Exploring the Social Inclusion of High Functioning Children with Autism in Regular Education Classes

1
Exploring the Social Inclusion of High
Functioning Children with Autism in Regular
Education Classes Current Interventions and
Future Needs

• Erin Rotheram-Fuller, Ph.D.
• Temple University

2
Goals

• Explore current methods of assessing
  socialization among children with autism.
• Learn about the Friendship Survey as an
  assessment tool and intervention guide.
• Examine differences in the level of social
  inclusion of high functioning children with
  autism across the elementary school years using
  the Friendship Survey.
• Review the preliminary results of a new
  intervention trial to improve social inclusion.

3
Social Lives of Children at School

• School is about academics.
• Unless you ask children..
• More about connecting to friends, and having fun
• Extensive data on connection between social
  ability and academic success

4
Social Lives of Children with Autism

• Social impairment--huge disadvantage for children
  entering school
• Consistent across age, ability
• Families invest great amounts of money to tutor
  children with ASD on social skills

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What does high-functioning autism look like?

• http//www.youtube.com/watch?vm5x0aJ3xIrwfeature
  related

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Adapted from Wing, L. (1995). The relationship
between Asperger's syndrome and Kanner's autism.
In U. Firth (Ed.), Autism and Asperger Syndrome
(pp. 93-121). Cambridge, MA Cambridge
University Press.
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Multiple Areas of Potential Assessment and
Intervention
Learning / Processing
Family
Residence /Community
Environment / Home
Diet Nutrition
Autism
Emotion / Behavior
Medical
Sensory
Vocation / Employment
Education / School
Communication
Friendships / Relationships
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What we know about children with autisms desire
for socialization.

• Report a desire for social connectedness
  (Bauminger Kasari, 2000 Chamberlain et al.,
  2007)

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Loneliness at School

Bauminger Kasari, 2000 (22
children with ASD)
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Loneliness at School

Chamberlain et al, 2007 Bauminger Kasari,
2000 (17 children with ASD) (22 children
with ASD)
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Loneliness at School


Chamberlain et al, 2006 Current Trial
Bauminger Kasari, 2000 (17 children with
ASD) (60 children ASD) (22 children with ASD)
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Inclusion ? Intervention?

• Push for inclusion
• (Fuchs Fuchs, 1994)
• Inclusion vs. Specialized Services Debate
• Exposure to
• Typical models
• Standard curriculum
• Activities
• But is inclusion enough to be considered THE
  intervention?

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Inclusion ? Intervention

• Inclusion is insufficient to socially engage
  children with autism with their typical peers.
• (Burack et al., 1997 Chamberlain et al, 2007)
• More often neglected rejected
• (Church et al., 2000 Ochs et al., 2001)
• More isolated, less responsive to others on
  playground
• (Sigman Ruskin, 1999)
• Teachers less willing to accept children in
  regular classrooms
• (McGregor Campbell, 2001)

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Reciprocated Best FriendsChamberlain, Kasari,
Rotheram-Fuller, 2007

• 58 of typical classmates nominated peers who
  reciprocated the friendship

• Only 13 of friends nominated by child with ASD
  reciprocated the friendship

Not Reciprocated
Not Reciprocated
N17 ASD
N17 Typical
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How do we measure the success of inclusion?
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Current Methods to Evaluate Inclusion

• Academic success
• Grades (keeping up with peers)
• Standardized testing
• Social success
• Measure specifically targeted social skills
• Initiations, responses, number of interactions
• Does the child interact with peers socially?
• Anecdotal reports from teachers and TSS
• Does the child feel socially successful?
• Self-report of friendships by the child with
  autism
• Self-report of loneliness
• Do other peers in the class feel the child is an
  important part of the class?
• Social networks from correlated student reports.

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Social Networks

• Ecological structure within which friendships
  develop
• Focus on reciprocity of classroom social
  relationships peer acceptance
• Simple nomination procedure that has been
  previously validated, and effective with as few
  as 50 of the class
• (Cairns Cairns, 1994)

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Friendship survey

• Are there any kids in your class that you like to
  hang out with?
• Circle the top 3, star the best friend.
• Do you see that best friend just at school?
• Are there any kids in your class that you dont
  like to hang out with?
• Are there kids in your class who like to hang out
  together?
• Draw a circle around each group.
• Prompt be sure to think of both boys and girls.

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1. Are there any kids in your class that you like
to hang out with?

