میانجیگری همسالان برای افزایش ارتباط و تعامل در زنگ تفریح برای دانش آموزان مبتلا به اختلالات طیف اوتیسم

Recess plays an integral role in the social and emotional development of children given the time provided to engage in interactions with others and practice important social skills. Students with ASD, however, typically fail to achieve even minimal benefit from recess due to social and communication impairments as well as a tendency to withdraw. Implementation of evidence-based interventions such as peer-mediated social skills groups, are necessary to ensure recess is an advantageous learning environment for students with ASD. A multiple-baseline design across participants was used to determine if a functional relationship exists between a social skills instructional program combined with peer networks with school staff as implementers and increases in level of communicative acts for participants with ASD at recess. Results indicate all participants demonstrated an immediate increase in the number of communicative acts with the introduction of the intervention. Implications for practice are discussed.

The American Academy of Pediatrics recently issued a policy statement on the importance of school recess (www.pediatrics.org/cgi/doi/10.1542/peds.2012-2993) stating, “Recess promotes social and emotional learning and development for children by offering them a time to engage in peer interactions in which they practice and role play essential social skills.” This type of activity, under adult supervision, extends teaching in the classroom to augment the school's social climate. Through play at recess, children learn valuable communication skills, including negotiation, cooperation, sharing, and problem solving as well as coping skills, such as perseverance and self-control. These skills become fundamental, lifelong personal tools.” (p. 184). This policy statement was issued in reaction to the debate over the role of schools in promoting development of the whole child, and with the increasing pressure to accelerate academic performance which may often preclude social activities. Despite inclusion in recess activities, students with autism spectrum disorder (ASD), generally miss out on the social benefits specific to recess. ASDs are defined as a group of developmental disabilities characterized by impairments in social interaction and communication and by restricted, repetitive, and stereotyped patterns of behavior (American Psychiatric Association, 2012). Other characteristics include lack of responding to their name, poor eye contact, limited affect and social responsiveness, and language delays or deviances (limited words by 16 months, echolalia, perseveration on topics) (National Institute of Neurological Disorders & Stroke, 2009). Koegel reported that problems engaging in social interactions for children with autism primarily serve two functions: avoidance of social attention (interaction) or seeking social attention but using inappropriate communication to do so (perseverative topics) (Koegel, Openden, Fredeen, & Koegel, 2006). Children with ASD use fewer toys, and less time playing appropriately with toys, demonstrate fewer functional play acts and symbolic play, show less imitation than typical peers and even actively avoid peers (Stone & Caro-Martinez, 1990 cited in Harper, Symon, & Frea, 2008). For school aged children these characteristics impact their ability to interact with teachers and peers across a multitude of settings including the classroom, transition areas, lunchroom, and playground. Interventions that target social and communication skills thus appear to be pivotal to improving their ability to initiate interactions, reciprocate during social exchanges, and infer the interests and emotions of others. Fortunately, research shows increasing evidence for interventions to address these core deficits for children with autism. Kasari, Paparella, Freeman, and Jahromi (2008) and others (Rogers, 2000) report treatment aimed at joint attention and symbolic play as effective for improving social and communication skills with young children with autism. A recent review of social skills interventions (Reichow & Volkmar, 2010) reported peer training, video modeling, and social skills groups as part of a treatment package as evidenced or emerging evidenced-based practices. Peer mediation or peer networks (Haring and Breen, 1992, Kamps et al., 1997 and Kamps et al., 2002) have also been shown effective for improving social and communication skills. Examples include peer dyads or small groups of peers to support a child with ASD or other disability to assist with specific tasks, for example as social and conversation partners, during transitions, as tutors, or providers of social reinforcement. General recommendations for children with ASD include the use of behavioral interventions with a focus on individual needs, responsiveness to intervention, functional outcomes, and generalization of skill use as key indicators of the effectiveness of interventions (Kasari and Lawton, 2010, Koegel et al., 2012a and Rao et al., 2008). Recommendations also support children with ASD being taught in more naturalistic settings with typical peers to improve social communication and language development (Koegel et al., 2012b and National Research Council, 2001; Reichow & Volkmar, 2010). 