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Promoting constructive engagement by two boys with autism spectrum disorders and high functioning through behavioral interventions
Research in Autism Spectrum Disorders 8 (2014) 376–380
Contents lists available at ScienceDirect
Research in Autism Spectrum Disorders Journal homepage: http://ees.elsevier.com/RASD/default.asp
Promoting constructive engagement by two boys with autism spectrum disorders and high functioning through behavioral interventions Fabrizio Stasolla a,*, Rita Damiani b, Alessandro O. Caffo` b a b
Lega del Filo d’Oro Research Center, Molfetta, Italy Department of Educational Sciences, Psychology, Communication, University of Bari, Italy
A R T I C L E I N F O
A B S T R A C T
Article history: Received 8 November 2013 Received in revised form 21 December 2013 Accepted 26 December 2013
We assessed a behavioral intervention-based strategy to promote constructive engagement and to reduce stereotyped behaviors by two boys with autism spectrum disorders and high functioning. The program included two functional activities for each participant (i.e. coloring and using a personal computer with a multimedia software for reading and writing) according to a multi-elements baseline design, during classroom. Both participants showed a preference for the computer activity during the choice phase. Results showed an increasing of constructive engagement, according to both functional activities, and a reduction of stereotyped behaviors during intervention phases for both participants. Psychological as well as practical implications of the findings are discussed. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Autism spectrum disorders Behavioral interventions Constructive engagement Stereotyped behaviors Multi-elements baseline design
1. Introduction Autism spectrum disorders (ASD) are neuro-developmental disabilities and core of generalized pervasive developmental impairments characterized by cognitive, social, emotional and communication inabilities. ASD are described with challenge and stereotyped behaviors (Matson & Smith, 2008). Children with ASD usually show a large variability in communication and social skills: some of them can communicate using complete sentences, others use single words to express basic needs, and some others will never speak. Some of them remain aloof while other ones will be affectionate and interested in interacting with people and surrounding objects (Ben-Itzchak & Zachor, 2007). In addition, all the children with ASD usually show very little or no eye contact and have difficulties reading and understanding people’s facial expressions and body language. Moreover, variability also concerns responses to interventions: some children achieve limited or no progress in target behaviors while others rapidly attain relevant results (Peters-Scheffer, Didden, Korzillius, & Sturmey, 2011). Among intervention strategies, several studies focused at improving (a) social skills, crucial to establish social relationship in everyday life (Rao, Beidel, & Murray, 2008; Reichow & Volkmar, 2010; Wang, Parrila, & Cui, 2013), and (b) adaptive skills, in order to enhance constructive engagement in children with high functioning ASD (Chang, Lung, Yen, & Yang, 2013; Love, Carr, Almason, & Ingeborg Petursdottir, 2009; Palmen, Didden, & Lang, 2012). Independent functioning represents an essential issue for children with ASD and high functioning. As mentioned above, those children may have difficulties to establish social relationship with other children, to engage with academic and/or recreational activities, to live autonomously (Eaves & Ho, 2008), and they need to rely on continuous support from parents and caregivers (Farley et al., 2009). Nonetheless, studies concerning adaptive activities in those children pointed out
* Corresponding author. Tel.: +39 3496635397; fax: +39 069384564. E-mail addresses: [email protected], [email protected] (F. Stasolla). 1750-9467/$ – see front matter ß 2014 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.rasd.2013.12.020
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discrepancies between level of adaptive skills and IQ scores. Thus, adaptive capacities seem to be lower than those predictable by cognitive level of functioning, as measured by standardized intelligence scales (Kenworthy, Case, Harms, Martin, & Wallace, 2010). Furthermore, those discrepancies would increase with age (Kanne et al., 2011). The latter point justify a large body of literature across the lifespan on adaptive and social skills for people with high-functioning ASD (Koegel, Vernon, & Koegel, 2009). Most of the studies used behavioral interventions based on techniques for people with or without intellectual disabilities, such as task analysis, modeling, prompting, self management and positive reinforcements (Begeer et al., 2011; Wang et al., 2013). Literature reviews on behavioral strategies suggest that early interventions are particularly promising and successful on ASD children’s challenge behaviors and social skills (Didden et al., 2008; Makrygianni & Reed, 2010). In a recent review, Matson, Hattier, and Belva (2012) pointed out the relevance of behavioral strategies aimed at improving adaptive skills in adolescent and adults with ASD. Those strategies resulted to be highly effective, and authors suggested that adaptive living skills should be investigated more intensively, given their impact on lifespan, on quality of life and on autonomous functioning. Studies reviewed focused largely on participants with ASD and intellectual disabilities, and it is noteworthy that research on persons with ASD and high functioning is lacking (for a review, see Palmen et al., 2012). Additional research is needed on the efficacy of behavioral interventions for the latter group. Among rehabilitation programs for persons with ASD, a growing interest has been given to the presentation of stimulation conditions (Hill, Trusler, Furniss, & Lancioni, 2012). There has been an interest for music stimulation, which provides sensory input, but does not necessarily require constructive engagement by participant (Lanovaz, Sladeczek, & Rapp, 2011; Lanovaz & Sladeczek, 2011). An appropriate intervention program should foster both the increase of stimulation input and the