East Tennessee State University. From the SelectedWorks of John J. Wheeler

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1 East Tennessee State University From the SelectedWorks of John J. Wheeler September, 2001 Acquisition and Generalization of Activity Schedules and their Effects on Task Engagement in a Young Child ith Autism in an Inclusive Pre-School Classroom N. Gayle Massey, Vanderbilt University John J. Wheeler, Tennessee Technological University Available at:

2 Education and Training in Mental Retardation and Developmental Disabilities, 2000, 35(3), Division on Mental Retardation and Developmental Disabilities Acquisition and Generalization of Activity Schedules and their Effects on Task Engagement in a Young Child ith Autism in an Inclusive Pre-School Classroom N. Gayle Massey John J. Wheeler Peabody College of Vanderbilt University Tennessee Technological University 0111 lh: Abstract: Efficacy of individualized activity schedules ith a 4-year old child diagnosed ith autism ho attended an integrated public pre-school classroom as examined. Graduated physical guidance and a system of most-to-least prompts ere used during skill acquisition stages ith teacher proximity and level of prompts being eventually faded. A multiple baseline across activities (ork and leisure) assessed performance _across baseline, treatment, and maintenance conditions ith stimulus generalization being assessed during a third activity (lunch). R.esults support the findings from MacDuff, Krantz, and McClannahan (1993) in that a child ith autism can successfully acquire the skills necessary to independently follo activity schedules and generalize these skills to other settings ith minimal training. The study represents an advance in applied research in the use of visual cues ith children ho experience autism in school settings; most notably an integrated pre-school classroom serving children ith disabilities and typical same-aged peers. ~ljl rj :~ Autism represents one specific form of Penrasive Developmental Disorders and is characterized by a severe and penrasive impairment in several key areas of development including: reciprocal social interaction skills, communication skills, and the presence of perseverative and stereotypical behavior, interests, and activities (American Psychiatric Association, 1994). Given these difficulties in communication and social interaction, children ith autism display significant difficulties in processing language and the subsequent verbal cues needed to function independently in school, home, and community environments. Language is typically represented in three forms: visuo-spacial symbols (graphics/riting), visuo-temporal symbols (sign), or auditory-temporal symbols (speech). Typically The authors ish to acknoledge the folloing persons for their support of this research: J. Christopher Barton, PhD., for his collaboration on the research, Audrey Rich for her assistance in the preparation of the manuscript, and Cathy Gallyon Keramidas and Joetta Herald for their assistance in the classroom. Correspondence concerning this article should be addressed tojohnj. Wheeler, Tennessee Technological University, Box 5074, Cookeville, TN children ith autism experience greater difficulty in attempting to process auditory symbols due to the presence of neurological processing disorders. Hoever, hen visuospacial symbols are used, they facilitate more expedient processing using a gestalt style of processing in that they store graphic information in unanalyzed holes (Quill, 1995). This accounts for the fact that some children ith autism can more readily process and remember a story that is ritten ith graphic symbols as opposed to a story that is recited to them verbally. For many of these children, visual cues represent a functional form of communication leading to greater degrees of independence in school, home, and community settings (Hodgdon, 199.5). Despite their impaired abilities to communicate by typical means, children ith autism display significant strengths that hen identified appropriately and reliably can lead to enhanced lifestyle outcomes. These strengths include rote memory, concrete thinking, and the ability to efficiently process visuo-spacial information (Quill, 1995). In addition. children ith autism experience greater difficulty in completing tasks that do not promote visual clarity for the learner. One method that has been demonstrated to be highly effective in 326 I Education and Training in Mental Retardation and Developmental Disabilities~September 2000