1.1. Recess interventions A few studies have successfully targeted social behaviors at recess (Harper et al., 2008). Lang et al. (2011) conducted a review of 15 studies that used recess time to teach target behaviors to students with ASD. In several studies, the perseverative interests or preferred activities of the children were incorporated into the recess or social events with improvements in social/play interactions and affect ratings (Baker et al., 1998, Koegel et al., 2012c, Licciardello et al., 2008 and Machalicek et al., 2009). Machalicek et al. taught three children with ASD to select pictures of preferred equipment to use on the playground and pictures were then used to create an activity schedule. Challenging behavior decreased, and appropriate play increased. Lang and colleagues decreased severe challenging behavior by increasing teacher attention and praise for appropriate behavior during recess (Lang et al., 2010 reported in Lang et al., 2011). Licciardello et al. also used teaching assistants to prompt and reinforce interactions between the participant and peers during recess for four, 6–8 year old children with autism resulting in increased social initiations and responses. Zanolli, Daggett, and Adams (1996) implemented a priming session in which 2 4-year old children with autism received a dense schedule of reinforcement with few demands just prior to recess. Peers were taught to respond to social initiations resulting in increases in the number and topography of initiations by the children with autism (reported in Lang et al., 2011). Others have incorporated peer training to increase interactions for children with autism at recess. Owen-Deschryver, Carr, Cale, and Blakely-Smith (2008) taught peers to initiate and respond to the children with ASD and to consider their interests when playing. McGee, Almeida, Sulzer-Azaraff, and Feldman (1992) using incidental strategies, taught peers to reinforce initiations for preferred toys, to praise, and to prompt turn taking with improved reciprocal interactions. Gonzalez-Lopez and Kamps (1997) taught peer mentors to give clear simple instructions, to model appropriate social skills, and to praise kindergarten children with ASD. Results indicated improved frequency and duration of social behaviors, and decreases in disruptive behaviors for participants. Others have used structured activities using music (Kern & Aldridge, 2006) and affection activities (McEvoy et al., 1988) to increase interactions between peers and young children with autism. Kasari, Rotheram-Fuller, Locke, and Gulsrud (2012) used two interventions to improve social skills for children with autism during recess and lunch time. The first program consisted of child-assisted direct instruction using role play and practice with an interventionist until skills were mastered. The second was a peer-mediation procedure with the interventionist training peers to engage the children with autism in social interaction and game playing. Skills were selected based on the individual child's needs and the setting (e.g., entering and sustaining attention in games, maintaining a conversation, game rules, steps for specific activities, good sportsmanship, etc.). Thirty children participated in the ‘child’ intervention and 30 children in the ‘peer mediation’ intervention, with each lasting 6 weeks with 20-min intervention sessions twice each week. Results included improved class-wide-rated social network status (nominations), improved teacher ratings of social skills, and decreased isolation on the playground for the children with autism. Minimal changes were noted in the percent of interactions with joint attention during recess observations for any of the interventions with a 9% increase during follow-up observations for the children in the peer mediation intervention. The use of Pivotal Response Training (PRT, Koegel et al., 1989, Koegel et al., 2006 and Pierce and Screibman, 1995) has been used to improve motivation and responding to increase language use and promote positive interactions for children with autism and their peers. Harper et al. (2008) taught peers to use naturalistic strategies including PRT during recess to increase initiations and play for children with ASD. Specific skills included gaining attention, varying activities, narrating play, reinforcing attempts, and turn-taking. Peers were taught to demonstrate each skill with 80% accuracy and to demonstrate providing play opportunities with a classmate. Teaching peers to use naturalistic activities increased initiations and number of turn-taking exchanges for two children with autism. One participant improved from baseline levels of 0–1 to 4.8 bids for attention during 10-min probes. The second participant increased from .89 in baseline to 1.9 during the peer condition and to 3.25 during generalization. Turn-taking exchanges were at zero levels in baseline with increases to 9–16 for participant one and to 1–3 for participant two during intervention. In a recent study Koegel and colleagues implemented PRT strategies with children with ASD and their peers during recess incorporating the child's choice of activities and peers. This intervention resulted in improvements in the percent of intervals with social engagement. The addition of initiation training however was necessary to promote improvements in initiation behaviors to peers and generalization in social engagement to recesses when the interventionists were not present (Koegel et al., 2012). McFadden, Kamps, and Heitzman-Powell (2013) similarly found improved social initiations and responses for children with autism in recess settings following implementation of peer training. Children with ASD and their classmates received training (modeling, priming, prompting, and feedback) in four key skills: (a) playing together and having fun, (b) complimenting and encouraging our friends, (c) talking about what we’re doing and giving ideas, and (d) using names and getting attention. A token system was used during recess to reinforce use of the skills by all participants. The percent of intervals with initiations and/or responses to peers increased from baseline to the peer networks condition for all four participants with ASD (i.e., 9–77%, 26–81%, 35–85%, and 15–77%, respectively). Findings for peer mediated interventions at recess for children with ASD are encouraging but the literature is quite sparse, particularly in elementary school settings. Additional research is needed with well-defined interventions, fidelity of treatment measures, and interventions that are deliverable by school personnel. 1.2. Purpose and research questions The purpose of this study was to evaluate the impact of a peer network package intervention at recess to increase the communicative acts of elementary students with autism spectrum disorder. The specific research question addressed by this study is: Is there a functional relationship between a peer mediated intervention package and increases in the number of communicative acts for participants with ASD at recess?

