Interventions’ outcomes on the behavior of students with ASD

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Search strategy

In order to answer the research questions, a systematic literature review was carried out through investi-gating four databases: ERIC, Academic Search Elite, PsycARTICLES, and PsycINFO. The search was done in March, 2016. Inclusion and exclusion criteria for articles are presented in section 5.2 (“Selection criteria”).
The search words initially intended to be used were “Autism Spectrum Disorders AND Behavior manage-ment AND Inclusive education”. Thesaurus on ERIC database was used to get alternative versions of this search word combination.
More specifically, instead of “Autism Spectrum Disorders” Thesaurus proposed “Pervasive Developmen-tal Disorders”, which was selected. It included other related terms, from which “Asperger Syndrome” and “Au-tism” were considered relevant to this study. These three terms were selected to be searched linked with “OR” for broader results. “Behavior management” was not identified in Thesaurus, thus it proposed to use “Behavior modification”. After selecting this term, other related ones were suggested from which “Intervention” was con-sidered relevant. These terms were selected to be used linked with “OR” as well. Finally, “Inclusive education” was replaced by “Inclusion” and, following the same procedure as for the above mentioned terms, “Inclusion” and “Mainstreaming” were linked with “OR”.
The final combination of words was (“Pervasive Developmental Disorders” OR “Asperger Syndrome” OR “Autism”) AND (“Behavior Modification” OR “Intervention”) AND (“Inclusion” OR “Mainstreaming”), using “OR” to broaden the search and “AND” to narrow it down. The same combination of search words was used in all four databases searched through.
However, in the databases PsycINFO and PsycARTICLES, there was also the option of excluding age groups that were not of focus for the study, i.e. younger than two and older than twelve years old, before reading the abstracts by selecting the appropriate boxes. Therefore, the age groups “Adulthood (18 yrs & older)”, “Ad-olescence (13-17 yrs)”, “Young Adulthood (18-29 yrs)”, “Thirties (30-39 yrs)”, “Middle Age (40-64 yrs)”, “In-fancy (2-23 mo)”, “Aged (65 yrs & older)” and “Neonatal (birth-1 mo)” were excluded in PsycINFO, in addition to “Very Old (85 yrs & older)” in PsycARTICLES.
The search procedure consisted of two basic steps. First, articles not published in peer-reviewed journals, and published before 1995 were removed in each database. Second, the articles remaining were reviewed on title and abstract level. At this point, duplicates (i.e. articles already found in one of the other databases) were removed. If the article was considered relevant for the study, but participants and setting of intervention were not mentioned in the abstract, the method section was reviewed. This was to check if the participants’ age and diagnosis, as well as the setting of intervention, met the inclusion criteria. Therefore, at this point a part of the full text review was conducted. A protocol was developed (Appendix A) based on the inclusion and exclusion criteria to review studies at this level. Some articles found in the four databases were considered appropriate for full text review, but they were not available through Jönköping University. These articles were also searched through Google Scholar for full text form.

Selection criteria

The inclusion and exclusion criteria described below were used both for abstract and for full text review.
These criteria are presented in table 5.1.
Inclusion criteria involved empirical studies (qualitative, quantitative or combined methods), which should describe interventions for behavior management of students with ASD. Thus, their goal should be either to increase a desirable behavior or to decrease a problem behavior. Even if the goal of intervention was not stated clearly but it was evident, then the study was considered for full text review, as long as it met the rest of the inclusion criteria. Participants in the study should be children between 2 and 12 years old with a diagnosis of ASD and they should also be students in an inclusive classroom of preschool or primary school. Both age and student identity of participants were mentioned in the studies. If the intervention included other groups of par-ticipants, such as typically developing peers or peers with other diagnoses, the study was included, if the inter-vention’s outcomes were specifically mentioned for each category. The intervention must be implemented in an inclusive classroom of preschool or primary school. When the intervention was implemented in the inclusive classroom, but part of the training (e.g. brief sessions to demonstrate the material, training of other participants) was outside this setting, the study was still considered for full text review. Articles should be in English, Greek, or Spanish, and published in a peer-reviewed journal to be included. Another inclusion criteria was that pub-lishing date should be after January 1995, taking into consideration that the Salamanca Statement was declared in July 1994.
Exclusion criteria consisted of participants with multiple diagnoses or a diagnosis other than ASD. In addition, when the intervention’s goal was not clear through the abstract and method or if it focused on areas not of interest for this review (such as academic achievement or medical treatment), then the study was excluded due to the intervention’s goal. Studies describing interventions which were implemented exclusively in a loca-tion other than the inclusive classroom (e.g. special school, clinic, home, a separate room in the inclusive school) were excluded due to the intervention setting. In addition, publication types such as literature reviews and book chapters were excluded.

Data extraction

Data extraction was done by one reviewer. Data about interventions was collected by reading the se-lected studies in detail (full text) with the use of a data extraction form (Appendix B). This was created based on the TIDieR checklist for reviewing interventions and the protocols provided during the course “Introduction to Interventions in childhood”. Having in mind the two research questions of this literature review, focus was on identifying the intervention used in each study, what was its goal, what assessment of the target behavior was carried out, who was the intervention provider and what outcomes were reported by the researchers on the student’s with ASD behavior.

