Guidelines for Group Presentation for Evidence-Based Literature

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Journal of Autism and Developmental Disorders (2018) 48:2530–2541 https://doi.org/10.1007/s10803-018-3523-z

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O R I G I N A L PA P E R

I Wanna Play Too: Factors Related to Changes in Social Behavior for Children With and Without Autism Spectrum Disorder After Implementation of a Structured Outdoor Play Curriculum

Michael J. Morrier1 · Sonja M. T. Ziegler1,2

Published online: 27 February 2018 © Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract Children with autism spectrum disorder (ASD) have difficulties interacting with same-aged peers during unstructured play (e.g., on the playground). Thirty-five toddler and preschool children with and without ASD participated in a structured 15-min outdoor play curriculum. The intervention, the Buddy Game, used familiar songs, movement, and games to promote peer social interaction. A 2 × 3 ANOVA assessed changes in overall targeted social behaviors during baseline, the Buddy Game, and generalization to free-pay. Multiple regression analyses examined factors related to increases in social interactions. Pre- dictors were ASD status of child and age of child. Results indicated the Buddy Game increased overall social interactions and that social interactions were influenced more by ASD status than age. Implications for practitioners are highlighted.

Keywords Autism spectrum disorder · Toddlers and preschoolers · Structured outdoor play curriculum · Peer interactions

Introduction

A diagnosis of autism spectrum disorder (ASD) requires significant differences in the key developmental areas of social communication and social interaction, as well as the presence of restricted and repetitive interests and behaviors (American Psychiatric Association [APA] 2013). Signifi- cant deficits in a child’s ability to initiate and respond to others, especially same-aged peers, are readily apparent in children with ASD. Recent prevalence estimates for 8-year- old children with ASD indicate that the rate of diagnosis is increasing and the disorder is more common than pre- viously believed (Christensen et al. 2016b). The Centers for Disease Control and Prevention’s Autism and Devel- opmental Disabilities Monitoring (ADDM) Network also has investigated the prevalence rates for 4-year-old with

ASD (Christensen et al. 2016a). Recent estimates from the ADDM Network indicate that for 4-year-old (i.e., preschool- aged) children, the prevalence of ASD is 13.4 per 1000 (or 1 in 74). Thus, early educational and other childcare settings will have increasing numbers of children with ASD in their classrooms.

In early educational settings, a daily playground period is usually offered for children to independently engage in social interactions with peers in a more unstructured setting. The social withdrawal of children with ASD can become most obvious when children are participating in these unstruc- tured times (Anderson et al. 2004). The lack of structured planned activities lends to children with ASD spending the majority of playground time isolated from peers, socially disconnected, and engaging in non-functional, self-stimu- latory behaviors (Peeters 1997; Veale 1998). Unstructured periods of time during the school day are missed opportuni- ties to teach children with ASD the peer-related social skills they need. Previous research has demonstrated that increases in social interactions of children with ASD can be accom- plished by specifically teaching their typically developing peers how to play with them (Harper et al. 2008; Kohler et al. 2007; Laushey and Heflin 2000; McGee et al. 1992; Owen-Deschryver et al. 2008).

Professionals from various fields have reached the consensus that early intervention for children with ASD,

* Michael J. Morrier [email protected]

1 Emory Autism Center, Department of Psychiatry & Behavioral Sciences, Emory University School of Medicine, 1551 Shoup Court, Decatur, GA 30033, USA

2 Department of Educational Psychology, Special Education, and Communication Disorders, College of Education and Human Development, Georgia State University, Atlanta, GA, USA

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including targeting the areas of social communication and social interactions, is most effective when started before 3 years of age (National Research Council 2001). In order to make changes in the fundamental social deficits of children with ASD social interventions need to be carefully planned and consistently implemented (McGee et al. 1999, 2001; Schreibman et al. 2015). Research has shown that effective interventions for children with ASD can be embedded into their natural play activities (Boyd et al. 2008; McGee et al. 1999, 2001; Stahmer et al. 2011; Strain and Bovey 2011). The characteristics of these effective interventions have been described by Schreibman et al. (2015), and include embed- ding applied behavior analysis treatment within a develop- mental framework, known as Naturalistic Developmental Behavioral Intervention, or NDBI. NDBIs are especially important for teaching socially meaningful skills within the context that a child with ASD will use them.

Increasing Social Interactions During Unstructured Preschool Activities

McGee and colleagues have demonstrated that by making small changes to environmental arrangements and structures in the classroom, teachers can significantly increase posi- tive social behaviors and decrease negative social behaviors between preschoolers with ASD and their typical peers (McGee and Daly 1999; Morrier et al. 2009). Adding coop- erative games to an educational setting has been shown to be associated with generalized increases in positive social behaviors and decreases in aggressive behaviors in typically developing preschools (Bay-Hinitz et al. 1994; Orlick 1981). In addition, McEvoy and colleagues (1988) have shown that by embedding interactive songs and games that include affection actions (e.g., giving your neighbor a hug, patting a friend on the back) can increase the social interactions of children with ASD.

