Peer mediation to increase communication and interaction at recess for students with autism spectrum disorders
Introduction
The American Academy of Pediatrics recently issued a policy statement on the importance of school recess (www.pediatrics.org/cgi/doi/10.1542/peds.2012-2993) stating, “Recess promotes social and emotional learning and development for children by offering them a time to engage in peer interactions in which they practice and role play essential social skills.” This type of activity, under adult supervision, extends teaching in the classroom to augment the school's social climate. Through play at recess, children learn valuable communication skills, including negotiation, cooperation, sharing, and problem solving as well as coping skills, such as perseverance and self-control. These skills become fundamental, lifelong personal tools.” (p. 184). This policy statement was issued in reaction to the debate over the role of schools in promoting development of the whole child, and with the increasing pressure to accelerate academic performance which may often preclude social activities. Despite inclusion in recess activities, students with autism spectrum disorder (ASD), generally miss out on the social benefits specific to recess.
ASDs are defined as a group of developmental disabilities characterized by impairments in social interaction and communication and by restricted, repetitive, and stereotyped patterns of behavior (American Psychiatric Association, 2012). Other characteristics include lack of responding to their name, poor eye contact, limited affect and social responsiveness, and language delays or deviances (limited words by 16 months, echolalia, perseveration on topics) (National Institute of Neurological Disorders & Stroke, 2009). Koegel reported that problems engaging in social interactions for children with autism primarily serve two functions: avoidance of social attention (interaction) or seeking social attention but using inappropriate communication to do so (perseverative topics) (Koegel, Openden, Fredeen, & Koegel, 2006). Children with ASD use fewer toys, and less time playing appropriately with toys, demonstrate fewer functional play acts and symbolic play, show less imitation than typical peers and even actively avoid peers (Stone & Caro-Martinez, 1990 cited in Harper, Symon, & Frea, 2008). For school aged children these characteristics impact their ability to interact with teachers and peers across a multitude of settings including the classroom, transition areas, lunchroom, and playground.
Interventions that target social and communication skills thus appear to be pivotal to improving their ability to initiate interactions, reciprocate during social exchanges, and infer the interests and emotions of others. Fortunately, research shows increasing evidence for interventions to address these core deficits for children with autism. Kasari, Paparella, Freeman, and Jahromi (2008) and others (Rogers, 2000) report treatment aimed at joint attention and symbolic play as effective for improving social and communication skills with young children with autism. A recent review of social skills interventions (Reichow & Volkmar, 2010) reported peer training, video modeling, and social skills groups as part of a treatment package as evidenced or emerging evidenced-based practices. Peer mediation or peer networks (Haring and Breen, 1992, Kamps et al., 1997, Kamps et al., 2002) have also been shown effective for improving social and communication skills. Examples include peer dyads or small groups of peers to support a child with ASD or other disability to assist with specific tasks, for example as social and conversation partners, during transitions, as tutors, or providers of social reinforcement. General recommendations for children with ASD include the use of behavioral interventions with a focus on individual needs, responsiveness to intervention, functional outcomes, and generalization of skill use as key indicators of the effectiveness of interventions (Kasari and Lawton, 2010, Koegel et al., 2012a, Rao et al., 2008). Recommendations also support children with ASD being taught in more naturalistic settings with typical peers to improve social communication and language development (Koegel et al., 2012b, National Research Council, 2001; Reichow & Volkmar, 2010).
A few studies have successfully targeted social behaviors at recess (Harper et al., 2008). Lang et al. (2011) conducted a review of 15 studies that used recess time to teach target behaviors to students with ASD. In several studies, the perseverative interests or preferred activities of the children were incorporated into the recess or social events with improvements in social/play interactions and affect ratings (Baker et al., 1998, Koegel et al., 2012c, Licciardello et al., 2008, Machalicek et al., 2009). Machalicek et al. taught three children with ASD to select pictures of preferred equipment to use on the playground and pictures were then used to create an activity schedule. Challenging behavior decreased, and appropriate play increased. Lang and colleagues decreased severe challenging behavior by increasing teacher attention and praise for appropriate behavior during recess (Lang et al., 2010 reported in Lang et al., 2011). Licciardello et al. also used teaching assistants to prompt and reinforce interactions between the participant and peers during recess for four, 6–8 year old children with autism resulting in increased social initiations and responses. Zanolli, Daggett, and Adams (1996) implemented a priming session in which 2 4-year old children with autism received a dense schedule of reinforcement with few demands just prior to recess. Peers were taught to respond to social initiations resulting in increases in the number and topography of initiations by the children with autism (reported in Lang et al., 2011). Others have incorporated peer training to increase interactions for children with autism at recess. Owen-Deschryver, Carr, Cale, and Blakely-Smith (2008) taught peers to initiate and respond to the children with ASD and to consider their interests when playing. McGee, Almeida, Sulzer-Azaraff, and Feldman (1992) using incidental strategies, taught peers to reinforce initiations for preferred toys, to praise, and to prompt turn taking with improved reciprocal interactions. Gonzalez-Lopez and Kamps (1997) taught peer mentors to give clear simple instructions, to model appropriate social skills, and to praise kindergarten children with ASD. Results indicated improved frequency and duration of social behaviors, and decreases in disruptive behaviors for participants. Others have used structured activities using music (Kern & Aldridge, 2006) and affection activities (McEvoy et al., 1988) to increase interactions between peers and young children with autism.