Quality assessment

The quality of the included studies was assessed on full-text level. Based on the form for data extraction (Appendix B) a protocol of ten items for quality assessment was created. This protocol is presented completed in the results section, paragraph 6.4. Eight of the items were only checked if identified in the study. These items were clear statement of aim, research questions and conclusion, explanation of theories and concepts used, detailed description of intervention procedures (when, how much, how often, where), mention of limitations and measurement of interobserver agreement and treatment fidelity. Two items (average rate of interobserver agreement and of treatment fidelity) were completed as high, medium or low, given that interobserver agreement and treatment fidelity had been measured in the study reviewed. The average rate was considered as high if it was 80% or higher, as medium if it was 50% – 79%, and as low if it was lower than 49%. The quality of the studies was considered as high, medium or low depending on certain factors. Namely, studies were not consid-ered of high quality if they did not measure interobserver agreement and treatment fidelity and if they did not describe in detail the intervention procedures. It was the same case if studies reported a low average rate of interobserver agreement or treatment fidelity. Apart from that, the fewer items checked for a study, the lower was considered its quality. More specifically, taking into account that the items to be checked were eight, a study having checked less than four was directly considered of low quality. If four or five items were checked, it could be considered whether as medium or as low quality, depending on the measurement of interobserver agreement or treatment fidelity. If six, seven or eight items were checked, the study was considered of high quality, given again the measurement of interobserver agreement or treatment fidelity.

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First, the search results are going to be presented in this section. Second, the results of the data extraction will be described. The results of the data extraction are presented in relation to the two research questions of the present study, in order to answer its aim. The first research question intended to identify interventions for be-havior management that have been implemented for students with ASD in inclusive classrooms since 1995, the year after the ratification of the Salamanca Statement. For this research question, the types of intervention were examined, but also what were their goals, how behavior was assessed prior to intervention and who was the intervention provider. The second research question intended to look into the observed outcomes of each inter-vention. Third, the results of the studies’ quality assessment will be presented.

Interventions for behavior management of students with ASD in inclusive classrooms of pre-school and primary school

The first research question aimed to identify interventions for behavior management of students with ASD in inclusive classrooms. In order to answer this question, results focused first on what types of interventions have been implemented. In addition, it was examined what was their goal, that is what behavior they aimed to manage, how they assessed the behavior prior to intervention, and who provided the intervention, because these three parts were considered significant for the implementation of the intervention. The names of the interven-tions identified, their goals, outcomes and intervention providers are presented in Appendix D. A basic descrip-tion of the interventions is presented in Appendix E.