Increasing Social Interactions During Outdoor Recess Activities

Pairing children with ASD with previously trained typical peers, or peer buddies, has been shown to increase appropri- ate social skills in kindergarteners with ASD (Laushey and Heflin 2000). Previous research on increasing social interac- tions between children with ASD and their typical peers dur- ing outdoor recess has primarily focused on elementary-aged students, and has often targeted only a few children at a time (Boyd et al. 2008; Harper et al. 2008; McEvoy et al. 1988; Owen-DeSchryver et  al. 2008). Research conducted on pre-school-aged children tends to focus solely on older pre- schoolers (i.e., those aged 3–5 years; McGee et al. 1992), and does not typically include toddler-aged or younger preschool-aged children. Research in comprehensive early

intervention programs for children with ASD that include typical peers has provided naturally occurring social interac- tion times during more structured, planned small and large group activities (McGee et al. 2001; Strain and Bovey 2011), but unstructured free-play periods such as playground recess are often ignored.

Adding structure to outdoor recess time in order to teach pivotal responses during recess increases social interactions between children with ASD and their typical peers (Harper et  al. 2008; Keogel et  al. 2006). In addition, when child choice is embedded within games, children with ASD can make significant gains in language and social skills (Carter 2001; Miller and Almon 2009). Previous research has dem- onstrated that the use of a structured, cooperative play recess curriculum with a focus on natural modelling and imita- tion, increased children with ASD’s frequency of social bids received from and social bid initiations to peers (Morrier et al. 2009; Ziegler and Morrier 2018). This study aimed to examine factors that might be related to the increases in social behaviors demonstrated by children with ASD and their typical peers during a Buddy Game intervention. Spe- cific hypotheses investigated were (a) that implementing the Buddy Game intervention would have positive effects on children’s overall social interactions during outdoor recess and generalize to a different time and setting (i.e., free-play); (b) although children with ASD would make significant gains despite the social deficits inherent in the ASD diag- nosis, the ASD status of the participating children (ASD versus typical) would be a significant factor that influenced the social gains observed, with typical children having sig- nificantly greater gains than the children with ASD; and (c) the age range of the child at study start, regardless of ASD status, would be a significant factor, with younger children displaying less increases in receipt of social bids and initia- tions to both peers with ASD and typical peers due to the maturation levels of the older children as well as the devel- opmental level of social behavior expected for toddler-aged children compared to pre-K aged children.

Method

Participants

Ten preschool-aged children with autism spectrum disorder (ASD) and 25 of their typically developing peers partici- pated in this study (N = 35). Mean age of the children with ASD was 55.70 months (sd = 13.92; range = 29–78 months), and mean age of the typical peers was 39.64 months (sd = 12.77; range 24–66 months). All children enrolled at Early Emory Center for Child Development and Enrich- ment (Early Emory) were invited to participate in this study. Children whose parents did not consent to their participation

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in the study remained in the educational environment for the study’s duration, though remaining in a different part of the playground than the intervention setting during the treatment phase. Just over half of the parents of children with ASD consented to participate in this study, thus these children were not representative of all children with ASD of the same age. Prior to the study’s commencement, any chil- dren with neurotypical development (NTD) who presented with characteristics indicative of ASD were screened by the Center’s clinical team.

All children whose parents’ consented to their participa- tion were included in the study. For children whose parents consented for research participation, mean time enrolled in the program for children with ASD was 23.90 months (sd = 13.77; range = 4–46 months), and mean enrollment for typical peers was 13.58 months (sd = 11.67; range 0–48 months). All children with ASD received a pre-admission assessment to confirm their diagnosis of ASD using the Autism Diagnostic Observation Schedule, 2nd edition (ADOS-2; Lord et  al. 2012a, b) and Autism Diagnostic

Interview-Revised (ADI-R; Rutter et  al. 2003). Prior to study participation, parents of children with ASD com- pleted the Vineland Adaptive Behavior Scales, 3rd edition (Vineland-3; Sparrow et al. 2016). One-way ANOVA indi- cated that there were no significant differences on any of the assessment measures for children with ASD based on gender of the child. No other assessments were conducted in relation to this study. T-test analyses on gender, age, time in program, racial/ethnic background, and ADOS-2, ADI- R, and Vineland-3 scores indicated that there were no dif- ferences in groups between those children whose parents consented to participation in the study and those children whose parents did not consent to participate. Characteristics of the 35 participants can be found in Table 1.