3 teaching children ith autism has been the use of visual cues as a primary form of instruction and communication (Mesibov, Shopler, & Hearsey, 1994). Visual cues can be represented in the form of individualized activity schedules comprised of objects, photographs, pic/syms, and/or ords. Often ords are paired ith photos or pic/syms depending on the abilities of the learner. This system has been developed and utilized over time by Shopler and colleagues at Division TEACCH at the University of North Carolina and has been referr_ed to as "structured teaching" (Mesibov et al., 1994). A photo activity schedule consists of a sequence of photographs depicting individual activities in a sequence as they are planned to occur. The photographs themselves can depict an object related to the task or a person conducting the task. The student is taught to refer to the activity schedule at the beginning and close of each activity as a means for determining hat activity is to be done and hen each activity is scheduled to take place. Not until recently has this methodology been examined empirically ith children diagnosed ith autism. Hall, Krantz, and McClannahan (1995) examined the use of photographic activity schedules and prompt reduction ith teaching aides ithin an integrated classroom setting. Specific dependent measures examined in the study conducted by Hall et al. (1995) included task engagement on the part of children ith autism and levels of prompt given by teaching assistants orking ith individual children. The results from this investigation indicated that hen photographic activity schedules ere present and utilized by individual children ith autism a decrease in prompts on the part of the teaching assistant as noted, as as an increase in task engagement on the part of the child. The findings from this study address the efficacy of such intenrention methodologies for children ith autism ithin integrated classroom settings as a means for promoting greater levels of independence. Another issue of concern that is common among many children ith autism is that of stereotypic behavior. Some examples of these behaviors include body rocking, hand flapping, verbal outbursts, and perseverative speech. Findings from a study conducted by Krantz, MacDuff, and McClannahan (1993) indicated that hen parents \Vere taught to assist their young child ith autism in the use of a photographic activity schedule during leisure, social interaction, self-care, and housekeeping activities that the children engaged in stereotypic behavior less frequently. These intenrention effects ere durable and lasting over time even hen the frequency of verbal, gestural, and physical prompts ere reduced resulting in a transfer of stimulus control from parent/ teacher delivered cues to less intrusive more naturally occurring cues in the form of photographic activity schedules. These findings ere supported in a subsequent study conducted by Pierce and Schreibman (1994) ho utilized picture prompts for teaching children ith autism ages 6 to 8 years to selfmanage their behavior. Results from this study indicated that use of picture prompts assisted the participants in reducing their levels of challenging behavior in the absence of the treatment provider. Other studies have also demonstrated that the use of photographic activity schedules has resulted in an increase in task engagement and a decrease in disruptive behavior (Krantz et al., 1993; Pierce & Schreibman, 1994) hen measured across child participants and tasks and settings and tasks respectively. MacDuff, Krantz, and McClannahan (1993) also noted anecdotally that aberrant behavior appeared to decrease during the time periods hen the participants utilized their activity schedules. One issue hich must be addressed hen teaching children ith autism to use photographic activity schedules is the methods employed for teaching such procedures. Research has shon that methods most commonly used have included the use of graduated guidance and rapid fading of prompts. This method has been demonstrated to be most successful in the acquisition of skills needed to utilize the schedule even in the absence of the treatment provider (MacDuff et al., 1993). Others including Krantz et al. (1993) and Pierce and Schreibman (1994) also found graduated guidance to be effective in promoting acquisition of schedule behavior in young children ith autism. Prior research that has investigated the use of photographic activity schedules has concen- Ill. ill l.i! Ill Activity Schedules I 327