enhancement of constructive engagement (Kazdin, 2001; Stasolla & Caffo`, 2013). The effects of such intervention are expected to reduce (a) isolation and/or passivity, and (b) stereotyped behaviors. Activities such as coloring, using the computer, sorting objects, may be viewed as helpful to pursue these rehabilitation goals. The present study was aimed to assess the effectiveness of a stimulation program with two boys with ASD and high functioning who presented stereotyped behaviors. Particularly, an academic activity (i.e. using personal computer for reading and writing) was compared with (a) a conventional stimulation condition (i.e. coloring pictures familiar to the boys, and (b) a baseline condition in which no specific activity/stimulation was programmed. A choice opportunity was then allowed between the computer use and the picture coloring activity. Eventually the condition more frequently chosen by each participant was retained and then compared with baseline condition. The objectives of the study concerned (a) the increasing of constructive engagement and (b) the reduction of stereotyped behaviors during intervention phases (Cunningham & Schreibman, 2008). 2. Method 2.1. Participants Bud and Martin were 8 and 7 years old at the beginning of the study and were diagnosed with severe ASD at childhood autism rating scale (CARS) (Rellini, Tortolani, Trillo, Carbone, & Montecchio, 2004) with scores of 40 and 42, respectively. Although no formal Intellectual Quotient scores were available, they were both estimated, by clinical observations, as borderline between normal and mild intellectual disabilities. The participants attended to a regular classroom with a special training and were able to communicate their personal needs, although their language were not easily understandable. They presented with frequent off task behaviors, especially linked to stereotyped behaviors (i.e. hand related movements, sound and noises production, withdrawal), relationship problems with peers, and had no resilience to frustration, showing aggressive behaviors against people surrounding them. Bud and Martin were autonomous on basic needs (i.e. personal hygiene), although they continuously needed reminders to be on task. They were recruited for the study through reporting by a neurologist. Their families considered the intervention program highly desirable and signed a formal consent for the participation of Bud and Martin to the research. The Review Board of the Institution approved the study protocol, and the whole study was performed in accordance with the Helsinki Declaration and its later amendments. 2.2. Setting, activities and data collection The study was carried out in the classroom. The participants’ desk was arranged with a laptop equipped with a multimedia interactive software, a series of preferred pictures and colored markers. The two activities selected for the study consisted of (a) coloring preferred and familiar pictures to the participants and (b) using a personal computer equipped with an interactive software to learn reading and writing. Those activities represented the most grateful ones by both participants and the most suitable ones in the school setting according to both parents’ and teachers’ interviews. Data recording concerned Bud and Martin’s stereotyped behaviors, constructive engagement (i.e. appropriate use of the materials) and choices between activities. The first two measures were recorded according to a partial interval system, in which 10 s of observation were followed by 5 s of scoring (Lancioni et al., 2007, 2010). Inter-rater agreement was assessed in 20% of sessions of each phase (see below Section 2.3) between two independent research assistants. The percentages of agreements (checked out separately for the two measures by dividing the number of agreements by the total of intervals and multiplying by 100) were between 90 and 100% with a mean of 94% for both measures. Two research assistants were involved to record
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the activities’ choice selected by Bud and Martin at each of 20 sessions available (see below). No disagreements between research assistants occurred for Bud nor for Martin. 2.3. Experimental conditions The study was carried out according a multi-element baseline design for each participant (Barlow, Andrasik, & Hersen, 2006). It involved 5-min sessions, 3–5 five sessions per day, 3 days a week for 4 months. Moreover, it consisted of five phases. The first phase was a baseline condition in which both participants were observed without any intervention. Thus, stereotyped behaviors were recorded. Bud and Martin were sitting in front of their desk and were asked to follow academic activities suggested by their teacher. The second phase served to compare the use of personal computer with a coloring activity and a non-stimulation (i.e. baseline) control condition, according to a multi-elements baseline design. The third phase provided a choice opportunity for both participants. Essentially, Bud and Martin were allowed to choose between personal computer use and coloring at the beginning of each session. The chosen condition was then implemented within each session. The fourth phase presented an alternating treatments condition between the condition regularly chosen during the previous phase (i.e. use of personal computer for both participants) and a control (baseline) condition. The fifth phase included only intervention sessions with computer activities for both participants. First phase: This phase involved 5 baseline sessions for each participant. Second phase: The phase included 10 sessions for each of three conditions. Third phase: This phase consisted of 20 choice trials between personal computer use and coloring activity. Participants were in front of their desk and were asked to choose the intervention condition they preferred. The session went on with the implementation of the chosen condition. The presentation of choice opportunity changed systematically across sessions. Fourth phase: This phase was completed with 15 sessions of personal computer use and 15 baseline sessions for Bud, according to an alternating treatments procedure across days. Twenty sessions of computer use and 20 baseline sessions were instead conducted for Martin.
