Picture Schedules Create Smoother Transitions for Children with Autism Spectrum Disorder

Transcription

1 Picture Schedules Create Smoother Transitions for Children with Autism Spectrum Disorder 1 Prepared by: Mykal Fenley, OTS-3, University of Oklahoma Health Science Center Carrie A. Ciro, PhD, ORT/L mykal-fenley@ouhsc.edu Date: 09/06/11 CLINICAL SCENARIO: In everyday life, transitions, moving from one activity to another activity, occur multiple times without conscious and attention from typically developing children and adults. Children with Autism Spectrum Disorder (ASD) or Pervasive Developmental Disorder (PDD) often have difficulties making transitions secondary to resistance to environmental or routine changes coupled with difficulties related to receptive and expressive communication (Dooley, Wilczenski, & Torem, 2001). Smooth transitions become extremely important when considering children in preschool and primary grade school spend up to 25% of the school day in transitions, moving from one activity to the next (Schmit, Alper, Raschke, & Ryndak, 2000). Utilizing the time taken to get between activities impacts the child s time spent actually participating in activities and learning opportunities. Children with ASD and PDD may benefit from a means of communicating expectations and anticipated changes to allow smoother transitions. A picture schedule (example below) showing the expected activities of the day are used with many children with developmental delays, however limited research has been done to show the effectiveness of such visual support systems. FOCUSED CLINICAL QUESTION: Do picture schedules create smoother transitions between activities of school aged children with Autism Spectrum Disorder (ASD) or Pervasive Developmental Disorder (PDD)?

2 2 SUMMARY of Search, Best Evidence appraised, and Key Findings: Reports from three studies are included in this review. Two articles focused on measuring the number of tantrum behaviors occurring during transitions (Schmit et al., 2000; Dooley et al., 2001). One article focused on the duration in seconds required to transition between activities (Dettmer, Simpson, Myles, & Ganz, 2000). All three studies focused on school aged children with ASD who had problems transitioning in the school environment. The studies used a picture/photograph schedule system to reduce problems occurring during the transitions during the school day. CLINICAL BOTTOM LINE: Three single subject studies observing four different children with ASD showed that children with ASD benefit from a picture schedule to smooth transitions by decreasing the time required to stop one activity and begin the next as well as problem behaviors that arose when the child was required to transition to a new activity. Limitation of this CAT: This critically appraised paper (or topic) has been peerreviewed by only one other independent professor. SEARCH STRATEGY: Terms used to guide Search Strategy: Patient/Client Group: School aged children with Autism Spectrum Disorder Intervention (or Assessment): Using a picture schedule Comparison: N/A Outcome(s): Smooth transitions between activities Databases and sites searched Medline PsychInfo ERIC Cochrane Google Scholar Search Terms autism picture schedules photograph schedules transitions children Limits used Studies using picture/photograph schedules School aged children with ASD or PDD Addressing transition times Published in previous 12 years ( )

3 3 INCLUSION and EXCLUSION CRITERIA Inclusion: Studies investigating the effectiveness of using a picture/photograph schedule with school aged children transitioning between activities. The children had to have a diagnosis of ASD or PDD. The children with PDD were included because, young children with PDD and ASD have more similarities than differences relating to behavior and transitions and ASD is a subdivision of PDD. Exclusion: Studies looking into the effectiveness of picture schedules related to anything outside of transitions between activities. Studies looking at adults or children with developmental delays other than ASD or PDD were not included. RESULTS OF SEARCH Table 1: Summary of Study Designs of Articles retrieved Study Design/ Methodology of Articles Retrieved Level Number Located Author (Year) Single Subject Study Design 4 8 Bryan & Gast (2000) Dettmer et al. (2000) Krantz et al. (1993) MacDuff et al. (1993) O Reilly et al. (2005) Schmit et al. (2000) Watanabe & Sturmey (2003) Review (Literature) 1 2 Banda & Grimmett (2008) Stromer et al. (2006) Case-Study N/A 1 Dooley et al. (2001) BEST EVIDENCE The following study/paper was identified as the best evidence and selected for critical appraisal: Schmit et al. (2000); Dooley et al. (2001); Dettmer et al. (2000). Reasons for selecting these studies were: Included school aged children with a diagnosis of Autism Spectrum Disorder or PDD Addressed transitions between activities Used some type of picture/photograph schedule as the intervention to prompt transition to the next activity