Setting

The study was primarily conducted on the outdoor play- ground of Early Emory, a component of the Emory Autism Center. Early Emory is an integrated preschool environment,

Table 1 Characteristics of study participants (N = 35)

ASD autism spectrum disorder, sd standard deviation, ADOS-2 autism diagnostic observation schedule, 2nd edition, RRB restricted, repetitive behavior, ADI-R autism diagnostic interview-revised, Vineland-3 Vine- land Adaptive Behavior Scales, 3rd edition *p < .05; **p < .001

Description Children with ASD Typical children

N 10 25 Male (%) 6 (60%) 15 (60%) Mean age in months (sd)** 55.70 (13.92) 39.64 (12.77) Mean months in program (sd)* 23.90 (13.77) 13.58 (11.67) Parent reported racial background  Asian 0% 9%  Black/African American 33% 9%  White/Caucasian 67% 64%  2 or more races 0% 18%

Mean ADOS-2 scores at program entry (sd)  Social affect 16.44 (3.36)  RRBs 5.33 (2.29)  Overall score 21.78 (4.44)

Mean ADI-R scores at program entry (sd)  Social 18 (3.93)  Verbal (n = 2) 19 (2.83)  Nonverbal (n = 8) 12.17 (1.94)  RRB 3.63 (1.85)  Development 3.5 (0.76)

Mean Vineland-3 domain scores (sd) at time of study  Communication 70.78 (20.17)  Daily living skills 71.33 (12.69)  Social 68.78 (16.88)  Motor 73.22 (9.76)  Adaptive behavior composite 70.11 (11.19)

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which supports the social communication development of both children with ASD and their typical peers through embedding applied behaviour analysis (ABA) techniques within natural preschool activities. The primary ABA technique used during the study was incidental teaching (McGee et al. 1992, 1999), which has been described as an NDBI (Schreibman et al. 2015). Incidental teaching uses a child’s interest in a particular item, topic, or activity to determine the timing and content of teaching opportunities (Hart and Risley 1968; McGee 2003a, b). Adults utilize the child’s interests to target their cognitive, language, or social development. Adults are aware of what concepts need to be taught, but the child determines the timing and context of their teaching.

The intervention occurred daily on the outdoor play- ground during each classroom’s regularly scheduled, 45-min recess period. The duration of the study’s phases for each classroom can be seen in Fig. 1. The intervention, referred to as the Buddy Game, was implemented during the second

15-min of the recess period. All participating classrooms opened directly onto the playground, which measured 139-ft by 34-ft. The playground was divided into three main sec- tions, called “zones”. The zones consisted of (a) swings and a plastic play house, a sandbox with sand toys, two bounc- ing ride-on toys, secured in the ground, (b) a wooden play structure with two stairwells, two plastic slides, a balance beam, and a multiseat Spring-a-Bout™, and (c) an open area referred to as “the field”, that contained a plastic play kitchen and a plastic play house. Additional playground toys were available, and the entire organic surface of the play- ground was covered in 6-in of mulch, as specified by state childcare licensing guidelines.

The Buddy Game was conducted on the 37-ft × 34-ft por- tion of the playground described as “the field”. Apart from the materials described in this study, no other playground activities were located in this section. Generalization data were collected inside each classroom during their afternoon free-play sessions (known as Generalization Free-Play).

Fig. 1 Duration of each study condition during the multiple baseline across classrooms design

CWA children with autism spectrum disorder; BL baseline; IV The Buddy Game intervention; MAIN maintenance; PK pre-kindergarten classroom; EPS early preschool classroom; PS preschool classroom

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The free-play area of each classroom contained cubbies for the children’s belongings, shelves, age appropriate toys and books, a small vinyl coach, small vinyl chairs, a reading center, a block center, an art center, and a dramatic play center.

Study Conditions

Pre‑baseline

One month prior to the start of the study, all teachers were instructed to discontinue any organized activities, games, or curriculum that they may have been implementing during their outside recess time. They were also instructed to stop singing all of the movement songs chosen for the treatment condition, and to not sing these songs during any part of the day. These songs were already part of the regular song repertoire in each classroom. Teachers were provided with an extensive list of new non-movement songs that could be added to their classroom’s repertoire. Teachers were instructed to make these changes to minimize confounding variables to the study.

Baseline Condition

Baseline occurred outside on the playground during the sec- ond 15-min of each classes’ 45-min recess time. During this condition, children were free to engage in any outdoor activ- ity that was available to them. Each teacher was assigned to facilitate one zone on the playground, and to contact children in their zone using normal program procedures (e.g., contact children engaged at a rate, which provides approximately 13–15 contacts in total, within a 5-min period). Unengaged children were matter-of-factly redirected to an ongoing play- ground activity. Teachers also routinely prompted verbal language expansions and ensured that safety and behavior management procedures were followed. During baseline, teachers were instructed not to prompt, to teach, or to rein- force any child to child interactions, except those required to settle a sharing dispute over materials or physical space.

Pre‑Buddy Game

During morning programming, before each classes’ outside time, teachers informed all the child participants that they would be playing the Buddy Game when they went outside, and to play game, they first needed to have buddies. Teach- ers then randomly paired each child with ASD with a typical peer. This was done by choosing a name out of a shaken con- tainer of names of children with ASD; then a name was cho- sen from a shaken identical container with the names of the typical children. This procedure continued until all children with ASD were paired with a typical peer. The remaining

