An Exploration of Perseverative Behaviors in Young Children with Autism

Introduction

The Diagnostic and Statistical Manual of Mental Disorders 5 (American Psychiatric Association, 2013) characterizes an autism spectrum disorder by social communication deficiencies and stereotypical or repetitive behaviors (SRBs) (American Psychiatric Association, 2013). The National Institute of Health defines SRBs as behaviors that exhibit stereotypies, rituals, compulsions, obsessions, perseverations, or repetitive speech (Watt, Wetherby, Barber, & Morgan, 2008). Stereotypical behaviors are the third most often studied behaviors of autism (Horner, Carr, Strain, Todd, & Reed, 2002). Due to the potential for their negative impacts on learning and/or social acceptance of SRBs, it is critical to find and implement a successful intervention at the onset of the behaviors. This paper presents a case study examining the interplay of SRBs and social skills interventions with two participants during a social skills clinic.

The Importance of Early Intervention

According to Horner and colleagues (2002), it is important to decrease or eliminate SRBs at a young age before they become habitual for the individual. The Individuals with Disabilities Education Act (IDEA 2004) requires that school districts provide a service called “early intervention” to those students age four to six who have a disability or who are at risk of a disability (IDEA, 2004) in order to teach young children socially and academically appropriate behaviors. Early intervention is particularly important because interventions are more successful before a child establishes a routine of disruptive behaviors (Horner et al., 2002). Not all SRBs are considered problem behaviors; those that impact learning and/or social skills are problematic and should be addressed through intervention (Watt et. al, 2008).

A Review of the Literature

Commonly Used Interventions

In 2014 the National Professional Development Center (NPDC) on Autism Spectrum Disorder conducted research to identify all evidence based practices (EBPs) successful in reducing problem behaviors associated with autism (Wong et al., 2015). NPDC identified 27 interventions that are EBPs for intervening behaviors associated with autism. The following section presents three interventions commonly used to replace or shape SRBs that are identified as EBPs by the NPDC: response interruption, reinforcement, and prompting.

Response Interruption/Redirection

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The NPDC defines response interruption/redirection (RIR) as the process of interrupting the relationship between the response and the reinforcer (Wong et al., 2015). One study implemented RIR to replace the rearrangement of objects of three participants with autism between the ages of 13 and 15 (Rodriguez et al., 2012). The experimenter put his/her hand between the participant with autism and the object he was seeking to rearrange. If the participant persisted, the experimenter would put the participant’s hand in his lap to interrupt the engagement of rearranging. For the first and second participants, response blocking almost completely eliminated the rearranging. RIR resulted in aggression for the third participant, so the interventionist implemented alternate interventions.

Ahearn, Clark, and MacDonald (2007) used RIR to disrupt vocal stereotypy. The teacher in the study interrupted the vocal stereotypy by asking the child a direct question. The child had to answer three questions without the vocal stereotypy being replaced before the teacher would deliver praise and move on. This implementation of RIR immediately reduced the vocal stereotypy in all four of the participants. For three participants, RIR also increased appropriate vocalizations.

Reinforcement

The NPDC defines reinforcement as the relationship between a particular behavior and the consequence that follows it (Wong et al., 2015). A consequence is only reinforcement if the reinforcer increases the appropriate behavior (Wong et al., 2015). One study conducted surveys to determine the type of reinforcement maintaining children with autism’s most severe SRB (Wilke et al., 2012). Of the 39 conclusive surveys, 35 indicated that automatic reinforcement maintained the behavior. Automatic reinforcement is reinforcement that occurs independent of anyone else or the social environment (Patterson defines this as positive non-social reinforcement) (Rodriguez, Thompson, Schlichenmeyer, & Stocco, 2012).

Additionally, Liu-Gitz and Banda (2010) sought to determine what was maintaining a ten-year-old with autism’s vocal stereotypy. This study implemented a multi-element design in which attention, demand, ignore, and free play were the variables. After implementing the condition, the researchers counted vocal stereotypy occurrences that followed. The experiment found that vocal stereotypy showed little variation between the conditions, proving automatic reinforcement to be the reinforcement maintaining this SRB. Further, this study tested the RIR intervention in combination with positive reinforcement in the form of praise to encourage positive vocalizations. The results were successful in that the participant’s SRB decreased from 41% to 10%.

Prompting

The NPDC defines prompting as an intervention that involves specific procedures used to help someone practice a certain skill (Wong et al., 2014). Prompting is typically used along with reinforcement. Interventionists can implement prompts as verbal, gestural, model, physical, or visual. Simultaneous prompting is when the cue and the controlled prompt are presented at the same time. One study explored the effectiveness of simultaneous prompting on a simple command (pointing to numbers). In this study, Akmanoglu & Batu (2004) implemented prompting cards that had a single number written on each (this is a visual and a physical prompt).

The trainer would model the numbers by saying their name while pointing to them. The trainer would then give the task direction command (“Which one is three?”) and the participant would point to the correct prompting card. The researchers acknowledged correct responses with verbal praise (positive reinforcement) and ignored incorrect responses. The study found that all of the three participants experienced success with simultaneous prompting. Further, the maintenance training session (conducted at one, two, and four weeks) showed that the first participant maintained 94.6% of the behaviors, the second maintained 85.7%, and the third maintained 100%.

Because of the large evidence base supporting reinforcement, prompting, and response interruption/redirection, it was expected that the researcher would observe these interventions in the practice of the Summer Social Skills Clinic. This study explored the following questions a) what intervention is used in the clinical setting to replace/reduce SRBs prevalent in a child aged 4-6? b) how is this intervention being conducted (number of interventionists, setting, procedures, etc.) and c) what impact does the intervention have on the SRB?