Kasari, Rotheram-Fuller, Locke, and Gulsrud (2012) used two interventions to improve social skills for children with autism during recess and lunch time. The first program consisted of child-assisted direct instruction using role play and practice with an interventionist until skills were mastered. The second was a peer-mediation procedure with the interventionist training peers to engage the children with autism in social interaction and game playing. Skills were selected based on the individual child's needs and the setting (e.g., entering and sustaining attention in games, maintaining a conversation, game rules, steps for specific activities, good sportsmanship, etc.). Thirty children participated in the ‘child’ intervention and 30 children in the ‘peer mediation’ intervention, with each lasting 6 weeks with 20-min intervention sessions twice each week. Results included improved class-wide-rated social network status (nominations), improved teacher ratings of social skills, and decreased isolation on the playground for the children with autism. Minimal changes were noted in the percent of interactions with joint attention during recess observations for any of the interventions with a 9% increase during follow-up observations for the children in the peer mediation intervention.
The use of Pivotal Response Training (PRT, Koegel et al., 1989, Koegel et al., 2006, Pierce and Screibman, 1995) has been used to improve motivation and responding to increase language use and promote positive interactions for children with autism and their peers. Harper et al. (2008) taught peers to use naturalistic strategies including PRT during recess to increase initiations and play for children with ASD. Specific skills included gaining attention, varying activities, narrating play, reinforcing attempts, and turn-taking. Peers were taught to demonstrate each skill with 80% accuracy and to demonstrate providing play opportunities with a classmate. Teaching peers to use naturalistic activities increased initiations and number of turn-taking exchanges for two children with autism. One participant improved from baseline levels of 0–1 to 4.8 bids for attention during 10-min probes. The second participant increased from .89 in baseline to 1.9 during the peer condition and to 3.25 during generalization. Turn-taking exchanges were at zero levels in baseline with increases to 9–16 for participant one and to 1–3 for participant two during intervention.
In a recent study Koegel and colleagues implemented PRT strategies with children with ASD and their peers during recess incorporating the child's choice of activities and peers. This intervention resulted in improvements in the percent of intervals with social engagement. The addition of initiation training however was necessary to promote improvements in initiation behaviors to peers and generalization in social engagement to recesses when the interventionists were not present (Koegel et al., 2012).
McFadden, Kamps, and Heitzman-Powell (2013) similarly found improved social initiations and responses for children with autism in recess settings following implementation of peer training. Children with ASD and their classmates received training (modeling, priming, prompting, and feedback) in four key skills: (a) playing together and having fun, (b) complimenting and encouraging our friends, (c) talking about what we’re doing and giving ideas, and (d) using names and getting attention. A token system was used during recess to reinforce use of the skills by all participants. The percent of intervals with initiations and/or responses to peers increased from baseline to the peer networks condition for all four participants with ASD (i.e., 9–77%, 26–81%, 35–85%, and 15–77%, respectively).
Findings for peer mediated interventions at recess for children with ASD are encouraging but the literature is quite sparse, particularly in elementary school settings. Additional research is needed with well-defined interventions, fidelity of treatment measures, and interventions that are deliverable by school personnel.
The purpose of this study was to evaluate the impact of a peer network package intervention at recess to increase the communicative acts of elementary students with autism spectrum disorder. The specific research question addressed by this study is: Is there a functional relationship between a peer mediated intervention package and increases in the number of communicative acts for participants with ASD at recess?
Section snippets
Participants
Three children diagnosed with autism were chosen from a larger pool of participants who were enrolled in a randomized control trial evaluating the effectiveness of peer networks, following university Institutional Review Board approval for human subjects’ research. Inclusion in the study required a diagnosis of ASD which had previously been determined through educational and/or clinical based assessments. Additional criteria for inclusion in the study included some verbal functional
Intervention
Fig. 2 is a graphical display of participants’ data. The y-axis indicates the number of communicative acts per 10-min session. The x-axis indicates the session number. The intervention was methodically introduced across the three participants beginning with Sam (top panel of Fig. 2). The study demonstrates experimental control as is evident by systematic introduction of the intervention, three demonstrations of change at different points in time, and immediate increase in communicative acts
Discussion
Social and communication deficits for children with ASD can severely interfere with the ability of children with ASD to benefit from the social opportunities provided in school settings, including recess. Thus the issue for children with ASD is not only inclusion in social activities such as recess, but ensuring that intervention is in place to promote positive social interactions with peers. Although recess is particularly challenging with limited structure and adult supervision, identifying
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