typical peers were paired together in the same manner. If there was a typical child who was not paired with a peer due to an odd number of class members, they were paired with a typical dyad. The buddy pairs were announced and placed together using each child’s nametag on a black poster board with Velcro™ dots titled the “Buddy Board”. Children were informed that when they were told that it was time for the Buddy Game, they should go to the field, find their buddy, and that they needed to stay together because they are going to do some movement songs. Children were reminded who their buddies were before going outside and what they should do when they heard a teacher say, “It’s time for the Buddy Game.” Just before the intervention, the children were informed that they were about to play, they needed to come to the field, find their buddy, and stay with them. They were reminded who their buddies were, both visually through the “Buddy Board” and verbally by the teachers. In all class- rooms, the ratio of children with ASD to peers with NTD was 1–3. As part of the center-wide culture, children with ASD were integrated throughout the day in all activities. No child was identified as having a diagnosis, and learning and skill differences were never highlighted. It was a typical practice of each classroom to have children with differing neurodevelopment participate in each activity, and paring of children to help one another or to transition from one activ- ity to the next was common. If a child protested playing the Buddy Game either vocally or gesturally, this would have been considered the revocation of the child’s assent to par- ticipate for that session. This did not occur during the study.

Buddy Game Intervention Condition

The Buddy Game was a novel intervention designed by the second author, based on tenants identified from the ABA and NDBI literature, with materials previously familiar to all study participants. When all children had gathered “at the field”, the lead teacher informed them that they were going to play the Buddy Game. The intervention consisted of child dyads singing songs with gestures and movements in front of one another in a larger group setting. Songs were randomly chosen from a selection of laminated 4-in × 6-in cards with the song’s title and related pictorial depiction. The lead teacher randomly chose a different child to select each song (see Table 2).

After the children gathered in the field, they were given the instructions: “Friends, we are going to sing some of our favourite songs with our buddies. They are here on these cards. (The lead teacher randomly chose a child to pick a card; the child picked a card). Oh, X chose song Y. Ok, we are going to stand in front of our buddies to sing. Remember we are dancing and singing with our buddies.” Both the lead teacher and assistant teachers supported the children to stand in front of their buddies in two lines, by gently leading them

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by the hands or gently applying pressure to the children’s upper backs to guide them into position, if needed. All teach- ers then stood behind the line of children they had supported. The lead teacher began the chosen song with movements and assistant teachers followed in singing and moving. Once a song was completed everyone cheered, and the process was repeated with song cards that had not been previously chosen. Before each song the children were instructed to, and if needed, supported to stand front of their buddy. If the 15-min intervention period had not ended before all song cards were chosen, the song cards were placed together again, shuffled, and the process continued until the 15-min period had ended. At that time, the lead teacher told the children, “We are all done singing. You can go play now.”

The nametags used on the Buddy Board closely resem- bled the nametags that each child used during the school day to identify their place at meals. The song cards used in the intervention closely resembled the children’s nametags in their design. Similar cards had been utilized in some class- rooms to visually support children in choosing songs to sing during circle time, prior to the study’s commencement.

If a child left “the field” during the 15-min intervention, an assistant teacher followed them, gently taking him or her by the hand and said “It’s time to sing song X with your buddy” in a matter-of-fact manner, brought child back to the field, and supported child them to face their buddy. If during a song, the lines dispersed and a group formed, the Buddy Game continued in that manner. Behavior management plans for child aggression towards another child, as defined in the ongoing curriculum, remained in place.

Generalization to Free‑Play Condition

In a 15-min free-play session following the Buddy Game, teacher behavior mirrored that of the baseline condition. During this condition, children were free to engage in any activity or with any of the toys that were available to them in their indoor free-play area. Teachers were instructed to contact children using regular classroom procedures. The normally occurring program procedure that teachers matter- of-factly redirect children who were unengaged to an activ- ity or to functionally play remained in place, and teachers

continued to prompt for verbal language expansion and ensured that safety and behaviour management procedures were followed. Teachers were instructed to not prompt or teach to, or reinforce any child to child interactions, except those required to settle a sharing dispute over materials of physical space.

Response Definitions

A multiple baseline across classrooms design was used to investigate the effect of a structured outdoor play curricu- lum on social communication behaviors between children with ASD and peers with NTD. Data were collected in vivo using a 120-s observe; 30-s record, partial interval system. Observe and record intervals were specified to each data col- lector through an individually worn ear bud attached to an Olympus Digital Voice Recorder (VN-100) so that only the data collector could hear the intervals. Each data collector developed their reliability of observation of the response def- initions through scoring videos of non-participants at play, and observing non-participants at play in situ. The study commenced when all observers demonstrated an interob- server agreement with the principle investigator of 80% or more over three consecutive observations.

Data were collected on three main behaviors during all study conditions. These three behaviors were also broken down by child status (i.e., ASD and non-ASD) to determine the effects of the Buddy Game on each population of child. Specific response definitions are provided below.

Overall proximity to peers (proximity) was defined as the target child being within 3-ft of another child, or a distance in which an item could be easily given by one to the other.

Proximity to a typical peer (typical proximity) was defined as the target child being within 3-ft of a typical peer, or a distance in which an item could be easily given by one to the other.

Proximity to a peer with ASD (ASD proximity) was defined as the target child being within 3-ft of a peer with ASD, or a distance in which an item could be easily given by one to the other.

