Social and Behavioural Outcomes of School Aged Autistic Children Who Received Community-Based Early Interventions

The benefits of early intervention (EI) for children with a diagnosis of autism spectrum disorder (ASD; hereafter autism) are well-established, with improvements in language, cognition, and adaptive behaviour widely documented (Reichow, 2012; Rogers et al., 2019; Smith & Iadarola, 2015; Warren et al., 2011). Yet, to date there has been little examination of outcomes following the cessation of EI, with the developmental trajectory and later outcomes, particularly during the school years, poorly understood.

As EI assists children to engage with and learn from their environment, social and otherwise, it is expected that autistic children in receipt of EI would continue learning and developing following EI cessation. Despite known difficulties with generalisation (Church et al., 2015; de Marchena et al., 2015; Hwang & Hughes, 2000), a recent review found that 8 of the 9 randomised control trials (RCTs) reported gains in learning amongst autistic children both within the intervention context, and generalisation across people, setting and/or activity. Importantly, generalisation varied across studies and skills, which is unsurprising given the heterogeneity in profiles of autistic children (Fountain et al., 2012; Jeste & Geschwind, 2014) that likely impact the rate of acquisition in response to EI, and the extent of generalisation. Learning skills within a naturalistic setting (i.e., at day-care, home and school) facilitates generalisation (Schreibman et al., 2015), which underpins the foundation of Naturalistic Developmental Behavioural Interventions (NDBIs) delivered in group environments. These interventions may therefore promote greater generalisation of skills into other social settings, such as the school playground.

School is the first opportunity whereby autistic children apply the skills learnt during EI in a new and socially complex setting, amongst their peers. Autistic students tend to experience greater behavioural and emotional difficulties, including aggressive and oppositional behaviour, anxiety, depression, attentional difficulties and hyperactivity relative to their typically developing (TD) peers (Ashburner et al., 2010; Macintosh & Dissanayake, 2006). Consequently, they are more likely to be on the periphery of social activity (Chamberlain et al., 2007), have fewer and poorer quality friendships (Bauminger & Kasari, 2000; Macintosh & Dissanayake, 2006), and experience increased loneliness (Bauminger & Kasari, 2000). However, social outcomes, while imperative for school adjustment, are often considered secondary to outcomes relating to academic success, such as language and cognition.

School-age follow-up studies yield important information on learning beyond the EI years. Starr et al. (2016) found many school-aged autistic children progressed beyond the gains made during intervention, while others regressed, experiencing pervasive social and behavioural difficulties at school. Clark et al. (2018) found earlier autism diagnoses (by 2-years) and commencement of EI at a younger age, contributed to improved cognition and language at school, while autism symptoms remained stable. Indeed, many EI outcome studies report developmental gains amongst autistic children post intervention, with autism symptomatology remaining stable over time (Fountain et al., 2012; Vivanti et al., 2014, 2016).

While autism symptoms, cognition and language remain the most common measures of outcome at school age, Towle et al. (2014) concluded that outcomes should be broadened beyond symptomatology and cognition, to capture more functional abilities such as adaptive behaviour. The limited research into adaptive functioning at school age has returned mixed results, with both improvements (Akshoomoff et al., 2010; Landa & Kalb, 2012; Magiati et al., 2011), and enduring adaptive functioning difficulties reported into the school years (O’Connor & Healy, 2010).

Other relevant school related behaviours such as social and peer interaction skills and attitudes towards school remain under researched. O’Connor and Healy (2010) highlighted the behavioural (inattention, hyperactivity) and social difficulties, including anxiety, amongst five school-aged autistic children. Similarly, social difficulties were found by Kasari et al. (2011) when comparing the social networks and friendships of 120 cognitively able children with (n = 60) and without Autism (n = 60). Significant differences in the friendships between groups were identified, such that autistic children nominated fewer peers as friends and received fewer friendship nominations from classmates. Importantly, while autistic children had lower friendship quality, fewer peer connections and reciprocal friendships overall, a proportion of them (20%) were identified as having reciprocal friendships. Peer engagement was the most distinguishing variable between groups—autistic children were less socially engaged than their classmates; even those with a reciprocal friendship were not engaged on the playground.

Peer engagement difficulties were also identified in a recent study of social and peer play skills (play interaction, play disruption and play disconnection) and problem behaviours amongst 35 autistic children aged 7 to 9 years (Clark et al., 2019). Parents and teachers alike reported similar social skills at home and school, while problem behaviours were highest at home. Informants emphasised similar peer engagement difficulties across settings, whereby play disconnection was the most problematic, indicating that autistic children had difficulties engaging in play, even when invited to do so by peers or siblings. Given the social difficulties experienced by autistic children, it is unsurprising that many seek adult interaction for play rather than peers and engage mostly in solitary functional play (Holmes & Willoughby, 2009), with increased repetitive behaviours linked with less engagement in play (Honey et al., 2007). Despite the importance of social skills for assimilation into the school environment, the knowledge of play behaviours of school-aged autistic children following EI remains limited.

