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Manipulation of the Situation or Contingencies to Promote Interaction
Integrated Play Groups.During integrated play groups, as used by Wolfberg and Schuler (1993,1999), an adult provides a structured environment and guides participation between children with autism and socially competent peers. A key facet of this approach involves providing a supportive environment to optimize interaction rather than using adult direction. Other important components of this method are a natural integrated setting, well-designed play spaces that take into account accessibility and size, and play materials that promote interaction. Integrated play groups also typically establish a consistent schedule and routine, use a small number of familiar peers, and match play activities to the child's developmental level (Wolfberg & Schuler, 1993). An adult monitors the play situation for evidence of developing play skills, interprets for and coaches the peers, and encourages the children to engage in activities slightly more advanced than their current abilities (Wolfberg & Schuler, 1999). In addition, the adult encourages the target child to engage in and maintain interaction by using prepared cues, such as posters, when the child seems uncertain. Such prompts are faded as the child begins to incorporate the strategies on his or her own.
Wolfberg and Schuler (1993) used a multiple-baseline design for three target participants in three different integrated play groups. All children were 7-year-old boys diagnosed with autism who had very little appropriate play, participated in a high degree of repetitive play, and had little to no language. All participants nearly doubled the amount of interaction with peers involving attention to a common activity in the final treatment condition. All participants also engaged in less repetitive play and more functional play, and all but one child engaged in more pretend play. Parents and teachers reported similar improvements outside the experimental setting, indicating some social validity and generalizability. However, there is no evidence that parents were kept blind to study hypotheses. In addition, initial behavior gains were not maintained when treatment was withdrawn. Although this is evidence that the behavior gains were due to the treatment, it also demonstrates that the treatment effect was dependent on adult support.
Roeyers (1996) also examined the possible impact of integrated play groups. However, in his study, the typically developing peers were informed about autism, and each was assigned to a target child; in addition, adults were less involved. Roeyers randomly assigned 85 children diagnosed with autistic disorder or pervasive developmental disorder not otherwise specified to an experimental or control group. All children were between 5 and 13 years of age and lived in the Dutch-speaking part of Belgium, but information on their level of impairment was not provided. The experimental group significantly increased the amount of time spent in interaction, increased the length of sustained interaction, increased their degree of responsiveness to the partner's initiations, increased the number of social initiations made, and decreased the amount of time spent in self-stimulatory behavior compared with the control group. Most increases represented a change of 20% or more over behavior prior to the intervention. However, despite these positive results, the interactions of the target children remained inconsistent and idiosyncratic.
Peer Buddy and Peer Tutor Approaches. Peer buddy and peer tutor approaches focus on dyads with one typically developing peer and one child with autism, rather than a group of children. Peer buddy approaches involve assigning each child with autism to a buddy, who is told to stay with, play with, and talk to the child with autism. Laushey and Heflin (2000) investigated this approach with two 5-year-old children diagnosed with an autism spectrum disorder. Both children had some language and could read at the kindergarten level but experienced social difficulties. Using a reversal design, the results indicated that the children with autism increased their social interaction 36% and 38% during the treatment phase, as compared with the baseline phase, in which children were integrated but not assigned a buddy.
Peer tutoring approaches consist of tutor-learner pairs and promote the incidental learning of social behaviors through natural interactions. Peer tutoring approaches have generally been studied with high-functioning school-aged children with autism (Kamps et al., 1994; Kamps, Dugan, Potucek, & Collins, 1999). Kamps et al. (1994) examined the peer tutoring approach using a multiple-baseline-across-participants-with-reversal design. Participants included three 8- and 9-year-old boys with autism, who were high functioning in terms of language and intellectual abilities but lacked social competence, and all other children in a third-grade classroom. Each week, students were assigned a different tutoring partner. Tutoring produced increases in interaction from 80 to 120 seconds per 5-minute sample for the three children with autism. In addition, the mean interaction time of peers increased, and the children with autism displayed improved academic achievement.
Kamps et al. (1999) studied a slight variation of the peer tutoring approach
by having moderate-to high-functioning school-age children with autism tutor
typically developing first-grade students who were experiencing academic difficulties.
An ABAB withdrawal design with replication was used to examine the impact of
three 9-year-old children with autism and five fourth-grade girls
tutoring six first-grade students. All three children had higher mean free
time social interaction following the peer tutoring. In addition, the first-grade
children who were tutored improved academically compared to those who were
not tutored. A second part of this study used the same tutoring program with
four 10- to 12-year-old children with autism as tutors. The results
were similar but more variable and less dramatic.