Overall social bid received from a peer (receives) was defined as the target child having facial orientation toward another child and receiving a verbal, non-verbal, or com- bined social initiation from that child; accidental bumping into each other was not counted as a social bid.

Social bid received from a typical peer (typical receives) was defined as the target child having facial orientation toward a typical peer and receiving a verbal, non-verbal, or combined social initiation from that peer; accidental bump- ing into each other was not counted as a social bid.

Social bid received from a peer with ASD (ASD receives) was defined as the target child having facial orientation toward a peer with ASD and receiving a verbal, non-verbal,

Table 2 Interactive songs used during the Buddy Game curriculum

● Baby Shark ● Head, Shoulders, Knees and Toes ● If You’re Happy and You Know It ● The Banana Song ● The Itsy-Bitsy Spider ● Wheels on the Bus ● The Hokey Pokey

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or combined social initiation from that peer; accidental bumping into each other was not counted as a social bid.

Overall social bid initiated by target child towards a peer (gives) was defined as the target child having facial orienta- tion towards another child and actively engaging in a (verbal, nonverbal, or combined) social interaction with that child.

Social bid initiated by target child towards a typical peer (typical gives) was defined as the target child having facial orientation towards a typical peer and actively engaging in a (verbal, nonverbal, or combined) social interaction with that peer.

Social bid initiated by target child towards a peer with ASD (ASD gives) was defined as the target child having facial orientation towards a peer with ASD and actively engaging in a (verbal, nonverbal, or combined) social inter- action with that peer.

Interobserver Agreement

Two independent observers simultaneously coded a total of 38% of sessions across all study conditions to determine the degree of accuracy in behaviors recorded. Interobserver agreement (IOA) was calculate using a Total Count IOA formula (Cooper et al. 2007, p. 115; Landis and Koch 1977). Both observers independently scored data using individual Olympus Digital Voice Recorders (VN-100) which were synchronized to play intervals at the same time. Observers were free to move around each setting in which data was col- lected in order to get the best view of children and to stay at minimum of 4-ft apart from each other. Specifically, agree- ment between the total frequency of responses recorded by the two independent observers was calculated by dividing the smaller frequency of behaviors recorded by the larger frequency of behaviors recorded and multiplying by 100. Percent agreement for overall proximity was 87% (range: 64–100%). Percent agreement for overall receives was 78% (range: 0–100%) Percent agreement for overall gives was 85% (range: 50–100%).

Data Analyses

Data analyses were conducted using IBM SPSS Statistics 24 software. Data collected during baseline, the Buddy Game intervention, and generalization to free-play were investigated. To determine the effectiveness of the Buddy Game intervention on the overall social behaviors targeted, a 2 (ASD status) × 3 (study condition) analysis of variance (ANOVA) was conducted. Multiple regression analyses were conducted to determine how well the factors, status of child (i.e., ASD versus typical) and age range of child, predicted each of the six specific social variables (i.e., typi- cal proximity, ASD proximity, typical receives, etc.) when children participated in the Buddy Game intervention. For

all six regression analyses, the predictor variables were ASD status and age range of child.

Since frequency of proximity was different for each child, we converted all proximity measures into a rate of proxim- ity by dividing the number of times the target child was in proximity to a typical/ASD child by 120-s. This new number became the rate of typical proximity and rate of ASD proxim- ity used in the analyses. Frequency of typical receives was determined by the number of times the target child received a social bid from a typical peer, while ASD receives was the number of times the target child received a social bid from a peer with ASD. Typical gives was the total frequency of times the target child initiated a social bid to a typical peer; ASD gives was the total frequency of times the target child initiated a social bid to a peer with ASD. Children were grouped into 6-mon age ranges based on the child’s age (in months) on the first day of the study.

Multiple Regressions Analyses

To determine how child’s ASD status (i.e., ASD versus non- ASD diagnosis) and age of child (in 6-mon interval) related to each targeted social behavior, multiple regression analyses were conducted with ASD status and age range entered as the first step of the regression analysis. The result of these six analyses determined the influence of each independent variable on the social behavior under investigation. To deter- mine how ASD status and age related specifically to the social behaviors studied, three additional regression analyses of these factors were conducted for each of the eight behav- iors. During these analyses, the independent variable that was not being considered was held constant.

Results

Overall Effects of Buddy Game Intervention on Peer Related Social Behaviors

A 2 (ASD status) × 3 (study condition) ANOVA was con- ducted to evaluate the effects of implementing the Buddy Game intervention on the overall levels of peer-related social behaviors of children with ASD and their typical peers dur- ing regularly scheduled outdoor recess time. Specific behav- iors targeted were overall rates of proximity to peers (prox- imity), overall frequency of social bids received from peers (receives), and overall frequency of social bids initiated to peers (gives). Data were collected during the baseline, inter- vention, and generalization to free-play conditions. Overall means and standard deviations for the targeted social vari- ables by study condition and participant group are provided in Table 3.