4.1. Discussion Social and communication deficits for children with ASD can severely interfere with the ability of children with ASD to benefit from the social opportunities provided in school settings, including recess. Thus the issue for children with ASD is not only inclusion in social activities such as recess, but ensuring that intervention is in place to promote positive social interactions with peers. Although recess is particularly challenging with limited structure and adult supervision, identifying evidence-based practices that can be integrated into this naturalistic setting is important particularly given the benefits of recess in promoting the development of social–emotional skills. In the current study, three children with ASD participated in peer network intervention at recess two to three times per week. The intervention consisted of multiple components including: selection of peer partners, instruction in social skills with practice at identifying exemplars with peers at the beginning of recess, praise for use of skills during recess activities, prompting peers to engage the children with ASD in play during recess, and use of rewards at the end of the recess session for maintaining social interactions. Results showed improvements in the total communication acts for all three participants. This multiple baseline design study with three systematic demonstrations of change at different points in time contributes to the evidence of the effectiveness of teaching communication skills with trained peer partners in recess settings. These findings support prior recess interventions using direct instruction of social behaviors and peer mediation in recess settings (Harper et al., 2008, Kasari et al., 2012 and Owen-Deschryver et al., 2008). The study also directly confirms the benefits of a peer network or small group of identified children to support the children with ASD through prompting and reinforcing use of skills in the natural settings including recess (Gonzalez-Lopez and Kamps, 1997, Kamps et al., 1997, Koegel et al., 2012c and McFadden et al., 2013). The improvements in communication frequency confirm the recommendations by Lang and colleagues “The presence of peers without disabilities on the playground should be seen as a potential instructional asset” (p. 1303). He states that peers may reduce demands on busy teachers, and further that peer mediation fosters inclusion by increasing the number of socially responsive partners, and opportunities to practice skills with multiple people in a natural environment which may promote generalization of skills. Consistent with several other studies at recess was the need to provide intervention directly in the target setting and with an interventionist present to prompt the peers to keep the child with ASD responsive to the social demands (McFadden et al., 2013 and Owen-Deschryver et al., 2008). Anecdotally, the interventionists noted that prompting was needed in order for children to change activities (when it appeared that the child with ASD or peers may have been losing interest), to give ideas on types of comments or encouragement to use to contextually fit a novel activity (i.e., one not previously used in role plays), or to structure the activity to provide interaction and turn taking opportunities. Other variables contributed to the efforts in implementation. Sam and Ed were highly verbal and interested in their peers. Their teachers and our observations suggested that they just needed instruction in how to interact and respond to peers. They appeared motivated to engage with peers, with the use of an incentive program. Brian however, often preferred to be alone and the playground was an easy environment in which to achieve this isolation. He also exhibited frequent behavior problems in his class which sometimes carried over to recess (e.g., running from the interventionist, refusing to respond, perseverating on the same toy or game). His interventionist provided extra supports including frequent visual reminders of the rewards chart, high levels of praise and frequent physical prompting. Important features of the intervention included typical agents, school staff, as implementers for two of the children, although with fairly consistent coaching from the researchers for Brian. All of the implementers also assisted with a peer-based social skills group. For Sam, the groups had occurred during kindergarten and first grade, with the current intervention in second grade. For Ed, the speech therapist implemented social skills groups two times per week and one to two of the recess interventions each week. Her schedule did not permit consistent availability, so the researcher served as interventionist for approximately half of the intervention sessions at recess. For Brian, his speech therapist implemented social groups two times per week, but was unavailable for recess. His resource room teacher was newly appointed as Brian's teacher and thus needed more frequent coaching in how to use the peer mediated social intervention. In spite of this variability, fidelity of implementation was strong, lending further evidence that the intervention procedures are rather straightforward promoting ease of implementation. Another important component of the intervention was use of feedback to participants during the sessions in the form of stars or smiley faces on a chart, and access to the treasure box at the end of the recess sessions. Small prizes (e.g., stickers, small tablets, tops, koosh balls, rings) were rewarding to children over the months of the study. Ed's teacher decided to tie the incentives into the class-wide rewards program. She had the recess peer network members earn tickets matching the class system which were added to the class counts to earn rewards. This allowed special recognition for children participating as ‘recess buddies’. 