The group contingency method has been found to increase social interactions of 4- to 6-year-old children with autism (Kohler et al., 1995; Lefebvre & Strain, 1989). Kohler et al. used group-oriented contingencies with three 4-year-old children with autism and six typical peers ranging in age from 3 to 4 years. Prior to the study, none of the children with autism engaged in more than occasional interactions with peers, and only one child used appropriate play skills. A withdrawal-of-treatment design was used with alternating baseline, social skills training, and group contingency conditions. The classwide social skills training package was developed by Odom, Kohler, and Strain (1987) and included play organizer suggestions, share offers and requests, and assistance offers and requests. The class-wide supportive skills training included reminding one another to use these skills. The amount of time that children with autism and their peers engaged in social interaction increased from 28% to 65% during group-oriented contingency conditions. However, rates of interaction remained variable. Peer prompts ranged from 2.6 to 7.6 times per session during group-oriented contingencies but returned to zero during baseline phases. In addition, social interactions in which the peers used supportive prompts were longer and more reciprocal. These results occurred independent of teacher and adult praise.
Lefebvre and Strain (1989) examined the use of group-oriented contingency in a similar withdrawal-of-treatment design with three children with autism ranging in age from 4 to 6 years. The social skills training targeted specific behaviors, including: say your friend's name, face him or her, keep trying, ask for a toy and hold out your hand, listen and help, give a toy to your friend by placing it in his or her hand, and remember to give the requested toy. Group-oriented contingencies following the social skills training produced a higher rate of interaction than that found at baseline. However, there was considerable fluctuation in the amount of interaction that the three target children engaged in.
Peer Instruction in Social Interaction Strategies to Promote
Peer Networks.Peer networks are based on the premise that an enhancement of peer understanding of, and interest in, children with disabilities will promote increased interactions. Peer network interventions thus develop a social support network by soliciting an intact group of peers to provide support for individuals with disabilities. Helping peers better understand and support children with autism is important because, as McEvoy and Odom (1987) noted, children with disabilities who have received training on how to interact with their peers will be successful only if there are receptive peers with whom to interact.
Two studies have used this approach with school-aged children (Garrison-Harrell, Kamps, & Kravitz, 1997; Kamps, Potucek, Lopez, Kravitz, & Kemmerer, 1997). Garrison-Harrell et al. used a multiple baseline design to investigate this method across three 6- to 7-year-old students who were diagnosed with autism. All target children were nonverbal or had minimal communication ability. Fifteen typical first-grade students were included in three peer networks of five peers per target child. Peers were taught how to use the target child's augmentative communication system; in addition, they were taught social skills, including initiating conversation, responding to conversation, giving compliments, sharing, providing instructions, and maintaining conversations. The target children then spent 20 minutes with their peer networks in three different settings, which were individualized to match the target child's interests. Following the intervention, peers reported higher acceptance of the students, and the target students increased the frequency and duration of their interactions across settings. However, these researchers did not test generalization to other settings. Kamps et al., using a similar strategy and sample, reported that the intervention improved interaction time for target students, and that the results generalized to nonintervention settings for two of the three children.
Haring and Breen (1992) used the peer network approach with two 13-year-old boys, one with autism and one with moderate mental retardation and severe language delay. Similar to the above studies, peers were taught how to initiate interactions with, reinforce, and prompt responses from target students. However, in this study adults also taught appropriate responses to target students, and one target child was taught to use a self-monitoring system. The results indicated an increased frequency of appropriate social interactions in nonstructured contexts. In addition, the peer network members reported improved attitudes and ratings of friendship toward the students with disabilities.
Pivotal Response Training.Pivotal response training, as described by Pierce and Schreibman (1995,1997a, 1997b), involves using role-play techniques to teach peers how to provide target children with social reinforcement, including paying attention, letting the child choose, varying toys, modeling appropriate social behavior, reinforcing attempts, encouraging conversation, extending conversation, taking turns, providing narration for play activities, and teaching responsivity to multiple cues. The approach is expected to increase social behaviors by providing multiple models who incorporate the target child's preferences in natural or loosely controlled contexts (Pierce & Schreibman, 1995).