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Overall Rates of Proximity to Peers

Results indicated that because both children with and with- out ASD had high rates of proximity to other children dur- ing baseline the Buddy Game intervention did not produce a meaningful change on this behavior, F = 0.007, p = .932, η2 = 0.00. Mean rates of proximity to peers remained rela- tively unchanged, although overall children showed sig- nificantly higher rates of proximity during baseline and in the Buddy Game than in generalization to free-play, F = 15.935, p < .001, η2 = 0.05, showing a moderate effect size based on condition. A significant ASD status × study phase interaction was also found, F = 6.443, p = .002, η2 = 0.02, indicating that children with ASD showed significantly higher rates of proximity during the Buddy Game than during baseline or generalization to free play, although this interaction had a small effect size.

Overall Frequency of Social Bid Received from Peers

Significant differences were found based on the ASD status of the child participating in the study, F = 8.624, p = .003, η2 = 0.01, with typical children receiving more social bids than children with ASD. ANOVA also found that study phase was also significant, F = 9.799, p < .001, η2 = 0.03, showing that both children with and without ASD received significantly fewer social bids from peers during the Buddy Game than during either baseline or generalization to free- play, although this had a small to moderate effect size. A significant ASD status x study phase interaction was also found, F = 3.473, p = .032, η2 = 0.01, indicating that typi- cal children received more social bids from peers during generalization to free-play than children with ASD in all three conditions, but again this was a small effect size.

Overall Frequency of Social Bids Initiated to Peers

Overall the ASD status of the child was not significant for initiations of social bids to peers, F = 1.49, p = .223, η2 = 0.00. Significant differences were found for gives based on study condition, F = 4.200, p < .015, η2 = 0.01, with chil- dren initiating significantly more social bids to peers during generalization to free-play over baseline levels. A significant ASD status x study phase interaction, F = 13.923, p < .001, η2 = 0.04, indicating that children with ASD initiated signifi- cantly more social bids towards their peers during the Buddy Game and generalization to free-play than during baseline, while typical children initiated more towards peers during generalization to free-play only.

Summary

These results indicate that the Buddy Game is an effective strategy for increasing social bids in both children with ASD as well as their typical peers. Given that both children with and without ASD displayed higher frequencies of receipt of social bids (receives) and initiations of social bids (gives) during the generalization to free play condition demonstrates that the naturally occurring peer imitation provided during the Buddy Game intervention may not show immediate effects during outdoor recess, but the behaviors are general- izing to a different time and different setting without direct teaching.

Factors Related to Targeted Social Behaviors

Means and standard deviations for each of the specific tar- geted social behaviors by are presented in Table 4. Indices of the relative strength of the individual predictors by social behavior targeted are presented in Table 5.

Table 3 Means and standard deviations of overall targeted social variables by study condition

Proximity overall rate of proximity to another child, Receives overall frequency of social bids received from peers, Gives overall frequency of a social bids initiated to peers, Typical typically developing children, ASD children with autism spectrum disorder, Total all children combined, Gen FP generalization to free-play condition *p < .05; **p < .01; ***p < .001

Condition Proximity Receives Gives

Typ ASD Total Typ ASD Total Typ ASD Total

Baseline 0.025 (0.017) 0.020 (0.015) 0.023*** (0.016)

1.66 (1.99) 0.94 (1.54) 1.37*** (1.85)

2.00 (2.38) 0.78 (1.30) 1.50 (2.09)

Intervention 0.021 (0.011) 0.026* (0.015) 0.023*** (0.013)

0.59 (1.08) 0.74 (1.25) 0.64 (1.14) 0.76 (1.64) 2.00*** (2.44)

1.19 (2.03)

Gen FP 0.016 (0.011) 0.016 (0.014) 0.016 (0.012) 1.99* (2.65) 1.12 (1.89) 1.68*** (2.44)

2.28 (2.58) 1.58 (2.49) 2.03* (2.57)

All phases combined

0.020 (0.13) 0.020 (0.015) 0.020 (0.014) 1.50** (2.19) 1.12 (1.89) 1.30 (2.012) 1.77 (2.37) 1.41 (2.19) 1.64 (2.31)

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Rates of Child Proximity

The linear combination of ASD status and age measures was statistically significantly related to rates of typical proximity, F(2, 165) = 9.758, p < .001, and for rates of ASD proximity, F(2, 165) = 11.741, p < .001. The sample multiple correla- tion coefficient for typical proximity was 0.33, indicating that approximately 11% of the variance for the typical proximity in the sample can be accounted for by the linear combina- tion of ASD status and age. The sample multiple correla- tion coefficient for ASD proximity was 0.35, indicating that approximately 12% of the variance for the ASD proximity can be accounted for by the linear combination of ASD sta- tus and gender. Table 6 presents R2 and adjusted R2 as well as relative strength of the individual predictors per scale.

Table  6 also presents indices to indicate the relative strength of the individual predictors. For the subscale typi- cal proximity, the bivariate and partial correlations between ASD status and age were significant. ASD status alone accounted for approximately 8% of the variance for typical proximity, while the age variable did not contributed to this behavior. For ASD proximity, ASD status alone accounted for approximately 11% of the variance, with age contributed an additional almost 8% of the variance observed. These results suggest that typical children, regardless of age, are

more likely to be in proximity to another typical child, whereas older typical children are more likely to be in prox- imity to children with ASD than younger typical children.