4 4 SUMMARY OF BEST EVIDENCE Table 2: Article Review Dooley et al. (2001) Objective of the Study: Examine the effectiveness of the Picture Exchange Communication System (PECS) as a behaviour support plan to resolve behavior issues displayed by a boy with PDD Study Design: Case Study Setting: Special education preschool 5 days per week Participants: A 3 year old boy named Chris with a diagnosis of PDD. He was referred for an evaluation secondary to dangerous and disruptive behaviors consisting of hitting, kicking, biting, crying, and screaming. Testing indicated he had strengths in nonverbal reasoning skills and weaknesses in attention, communication, and behavioural challenges. Intervention Investigated Classroom teacher and assistant administered the picture schedule system in the classroom (the article does not clarify who trained the teacher and assistant). Observations were made by a graduate student and behavioral consultant. Participant and assistant reviewed schedule board at beginning of day. He then pulled the first Velcro picture off and proceeded to the activity. During the first 6 days of intervention, Chris was given a pretzel reward upon completion of the activity; The pretzel reward was withdrawn after 6 days. Transitions were signalled by the lights turning off and on. Chris would return to the board to see which activity was next. Outcome Measures Counting observation the number of problem bahaviors during transitions. Main Findings: Table 3: Child Outburst During Transitions Total Days Total Outburst Avg. Outburst/Day Baseline Intervention Phase Intervention Phase Disruptive and aggressive behavior decreased from 13/day during a 2 day baseline, to 10 total over a 6 day period during the first phase of intervention, and 2 total during the second phase of intervention lasting 9 days. Withdrawing the pretzel reward had no negative effects on behavior.

5 5 Original Authors Conclusions Chris s aggressive behaviors during transitions were secondary to a breakdown in language and communication ability. The picture schedule allowed Chris more control because he was better informed of what to expect next. Critical Appraisal: Validity The measures used are not validated. This behavioural assessment was scored by observation and lacked validation. Without established psychometrics there is risk for the integrity of outcomes. Validity can also be compromised in a single subject research design with varying time periods for the baseline and intervention periods. This compromise can occur because the change noted in a longer intervention might also be reflected in a longer baseline period. Reliability: The authors calculated the interobserver agreement by dividing the number of agreements by the number of agreements plus disagreements. Agreement was always equal to 100%. Interpretation of Results The article shows the effectiveness of using a picture schedule with a child who has problematic transitions; however, the information is not readily generalizable to other children due to the limited statistics, decreased sample size, and non-experimental design. Summary/Conclusion: The article supports the use of picture schedules with children with PDD but lacks a high level of evidence or generalizability. Further research is needed to confidently apply this technique with this population of children. Schmit et al. (2000) Objective of the Study: Examine the effectiveness of photographic cueing package to signal transitions to reduce tantrums between activities in a child with ASD. Study Design: Single subject research design with multiple baselines across settings Table 4: Multiple Baseline Study Design Within Classroom Outside to Inside Classroom to Library Baseline= 6 days Baseline= 13 days Baseline= 29 days Intervention= 18 days Intervention= 16 days Intervention= 4 days Maintenance= 13 days Maintenance= 10 days Maintenance= 6 days Setting: The study was conducted over 39 days in the early childhood special education classroom where Alex attended class 4 days per week and on the school playground.