Constructive Engagement PHASE II Multi Elements
PHASE I Baseline Baseline
2
3
3
4
Coloring
PHASE III Choice Computer
Computer
PHASE IV Alternating Baseline
4
100 3
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3 4
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4
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PHASE V Intervention Computer
Computer
5
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0
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100 80 60
60 40
40
MARTIN
20
Mean Percentages of Intervals with Stereoptyped Behaviors
Mean Percentages of Intervals with Constructive Engagement
Stereotyped Behaviors
20 0
0 1
3
5
7
9
11
13
15
17
19
21
23
Blo cks of Ses sion s Fig. 1. Data arrangement for Bud (upper panel) and Martin (lower panel). The light gray bars indicate mean percentages of observation intervals with constructive engagement during blocks of baseline sessions, coloring activity sessions and computer use sessions. The black diamonds indicate mean percentages of observation intervals with stereotyped behaviors over the same blocks of sessions. The numbers of sessions included in the blocks are indicated by the numerals above them.
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Fifth phase: The final phase included 40 sessions of intervention (computer use) for Bud and 30 sessions of intervention for Martin. 3. Results Data are summarized over blocks of sessions and represented in Fig. 1. The upper panel of the figure represents Bud’s results. The lower panel indicated Martin’s data. For both participants, the figure includes the mean percentages of intervals with constructive engagement and with stereotyped behaviors, respectively. The light gray bars represent the mean percentages of intervals with constructive engagement, over blocks of baseline sessions, coloring activity and personal computer use. The black diamonds represent the mean percentages of intervals with stereotyped behaviors over the same blocks of sessions. The numbers of sessions included in each block (i.e. bars-diamonds combinations) are indicated by the numerals above them. Bud showed no constructive engagement during baseline condition in phase I. The mean percentages of constructive engagement during phase II were 0, 88 and 94% for baseline, coloring and computer use, respectively. During the choice phase (III) the mean percentage of constructive engagement was 94%. During phase IV, the mean percentages were 0 and 93% for baseline and personal computer use, respectively. The fifth phase showed a mean percentage of 94%. Bud completed his baseline (phase I) with a mean percentage of stereotyped behaviors of 100%. During the second phase, the mean percentage of stereotyped behavior were 100, 14 and 9% within baseline, coloring and computer use conditions, respectively. During the third phase, the mean percentage of stereotyped behavior within the chosen activity (i.e. use of personal computer) was 11.5%. During the fourth phase, the mean percentages were 89 and 11% concerning baseline and computer use conditions, respectively. The fifth phase provided a mean percentage of stereotyped behavior of 13%. Martin’s data showed no constructive engagement during baseline in phase I. The mean percentage of constructive engagement were 0, 76, and 96% during baseline, coloring and computer use, respectively (phase II). The third phase showed a mean percentage of constructive engagement of 97%. During the fourth phase the mean percentages were 0 and 97% in baseline and in computer use conditions, respectively. The fifth phase showed a mean percentage of 98%. Martin showed a mean percentage of stereotyped behavior of 100% during baseline in the first phase. The second phase showed a mean percentage of stereotyped behavior of 100, 25, and 4% for baseline, coloring and computer use, respectively. The third phase showed a mean percentage of stereotypies of 3%. The fourth phase showed a mean percentages of 100 and 3% for baseline and computer use, respectively. The fifth phase showed a mean percentage of 2% concerning stereotyped behavior. 4. Discussion Results of the present study showed that functional activities were useful by increasing constructive engagement and by reducing stereotyped behaviors for both participants. The data indicated that stereotyped behaviors were fairly continuous and constant for both participants during baseline phases. Bud and Martin were not involved in any specific activity. Stereotyped behaviors dropped down during intervention phases (i.e. coloring and computer use conditions). Both participants chose and preferred computer condition instead of coloring during the third phase of the study. These results are supported by a slightly higher levels of constructive engagement showed in the former condition. Moreover, the greater appeal for computer use could be due to a larger variety of stimuli provided by the computer software with respect to the coloring activity, which may encounter with sensory saturation (Matson & Kozlowski, 2010). Beneficial effects of the computer condition on stereotyped behaviors are evident during the fourth phase, in which baseline and intervention were alternated. Furthermore, the fifth phase confirms results previously observed and support the effectiveness of the rehabilitative program. In light of above, some considerations may be pointed out. First, it is not possible to determine whether coloring and computer activities were effective since they substituted stereotyped behaviors, thus making these redundant, or since they were rewarding per se (Lancioni, Singh, O’Reilly, & Sigafoos, 