Pierce and Schreibman (1995,1997a, 1997b) tested this model in three studies using multiple-baseline designs. Participants in the first study were two 10-year-old children with autism who were socially nonresponsive and who had expressive verbal abilities similar to a typical 3-year-old's (Pierce & Schreibman, 1995). After several weeks of intervention, both children began to initiate play and social conversation with the trained peer, and these gains were maintained during a follow-up period. There was evidence of some response generalization, but only one child generalized to untrained peers. Two other studies involving 7- and 8-year-old children with autism (Pierce & Schreibman, 1997a, 1997b) yielded similar results, with less repetitive play and increased social conversation. Interactions with untrained peers reached levels near 100% after treatment, compared with near-zero levels at baseline, a change that is clinically as well as statistically significant (Pierce & Schreibman, 1997b).
Peer Initiation Training. The goal of teaching peers techniques for initiating interactions is that the children with autism will then be involved in more interactions in which they can receive reinforcement for appropriate responses. One line of research teaches typical peers to initiate "play organizers," which includes such things as share offers and requests, assistance offers and requests, and strategies to gain the target child's attention. In addition, peers are taught how to appropriately use affection and complimentary statements with children with autism.
This approach has been evaluated for use with preschool-aged children (e.g., Goldstein, Kaczmarek, Pennington, & Shafer, 1992; Kohler, Strain, Maretesky, & DeCesare, 1990; Odom & Strain, 1986; Odom & Watts, 1991; Sainato, Goldstein, & Strain, 1992). Odom and Watts used a multiple-baseline design to investigate the utility of the peer initiation training approach with three children with autism between the ages of 3 and 5 years. All children engaged in infrequent social interactions and had communication abilities ranging from the 9- to 35-month levels. Four preschool-aged typically developing children received the peer-initiation intervention as described above. Though there was considerable variability across participants, the children with autism substantially increased their interactions during the intervention phase when teachers prompted the peers to use the initiation strategies. Odom and Watts also examined the impact of adding correspondence training/ visual feedback in which the teacher provided reinforcement to the peers when they used the initiation strategies by giving a visual cue during the play session and providing a tangible reward following the play session. This feedback intervention, combined with the peer-initiation intervention, produced increased engagement from the children with autism in a setting where adults gave verbal prompts to the peers and a setting in which they only gave feedback. However, the peer initiation intervention alone without verbal prompts from teachers regarding initiation did not lead to increases in social interactions. Sainato et al. similarly found that teaching the peers initiation strategies was not enough to ensure that they would use them.
Though peer-initiation strategies have had success in increasing the social
interactions of preschool-aged children with autism, those interactions
have consisted primarily of responses, rather than social initiations (Odom & Strain,
1986; Odom & Watts, 1991; Sainato et al., 1992). Using a modification of
the peer-initiation intervention developed by Odom and Strain, Mundschenk and
Sasso (1995) investigated use of this strategy with 7- to 10-year-old children
with autism. As in previous studies, peer initiations were found to
increase the responses of the children with autism. In addition, responding
generalized to non-trained peers when at least three trained peers were present.
Peer-initiation training was also found to increase the rate of initiations
by the children with autism from 2% to 7%. However, because the children
with autism were not specifically taught social initiation
and response skills, their interactions remained idiosyncratic.
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Table of Contents
Autism, Ahead of Print.
Using a cross-sectional survey of 673 multidisciplinary autism spectrum disorder providers recruited from five different sites in the United States, we examined the frequency with which community-based providers inquire about, screen, and treat trauma-related symptoms in their patients/students and assessed their perceptions regarding the need for and barriers to providing these services. Univariate and bivariate frequencies of self-reported trauma service provision, training needs, and barriers were estimated. Multivariable logistic regressions identified provider and patient-related factors associated with trauma-related symptoms screening and treatment. Over 50% of providers reported some screening and treatment of trauma-related symptoms in youth with autism spectrum disorder. Over 70% informally inquired about trauma-related symptoms; only 10% universally screened. Screening and treatment varied by provider discipline, setting, amount of interaction, and years of experience with autism spectrum disorder, as well as by patient/student sex, ethnicity, and socioeconomic status. Most providers agreed that trauma screening is a needed service impeded by inadequate provider training in trauma identification and treatment. The findings indicate that community providers in the United States of varied disciplines are assessing and treating trauma-related symptoms in youth with autism spectrum disorder, and that evidence-based approaches are needed to inform and maximize these efforts.
Autism, Ahead of Print.