6 6 Participants: A 6 year old boy named Alex with a diagnosis of ASD. His parents are actively involved, maintaining close contact with the school and display concern for Alex s wellbeing. Alex was taking no medications at the time of the study and his parents reported they would prefer environmental modifications over medication. Alex s only verbal communication at the time of the study was using the word no when he wanted more space from an adult or child or did not want to participate in an activity. Alex was being taught to use a Picture Exchange for four months prior to the study and at the time of the study he was using cards at home and school. Intervention Investigation -Nine transition periods during the school day (3 occurred from activity to activity in the classroom, 3 occurred from outside to inside the building, and 3 occurred from inside the classroom to another part of the building) -Alex was given 5 seconds to stand and begin the transition to the next activity when given the verbal cue Time to go to during baseline -He was physically guided by providing support around the waist if he did not respond -intervention presented Alex a 35-mm photograph in front of his face representing the next activity with a paired verbal cue, Time to go. -The instructor waited and observed Alex s behavior 5 seconds, then recorded his response as compliance or tantrum (both terms are defined in depth under the Target Behavior section of the article). Outcome Measures Data was collected by observation and recording of tantrum or compliance within the 5 seconds given for a transition. The classroom teacher observed and recorded data. The data used was that collected by the classroom teacher. To check reliability the special education program associate independently watched and recorded 18 of the transitions or 7.14% of all transitions. The reliability data is discussed under the Validity section of this paper. Main Findings: -Tantrum behavior decreased during transitions when using photographic cueing -Best results were observed inside the building with transitions; greater problems with transitions were observed from outside to inside and is suspected to be secondary to Alex s enjoyment of outdoor activities and desire to remain outdoors playing.

7 7 Mean scores for transitions creating tantrums: Within Classroom Baseline M=2.83 Intervention M=0.23 Maintenance M=0.17 Outside to Inside- Baseline M=2.62 Intervention M=0.84 Maintenance M=0.50 Classroom to Library- Baseline M=2.5 Intervention M=0 Maintenance M=0 *M=average number of tantrums Table taken from Schmit et al., 2000, p. 135 Original Authors Conclusions -Alex s tantruming reduced when he was given advance notice of a transition by combining verbal and photographic cues. -The authors concluded that advance warning to a transition and change of activity can help a person with ASD prepare to make the transition resulting in reduced inappropriate behaviors.

8 8 Critical Appraisal: Validity The measures used are not validated. This behavioural assessment was scored by observation and lacked validation. Without established psychometrics there is risk for the integrity of outcomes. Validity can also be compromised in a single subject research design with varying time periods for the baseline and intervention periods. This compromise can occur because the change noted in a longer intervention might also be reflected in a longer baseline period. Reliability: The authors calculated the interrater reliability by taking the number of agreements and dividing by the number of agreements plus disagreements, multiplied by 100. The reliability between the teacher and program associate s observations was 100%. Interpretation of Results The article shows the effectiveness of using photographic cueing with a child with ASD who has tantrums during transitions; however, the information is not readily generalizable to other children due to the limited statistics, decreased sample size, and non-experimental design. Summary/Conclusion: The article supports the use of photographic cueing with children to signal transitions but lacks a high level of evidence or generalizability. Further research is needed to confidently apply these to techniques within this population of children. Dettmer et al. (2000) Objective of the Study: Analyze the effectiveness of visual supports in decreasing the amount of time spent transitioning between activities for two children with ASD. Study Design: Single subject reversal design (ABAB) Table 5: Number of Sessions* in each Phase: Jeff Josh Baseline Intervention Baseline Intervention *Each Session contained multiple opportunity for transitions. Setting: A. Conducted during community activities B. Conducted during educational sessions in the home