4 di JUI trated on children six years of age or older (Krantz et al., 1993; Pierce & Schreibman, 1994). In addition, hereas only to previous studies have examined the effects of visual cuing procedures on task engagement and inappropriate behavior in a group home, clinic, and home settings, the present study extends the findings by investigating the effects of such procedures ithin a classroom setting. The purpose of the present study as to (1) measure the efficacy of photographic activity schedules as a form of self-management pro. cedure aimed at reducing teacher delivered prompts to promote task engagement; and (2) assess the levels of task engagement and challenging behaviors and their generalization across activities (ork, leisure, and lunch). Method Participant and Setting The participant as a 4-year-old male child (Karl) ho had been given the diagnosis of autism. At the outset of the study, Karl exhibited very limited use of language and relied primarily on gestural forms of communication. He exhibited great difficulty ith planned and unplanned transitions beteen activities as evidenced by his crying. He exhibited a strong disinterest in joint attention activities, but did communicate for the purpose of having his basic needs met. The setting consisted of an integrated preschool classroom for children ith autism and same-aged typical peers located vithin an elementary school. The class as comprised of a total of six children ranging in age from 3-5 years, a classroom teacher, and one teachers aide. Three children ere diagnosed ith autism and three children served as same-aged typical peers. The room as approximately 15 X 20 1 ith individual desks for each child placed adjacent to one all. On the adjacent all as a storage shelf that contained individual ork sets for each childs in-seat pre-academic ork. Leaming- centers ere present ithin the room, as as a designated area for leisure complete ith a mini-recliner, story books, and mats. The room as designed to place emphasis on visual clarity to facilitate predictability and ease in routine for each child. Materials Photographic activity schedules consisted of color Polaroid photos (3.5"x 5"), hich ere used to display each task for both ork and leisure conditions. The photos ere placed on a manila folder ith Velcro and ere then placed on the board in front of the childs desk during the ork condition, and on the all in the play area during the leisure condition. When the generalization condition (lunch) as implemented, picture/symbols depicting the steps of each task ere placed on an 8.5" X 11" sheet of hite construction paper. This modification as necessary in an effort to reduce the size and level of intrusiveness of the photo schedule in a fully inclusive setting (i.e., cafeteria). Dependent Measures Task Engagement as scored hen the child as looking at the photograph on the schedule, holding the appropriate photograph for the appropriate task, progressing successfully through transitions beteen activities, and manipulating task materials in the manner in hich they ere to be used. Task Disengagement as scored hen the child as not engaged in looking at the photograph or materials, engaged in a behavior not displayed in the photograph including any appropriate behavior, manipulating materials, but not visually attending to them, and/ or using materials in a manner inappropriate to the task or in ays in hich they ere not intended to be used. Challenging Behavior as defined as verbal or physical aggression, destructive behavior, tantrums, noncompliance, and stereotypy (including, but not limited to hand flapping). Independent Measures Physical prompts ere defined as light touches on the childs arm or hand, and/or hand-over-hand physical guidance. Gestural prompts ere defined as any physical motioning or gesture given in order to orient the child to an activity or to assist in their comple- 328 I Education and Training in Mental Retardation and Developmental Disabilities-September 2000

5 1 tion of an activity. Examples of these included head nodding, motioning ith hands, or pointing. Verbal prompts included.praise, insrructions, and questions related to task performance or completion. Procedures All sessions started ith the teacher providing the instruction "O.K everyone, no it is time to ork" (play, go to lunch, respectively). Karl as initially taught ho to use the photographic activity schedule for the first task (i.e., ork) by using a system of graduated guidance (i.e., the use of physical prompting that includes physical touches to the arm or handover-hand assistance) involving a most-to-least prompt hierarchy hich included the use of physical, gestural, and verbal prompts. A 5 s time delay as used throughout all instructional sessions. Prompts ere faded based on the folloing performance criteria. If Karl as on-task or engaged during 80% of observed intervals during the session for six consecutive sessions, prompts ere reduced. When Karls performance reached a stable percentage of task engagement (80% for six consecutive sessions), he as given another set of photographs for the second and third c::ondition (leisure). This same instructional procedure and criteria ere used in the generalization condition (lunch). The amount of training required as determined by ho ell Karl acquired the task (80% of task engagement per session for six consecutive trials). The frequency of challenging behavior as not a determinant of the introduction of subsequent tasks, but as measured throughout all sessions. Design and Data Recording Procedures A multiple-baseline across activities as used to measure skill acquisition and generalization of task engagement across activities and the frequency of challenging behavior. A 15s momentary time sampling (ith 5s interval folloing for recording purposes) as used across all sessions by both observers to score occurrence/non-occurrence of challenging behavior, frequency of task engagement, and level of prompt. Occurrences of task engagement and challenging behavior ere converted into percentages by dividing the number of occurrences for engagement/behavior by the total number of observations. Reliability Interobserver reliability as assessed across 20% of all sessions. The classroom teacher assisted the principal investigator. Prior to initiating reliability sessions, the classroom teacher as trained in the observation and recording of behaviors and possessed a fluent orking knoledge of all operational definitions prior to beginning baseline data collection. Interobserver reliability as scored for task engagement and inappropriate behavior and as calculated by dividing the number of agreements by the number of agreements plus disagreements and multiplying by 100. The range ofinterobserver reliability across all sessions as 80% to 100%, ith a mean of 91 %. Social Validity A social validity rating scale as developed and administered to each of Karls teachers in the classroom, Karls mother, and a behavior consultant that orked regularly ith Karl throughout the school year. These measures ere collected during baseline, treatment, and follo-along phases of the study. See Table I for a summary of these ratings across raters across all conditions. Results Task engagement and challenging behavior "\Vere scored during baseline, intervention, and maintenance sessions. Once training for the first task, ork, as implemented, task engagement stabilized and remained above the criterion (M = 90.9%) (see Figures I and 2). During baseline, the participant remained engaged in the ongoing task an average of 83.6%. Levels of challenging behavior decreased as ell. Challenging behavior during baseline for the "\Vork condition as 15% dropping to only 1.3% during intervention sessions (see Figure 3). During the second condition (leisure) Karl shoed a marked increase in task engage~ ment. Task engagement ranged from 0% to r iii Iii! 11,!. Activity Schedules I 329