2009). Nevertheless, constructive engagement which emerged from coloring and computer activities prevented isolation, passivity and withdrawal (Stasolla, Caffo`, Picucci, & Bosco, 2013; Stasolla & Caffo`, 2013). Furthermore, it can be the case that the variety of stimulation during the second phase reduced saturation. Second, computer use condition seemed to be preferable to coloring condition because it promoted more constructive engagement and adaptive behaviors. The computer activity might enhance educational and rehabilitative value of the intervention program. It may also allow both participants to have a more acceptable social image and provide also a beneficial impact on parents, teachers and caregivers (Lancioni, Singh, O’Reilly, Sigafoos, Green, et al., 2009; Lancioni, Singh, O’Reilly, Sigafoos, Didden, et al., 2009). Moreover, the aforementioned positive aspects related to computer use are corroborated by participants’ preferences during intervention phases. Third, the positive effects of the intervention pointed out in the present study need to be taken with caution since the evidences are based only on two single-case studies (Kennedy, 2005). The basic question that remains still open is to specify whether these results can be generalized (a) to other participants with ASD and high functioning, (b) to other practicable and suitable educational and/or academic activities, and (c) to other contexts such as home and rehabilitative center (Barlow et al., 2006). The second question is to assess whether the correct performance of both participants to the proposed activities is useful or not to substitute stereotyped behaviors, or the activities themselves are sufficient for this objective. Pursuing this goal, it should be needed to (a) determine the range of academic and/or educational activities eventually available in
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classroom and other contexts (Machalicek et al., 2008), and (b) assess the preference and the pleasantness of these activities for children with ASD and high functioning, also recurring to preference checks and indices of happiness, respectively (Lancioni et al., 2006). Conflict of interest The authors declare that they have no conflict of interest. References Barlow, D. H., Andrasik, F., & Hersen, M. (2006). Single-case experimental designs (3rd ed.). New York: Allyn & Bacon. Begeer, S., Evers, C., Clifford, P., Verhoeve, M., Kat, K., Hoddenbach, E., et al. (2011). Theory of mind training in children with autism: A randomized controlled trial. Journal of Autism and Developmental Disorders, 41(8), 997–1006. Ben-Itzchak, E., & Zachor, D. A. (2007). The effects of intellectual functioning and autism severity on outcome of early behavioral intervention for children with autism. Research in Developmental Disabilities, 28(3), 287–303. Chang, C.-L., Lung, F.-W., Yen, C.-F., & Yang, P. (2013). Adaptive behaviors in high-functioning Taiwanese children with autism spectrum disorders: An investigation of the mediating roles of symptom severity and cognitive ability. Journal of Autism and Developmental Disorders, 43(6), 1347–1355. Cunningham, A. B., & Schreibman, L. (2008). Stereotypy in autism: The importance of function. Research in Autism Spectrum Disorders, 2(3), 469–479. Didden, R., Sigafoos, J., Green, V., Korzilius, H., Mouws, C., Lancioni, G., et al. (2008). Behavioral flexibility in individuals with Angelman syndrome, Down syndrome, non-specific intellectual disability and Autism spectrum disorder. Journal of Intellectual Disability Research, 52(6), 503–509. Eaves, L. C., & Ho, H. H. (2008). Young adult outcome of autism spectrum disorders. Journal of Autism and Developmental Disorders, 38(4), 739–747. Farley, M. A., McMahon, W. M., Fombonne, E., Jenson, W. R., Miller, J., Gardner, M., et al. (2009). Twenty-year outcome for individuals with autism and average or near-average cognitive abilities. Autism Research, 2(2), 109–118. Hill, L., Trusler, K., Furniss, F., & Lancioni, G. (2012). Effects of multisensory environments on stereotyped behaviours assessed as maintained by automatic reinforcement. Journal of Applied Research in Intellectual Disabilities, 25(6), 509–521. Kanne, A. M., Gerber, A. J., Quirmbach, L. M., Sparrow, S. S., Cicchetti, D. V., & Saulnier, C. A. (2011). The role of adaptive behavior in Autism Spectrum Disorders: Implications for functional outcome. Journal of Autism and Developmental Disorders, 41(8), 1007–1018. Kazdin, A. E. (2001). Behavior modification in applied settings (6th ed.). New York: Wadsworth. Kennedy, K. (2005). Single case designs for educational research. New York: Allyn & Bacon. Kenworthy, L., Case, L., Harms, M. B., Martin, A., & Wallace, G. L. (2010). Adaptive behavior ratings correlate with symptomatology and IQ among individuals with high-functioning autism spectrum disorders. Journal of Autism and Developmental Disorders, 40(4), 416–423. Koegel, R. L., Vernon, T. W., & Koegel, L. K. (2009). Improving social initiations in young children with autism using reinforcers with embedded social interactions. Journal of Autism and Developmental Disorders, 39(9), 1240–1251. Lancioni, G. E., O’Reilly, M. F., Singh, N. N., Green, V., Chiapparino, C., De Pace, C., et al. (2010). Use of microswitch technology and a keyboard emulator to support literacy performance of persons with extensive neuro-motor disabilities. Developmental Neurorehabilitation, 13(4), 248–257. Lancioni, G. E., Singh, N. N., O’Reilly, M. F., & Sigafoos, J. (2009). An overview of behavioral strategies for reducing hand-related stereotypies of persons with severe to profound intellectual