9 9 Participants: 1. Jeff, age 7, has a diagnosis of ASD and was observed to and reported by caregiver to have problems with transitions between activities. Jeff s communication was primarily delayed and immediate echolalia. He would repeat instructions that were given to him or repeat lines from cartoons he had watched. Jeff had minimal experience with picture schedules prior to the study. Caregivers and other adults involved in Jeff s life reported that he appeared to have a difficult time realizing when one activity was over and it was time to begin the next. His caregiver frequently would have to physically move him to the next activity. 2. Josh, age 5, has a diagnosis of ASD and was observed to and reported by caregiver to have problems with transitions between activities. Josh s speech consisted of three to five word sentences but required cueing to do so. He did not initiate spontaneous communication. Josh had difficulty transitioning between activities, especially when asked to stop a favored activity. He would often display self-stimulating activities when asked to transition. He had limited experience with a picture schedule prior to beginning the study. Intervention Investigated -During baseline the children were provided with (a) verbal prompts, (b) physical prompts, and (c) proximity control (inferred to mean keeping child in activity location) -During intervention (d) visual prompts were added to the above prompts. -Several transitions occurred during each session -Each participant was allowed 1 minute to initiate movement toward the next activity signalling a transition after given either the verbal or picture prompt; if movement toward the activity did not occur then a 2 nd verbal cue was given, after minute 3 a picture of the next activity paired with a verbal cue was given. After 10 minutes if a transition had not occurred, the child was physically moved to the next activity. 1. Intervention for Jeff occurred in the community. The dash of the car was equipped with a Velcro picture schedule displaying the events for the day. His caregiver was also equipped with a portable schedule in the form of an album with the same pictures as the care schedule representing the order of activities for the day. 2. Intervention for Josh occurred in his home while engaging in an educational program used in the home. The caregiver had a Velcro strip schedule displaying all the activities to be performed. While doing work time activities, Josh had notecards with activities listed and upon completion they were placed in a finished box. Third, a timer was displayed in Josh s viewing that showed the allotted time left per activity. Outcome Measures Frequency counts were used by observers to score the number of prompts given by the caregiver and the number of removals from a setting. Observers collected latency data using a stopwatch to record the time latency between prompts and child initiation of movement toward an activity.

10 10 Main Findings: 1. Jeff s average time latency from verbal cue until beginning a new activity were: -Baseline -6.2 minutes -Intervention minutes -Baseline -7.5 minutes -Intervention minutes Figure taken from Dettmer et al., 2000, p. 165

11 11 2. Josh s average time latency from verbal cue until beginning a new activity were: -Baseline -2.5 minutes -Intervention minutes -Baseline -2.3 minutes -Intervention minutes Figure taken from Dettmer et al, 2000, p Jeff s number of physical removals -Baseline -14 -Intervention 1-2 -Baseline -2 -Intervention Josh s number of physical removals -Baseline -0 -Intervention 1-0 -Baseline -0 -Intervention 2-0 Original Authors Conclusions -The study reinforces previous research suggesting visually oriented interventions have positive effects when used with students who have ASD. -The authors propose that caregivers and educators can have reasonable confidence that visual supports are useful tools

12 12 -Visual supports are a basic tool that has been shown to have positive effects when used with children with ASD and are generally inexpensive and easy to implement. Critical Appraisal: Validity The measures used are not validated. This behavioural assessment was scored by observation and lacked validation. Without established psychometrics there is risk for the integrity of outcomes. Validity can also be compromised in a single subject research design with varying time periods for the baseline and intervention periods. This compromise can occur because the change noted in a longer intervention might also be reflected in a longer baseline period. Reliability: The interobserver agreement data was collected on 15% of all observations. The authors calculated the interobserver reliability by taking the number of agreements and dividing by the number of agreements plus disagreements, multiplied by 100. The authors defined an agreement by all observers independently recording the same time latency within a range of 1-3 seconds. The interobserver reliability was 95%. Interpretation of Results The article shows the effectiveness of using visual supports with children with ASD who have problematic transitions; however, the information is not readily generalizable to other children due to the limited statistics, decreased sample size, and nonexperimental design. Summary/Conclusion: The article supports the use of visual supports with children to signal transitions but lacks a high level of evidence or generalizability. Further research is needed to confidently apply these to techniques within this population of children. Table 6 : Characteristics of included studies Study 1 Study 2 Dooley et al. (2001) Schmit et al. Intervention investigated Comparison intervention Outcomes used Findings Picture schedule and pretzel reward to transition between activities (2000) Picture schedule to transition between activities N/A N/A N/A Behavior assessment and Observation Problematic behavior reduced when picture schedules were used during transition for a child with PDD. Observation and counting number of tantrums Tantrums during transitions between activities decreased when using a picture schedule. Study 3 Dettmer et al. (2000) Picture schedule to transition between activities Time latency using a stopwatch and observation Time latency transitioning between activities decreased when using visual