4.2. Limitations In spite of positive findings, there are a number of limitations of the study. The small number of participants restricts the generalizability of the findings. In addition, the interventionist's presence and prompting was not faded and thus maintenance was not addressed in this study. As the intervention incorporated priming through the pre-teaching component and introduction of the reinforcement, the interventionist served as a discriminative stimulus, priming both the peers and target students to engage in interactions with one another. The lack of maintenance data prohibits analysis of whether the communicative behaviors continued without the presence of the interventionist. Additional features to the intervention or more time might have permitted fading of adult assistance. For all three participants, the use of a structured intervention at recess was a novel experience. Anecdotal data provided by the interventionist several months after the intervention ended did provide some qualitative information that the communicative acts of the participants and interactions with peers did continue after the intervention was withdrawn. The intervention package consisted of several components including pre-teaching, priming, prompting and reinforcement of communicative acts. This did result in meaningful changes in the number of communicative acts for each participant; however, given the nature of a treatment package, identification of whether or not implementation of just one of the components (e.g., reinforcement) would have yielded the same meaningful change is not feasible. Future research should demonstrate whether or not each component is effective when implemented alone and whether or not the package has added affects above and beyond the individual components. In addition, there was a great deal of variability in communicative acts across sessions, especially for Sam and Brian. This trend in social data is common across intervention studies for children with autism (e.g., Koegel et al., 2009 and Thiemann and Goldstein, 2004), and likely due to a number of variables including activities selected during recess, the opportunity for greater physical movement across large spaces, and different peers in the network on different days. Finally, additional measures might add to more understanding of the variability of performance and suggestions for future interventions in recess settings. For example, frequency or quality of adult and peer prompts were not measured, nor were inappropriate behaviors or rates of general social engagement assessed. 4.3. Implications for practice Findings from the study clearly show the benefits of intervention during recess for children with autism. The procedures used in the study further suggest that many practitioners can implement the intervention with positive benefits. First, strategies that comprised the intervention were those commonly used with children with autism including visual text cues, modeling for the children with autism as well as the peers at the beginning of each recess session, prompting during sessions to promote continued engagement, and frequent reinforcement for skill use. It is likely that many school staff are already trained in the use of these strategies, and with planning and accommodations for individual children, the intervention can be replicated for many children with autism. A dense schedule of reinforcement for children with behavior problems may be necessary as was the case for Brian. The scheduling of staff time to oversee the intervention will require administrative and team support as supervision is generally limited during recess. Scheduling of multiple peers to participate in the intervention is also important to prevent overuse of a small number of peers. Rotating peers from the same class as well as other classes will prevent this problem and likely increase maintenance of interactions for the children with autism as well. In addition, all the participants in the study were also participating in small social groups at times other than recess with their peers. It may be necessary to first teach use of social skills in smaller controlled settings prior to or concurrently with teaching social behaviors at recess. In general, the study suggests that the allocation of time for staff and involvement of multiple groups of peers during social settings in schools is both necessary and beneficial for improving the social competence for the children with autism. 4.4. Implications for future research The use of peer networks at recess was shown to be an effective intervention and fairly easy to implement. Children were responsive with general improvements in communication over baseline levels. Peers appeared to be comfortable prompting the children with ASD to be socially engaged. Future research is needed to identify strategies for fading adult assistance, and for maintaining the social interactions and communications between children with ASD and their peers. The contextual variables of playgrounds are challenging however and continued interventionist presence may be necessary for the improved social behaviors to be sustained. Additional areas of study might include environmental structures (e.g., types of games, activities that promote increased cooperative play at recess), priming and initiation strategies, and the use of self-management strategies for the children with ASD.