and multiple disabilities: 1995–2007. Research in Developmental Disabilities, 30(1), 20–43. Lancioni, G. E., Singh, N. N., O’Reilly, M. F., Oliva, D., Smaldone, A., Tota, A., et al. (2006). Assessing effects of stimulation versus microswitch-based programmes on indices of happiness of students with multiple disabilities. Journal of Intellectual Disability Research, 50(10), 739–746. Lancioni, G. E., Singh, N. N., O’Reilly, M. F., Sigafoos, J., Chiapparino, C., Stasolla, F., et al. (2007). Using an optic sensor and a scanning keyboard emulator to facilitate writing by persons with pervasive motor disabilities. Journal of Developmental and Physical Disabilities, 19(6), 593–603. Lancioni, G. E., Singh, N. N., O’Reilly, M. F., Sigafoos, J., Green, V., Chiapparino, C., et al. (2009). A voice detecting sensor and a scanning keyboard emulator to support word writing by two boys with extensive motor disabilities. Research in Developmental Disabilities, 30(2), 203–209. Lancioni, G. E., Singh, N. N., O’Reilly, M. F., Sigafoos, J., Didden, R., Manfredi, F., et al. (2009). Fostering locomotor behavior of children with developmental disabilities: An overview of studies using treadmills and walkers with microswitches. Research in Developmental Disabilities, 30(2), 308–322. Lanovaz, M. J., & Sladeczek, I. E. (2011). Vocal stereotypy in children with autism: Structural characteristics, variability, and effects of auditory stimulation. Research in Autism Spectrum Disorders, 5(3), 1159–1168. Lanovaz, M. J., Sladeczek, I. E., & Rapp, J. T. (2011). Effects of music on vocal stereotypy in children with autism. Journal of Applied Behavior Analysis, 44(3), 647–651. Love, J. R., Carr, J. E., Almason, S. M., & Ingeborg Petursdottir, A. (2009). Early and intensive behavioral intervention for autism: A survey of clinical practices. Research in Autism Spectrum Disorders, 3(2), 421–428. Machalicek, W., O’Reilly, M. F., Beretvas, N., Sigafoos, J., Lancioni, G., Sorrells, A., et al. (2008). A review of school-based instructional interventions for students with autism spectrum disorders. Research in Autism Spectrum Disorders, 2(3), 395–416. Makrygianni, M. K., & Reed, P. (2010). A meta-analytic review of the effectiveness of behavioral early intervention programs for children with autistic spectrum disorders. Research in Autism Spectrum Disorders, 4(4), 577–593. Matson, J. L., Hattier, M. A., & Belva, B. (2012). Treating adaptive living skills of persons with autism using applied behavior analysis: A review. Research in Autism Spectrum Disorders, 6(1), 271–276. Matson, J. L., & Kozlowski, A. M. (2010). Autistic regression. Research in Autism Spectrum Disorders, 4(3), 340–345. Matson, J. L., & Smith, K. R. M. (2008). Current status of intensive behavioral interventions for young children with autism and PDD-NOS. Research in Autism Spectrum Disorders, 2(1), 60–74. Palmen, A., Didden, R., & Lang, R. (2012). A systematic review of behavioral intervention research on adaptive skill building in high-functioning young adults with autism spectrum disorder. Research in Autism Spectrum Disorders, 6(2), 602–617. Peters-Scheffer, N., Didden, R., Korzilius, H., & Sturmey, P. (2011). A meta-analytic study on the effectiveness of comprehensive ABA-based early intervention programs for children with autism spectrum disorders. Research in Autism Spectrum Disorders, 5(1), 60–69. Rao, P. A., Beidel, D. C., & Murray, M. J. (2008). Social skills interventions for children with Asperger’s syndrome or high-functioning autism: A review and recommendations. Journal of Autism and Developmental Disorders, 38(2), 353–361. Reichow, B., & Volkmar, F. R. (2010). Social skills interventions for individuals with autism: Evaluation for evidence-based practices within a best evidence synthesis framework. Journal of Autism and Developmental Disorders, 40(2), 149–166. 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Contents lists available at ScienceDirect
Research in Autism Spectrum Disorders Journal homepage: http://ees.elsevier.com/RASD/default.asp
Promoting constructive engagement by two boys with autism spectrum disorders and high functioning through behavioral interventions Fabrizio Stasolla a,*, Rita Damiani b, Alessandro O. Caffo` b a b
Lega del Filo d’Oro Research Center, Molfetta, Italy Department of Educational Sciences, Psychology, Communication, University of Bari, Italy
A R T I C L E I N F O
A B S T R A C T
Article history: Received 8 November 2013 Received in revised form 21 December 2013 Accepted 26 December 2013
We assessed a behavioral intervention-based strategy to promote constructive engagement and to reduce stereotyped behaviors by two boys with autism spectrum disorders and high functioning. The program included two functional activities for each participant (i.e. coloring and using a personal computer with a multimedia software for reading and writing) according to a multi-elements baseline design, during classroom. Both participants showed a preference for the computer activity during the choice phase. Results showed an increasing of constructive engagement, according to both functional activities, and a reduction of stereotyped behaviors during intervention phases for both participants. Psychological as well as practical implications of the findings are discussed. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Autism spectrum disorders Behavioral interventions Constructive engagement Stereotyped behaviors Multi-elements baseline design