Obsessive–compulsive disorder and autism spectrum disorder commonly co-occur. Adapted cognitive behavior therapy for obsessive–compulsive disorder in adults with autism spectrum disorder has not previously been evaluated outside the United Kingdom. In this study, 19 adults with obsessive–compulsive disorder and autism spectrum disorder were treated using an adapted cognitive behavior therapy protocol that consisted of 20 sessions focused on exposure with response prevention. The primary outcome was the clinician-rated Yale–Brown Obsessive–Compulsive Scale. Participants were assessed up to 3 months after treatment. There were significant reductions on the Yale–Brown Obsessive–Compulsive Scale at post-treatment (d = 1.5), and improvements were sustained at follow-up (d = 1.2). Self-rated obsessive–compulsive disorder and depressive symptoms showed statistically significant reductions. Improvements in general functioning and quality of life were statistically non-significant. Three participants (16%) were responders at post-treatment and four (21%) were in remission from obsessive–compulsive disorder. At follow-up, three participants (16%) were responders and one (5%) was in full remission. Adapted cognitive behavior therapy for obsessive–compulsive disorder in adults with co-occurring autism spectrum disorder is associated with reductions in obsessive–compulsive symptoms and depressive symptoms. However, outcomes are modest; few patients were completely symptom free, and treatment engagement was low with few completed exposures and low adherence to homework assignments. We identify and discuss the need for further treatment refinement for this vulnerable group.
Autism, Ahead of Print.
Parent–Child Interaction Therapy is an empirically based, behavioral parent training program for young children exhibiting disruptive behaviors. Parent–Child Interaction Therapy shows promise for treating disruptive behaviors in children with autism spectrum disorder. Treatment processes (i.e. treatment length and homework compliance), parenting skills, parenting stress, and behavioral outcomes (i.e. disruptive and externalizing behaviors and executive functioning) were compared in 16 children with autism spectrum disorder and 16 children without autism spectrum disorder matched on gender, age, and initial intensity of disruptive behaviors. Samples were statistically similar in terms of child receptive language, child race and ethnicity, parent age, gender and education, and number of two-parent families in treatment. Families received standard, mastery-based Parent–Child Interaction Therapy. Both groups demonstrated significant and clinically meaningful improvements in child disruptive and externalizing behavior and executive functioning, parenting skills, and parenting stress. Length of treatment, homework compliance, and parent and child outcomes did not differ significantly between groups. A subset of children with autism spectrum disorder also showed significant improvements in social responsiveness, adaptive skills, and restricted/repetitive behaviors. This study replicates and extends prior research by demonstrating that children with and without autism spectrum disorder experience similar benefits following Parent–Child Interaction Therapy. Findings may expand the availability and dissemination of time-limited, evidence-based interventions for autism spectrum disorder and comorbid disruptive behaviors.
Autism, Ahead of Print.
A retrospective data analysis using 2004–2014 Healthcare Cost and Utilization Project Nationwide Inpatient Sample was conducted to examine in-hospital mortality among adults with autism spectrum disorders in the United States compared to individuals in the general population. We modeled logistic regressions to compare inpatient hospital mortality between adults with autism spectrum disorders (n = 34,237) and age-matched and sex-matched controls (n = 102,711) in a 1:3 ratio. Adults with autism spectrum disorders had higher odds for inpatient hospital mortality than controls (odds ratio = 1.44, 95% confidence interval: 1.29–1.61, p < 0.001). This risk remained high even after adjustment for age, sex, race/ethnicity, income, number of comorbidities, epilepsy and psychiatric comorbidities, hospital bed size, hospital region, and hospitalization year (odds ratio = 1.51, 95% confidence interval: 1.33–1.72, p < 0.001). Adults with autism spectrum disorders who experienced in-hospital mortality had a higher risk for having 10 out of 27 observed Elixhauser-based medical comorbidities at the time of death, including psychoses, other neurological disorders, diabetes, hypothyroidism, rheumatoid arthritis collagen vascular disease, obesity, weight loss, fluid and electrolyte disorders, deficiency anemias, and paralysis. The results from the interaction of sex and autism spectrum disorders status suggest that women with autism spectrum disorders have almost two times higher odds for in-hospital mortality (odds ratio = 1.95, p < 0.001) than men with autism spectrum disorders. The results from the stratified analysis also showed that women with autism spectrum disorders had 3.17 times higher odds (95% confidence interval: 2.50–4.01, p < 0.001) of in-hospital mortality compared to women from the non–autism spectrum disorders matched control group; this difference persisted even after adjusting for socioeconomic, clinical, and hospital characteristics (odds ratio = 2.75, 95% confidence interval: 2.09–3.64, p < 0.001). Our findings underscore the need for more research to develop better strategies for healthcare and service delivery to people with autism spectrum disorders.
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