Social Bids Received from Peers

The regression equation with both factors under investiga- tion (i.e., ASD status and age) revealed non-significant cor- relations with social bids received from a typical peer (typi- cal receives), F(2, 165) = 1.233, p = .294, as well as social bids received from a child with ASD (ASD receives), F(2, 165) = 1.153, p = .318. The multiple correlation coefficient for typical receives was 0.12, accounting for only 1.5% of the variance. The correlation coefficient for ASD receives was 0.12, accounting for less than 1% (0.006) of the variability. These results suggest the frequency of social bids received from peers during the structured Buddy Game time did not depend on age or diagnostic status of child.

Social Bids Initiated by a Peer

The linear combination of ASD status and age measures was statistically significantly related to the frequency of social bids initiated by a typical peer (typical gives), F(2, 165) = 9.545, p < .001. The sample multiple correlation coefficient for this social behavior was 0.32, indicating that approximately 10% of the variance in the sample can be accounted for by the linear combination of ASD status and age. The bivariate and partial correlations between ASD sta- tus and age were significant. ASD status alone accounted for approximately 8% of the variance for typical gives, while the age variable did not contributed to this behavior. These results suggest that typical children, regardless of age, are more likely to initiate a social bid towards another typical child.

For overall ASD gives, the linear combination of ASD status and age measures was not statistically significantly related to the frequency of social bids initiated by a peer with ASD (ASD gives), F(2, 165) = 1.100, p = .335. The sample multiple correlation coefficient for this social behavior was

Table 4 Means and standard deviations for specific targeted social behaviors during the Buddy Game intervention

Targeted behavior Mean Standard deviation

Rate typical proximity 0.03 0.02 Rate ASD proximity 0.01 0.01 Typical receives 0.49 1.02 ASD receives 0.15 0.45 Typical gives 0.98 1.84 ASD gives 0.21 0.66

Table 5 ASD status and age by specific targeted social behavior dur- ing the Buddy Game intervention

*p < .001

Social behavior Correlation predictor and social behavior

Correlation controlling for other predictor

ASD status Age range ASD status Age range

Typical proximity 0.32* 0.17 0.28 0.03 ASD proximity − 0.23* 0.14* − 0.33 0.28 Typical receives 0.12 0.07 0.10 0.02 ASD receives − 0.11 − 0.01 − 0.12 0.04 Typical gives 0.32* 0.15 0.29 0.02 ASD gives − 0.00 0.10 − 0.05 0.12

Table 6 ASD status and age entered as the first step of the regression analysis for each specific social behavior

*p < .001

Targeted behavior R2 Adjusted R2 F(2, 165) p

Rate typical proximity 0.106 0.095 9.758 0.00* Rate ASD proximity 0.125 0.114 11.741 0.00* Typical receives 0.015 0.003 1.233 0.29 ASD receives 0.014 0.002 1.153 0.32 Typical gives 0.104 0.093 9.545 0.00* ASD gives 0.013 0.001 1.100 0.36

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0.12, indicating that approximately 1% of the variance in the sample could be accounted for by the linear combination of ASD status and age. These results indicate that diagnosis and age do not play a role in the frequency of social bids initiated towards a child with ASD.

Discussion

Toddler- and preschool-aged children with ASD have signifi- cant difficulties engaging appropriately with other children, especially during unstructured times such as those found during outdoor recess. Commonly, unstructured times in early childhood settings have less adult supervision and children are left to engage in play schemes of their choos- ing. In this study we implemented a structured outdoor play curriculum to determine the changes in social behaviors displayed by typical children and children with ASD. The social behaviors under focus were those that are considered hallmarks of the ASD diagnosis, namely receipt of social bids from peers (i.e., receives) and the frequency of initia- tions of social bids towards other children (i.e., gives) (APA 2013). Proximity to peers was also measured, as the other two social behaviors are more difficult if one is not near one’s social partner. Results demonstrated that children with ASD can increase their initiations to, and receipts of social bids from other children when a structured play curriculum is implemented. Generalization of skills was also observed as presented in Table 3. These data demonstrate that focus- ing on social interaction skills by structuring outside time can have beneficial effects children with ASD using these skills outside of the intervention time, as well as maintain- ing them once the intervention has ended. Multiple regres- sion analyses were conducted to determine the influence of a child’s ASD diagnosis and age on the increases in the tar- geted social behaviors. Results from the regression analyses indicated that ASD status had a bigger influence on social behavior than the age of the child. This was surprising given an a priori hypothesis that there would be an interaction effect of young children with ASD displaying less social behavior than older children with ASD due to maturation and developmental complexity of the social behaviors tar- geted. These results could be explained by the younger chil- dren in the toddler and early preschool classrooms having participated in an intensive ABA treatment targeting social communication behaviors for a shorter period of time prior (average time approximately 10 months) to the Buddy Game intervention than the children who were enrolled in the preschool and pre-kindergarten classrooms (average time approximately 28 months).