Methodology

The goal of this study was to explore stereotypical repetitive behaviors (SRBs) in participants with autism and the impact of interventions on participants’ SRBs using qualitative case study. Participants were ages 4-6 and enrolled in a summer social skills clinic. Consent to participate in this study was included in parent’s consent to participate in the clinic. The study was approved through the university’s Internal Review Board process.

Case Study

The researcher employed instrumental case study for this study as a means to gain insight on a subject by studying a single case (Stake, 1995). This is a secondary means of case study, meaning the researcher is observing in a supporting role to better understand something else. This form of case study observes the setting, events, and participants in depth by recording every relevant detail. In the context of this study, the case study was instrumental because it was observing interventions applied to teach social skills to determine if there was an additional impact on SRBs. The researcher/first author’s role in this case study was observing the interventionists and participants and completing fidelity checklists at the end of each session.

Setting

The social skills clinic took place on the campus of a university located in the southern United States for nine weeks (June 2 through July 30); it met on Tuesdays and Thursdays from 1:00 to 3:00. The researcher observed every session except for the very last session (Thursday, July 30). The observed group held all sessions in a university classroom approximately 15 by 20 furnished with a computer table, an Apple computer, a built-in bookshelf, a Tupperware bucket (which served as the toy bucket), a television, and a bench. A video camera on a tripod was brought in each session in order to film certain participants for another study. For each session, toys were spread out on the carpet for “free play.” These toys included the following: Spongebob “Ants in the Pants” game, plastic colorful blocks, “Don’t Break the Ice,” a bucket of cars, plastic animals, and pieces of roads that fit together. Two weeks into the clinic, a puzzle, crayons, and a coloring book were added to the toys.

Participants

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The clinic divided participants into different groups based on age. For the purpose of this study, the researcher chose to observe a group of children ages 4-6 (the youngest group) both with ASD and without a diagnosis. From this group of eight children, the researcher chose the participants for this case study based on the stereotypies exemplified during the observations. The researcher chose not to look at the participants’ case files initially so as to eliminate any bias that may have been formed regarding the diagnosis. Names of all participants are pseudonyms.

During the first two weeks of the clinic, the researcher took general observations. On the third week, the researcher narrowed down the participants from eight to four based on participants that showed potential stereotypies or perseverations. Perseverations are defined as attempts at communication for individuals with autism, but are not meant by the individual as speech that desires a response (Arora, 2012). On the fourth week, the researcher narrowed down to two participants that showed verbal and behavioral perseverations. The two participants exhibited behaviors that were relative to those identified in the literature, and were, therefore, chosen for the study. Caleb was a five-year-old male that had demonstrated a stereotypical behavioral pattern that was classified by the researcher as a stereotypy. Mary was a five-year-old female who perseverated on numerous phrases and exemplified a fixation on names.

Others involved in the clinic included Dr. Raoul, Erik, Christine, Meg and Carlotta. Dr. Raoul was the head of the Summer Social Skills Clinic. He did not participant in the sessions with group one, but compiled the data, analyzed the data, and facilitated the entire clinic. Erik was the lead interventionist for group one who prepped the group of interventionists for each session, facilitated each group one session, and collected the data within the group. Christine, Meg, and Carlotta were interventionists for group one of the clinic. Overall, the case study focused on two participants involved in social skills intervention and five staff members implementing the interventions.

Data Collection Procedures

Data collection procedures observations

During clinic sessions, the researcher sat on the carpet of the room recording observations using pen and paper. The researcher would respond to the participant if directly addressed, but would not initiate conversation with the participants or the interventionists. The researcher had two roles in the clinic: taking observation notes and filling out a fidelity checklist at the end of each session. The researcher and one other interventionist completed a fidelity checklist after the participants left at each session.

During the first two weeks of the clinic, the researcher took notes in the notebook by labeling the observations by date, session, and times as each observation was noted. During week three, the time was recorded every five minutes to label the continuous observations. The researcher also began adding pre summaries and post summaries to the content; the researcher found that there needed to be documentation of the expectations, thoughts, and anticipations for each clinic session. Pre summaries included expectations for the session, questions regarding methods and participants, and behaviors that would be the target of the researcher’s focus. Post summaries included aspects of the session that interested the researcher, questions the researcher formed during the session, answers to the questions formed in the pre summaries, and emerging themes within the clinic.

After week three, the researcher focused the observations primarily on Caleb and Mary. Caleb began each session by coming in the room and immediately finding a toy. Caleb often kept to himself and fixated on a toy during each session. When another participant would try to interact with either Caleb or the toy, he would scream, hit, throw things, call for his mom, and try to run out of the room. Caleb also developed the behavior of laughing at himself and the interventionists when he would be told not to do something. Caleb met the researcher’s criteria because the behaviors he exhibited after coming in contact with an aversive stimulus showed a stereotypical pattern.

Mary began each session by walking in the room and saying “hi” to every person. Mary repeated names and phrases throughout every session. She would typically only engage in an activity if an interventionist prompted her to. Mary would spend the sessions asking to fix the interventionists’ hair, walking around the room trying to scare others by saying “rawr,” or talking to the interventionists. Mary met the researcher’s criteria because she repeated the same subjects and phrases each session.

Data collection procedures interviews

Following observations, interviews were conducted with Dr. Raoul and Erik, the director of the social skills clinic and the lead interventionist for group one. The researcher designed the structured interview questions after looking at the emerging themes and the pre and post summaries from the observations (Fontana & Frey, 2000). . As the interviewee responded, the researcher typed the responses verbatim using a laptop. Dr. Raoul and Erik were asked the same nine questions. After the interviews, the researcher member checked the transcripts with both participants to insure transcripts reflected responses as intended (Creswell & Miller, 2000).Continued on Next Page »