6 TABLE I Students Progress Evaluation Form Key: 4-Strongly disagree 3-Disagree 2-Agree I-Strongly agree Upon Completion of Project Ifill,).:11. ""I,, The educational intervention used in the project as acceptable to you. 2. The design and use of visual supports for your child/student ere individualized and child-centered based on his/her needs. 3. The visual supports ere practical and easy to implement In your opinion, your child/student appeared to enjoy the use of visual support strategies in his/her educational program In your opinion, your child/student has made significant progress during the intervention. 6. In your opinion, having learned the use of visual support strategies, your child/student ill enjoy increased options and freedoms no and in the future hen learning ne skills. 7. Since the introduction of visual support strategies in your childs/students educational program, you have itnessed measurable improvement in his/her skills. 8. Overall, rate your level of satisfaction ith the outcome of this project on behalf of your child/student. 1i: Baseline Picture/Symbol Schedule 100 1~ CJ) _J 90 ;;; 80 a: I- 70 ;;; 60 LL 0 50 (.) 40 I ~ z 30 u a: 20 " Maintenance LUNCH SESSIONS Figure 1. Percentage of intervals of task engagement during ork and leisure activities. 330 I Education and Training in Mental Retardation and Developmental Disabilities-September 2000

7 r~ l...i 100 Baseline 1st Task 2nd Task Maintenance 90!~!~! C/l <{ > 40 a: f- 30 ;?; 20 LI L L- 1 1 (.) <{ 100 f- \ WORK J z 90 \ (v\r~:/v\ () 80 a: 70 <l I I LEISURE 1111 I! ; I SESSIONS Figure 2. Percentage of intervals of task engagement during stimulus generalization phase (picture/symbols) ithin lunch. 100% during baseline (M = 61.9%) itb large discrepancies beteen sessions. During intervention, the discrepancies decreased (M = 74.2%) and remained above criterion ith one exception (score of 79%). Aberrant behavior also increased in that the average instances of behavior occurred 0% during baselines and 5.5% during intervention. Karl demonstrated a significant increase in task engagement during the third condition (lunch). He remained on-task for 54. 7% of the time during baseline and 91.3% during the training condition. Levels of challenging behavior during this condition decreased from M = 9.5% during baseline sessions to M = 3.3% during training sessions. Maintenance sessions ere scored and the percentage of task engagement increased across all three conditions. Measures from maintenance sessions produced means for task engagement of 97.5% during the ork condition, 91.8% during leisure, and 92.5% during lunch. The maintenance measures for inappropriate behavior also indicated declines in that the average percentage during the ork condition as 0%, 2.75% during leisure, and 2% during lunch. Prompts ere also measured to assess the childs ability to perform tasks ith minimal assistance from school personnel. During the ork condition, the participant as given a total of 265 prompts (70 physical, 25 gestural, and 170 verbal). As the prompts ere gradually faded based upon the established criteria Activity Schedules I 331

8 ;:IHI ~ (/) 0...I <( 100 > a: 90 UJ 80 I- z Work LL UJ 0 40 <( I- 30 z 20 UJ (_) 10 a: I LU 0 e a... r\a I Ii A " ;\(\,..,I\"" Leisure Lunch SESSIONS Figure 3. Percentage of intervals scored as challenging behavior across phases and activities. 332 I Education and Training in Mental Retardation and Developmental Disabilities-September 2000