1. Introduction Autism spectrum disorders (ASD) are neuro-developmental disabilities and core of generalized pervasive developmental impairments characterized by cognitive, social, emotional and communication inabilities. ASD are described with challenge and stereotyped behaviors (Matson & Smith, 2008). Children with ASD usually show a large variability in communication and social skills: some of them can communicate using complete sentences, others use single words to express basic needs, and some others will never speak. Some of them remain aloof while other ones will be affectionate and interested in interacting with people and surrounding objects (Ben-Itzchak & Zachor, 2007). In addition, all the children with ASD usually show very little or no eye contact and have difficulties reading and understanding people’s facial expressions and body language. Moreover, variability also concerns responses to interventions: some children achieve limited or no progress in target behaviors while others rapidly attain relevant results (Peters-Scheffer, Didden, Korzillius, & Sturmey, 2011). Among intervention strategies, several studies focused at improving (a) social skills, crucial to establish social relationship in everyday life (Rao, Beidel, & Murray, 2008; Reichow & Volkmar, 2010; Wang, Parrila, & Cui, 2013), and (b) adaptive skills, in order to enhance constructive engagement in children with high functioning ASD (Chang, Lung, Yen, & Yang, 2013; Love, Carr, Almason, & Ingeborg Petursdottir, 2009; Palmen, Didden, & Lang, 2012). Independent functioning represents an essential issue for children with ASD and high functioning. As mentioned above, those children may have difficulties to establish social relationship with other children, to engage with academic and/or recreational activities, to live autonomously (Eaves & Ho, 2008), and they need to rely on continuous support from parents and caregivers (Farley et al., 2009). Nonetheless, studies concerning adaptive activities in those children pointed out
* Corresponding author. Tel.: +39 3496635397; fax: +39 069384564. E-mail addresses: [email protected], [email protected] (F. Stasolla). 1750-9467/$ – see front matter ß 2014 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.rasd.2013.12.020
F. Stasolla et al. / Research in Autism Spectrum Disorders 8 (2014) 376–380
377
discrepancies between level of adaptive skills and IQ scores. Thus, adaptive capacities seem to be lower than those predictable by cognitive level of functioning, as measured by standardized intelligence scales (Kenworthy, Case, Harms, Martin, & Wallace, 2010). Furthermore, those discrepancies would increase with age (Kanne et al., 2011). The latter point justify a large body of literature across the lifespan on adaptive and social skills for people with high-functioning ASD (Koegel, Vernon, & Koegel, 2009). Most of the studies used behavioral interventions based on techniques for people with or without intellectual disabilities, such as task analysis, modeling, prompting, self management and positive reinforcements (Begeer et al., 2011; Wang et al., 2013). Literature reviews on behavioral strategies suggest that early interventions are particularly promising and successful on ASD children’s challenge behaviors and social skills (Didden et al., 2008; Makrygianni & Reed, 2010). In a recent review, Matson, Hattier, and Belva (2012) pointed out the relevance of behavioral strategies aimed at improving adaptive skills in adolescent and adults with ASD. Those strategies resulted to be highly effective, and authors suggested that adaptive living skills should be investigated more intensively, given their impact on lifespan, on quality of life and on autonomous functioning. Studies reviewed focused largely on participants with ASD and intellectual disabilities, and it is noteworthy that research on persons with ASD and high functioning is lacking (for a review, see Palmen et al., 2012). Additional research is needed on the efficacy of behavioral interventions for the latter group. Among rehabilitation programs for persons with ASD, a growing interest has been given to the presentation of stimulation conditions (Hill, Trusler, Furniss, & Lancioni, 2012). There has been an interest for music stimulation, which provides sensory input, but does not necessarily require constructive engagement by participant (Lanovaz, Sladeczek, & Rapp, 2011; Lanovaz & Sladeczek, 2011). An appropriate intervention program should foster both the increase of stimulation input and the enhancement of constructive engagement (Kazdin, 2001; Stasolla & Caffo`, 2013). The effects of such intervention are expected to reduce (a) isolation and/or passivity, and (b) stereotyped behaviors. Activities such as coloring, using the computer, sorting objects, may be viewed as helpful to pursue these rehabilitation goals. The present study was aimed to assess the effectiveness of a stimulation program with two boys with ASD and high functioning who presented stereotyped behaviors. Particularly, an academic activity (i.e. using personal computer for reading and writing) was compared with (a) a conventional stimulation condition (i.e. coloring pictures familiar to the boys, and (b) a baseline condition in which no specific activity/stimulation was programmed. A choice opportunity was then allowed between the computer use and the picture coloring activity. Eventually the condition more frequently chosen by each participant was retained and then compared with baseline condition. The objectives of the study concerned (a) the increasing of constructive engagement and (b) the reduction of stereotyped behaviors during intervention phases (Cunningham & Schreibman, 2008). 