Results from this study support previous research on structuring peer interactions during unstructured times as a means to increase social bids between typical peers and

peers with ASD (Boyd et al. 2008; Harper et al. 2008), and extends the research downward in age to toddler and pre- school-aged children. The use of a structured outdoor play curriculum can be used as part of a comprehensive center- based NDBI program to help promote positive peer inter- actions across the entire treatment day. Previous research demonstrated that buddy pairs increased social interaction for children with ASD (Kohler et al. 2007), and the results from our study indicate age of child participating may not be as big an influencer on results obtained than previously hypothesized.

Following the concept of “benchmark social behaviors” identified by McGee et al. (1997), this study used social behaviors displayed by typically developing children to determine when intervention should be implemented, as well as when intervention was discontinued. To exit inter- vention, children with ASD needed to display a minimum of the baseline average for typical receives for three or more consecutive days. The use of typical data as a measure of progress may explain why age was not a significant factor in results as the comparison behavior was from children of the same age. Use of typical development as an intervention result still needs further refinement due to the high vari- ability of social behaviors displayed by typical peers across the 2, 3, 4, and 5 year age ranges. Future research needs to examine the use of typical data as a metric for social behav- ior more fully.

Limitations and Future Directions

Several limitations that might have affected the results of this study should be mentioned. The first limitation related to the children and the time of year, as this study was conducted in the summer, children were transitioning between Center classrooms during all phases of the study. A child’s base- line data might have been collected in the early preschool classroom but his intervention data were collected after he transitioned to a preschool classroom. Thus, data were col- lected with different groups of children throughout the study. To compensate for this, we analyzed all data based on the age the child on the first day he or she entered the study and maintained that age throughout.

Both children with ASD and their typical peers had been enrolled in the program for various amounts of time, ranging from 2 days to 4 years. Thus, the amount of treatment and education on how to interact with their peers had varied prior to study implementation. Future research would start data collection at the beginning of the year and only use children new to treatment to determine effects of the intervention on targeted social behaviors. Lastly, due to the small sample size of 10 children with ASD, the study’s results are limited in their generalization to other treatment settings without further research. The overall sample size (n = 35) produced

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small sub-populations of children based on 6  month age ranges. Thus, these results cannot be generalized further than this overall sample. Future research would be neces- sary to make more definitive age-related conclusion using larger samples within each age-ranged studied.

Implications for Practitioners

With little training and a minimal structure imposed, teach- ers can increase the social skills of children with ASD on the playground. Buddy pairs were randomly chosen, enabling every child with ASD to learn to initiate and respond to a variety of children in their classroom. Outdoor recess, or playground time, is meant to be an opportunity for children to interact freely with each other. By structuring a 15-min play period using fun games, songs, and movement, teachers can increase the social behaviors of all children. An added benefit is that the skills taught outside can generalize to other unstructured play environments, and maintain over time.

Acknowledgements The findings and conclusions in this study are those of the authors and do not necessarily present the official position of Emory University School of Medicine. We would like to thank all of the families and staff from the Early Emory Center for Child Develop- ment and Enrichment who participated in this study. This study would not have been able to be completed without your participation. A spe- cial thank you to Devika Persaud and Brittni Williams for painstakingly collecting data with us.

Author Contribution MJM conceived of original study, participated in study design and coordination, participated in data collection, per- formed statistical analyses, drafted manuscript; SMTZ conceived of current study and design, conducted the literature review, developed data collection system and social validity questionnaires, participated in data collection, and coordinated with classrooms for study imple- mentation. Both authors read, edited, and approved final manuscript.

Compliance with Ethical Standards

Conflict of interest The authors declare that they have no conflict of interest.

Ethical Approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the insti- tutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent Informed consent was obtained from all individual adult participants as well as a parent/legal guardian of all child partici- pants included in the study.

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Journal of Autism & Developmental Disorders is a copyright of Springer, 2018. All Rights Reserved.

  • I Wanna Play Too: Factors Related to Changes in Social Behavior for Children With and Without Autism Spectrum Disorder After Implementation of a Structured Outdoor Play Curriculum
    • Abstract
    • Introduction
      • Increasing Social Interactions During Unstructured Preschool Activities
      • Increasing Social Interactions During Outdoor Recess Activities
    • Method
      • Participants
      • Setting
      • Study Conditions
        • Pre-baseline
        • Baseline Condition
        • Pre-Buddy Game
        • Buddy Game Intervention Condition
        • Generalization to Free-Play Condition
      • Response Definitions
        • Interobserver Agreement
        • Data Analyses
        • Multiple Regressions Analyses
    • Results
      • Overall Effects of Buddy Game Intervention on Peer Related Social Behaviors
        • Overall Rates of Proximity to Peers
        • Overall Frequency of Social Bid Received from Peers
        • Overall Frequency of Social Bids Initiated to Peers
        • Summary
      • Factors Related to Targeted Social Behaviors
        • Rates of Child Proximity
        • Social Bids Received from Peers
        • Social Bids Initiated by a Peer
    • Discussion
      • Limitations and Future Directions
        • Implications for Practitioners
    • Acknowledgements
    • References