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Antecedent Motor-Based Intervention
The Effect of an Antecedent Motor-Based Intervention on Repetitive Behaviors for students with Autism:
A single case ABC multiple baseline design
By Sarah E. Moorhead, AT, APES
The Centers for Disease Control and Prevention estimates that about 1 in 88 children have been identified with an autism spectrum disorder (ASD) according to their Autism and Developmental Disabilities Monitoring (ADDM) Network. ASDs are reported to occur in all racial, ethnic, and socioeconomic groups. ASD’s are almost 5 times more common among boys (1 in 54) than among girls (1 in 252). ASD represent a spectrum of conditions with deficits in social interaction, communication, restricted interests and repetitive behavior (WHO, 2006). Autism is one of the most common diagnoses on the Autism Spectrum (Reid and Collier, 2002). Autism Spectrum Disorders is a significant disability challenging the educational system in America.
What is Autism Spectrum Disorder?
Autism Spectrum Disorder is a severe neurodevelopmental disorder. This disability has been found to significantly affect the persons’ ability to communicate or use language skills appropriately and participate in social interactions. ASD is also characterized by a person engaging in repetitive and stereotyped behaviors, having difficulty transitioning or change in routines, as well as, hypo or hyper sensitivities to sensory experiences (Boutot, & Myles, 2011). By definition, spectrum means the symptoms and characteristics of ASD can be mild to severe in nature and may present in each person differently. To date there is no known etiology or cure; however, there are a few but limited number of evidence based practices and promising practices available to treat the symptoms for ASD. Recently, with the implementation of the DSM-V (Diagnostic and Statistical Manual of Mental Disorders, Fifth edition), rather than three categories of symptoms there are now two, social-communication impairment and repetitive/ restricted behaviors. In addition to the new categories of symptoms, the DSM-V recognizes the three former subtypes of autism, Autism, Pervasive Developmental Disorder Not Otherwise Specified and Asperger’s Syndrome (Tovin, 2013), as an all-encompassing Autism Spectrum Disorder (ASD) (autismspeaks.org).
Repetitive & Restricted Behaviors
Repetitive behaviors and restricted interests limit the person’s ability to respond to their environment appropriately (Reid & Levinson, 1993). Myles and Boutot (2011) describe these Repetitive/Stereotypic behaviors are one of the most significant barrier to education for youth with ASD. Students or persons with ASD often engage in repetitive and self-stimulatory behaviors (e.g., hand flapping, spinning, and rocking), sensory avoidance behaviors, difficulty with attention and focus, poor motor planning, difficulty in following verbal instructions, low motivation, poor self-esteem, and difficulty in self-monitoring. These behaviors interfere with the activity at hand, and may distract others around them. The repetitive/ stereotypic behaviors make it difficult to participate in activities of daily living, including environments of education and socialization. The trigger or antecedent or purpose to these behaviors will be different for each person and maybe unclear, but each person with ASD will suffer from these symptoms at some point and on some level. “There is some evidence to suggest that these behaviors serve to calm persons with autism when their anxiety level increase- the behaviors serving as the routine they lack and crave” (Myles, & Boutot, 2011).
Students or persons that engage in stereotypic behaviors can become distracted with the behavior, taking their attention away from their environment. In the educational setting, this distraction removes the student’s attention from opportunities to learn. In a specially designed class for students with Autism Spectrum Disorder, various educational techniques are used to introduce and encourage academic knowledge and limit the distractions from their stereotypic behaviors. These techniques are known as scientifically based or evidence based practices.
These practices conform to the “No Child Left Behind Act” and meets the requirements for education of a person with a disability (IDEA, 2004). These practices include Applied Behavior Analysis (ABA), Discreet Trial Training (DTT), Pivotal Response Training (PRT) and Learning Experiences: An Alternative Program for Preschoolers and Parents (LEAP). Through these techniques a student will have repeated and structured opportunities to “learn the skills necessary to interact with others” (Boutot & Myles, 2011). By implementing an antecedent intervention that can successfully decrease the frequency and or duration of distracting stereotypic behaviors, the use of these evidence based practices to focus learning time, could ultimately increase academic learning for students with ASD.