2. Method 2.1. Participants Bud and Martin were 8 and 7 years old at the beginning of the study and were diagnosed with severe ASD at childhood autism rating scale (CARS) (Rellini, Tortolani, Trillo, Carbone, & Montecchio, 2004) with scores of 40 and 42, respectively. Although no formal Intellectual Quotient scores were available, they were both estimated, by clinical observations, as borderline between normal and mild intellectual disabilities. The participants attended to a regular classroom with a special training and were able to communicate their personal needs, although their language were not easily understandable. They presented with frequent off task behaviors, especially linked to stereotyped behaviors (i.e. hand related movements, sound and noises production, withdrawal), relationship problems with peers, and had no resilience to frustration, showing aggressive behaviors against people surrounding them. Bud and Martin were autonomous on basic needs (i.e. personal hygiene), although they continuously needed reminders to be on task. They were recruited for the study through reporting by a neurologist. Their families considered the intervention program highly desirable and signed a formal consent for the participation of Bud and Martin to the research. The Review Board of the Institution approved the study protocol, and the whole study was performed in accordance with the Helsinki Declaration and its later amendments. 2.2. Setting, activities and data collection The study was carried out in the classroom. The participants’ desk was arranged with a laptop equipped with a multimedia interactive software, a series of preferred pictures and colored markers. The two activities selected for the study consisted of (a) coloring preferred and familiar pictures to the participants and (b) using a personal computer equipped with an interactive software to learn reading and writing. Those activities represented the most grateful ones by both participants and the most suitable ones in the school setting according to both parents’ and teachers’ interviews. Data recording concerned Bud and Martin’s stereotyped behaviors, constructive engagement (i.e. appropriate use of the materials) and choices between activities. The first two measures were recorded according to a partial interval system, in which 10 s of observation were followed by 5 s of scoring (Lancioni et al., 2007, 2010). Inter-rater agreement was assessed in 20% of sessions of each phase (see below Section 2.3) between two independent research assistants. The percentages of agreements (checked out separately for the two measures by dividing the number of agreements by the total of intervals and multiplying by 100) were between 90 and 100% with a mean of 94% for both measures. Two research assistants were involved to record
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the activities’ choice selected by Bud and Martin at each of 20 sessions available (see below). No disagreements between research assistants occurred for Bud nor for Martin. 2.3. Experimental conditions The study was carried out according a multi-element baseline design for each participant (Barlow, Andrasik, & Hersen, 2006). It involved 5-min sessions, 3–5 five sessions per day, 3 days a week for 4 months. Moreover, it consisted of five phases. The first phase was a baseline condition in which both participants were observed without any intervention. Thus, stereotyped behaviors were recorded. Bud and Martin were sitting in front of their desk and were asked to follow academic activities suggested by their teacher. The second phase served to compare the use of personal computer with a coloring activity and a non-stimulation (i.e. baseline) control condition, according to a multi-elements baseline design. The third phase provided a choice opportunity for both participants. Essentially, Bud and Martin were allowed to choose between personal computer use and coloring at the beginning of each session. The chosen condition was then implemented within each session. The fourth phase presented an alternating treatments condition between the condition regularly chosen during the previous phase (i.e. use of personal computer for both participants) and a control (baseline) condition. The fifth phase included only intervention sessions with computer activities for both participants. First phase: This phase involved 5 baseline sessions for each participant. Second phase: The phase included 10 sessions for each of three conditions. Third phase: This phase consisted of 20 choice trials between personal computer use and coloring activity. Participants were in front of their desk and were asked to choose the intervention condition they preferred. The session went on with the implementation of the chosen condition. The presentation of choice opportunity changed systematically across sessions. Fourth phase: This phase was completed with 15 sessions of personal computer use and 15 baseline sessions for Bud, according to an alternating treatments procedure across days. Twenty sessions of computer use and 20 baseline sessions were instead conducted for Martin.
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Blo cks of Ses sion s Fig. 1. Data arrangement for Bud (upper panel) and Martin (lower panel). The light gray bars indicate mean percentages of observation intervals with constructive engagement during blocks of baseline sessions, coloring activity sessions and computer use sessions. The black diamonds indicate mean percentages of observation intervals with stereotyped behaviors over the same blocks of sessions. The numbers of sessions included in the blocks are indicated by the numerals above them.