13 13 supports. IMPLICATIONS FOR PRACTICE Picture schedules, photograph schedules, and activity schedules are all phrases used to describe a type of visual schedule and cueing that are frequently used with children diagnosed with ASD and other developmental delays. The visual schedules allow a child who has limited communication to understand expectations and anticipate transitions before they are to be made. The notification of upcoming changes and expectations has been shown to decrease problem behaviors that arise because of the transitions (Banda & Grimmett, 2008; Dooley et al., 2000; Dettmer et al., 2000; Schmit et al., 2000). Visual supports are a form of inexpensive support system that can be easily implemented to various settings and have been shown to have a positive impact on children with ASD, PDD, and other developmental disabilities (Dettmer et al., 2000; Schmit et al., 2000). Another positive aspect of visual supports is the ability to individualize the plan of support to each child with little difficulty (Dettmer et al., 2000). However, picture schedules are a highly utilized tool with a limited amount of research and low evidence for the research that does exist (Dettmer et al, 2000). Most of the research showing the success of visual supports for children with ASD are single subject research studies with limited validity because of the lack of psychometric properties to support the outcome measures that are used. EDUCATION A clinician considering the use of a visual support for a child with ASD or PDD may need continuing education to review options on varying types of visual supports that can be used. A clinician considering use of a visual support for a child with ASD or PDD may find limited resources to explore unanswered questions such as: 1. Various types of visual supports 2. The best time to implement the visual schedule and, 3. The fading of the schedule to decrease dependence on the schedule. FUTURE RESEARCH There is need for further research to address visual supports, specifically picture schedules that are used with children diagnosed with ASD or other developmental disabilities. Current research on the topic has a low level of evidence and is not generalizable to other children. A validated tool to assess the usefulness of a visual support system with a child is needed so that validity of results is stronger. Larger studies, investigating more than one subject are needed to increase the ability to generalize the information to the general population of children with ASD. Each article used in this critically appraised topic varies the way the intervention was used and presented to the child. Further research could explore standardizing the procedure and tools. Some articles argue the value of the visual supports is the ability to individualize each support to the client, but there is not any research showing the variation in results based on the type of implementation. Last, if visual supports have successful results with children with ASD, research addressing the generalizability of visual supports with other populations could strengthen the support of the supports and hopefully, widen the use of such supports across settings and across populations.

14 14 REFERENCES Banda, D.R. & Grimmett, E. (2008). Enhancing social and transition behaviors of persons with autism through activity schedules: A review. Education and Training in Developmental Disabilities 43, Bryan, L.C. & Gast, D.L. (2000). Teaching on-task and on-schedule behaviors to highfunctioning children with autism via picture activity schedules. Journal of Autism and Developmental Disorders, 30, Dettmer, S., Simpson, R.L., Myles, B.S., & Ganz, J.B. (2000). The use of visual supports to facilitate transitions of students with autism. Focus on Autism and Other Developmental Disabilities, 15, Dooley, P., Wilczenski, F.L., & Torem, C. (2001). Using an activity schedule to smooth school transitions. Journal of Positive Behavior Interventions, 3, Krantz, P.J., MacDuff, M.T., & McClannahan, L.E. (1993). Programming participation in family activities for children with autism: Parents use of photographic activity schedules. Journal of Applied Behavior Analysis, 26, MacDuff, G.S., Krantz, P.J., & McClannahan, L.E. (1993). Teaching children with autism to use photographic activity schedules: Maintenance and generalization of complex response chains. Journal of Applied Behavior Analysis, 26, O Reilly, M., Sigafoos, J., Lancioni, G., Edrisinha, C., & Andrews, A. (2005). An examination of effects of a classroom activity schedule on levels of self-injury and engagement for a child with severe autism. Journal of Autism and Developmental Disorders, 35, Schmit, J., Alper, S., Raschke, D., & Ryndak, D. (2000). Effects of using a photographic cueing package during routine school transitions with a child who has autism. Mental Retardation, 38,

15 15 Stromer, R., Kimball J.W., Kinney, E.M., & Taylor, B.A. (2006). Activity schedules, computer technology, and teaching children with autism spectrum disorders. Focus on Autism and Other Developmental Disabilities, 21, Watanabe, M. & Sturmey, P. (2003). The effect of choice-making opportunities during activity schedules on task engagement of adults with autism. Journal of Autism and Developmental Disorders, 33,