“Effective Behavioral Interventions use Behavioral Principles. Behavior Principles rely on the bases of learning and motivation. The principles of behavior consist of three parts; first, behavior is learned through classical conditioning and operant conditioning. Second, all behaviors serve a purpose. The function of the behavior may vary from person to person including escape or avoidance of task, attention, to obtain something tangible or a preferred activity, or for self-soothing/ self-stimulation. Last, all behavior is contextual. Behavior is influenced by the environment in which it occurs; sometimes referred to as the trigger for behavior. The antecedent events in the immediate environment or setting events that have happened previously” (Boutot & Myles, 2011). Applied behavior analysis (ABA) uses the basic principles of learning and motivation, or principles of behavior, to instruct students with ASD in academics and socially acceptable practices.
Motor Based Intervention History
“Motor functioning of individuals with ASD has been a neglected area despite the fact that participation in physical activity have been shown to have multiple benefits, including reduction of stereotypic behaviors, increased appropriate responding, and the potential for social interactions” (Todd & Reid, 2006). Participation in physical activity is often a challenge for people with autism because of poor motor functioning and low motivation (Koegel, Koegel, & McNerney, 2001; Reid, O’Connor, & Lloyd, 2003; Todd, & Reid, 2006).
In 2010 a review of literature conducted through the Eli and Edythe L. Broad Asperger Research Center at the University of California, Santa Barbara, looked at studies involving physical exercise and individuals with ASD. Exercise and motor interventions were used in various forms. They reported that implementing motor intervention showed improvements in behavior (e.g. stereotypic behaviors) and or academic, including on-task behaviors. Specifically, eleven of the studies reported that with an increase in exercise (“jogging”) there was a decrease in stereotypic behaviors.
Their review reports four studies that compare the effectiveness of jogging on behaviors to other forms of exercise like stationary bike riding, walking, throwing and catching a ball, and snowshoeing. In all four cases the “jogging” intervention demonstrated significant results in the reduction of stereotypic behaviors post intervention and or increases in on-task academic behaviors. One study conducted by Prupas and Reid in 2001, involving 4 children ages 5-9, compared behavior reduction after one 10 minute jogging intervention during the day to three 10 minute jogging interventions throughout the day. Both resulted in significant decrease in stereotypic behaviors, however there was more significant reduction with multiple interventions throughout the day, 51.6% to 58.9%.
Two of the studies, Elliot et al. (1994) and Levinson and Reid (1993), specifically looked that the effectiveness of the motor intervention over time post intervention. Elliot et al. found that the decrease in stereotypic behaviors was less pronounced towards the end of the session, however they remained under baseline levels for up to 40 minutes post-intervention. Levinson and Reid found that stereotypic behaviors returned to baseline levels 90 minutes post-exercise.
Children with autism benefit from regular physical activity in the same ways as their typically-developing peers. These benefits can include cardiovascular health, well-being, and helps prevent secondary health conditions like obesity. In addition, children with ASD have other benefits produced by participation in physical activity including improved motor function and exercise capacity, reduced self-stimulatory behaviors, and improved self-esteem, mood, and attention.
The purpose of this single case design is to investigate the effects of an Antecedent movement program on stereotypic behaviors in students diagnosed with Autism Spectrum Disorder throughout their regular school day. The movement program includes jogging for 15 minutes. The focus group is one student diagnosed with Autism with high frequency of stereotypic behaviors, and enrolled in the Autism Special Day Class located in Moreno Valley, CA.
There is a significant gender difference with respect to the rate of an ASD diagnosis. For this reason a male student participant was selected. Other criteria for inclusion in this study was a formal diagnosis of ASD, the ability to engage in a motor based intervention and a high frequency of stereotypic/ repetitive behaviors. The participant in this study is 10 years old who is enrolled in a special education special day class specifically designed for learners with ASD, in Moreno Valley, California. The participant lives at home with his mother and father. He was formally evaluated through the local school system in October 2013 as part of a triennial review for continued eligibility for Special Education services. It was determined through the assessments that the participant does appear to meet eligibility criteria for Special Education services under the handicapping condition of Autistic-Like Behaviors and Language Disorder. The stereotypic/ repetitive behaviors frequently demonstrated by the participant can be found in Table 1. Only one behavior was selected for data tracking for the purposes of this study.