Positive perceptions by children of their school environment are known to promote healthy development and enhance school performance (Van Ryzin, 2011). However, the attitudes of autistic children towards school in the early school years—when such attitudes are forming—remain largely unknown. Understanding attitudes towards school is important, especially given the high rates of school refusal amongst this population of children (Bitsika et al., 2021; McClemont et al., 2020; Munkhaugen et al., 2017; Ochi et al., 2020).

The data were first screened to ensure the assumptions for MANOVA were met. Data were normally distributed and there was no evidence of multicollinearity amongst variables. As the sample sizes were uneven, Levene’s test of homogeneity of variance revealed equal population variance.

This is the first study to compare the school-aged outcomes of autistic children who had received community-based G-ESDM to those in receipt of standard community EI. The current study extends on the work of Vinen et al. (2018) that found improvements in cognitive functioning in both groups (ESDM and comparison) of children studied here irrespective of intervention type. The same 59 children participated in the current study, with a focus on their social, peer play and behavioural outcomes and attitudes towards school. While the two groups did not differ on adaptive behaviour as hypothesized, their social and peer play skills, problem behaviours, and attitudes towards school also failed to differentiate the groups, counter to the stated hypotheses. Further, groups did not differ in their peer play skills (play interaction and play disconnection) with one exception, children in the G-ESDM group displayed less play disruption with their peers than those in the comparison group according to their parents. The difficulties in adaptive and social functioning at school age is not completely unexpected as EI is known to target improvements in communication, language and cognition which have also been identified in this same cohort (Vinen et al., 2018). In the current study, the mean adaptive behaviour scores indicate that children in both groups scored in the ‘moderately low’ range, demonstrating pervasive difficulties in adaptive functioning at school age, irrespective of the EI received. Studies have also reported enduring difficulties with adaptive functioning throughout the course of childhood (Cohen et al., 2006; Eikeseth et al., 2007; Estes et al., 2015; Magiati et al., 2011; O’Connor & Healy, 2010). Further to this, the lack of difference between the groups in adaptive behaviour align with that reported by Vivanti et al. (2014), where no differences in adaptive behaviour were found immediately post intervention between children in receipt of G-ESDM and a comparison group (other community interventions). They contrast, however, with the findings of Estes et al. (2015) who reported significant improvements in adaptive functioning at follow-up in children that received ESDM, further re-iterating the variability in adaptive functioning outcomes of autistic children.

Children in both the G-ESDM and comparison groups had similar social skills and problem behaviours at school age. On the basis of parent report, children displayed fewer prosocial skills than would be expected relative to their TD peers. In turn, they showed higher levels of problems behaviours. Importantly, as autism spectrum behaviours were measured within the problem behaviours scale, it is not surprising that there is an elevation of these behaviours. Certainly, research has indicated lower levels of social skills amongst autistic children at school age, despite the provision of EI (O'Connor & Healy, 2010; Towle, et al., 2014).

In keeping with similar social skills, both groups also displayed similar levels of play interaction and play disconnection. However, children in the G-ESDM group demonstrated less play disruption, such as aggressive or antisocial behaviour, when compared to the comparison group. The significantly lower levels of play disruption may be explained by the play-based learning approach of the G-ESDM that targets children’s learning, communication and social goals while engaging them in play (Vivanti et al., 2014). While these findings are encouraging, few studies have explored these same three dimensions of play, and replication is needed to examine changes in play behaviours including play disruption, from pre-intervention to school age. Despite this positive finding, some play difficulties were also identified in the current study with both groups showing, on average, less interaction and greater disconnection in peer play compared to the standardized means. These findings partially align with the work of Clark et al. (2019) who also measured the same dimensions of play using the PIPPS in school-aged autistic children (aged 7 to 9 years). Clark et al. found that autistic children scored highest in play disconnection, experiencing the most difficulty connecting with peers, joining in and remaining engaged in play even when invited to do so by their peers. Collectively, these findings indicate that school-aged autistic children are presenting with behaviours that are counterintuitive to positive peer engagement in play, with either high levels of disruptive behaviour and/or disconnection from peers. Consequently, such known difficulties (increased disruption and disconnection in play) coupled with poor social skills, may impact children’s opportunities to develop and maintain peer relationships, another area deserving further investigation (Bauminger & Kasari, 2000).

Similarly overlooked in the EI outcome literature is children’s attitude towards school. Once again, comparable displays of school liking and avoidance behaviours were reported for children in G-ESDM and comparison groups. Encouragingly, parents/carers typically reported greater school liking than avoidance behaviours irrespective of the EI received. This is of particular interest given common reports of school refusal behaviours amongst autistic children (Bitsika et al., 2021; McClemont et al., 2020; Ochi et al., 2020) and the increased risk of school avoidance of autistic children relative to TD children (Munkhaugen et al., 2017). However, as the SLAQ (Birch & Ladd, 1997) is not a standardized measure, no further inferences can be drawn from these data. Further examination of such attitudes is warranted in future research, as behaviour associated with early school avoidance may be a risk factor for later school refusal behaviours which can subsequently impact on children’s social and academic developmental and later outcomes.