• Indegrees number of classmates that nominate a
  child as one of their friends.
• Acceptance z-score within the class of the
  number of indegrees received by each student.
• Outdegrees number of classmates that a child
  nominates as a friend.
• Reciprocal Top 3 Number of times a child
  nominated a classmate as in their top 3 closest
  friends in the class, in which that classmate
  also nominated them (if the classmate did not
  complete the measure, the result is missing data,
  not counted as a non-reciprocal friendship).
• Reciprocal Best Friend Same as Top 3, but with
  top 1.

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2. Are there any kids in your class that you
dont like to hang out with?

• Rejection Number of times a child was nominated
  as being not liked by classmates.

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3. Are there kids in your class who like to hang
out together?

• Class of
• Chris
• Jane
• John
• Lisa
• Mark
• Rebecca

Groups identified by students 1. Chris, Lisa,
John 2. John, Jane, Lisa 3. Rebecca, Jane 4.
Lisa, John 5. Chris, John 6. Rebecca, Lisa, Jane
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Drawing the social network map
Group Centrality Score
Chris (2)
Jane (3)
3
2.5
John (4)
Rebecca (2)
Individual Centrality Score
Isolates John, Lisa, and Mark
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3. Are there kids in your class who like to hang
out together?

• Number of Social Connections
• Male and Female connections
• Social Network Centrality
• 0 Isolated
• 1 Peripheral
• 2 Secondary
• 3 Nuclear

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Social Network Map
M(9)
High Group Centrality
X(16)
A(9)
S(19)
9
Medium Group Centrality
C(7)
U(7)
17.5
J(6)
R(3)
D(5)
I(2)
K(13)
O(10)
H(10)
G(13)
P(17)
V(11)
N(10)
B (8)
Q(14)
17
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High Group Centrality
High Group Centrality
L(17)
T(13)
E(15)
W(10)
F(0)
Isolate
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Study Design
Recruitment LA schools, Autism Evaluation Clinic,
clinic agencies referrals
Children with Autism (n 79)
Typical Peers (n 2170 1064 signed
consent/assent)
Kindergarten 1st grade (n 20 autism) (n 375
peers)
Grades 4-5th (n 21 autism) (n 673 peers)
Grades 2-3rd (n 38 autism) (n 722 peers)
Survey Assessment Child Assent Peer Network
Measure Group administration with individual
assistance.
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Setting

• In Los Angeles Unified School District, there are
  about 750,000 children.
• LAUSD spans a distance of 30 miles East to West,
  and 55 miles North to South. Containing 219
  year-round and 429 traditional schools.

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LAUSD Demographics
Almost 40 (293,566 students) are learning
English as a second language. Large class
sizes M36.72, SD 18.67 Range 16-81

• Over 53,000 children with autism have been
  identified in LAUSD alone (about 7).

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Demographics of Children with Autism

• Multiple ethnicities
• 46.2 Caucasian
• 23.1 Latino
• 16.9 Asian
• 6.2 African American
• 7.7 Other
• Wide IQ range 52-129,
• M 89.80, SD 17.29
• 88.6 Male (70/79)

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Reciprocal Top Friendships by Grade Group
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Acceptance by Grade Group
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Rejection Nominations from Peers by Grade Group
32
Social Outcomes by Grade
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Social Network Centrality
P lt .05
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Grade Related Differences in Social Inclusion

• Social inclusion of children with autism shows a
  different pattern to typical peers.
• Social difficulties are especially apparent for
  children with autism in the older grades.
• Some possible explanations
• Delayed cognitive
• skills
• Decreased school
• resources
• Shared Activities

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Shifts in School Activities

• Games on the playground change
• Cooperative activities at younger ages
• Competitive activities at older ages
• Changing rules, and increasing skill levels make
  inclusion difficult
• Increasingly more same-sex relationships with age
  that challenges males with autism to join
  male-centered games.