The antecedent motor-based intervention was the independent variable. The motor-based intervention was a 15 minute jog around a baseball diamond. For each lap completed the participant collected a running stick. The running sticks were counted at the end of the intervention. The duration of the motor-based intervention was based on previous research indicating a decrease in stereotypic or repetitive behaviors as a result of participation in a jogging intervention of similar length Lang, Koegel, Ashbaugh, Regester, Ence & Smith, 2010). Jogging is defined as a speed faster than a walk. The motor-based intervention was designed to imitate the typical fitness running program that the participant completes once weekly during his Physical Education class. The participant was encouraged to jog independently for 15 minutes; however, verbal and physical prompting was also used to maintain the “jogging” speed during the intervention. Guided jogging was also used at times.
The participant in this study was identified as having a high frequency of stereotypic/ repetitive behaviors during structured and non-structured activities. The stereotypic/ repetitive behavior, hand tapping, was the dependent variable in this study. The target behavior description used in the inter-rater agreement can be found in Table 2).
Inter-rater Observer Agreement
The observers coded in common 25% of the observational periods across the 3 study days and achieved an inter-observer agreement of 90%.
A Single Case ABAB or Reversal Multiple Baseline design was attempted, however due to the involvement, behavior and needs, a tiered ABC Multiple Baseline design was used. The study took place over a 3 day period. Day A (Baseline) data was collected throughout the regular school day during only structured learning activities. Behavior frequency was charted based on the “Target Behavior” definition (see Table 2). A frequency chart was used to record data in 10 minute intervals throughout the day (Appendix A). Intervention was implemented on Day B (AM intervention) during morning academic sessions and attempted unsuccessfully in the afternoon. Baseline data collection and intervention was implemented on Day C (PM intervention). Intervention consisted of a 15 minute jog around a baseball diamond once a day on intervention days.
Parental consent and student participant assent were obtained. Parent consent was translated to Spanish and reviewed with parent by experimenter through an interrupter. Due to the participant’s Language Disorder and ASD specific needs, the student assent was written in a developmentally appropriate language, with consent in the form of coloring a happy face or sad face for his desire of participation level. District consent was also obtained to conduct research within a district program and during regular school hours. (Appendix B District Consent form, Appendix C recruiting letter and parent consent form, Appendix D translated recruiting letter and parent consent form, Appendix E participant assent form).
The participant was observed on Day A to collect baseline data. Observations were conducted in the classroom and on the playground during physical activity time. The participant was video recorded and frequency of target behavior was recorded (Appendix A). Frequency of target behavior was recorded only during structured learning activities. Reinforcement times/ Break times, recess, meal times, toileting and during physical activity time were not considered structured learning times; frequency of target behaviors was not collected during these times.
The interventions were conducted over two days. On Day B, the 15 minute motor intervention was implemented in the morning during the regularly scheduled Physical Education time and target behavior data was collected for the rest of the school day during structured learning activities. A second intervention was attempted on Day B immediately following the afternoon toileting routine in a secluded setting with experimenter and one instructional aide. The participant became very distressed due to the change in daily schedule, the intervention was stopped, recorded and participant was returned to class. On Day C baseline data was collected in the morning hours and then the 15 minute motor intervention was implemented immediately following the lunch recess and toileting routine. This intervention was conducted with the participant’s classroom peers to help with the change in schedule. The afternoon motor intervention in a group setting was successful and post intervention the participant returned to class to continue observation of target behavior in structured learning activities.
The motor intervention was for a period of 15 minutes running around a baseball diamond (approximately the infield dirt area) that is in close proximity to the classroom. The student followed his typical school day routine with the only change being the 15 minute motor intervention once a day on intervention days. During the interventions the participant was assisted by either the experimenter or instructional aide to encourage/ maintain the “jogging” speed. Distance traveled during the intervention was tracked using the collection of running sticks per lap completed. Total laps completed in the 15 minute intervention was recorded.
Previous studies indicate that motor interventions show a significant reduction in stereotypic behaviors for up to 1.5 hours post intervention (Levinson & Reid, 1993). The interval recording should indicate if the response to intervention was significant, duration of intervention benefit with regards to stereotypic behaviors and should indicate if two interventions or more would be needed to show greater benefit to reduction of stereotypic behaviors throughout a school day.
Target Behavior Data Analysis
Frequency of the target behavior was recorded into 10 minute intervals throughout the school day to demonstrate the effects of the target behavior over time and in various structured activities throughout the day. The data collected was graphed using a side-by-side scatter plot (Table 5). The scatter plot was used to see the functional relationship between the motor based interventions and target behavior. A copy of daily class schedule can be found in Table 4.