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Fifth phase: The final phase included 40 sessions of intervention (computer use) for Bud and 30 sessions of intervention for Martin. 3. Results Data are summarized over blocks of sessions and represented in Fig. 1. The upper panel of the figure represents Bud’s results. The lower panel indicated Martin’s data. For both participants, the figure includes the mean percentages of intervals with constructive engagement and with stereotyped behaviors, respectively. The light gray bars represent the mean percentages of intervals with constructive engagement, over blocks of baseline sessions, coloring activity and personal computer use. The black diamonds represent the mean percentages of intervals with stereotyped behaviors over the same blocks of sessions. The numbers of sessions included in each block (i.e. bars-diamonds combinations) are indicated by the numerals above them. Bud showed no constructive engagement during baseline condition in phase I. The mean percentages of constructive engagement during phase II were 0, 88 and 94% for baseline, coloring and computer use, respectively. During the choice phase (III) the mean percentage of constructive engagement was 94%. During phase IV, the mean percentages were 0 and 93% for baseline and personal computer use, respectively. The fifth phase showed a mean percentage of 94%. Bud completed his baseline (phase I) with a mean percentage of stereotyped behaviors of 100%. During the second phase, the mean percentage of stereotyped behavior were 100, 14 and 9% within baseline, coloring and computer use conditions, respectively. During the third phase, the mean percentage of stereotyped behavior within the chosen activity (i.e. use of personal computer) was 11.5%. During the fourth phase, the mean percentages were 89 and 11% concerning baseline and computer use conditions, respectively. The fifth phase provided a mean percentage of stereotyped behavior of 13%. Martin’s data showed no constructive engagement during baseline in phase I. The mean percentage of constructive engagement were 0, 76, and 96% during baseline, coloring and computer use, respectively (phase II). The third phase showed a mean percentage of constructive engagement of 97%. During the fourth phase the mean percentages were 0 and 97% in baseline and in computer use conditions, respectively. The fifth phase showed a mean percentage of 98%. Martin showed a mean percentage of stereotyped behavior of 100% during baseline in the first phase. The second phase showed a mean percentage of stereotyped behavior of 100, 25, and 4% for baseline, coloring and computer use, respectively. The third phase showed a mean percentage of stereotypies of 3%. The fourth phase showed a mean percentages of 100 and 3% for baseline and computer use, respectively. The fifth phase showed a mean percentage of 2% concerning stereotyped behavior. 4. Discussion Results of the present study showed that functional activities were useful by increasing constructive engagement and by reducing stereotyped behaviors for both participants. The data indicated that stereotyped behaviors were fairly continuous and constant for both participants during baseline phases. Bud and Martin were not involved in any specific activity. Stereotyped behaviors dropped down during intervention phases (i.e. coloring and computer use conditions). Both participants chose and preferred computer condition instead of coloring during the third phase of the study. These results are supported by a slightly higher levels of constructive engagement showed in the former condition. Moreover, the greater appeal for computer use could be due to a larger variety of stimuli provided by the computer software with respect to the coloring activity, which may encounter with sensory saturation (Matson & Kozlowski, 2010). Beneficial effects of the computer condition on stereotyped behaviors are evident during the fourth phase, in which baseline and intervention were alternated. Furthermore, the fifth phase confirms results previously observed and support the effectiveness of the rehabilitative program. In light of above, some considerations may be pointed out. First, it is not possible to determine whether coloring and computer activities were effective since they substituted stereotyped behaviors, thus making these redundant, or since they were rewarding per se (Lancioni, Singh, O’Reilly, & Sigafoos, 2009). Nevertheless, constructive engagement which emerged from coloring and computer activities prevented isolation, passivity and withdrawal (Stasolla, Caffo`, Picucci, & Bosco, 2013; Stasolla & Caffo`, 2013). Furthermore, it can be the case that the variety of stimulation during the second phase reduced saturation. Second, computer use condition seemed to be preferable to coloring condition because it promoted more constructive engagement and adaptive behaviors. The computer activity might enhance educational and rehabilitative value of the intervention program. It may also allow both participants to have a more acceptable social image and provide also a beneficial impact on parents, teachers and caregivers (Lancioni, Singh, O’Reilly, Sigafoos, Green, et al., 2009; Lancioni, Singh, O’Reilly, Sigafoos, Didden, et al., 2009). Moreover, the aforementioned positive aspects related to computer use are corroborated by participants’ preferences during intervention phases. Third, the positive effects of the intervention pointed out in the present study need to be taken with caution since the evidences are based only on two single-case studies (Kennedy, 2005). The basic question that remains still open is to specify whether these results can be generalized (a) to other participants with ASD and high functioning, (b) to other practicable and suitable educational and/or academic activities, and (c) to other contexts such as home and rehabilitative center (Barlow et al., 2006). The second question is to assess whether the correct performance of both participants to the proposed activities is useful or not to substitute stereotyped behaviors, or the activities themselves are sufficient for this objective. Pursuing this goal, it should be needed to (a) determine the range of academic and/or educational activities eventually available in
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