conflict of interest.
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