Together, the current findings demonstrate similar early school-aged outcomes amongst children who received different models of community based EI during their preschool years. Importantly, the community interventions provided to children in the treatment as usual group incorporated strategies from a number of evidence-based interventions. Even so, as indicated in the literature to date (Starr et al., 2016), despite the known positive effects of EI on the developmental trajectory of young autistic children, the difficulties facing many of these children as they enter their schooling years remain present. Adding to the current research evidence, this study identified ongoing challenges in adaptive behaviour, social skills, and play behaviour in the early school years. Thus, further supports and interventions are needed at school-age to assist autistic children to continue to develop and learn.

A limitation in the present study is the variability in interventions received by the participants in the comparison group. Moreover, it is not possible to comment on the fidelity of the intervention delivered as there is likely individual variability in the approaches across service providers and allied health professionals in the community. Further, the EI received relied on retrospective recall by parents and thus, may be limited by recall bias. Based on this qualitative information provided by parents at the school-age follow-up, most children received a variety of EI types, provided in an autism specific intervention service or otherwise. There was also likely variation in the resources children received when at school to assist with their learning, but these data were not systematically recorded. The lack of significant difference in children’s attitudes towards school—despite a medium effect size—may be due to an underpowered sample. Thus, further exploration of the attitudes towards school of autistic children is warranted within a larger sample.

It is important to consider the impact of situational specificity which posits that children’s behaviour varies depending on the context (Achenbach et al., 1987). This is particularly important to consider when interpreting findings that directly relate to other contexts including attitudes towards school and engagement with peers which relate to the child’s behaviours outside of their familiar home environment. For example, Clark et al. (2019) reiterates the value of multi-informant perspectives whereby each respondent provides an inherently different perspective based on experience. Despite efforts to obtain parent and teacher reports, only parent data could be reported due to low response rates from teachers. Thus, despite the children being of school-age, information from the school context was not available which would have been valuable in interpreting the study findings. Unlike teachers who are present in the school environment and able to observe children’s peer interactions, it is difficult for parents to report on their child’s social experiences at school, as parents are not privy to the social interactions that occur in the school setting. Therefore, when commenting on peer interactions and play, parents were asked to report any interactions they had observed between their child and other children/siblings in the community. As such, the information provided by parents needs to be considered within the context of several factors such as the child’s opportunity to engage with other children, the presence of near age siblings or cousins within the family and whether there are multiple autistic children in the family unit. The addition of an observational measure of play skills would supplement parental report providing a more in-depth picture of children’s social functioning within the context of an unstructured peer interaction in the school setting. Further to this, it is unclear how the school environment shapes children’s positive and negative behaviours which proved beyond the scope of this study. While investigations into children’s attitudes towards school is an important first step in gauging a child’s experience within their school environment, further work is needed to understand how a child on the autism spectrum interacts within their classroom and playground environments, and the subsequent impact on behaviour, learning and peer interactions. With new evidence suggesting that sensory aspects of the physical environment (noise and lighting) can impact the learning and engagement of students on the autism spectrum (Dargue et al., 2021) and that sensory difficulties are a leading barrier to participation (Ismael et al., 2018), the impacts of the environment may extend beyond engagement with learning, potentially impacting behaviour and social outcomes of autistic students.

Parents provide reliable valid reports on their child’s skills and abilities and are often used as a proxy to report on their child’s feelings (Achenbach et al., 1987; Clark et al., 2019). Yet, it is children themselves who are arguably best equipped to comment on internal, subjective experiences and attitudes (Egilson et al., 2017). However, as the current study relied on single reports from parents to capture attitudes towards school, the current study reflects parents’ perception of their child’s attitudes towards school, based on information communicated to them by their child, the child’s teacher, or from their own observations. To that end, research is beginning to provide adults (Teti et al., 2016) and autistic children a much-needed voice in the literature (Clark & Adams, 2020; Goodwin, 2019). The past decade has seen a push within autism research to increase the uptake of self-report methodology, to include the lived experiences of autistic individuals who are able to provide valid and reliable accounts of their own perceptions and experiences (Shipman et al., 2010). Importantly, future research exploring the attitudes and experiences of autistic children should seek to engage the children themselves directly in the research process, rather than relying solely on parent report.

Autistic children in receipt of community-based EI continue to display moderate to low levels of adaptive behaviour, social skills, and peer play behaviours as they begin their schooling years. Children who received community-based G-ESDM intervention were indistinguishable from those who received standard community provisions for ASD on their adaptive behaviours, social skills, attitude towards school and problem behaviours at school age. However, the level of play disruption was found to be significantly higher amongst the comparison children, despite no differences in play interaction or disconnection at this age.

Overall, the school-aged autistic children studied here experienced continued difficulties despite receipt of EI during their preschool years, emphasizing the need for ongoing supports at school. It is important to consider the current findings in the context of several unknown factors which may have impacted the outcomes of children in this study. Further replication is needed to confirm the current school-aged outcomes of children following cessation of EI.