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So what do we do once we have identified the
problem?
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Current Interventions

• ABA
• Floortime
• Gluten Free, Casein Free Diet (GFCF)
• Occupational Therapy
• PECS
• Relationship Development Intervention
• SCERTS
• Sensory Integration Therapy
• Speech Therapy
• TEACCH
• STAR
• Verbal Behavior Intervention

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Current Interventions

• In practice.most standardized programs are done
  off campus, and by private clinicians.
• Video-self-modeling (Bellini et al, 2007)
• Friendship training (Frankel, 2008)
• Emotion knowledge/regulation training (Bauminger,
  2002 Solomon, et al., 2004)
• On-school campus
• programs include
• Lunch bunch
• approach
• 11 aide (TSS)

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Common Targets of Social Interventions

• Communication skills
• Initiations, responses, joint attention,
  conversations, pragmatics, prosody, etc.
• Play skills
• Symbolic play, interactive play, collaborative
  play, competitive play
• Challenging/Disruptive Behaviors

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Evaluation of Current Interventions

• Several recent reviews
• Conclusion-- not very effective (Bellini, 2007
  Rao, et al, 2008 White et al, 2008).
• Why?
• Treatments mostly limited
• In focus.child alone
• In time.little follow up
• In generalization.
• to new contexts
• In transfer.
• to more global skills
• Not connected to
• individual needs of children.

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How are interventions selected in daily practice?
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How are interventions selected in daily practice?

• Familiarity
• Ease of implementation
• Available resources

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How can we improve the use of validated
interventions in practice?

• Know what to target Good assessment of skill
  deficits or social problems.
• Make interventions adaptive to multiple
  environments.
• Compare interventions to identify which is most
  effective with which children, in which settings.

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Recently Completed Randomized Control Trial

• 60 Children with autism
• 6-week intervention
• 2x/week for 20 min, in school
• 4 groups
• Child with Autism
• 3 Typical Peers
• Combination separate but concurrent
• Control
• 3 month follow-up evaluation

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Baseline Social Network Results
Percentage of Children with Autism

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Picking typical peers for intervention

• Teacher nomination suggesting report of
  likelihood to participate and interact with the
  child with autism.
• High salience within the class network
• Other students likely to follow the model peers
  behavior.

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Primary Intervention Components

• Interactive play with the children in natural
  environment.
• Concrete description of desired behavior.
• Modeling of desired behavior.
• Opportunities to practice.

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Second Grade T2
Social Network Centrality Second Grade - T1
I9 (7)
2.5
A1 (2)
H8 (8)
G7 (1)
C3 (2)
E5 (3)
F6 (1)
K11 (1)
6.5
8
D4 (6)
3
B2 (3)
2
J10 (8)
I9 (3)
N14 (3)
3
6
L12 (3)
N14 (6)
O15 (5)
G7 (3)
Q17 (6)
R18 (6)
M13 (1)
H8 (7)
P16 (7)
P16 (6)
6
6.5
M13 (2)
5
R17 (5)
6.5
K11 (1)
J10 (7)
7
F6 (2)
S18 (6)
2.5
1.5
D4 (1)
O15 (4)
L12 (4)
Isolates A1, C3, E5
Second Grade -T3
B2 (1)
E5 (3)
G7 (6)
R18 (5)
A1 (3)
H8 (3)
Q17 (5)
7
8
7
P16 (1)
I9 (9)
C3 (4)
J10 (3)
1
3.5
F6 (1)
D4 (2)
K11 (5)
T20 (10)
O15 (1)
Isolates L12, M13, N14, S19
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Preliminary Treatment Changes

• Combination Tx Effect size large (1.0)
• Peer Tx Effect size medium (.60)

Social Network Centrality Changes
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How do the children with autism see their
Friendship Quality?

• Feelings of Closeness with peers before to
  after the intervention.

Peer treatment most effective
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How do the children with autism rate their
loneliness?

• Change in Dyadic Loneliness from before to after
  treatment.

Combination tx most effective
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Change in the number of Social Connections before
to after treatment.

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Key Findings

• Can make changes with brief intervention (6
  weeks, 12 sessions)
• Peer and combination treatments most effective
• Suggests that typical peers should be involved in
  treatments at school for children in inclusive
  settings
• To truly change situation for children at school
  we must try to improve the school environment
• With peers and teachers

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Next Steps

• Identify the specific resources needed to
  implement the interventions in school settings.
• Use class-wide interventions to improve classroom
  cohesion for all students.
• Develop more studies to directly compare
  interventions in the same settings.

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Acknowledgements

• Connie Kasari, Ph.D.
• Tracy Guiou
• Steve Johnson
• Jill Locke
• Amanda Gulsrud
• Brandt Chamberlain
• Nirit Bauminger
• Lisa Lee
• Nancy Huynh
• Eric Ishijima
• Mark Kretzmann