9 TABLE 2 Frequency of Prompts Across Conditions Condition Physical Gestural Work Gestural 3 69 Verbal 0 9 Verbal (80% task engagement for 6 consecutive sessions), a total of 190 prompts ere administered during the leisure condition (3 physical, 69 gestural, and 118 verbal). The amount of prompting given dramatically decreased during the third condition in that only 32 total prompts ere issued (0 physical, 9 gestural, and 23 verbal) (see Table 2). Discussion The present study as designed to measure the efficacy of activity schedules and the acquisition and generalization of such skills vvith a 4-year-old boy diagnosed ith autism. Dependent measures for the study included task engagement and challenging behavior ith frequency of prompt levels being measured as ell. With the introduction of the photo activity schedule, task engagement increased across both conditions (ork and leisure). This 1vas also consistent in the third condition (lunch) in hich the participant utilized the picture/symbol activity schedule (see Figure 2). Levels of challenging behavior decreased in both \Vork and lunch conditions, but increased during the leisure condition. This may be attributable to the fact that leisure skills typically represent a major area of difficulty for children -ith autism, and the fact that Karl as taught to ne leisure skills (i.e., unfamiliar tasks once training as implemented). High percentages of inappropriate behavior ere exhibited during the first eek of training for leisure. Hoever, instances of this behavior steadily decreased during subsequent sessions. The discrepancy berureen the amount of sessions for ork and leisure compared to lunch as due to the naturally occurring frequency of activities throughout the childs regular school day. Work and leisure periods occurred more frequently, hereas lunch occurred only once per day. Based on the ability of the participant (Karl) to generalize his knoledge of activity schedules to an inclusive setting-ith ne tasks (verbally reciting his individual student account number to the cafeteria orker upon request and retrieving the necessary materials for lunch) by using a more abstract stimulus (picture/symbols), the data provided lends validity to the efficacy of the activity schedule. These skills ere.rapidly acquired -ith prompt levels being dramatically reduced based on Karls excellent demonstration of these skills. Karls task engagement increased in all three conditions, especially during the lunch sessions When the schedule as implemented. This lends support to previous research hich demonstrated enhanced levels of task engagement as a result of teaching children ith autism to utilize photo activity schedules (Hall et al., 1995; Krantz etal., 1993; Pierce & Schreibman, 1994). Another factor to consider resulting from the present study is the role of prompts and teacher supervision. By the introduction of the second task (leisure), the participant successfully folloed the schedule ithout any prompting, and teacher proximity as faded successfully as demonstrated by Karls ability to ork independently hile the teacher moved to the other side of the room. In addition, the total number of prompts decreased across all three conditions and the participant acquired subsequent leisure and lunch skills ith minimal training. These findings support the use of activity schedules as a means of promoting independence and are consistent ith the findings of Hall et al. (1995). The current study lends inconclusive results as to the effects of prompts on aberrant behavior in children ith autism as has been previously researched by Krantz et al. (1993) and Symons and Davis (1994). The participant in the present study exhibited feer instances of challenging behavior hen the frequency of prompts as high such as during the ork condition, and he exhibited the highest frequencies of behavior hen the frequency of prompts as moderate such as during ork and lunch. Therefore, the results do not appear to indicate a significant correlation beteen these to factors, but are more in con- Activity Schedules I 333