Types and basic steps of interventions

Various types of interventions were identified through reviewing the studies. Two interventions were an-tecedent-based using visual cue cards (Conroy, Asmus, Sellers, & Ladwig, 2005; Haley, Heick, & Luiselli, 2010) and consisted of similar procedures. Specifically, there were pre-instructional sessions with the students to explain them the cards, what they meant and how they would be used. One card meant it was inappropriate to engage in the stereotypic behavior, whereas the other meant it was acceptable to engage in that behavior. At the intervention sessions during the target instructional time, each of the cue cards was presented to the students. When the presented card was the one indicating that stereotypic behavior was acceptable, there were no conse-quences for that behavior. When the presented card was the one indicating that stereotypic behavior was unac-ceptable but the student still engaged in it, the responsible adult pointed out the card to remind the student that it was inappropriate to display this behavior. In one case, the adult also reminded of that verbally (Conroy et al., 2005), but in the other case there were not verbal reminders or other repercussions (Haley et al., 2010).
Two other interventions mainly involved typically developing peers as supporters or buddies of the child with ASD. The first one was a simple peer-support intervention (McCurdy & Cole, 2014). Before training of peers, the researcher interviewed the peer supporter about his perspectives of the student with ASD. The peer training involved explaining to the peer supporter what off-task behavior is, as well as training him or her to identify it, to prompt desirable behavior and to give verbal feedback. During the peer support intervention, peer supporter and child with ASD were sitting close. At the beginning of class, the peer reminded the student of the desirable behaviors and gave him verbal encouragement. When the student with ASD displayed off-task behav-iors, the peer prompted as he was taught to do at the training sessions. When the student with ASD displayed on-task behaviors, the peer encouraged him through nonverbal forms. At the end of each intervention session, the peer provided feedback and encouraged the student.
The second one was a peer buddies intervention combined with social scripts (Hundert, Rowe, & Harrison, 2014). The Training sessions involved the social script intervention, the peer buddies program and a combina-tion of these two. During the social script intervention, the play script was presented to the class through a video. After that, a volunteer was chosen to play the script with the student with ASD. This consisted of eight steps and for each one a correct response from the play partner and from the student with ASD was defined. In addi-tion, a token was given to the students for each step of the social script implemented correctly. Regarding the peer buddies program, the teacher and the play leader (an undergraduate student) first presented verbally and demonstrated how to start playing with a peer, how to accept an invitation to play and how to keep up a play behavior. At the beginning of each peer buddies training session, the class had to pay attention to a schedule and a list of the three rules of peer buddies in the classroom, which also presented the pairs of peer buddies for that session. During the session, teacher and play leader reinforced verbally the pairs of students who were following the peer buddies rules. At the end of each session, there was a brief discussion period when each student in the pair received a sticker from the teacher. The students who did not get a sticker were told what they needed to do next time. When the social script training was combined with the peer buddies program, the social script procedures were the same, except that peer partners were decided through the peer buddies proce-dures. This intervention also included generalization sessions which were the same as the training sessions, but play material related to a social script was unavailable and no new interventions were introduced.
One intervention applied the Structured Teaching System in combination with Graduated Guidance for one student with ASD who displayed stereotypic behavior (Bennett, Reichow, & Wolery, 2011). One puzzle was available at a time (three puzzles in total) and the girl was given three minutes to complete it. The structured work system involved checking a visual activity schedule, identifying the activity to be completed, completing the puzzle, putting the competed puzzle in a special basket, and rechecking the visual activity schedule to de-termine what to do next. When the girl needed help to use this system, the researcher indicated the steps using Graduated Guidance and pointing. However, help in completing the activity was not provided. Graduated guid-ance was faded gradually.
Conroy, Boyd, Asmus and Madera (2007) described an intervention using social stories and specific adult prompts. First, the teacher asked the student to select one of his classmates to read the social story with. Then, the two students acted out the scenario throughout free play time. However, the research team and the teacher decided to stop the social stories after one week, because they considered it did not offer enough benefits but rather hindered the intervention process. Therefore, only specific prompts by the teacher were used from that time on and results in this study were obtained and presented only for this part of the intervention. Specifically, the teacher provided three prompts to the student with ASD. The student was prompted to select the peer and then the material to play with, as well as how to ask his peer to play with him. The intention was to make the student independent in his social interactions and gradually diminish the prompts.
One intervention used the Prevent-Teach-Reinforce (PTR) model of behavior support for two students with ASD (Strain, Wilson, & Dunlap, 2011). For one student, the Prevent element included clear behavioral expec-tations by the teacher in consultation with the student, and a card was given to him listing four expectations. The Teach element was about self-management, thus the student had to look at his card and remind himself of what he needed to do. Student and teacher reviewed the expectations multiple times per day. The Reinforce element included specific verbal praise and comments by the teacher, hits on the student’s card that could be exchanged for items (reinforcers) and the possibility for the student to take his cards home to show his mother.
This was done in order to create a more positive atmosphere in the school-home communication, instead of communicating with the mother only when problems occurred (Strain et al., 2011). The teacher ignored the student’s problem behaviors and redirected his behavior using only visual cues. For the other participant in this study the intervention had two goals and, hence, two components. For the first component, a written schedule was developed which indicated the student what to do (Prevent), then he was taught a specific academic skill (Teach), and he was reinforced with access to a bucket with items he liked (seashells and insects) when he wrote a specific amount of words (Reinforce). For the second component, a buddy time was scheduled during large group activities (Prevent). Moreover, the PTR team developed three social phrases for the student (also put on cards attached to key ring which was given to him) he could practice during buddy time and at home (Teach). The student was reinforced for using the social phrases and for communicating verbally with peers by earning stickers which led to his access to the same bucket with items as in the first component (Reinforce). When this student displayed problem behavior, adults used visual cues to redirect him.
Finally, Reeves, Umbreit, Ferro and Liaupsin (2013) described a comprehensive function-based interven-tion that had three components. The first was to teach the replacement behavior to the three students with ASD. They were taught to use visual instructions to complete activities independently, to raise their hands when they needed assistance, and to use the “taking time area” (pp. 384) (a table in the back of the classroom) when they needed to calm down. The second component was the reinforcement of replacement behavior. A token economy system was established (i.e. collecting items that could be exchanged with a reinforcer) and, when the students displayed that behavior, the teaching assistants praised them verbally. The third component was an extinction procedure for the occurrence of the problem behaviors. On one hand, this meant that adults ignored the problem behaviors (attention extinction) and, on the other hand, it meant that the students with ASD had to complete the assignment during lunch recess, if it was not completed by then due to the problem behaviors (escape extinc-tion).

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Table of Contents
1 Introduction 
1.1 Autism Spectrum Disorders (ASD)
1.2 Preschool and Primary School settings
1.3 Inclusive education
1.4 Inclusive education for students with ASD: benefits and challenges
1.5 Behavior management
1.6 Interventions
2 Rationale 
3 Aim 
4 Research questions 
5 Method 
5.1 Search strategy
5.2 Selection criteri
5.3 Data extraction
5.4 Quality assessment
6 Results 
6.1 Interventions for behavior management of students with ASD in inclusive classrooms of preschool and primary school
6.2 Interventions’ outcomes on the behavior of students with ASD
6.3 Quality assessment
7 Discussion
7.1 Discussion of results
7.2 Methodological discussion
7.3 Implications for future research
8 Conclusion 

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