10 11:111 M!illll Ii ~ I ", I junction ith the findings produced by Pierce and Schreibman (1994) hich indicated that teaching children ith autism to use activity schedules may result in feer instances of aberrant behavior. Perhaps this topic could be further researched to determine if the frequency and type of prompts used has an effect on reducing the frequency of challenging behavior. Prior to the implementation of the intervention, Karl engaged in challenging behavior henever a transition occurred. Although his frequency of challenging behaviors as not extreme it as deemed sufficient enough by the teacher and his mother to arrant remediation. An activity schedule as developed for purposes of assisting him ith all aspects of his daily routine including scheduled activities and transitions. Upon acquiring the ability to independently utilize his individual activity schedule, Karl successfully transitioned ith minimal prompts from the teacher ithout episodes of challenging behaviors. Another major outcome from this study as the acquisition of skills needed to utilize an individualized activity schedule ith minimal prompting hich permitted Karl greater degrees of independence and enjoyment. These skills can be given additional consideration in the future as Karl transitions through his educational career and can also be inclusive of vocational, community, and home environments as he begins to refine these skills in an effort to achieve greater degrees of independence and enhanced lifestyle outcomes. Social validity data collected from Karls teachers, care givers, and mother demonstrated high levels of satisfaction ith intervention outcomes and concurring levels of agreement on the use of such an intervention in the future. Strengths of the present study include acquisition of skills necessary for independent use of an individual activity schedule, generalization of these skills across ork, leisure, and lunch settings, and also generalization across ne and novel tasks that had not been previously taught. In addition, Karl as able to successfully generalize using a picture/ symbol activity schedule in an inclusive setting (cafeteria) ith limited prompting from school personnel. Finally, this study has demonstrated the efficacy of an activity schedule for use ith a young child ith autism hich in turn facilitated greater levels of self-management of behavior ith minimal assistance from teachers resulting in increased levels of task engagement and reduced levels of challenging behavior. Other important implications realized during this study include definitive qualitative outcomes. Toard the completion of the study, Karl evidenced more frequent attempts at social interaction, joint attention activities ith both the primary researcher and other children, and more spontaneous communication efforts. Prior to the study he utilized communication solely for the purpose of meeting his immediate needs hereas, by the end of the study Karl ould initiate interactions such as "hi, ho are you today?" and "I ant to play no". Although these indices ere not systematically measured they ere observed and noted on several occasions by many people associated ith Karl including his primary teacher, his mother, program consultants, and typical same-aged peers ith hom Karl played. It is our belief based on the findings from this study and the results from other studies previously conducted and cited ithin this paper that photographic activity schedules can successfully assist young children ith autism in developing self-management skills, hich in turn promotes increased levels of independence. Based on the outcomes from this study e concur ith other researchers ho have stated the positive benefits of such procedures for promoting predictability and communicating task demands for young children ith autism resulting in feer episodes of maladaptive behavior and enhanced educational and lifestyle outcomes. It is also apparent from our study that more research is needed in this area to systematically examine the relationship beteen these variables in order to further our efforts toard a better understanding of the divergent learning patterns of young children ith autism and as a means for providing educational and behavioral supp~rts to these children. References American Psychiatric Association (1994). Diagnostic and Statistical lvlanual of Mental Disorders (4th ed.). Washington, D.C.: Author. Hall, L. J., Krantz, P. J., & McClannahan, L. E. 334 I Education and Training in Mental Retardation and Developmental Disabilities-September 2000

11 (1995). Promoting independence in integrated classrooms by teaching aides to use activity schedules and decreased prompts. Education and Training in Mental Retardation and Developmental Disabilities, 30, Hodgdon, L. A. ( 1995). Visual strategi,es for improving communication. Troy, MI: Quirk Roberts Publishing. Krantz, P.J., MacDuff, M. T., & McClannahan, L. E. (1993). Programming participation in family activities for children ith autism: Parents use of photographic activity schedules. Journal of Applied Behavior Ana~sis, 26, MacDuff, G. S., Krantz, P.J., & McClannahan, L. E. (1993). Teaching children ith autism to use photographic activity schedules: Maintenance and generalization of complex response chains. Journal of Applied Behavior Analysis, 26, Mesibov, G. B., Shopler, E., & Hearsey, K. A. (1994). Structured teaching. In E. B. Shopler and G. B. Mesibov (Eds.) Behavioral issues in autism (pp ). Ne York: Plenum. Pierce, KL., & Schreibman, L. (1994). Teaching daily living skills to children ith autism in unsupervised settings through pictorial self-management. Journal of Applied Behavior Analysis, 27, Quill, K. A. (1995). Visually cued instruction for children ith autism and pervasive developmental disorder. Jiocus on Autistic Behavior, 10, Symons, F., & Davis, M. (1994). Instructional conditions and stereotyped behavior: The function of prompts. Journal of Behavior Therapy and bxperimental Psychiatry, 25, Received: 11 March 1999 Initial Acceptance: 20 May 1999 Final Acceptance: 15 August 1999 Activity Schedules i 335