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Per-mediated Interventions for Socialisation and Communication in Children with Autism

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08/02/20 Health And Social Care Reference this

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What peer-mediated interventions have been found to be effective in the socialisation & development of communication in children with autism?

Abstract

This literature review is based on the research question: What peer-mediated interventions have been found to be effective in the socialisation & development of communication in children with autism? Peer mediated interventions (PMI’s) are used to develop social skills in students with ASD. Peers assume an instructional role to encourage prosocial behaviours. Students with Autism Spectrum Disorder often struggle with socialisation and communication with their peers. Many interventions have been researched and trialled over the years, however researchers continue to search for a successful solution. This paper reviews 15 studies completed over the last ten years that are based on peer mediation. The majority of studies used single case, multiple baseline designs. In future, research should consider including larger randomised controlled studies to enable greater generalisability.

Key words: Peer-mediated, Evidence-based practice; Autism Spectrum Disorder; Intervention; Education; Children and youth.


Introduction

As stated in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) one of the defining characteristics of Autism Spectrum Disorder (ASD) is a continued difficulty with social interaction and communication (DSM-5; American Psychiatric Association, 2013). Currently the prevalence of ASD in New Zealand is akin to the United States with ASD affecting 1 in 66 people (Autism New Zealand, 2018). Often without intervention students with ASD will have an ongoing inability to develop and manage successful relationships with their peers (Dunlap, Strain, Fox, Carta, Conroy & Smith, 2006). Interventions to assist students with ASD have been researched for decades and in recent years a focus has been on peer-mediated interventions. Often these interventions have been found to be effective in assisting the students with ASD to communicate more freely with their peers, teachers and families. Peer mediated interventions (PMI’s) involve peers taking on an instructional role with students who have ASD (Harper, Symon, & Frea, 2008). This enables students to build social competence with their peers. PMI is one of the most empirically supported social skills interventions for students with ASD (Bass & Mulick, 2007).

This subject has been chosen, as the prevalence rates of ASD continue to grow, there is a need for successful interventions to assist these students with their social communication skills. It’s important in professional practice as teachers need evidence based practices to implement in their own school environments, that will assist the students with ASD. This review shows that there is a quantitative bias in relation to peer mediated intervention literature and that qualitative or mixed methodologies should be considered for future research. The aim of the literature review is to determine what peer-mediated interventions have been found to be effective in the socialisation & development of communication in children with autism.

Methods

To create the Literature Review studies were researched online utilising databases such as; ScienceDirect, ERIC, PsycINFO, NCBI, Wiley and SAGE Journals. The keywords used were peer-mediated, autism interventions, social and communication skills and peer to peer interventions. The criteria for inclusion in the study was limited to; studies in English, and peer-reviewed articles that had been published between 2008-2018. The study participants were limited to preschool, primary school and high school students with a focus on interventions within the school context. The studies had to be based in the Western World and involve children with Autism Spectrum Disorder (ASD). There were many studies to search through to ensure they met the criteria of the assignment.

As the literature was reviewed it was classified into centrally, marginally or only of background relevance (Punch, 2014).

The studies that met the criteria are twelve experimental studies, that included single subject and single subject multiple baseline as well as three randomised control trials. Unfortunately, diversity in studies was not to be found with quantitative studies being the only ones to meet the criteria and no mixed method studies or qualitative studies to be found within the 10 year time frame.

Results

The summaries of the 15 studies in the review are shown in Table 1. The studies contain a range of interventions and methodologies.

Table 1

Summary of the 15 studies in alphabetical order according to the first author

Study & year

Participants

School setting

Study design

Aim of study

Intervention style

Key findings

Cannella- Malone et al., 2010

   n= 4

 ASD: 2

Peers:2

Age: 8

Gender: 3 Female, 1 Male

Location: Canada

Primary school

Quantitative: Single case experimental

multiple baseline

To investigate effectiveness of peer led Picture Exchange Communication System (PECS) on social communication.  

One on one sessions  in the classroom

Modest increases in social interaction with both students.

Social validity questionnaires stated that teachers found the intervention beneficial.

Harper et al., 2008

n = 8

Age: 8-9 Gender: Male & Female (4 boys & 4 girls)

Ethnicity: Not stated

Location: USA

Primary School

Quantitative : Single case experimental multiple baseline

To  investigate the use of (PRT) strategies as a social skills intervention.

Pivotal Response Treatment (PRT)

 Increase in social interactions.

 

Sustained by generalisation probe observations.  

Huskens et al., 2014

  n= 6

 ASD: 3

Peers:3

Age: 5-11

Gender: 4 Male, 2 Female

Location: The Netherlands

Primary school students

Quantitative: Single case experimental

multiple baseline

To investigate the

effectiveness of a robot-mediated intervention based

on Lego therapy, to improve collaborative behaviours.

Five 30 minute sessions once a week. Sessions were led by the robot.

The therapy was not effective in improving collaboration, however two out of three pairs did show increases in their responses across sessions.

 

Jung et al., 2008

n= 9

ASD: 3

Peers: 6

Age=5-6

Gender: Male & Female

Ethnicity: Not stated

Location: USA

Private charter Preschool (transition classroom)

Quantitative: Single case experimental multiple baseline

To examine the request sequences with peer modelling.

Peer training.

Respond to the students with prompts, then slowly withdrawing prompts.

Increased unprompted social interactions for the target students.

 

Social Validity-professionals found the intervention useful.

Kasari et al.,  2012

    n = 60

Age: 5-11

Gender: Male & Female (90% male)

Ethnicity: Not stated

Location: USA

Primary school

Quantitative: Randomized control trial (RTC)

To compare interventions for improving social skills

Peer training.

Six weeks graduate students sessions.

Peer meetings.

Decreased isolation, social networking improvements.


 

Changes continued at 3 month follow up.

Kasari et al., 2015

n=137

Age: 5-11

Gender: Mixed

Ethnicity: Not stated

Country: USA

Preschool & Primary School (Kindergarten to Fifth Grade)

Quantitative: Randomized control trial (RTC)

To create social connections between the students, for example in the school playground.


 

16 sessions over 8 weeks and an 8 week follow up.

Students in the SKILLS intervention groups were found to have increased their peer engagement.

Kent et al., 2018

n=20

ASD: 10

Peers:10

Gender: not specified

Location: USA

Primary school students

Quantitative: Randomized control trial (RTC)

To improve play skills for children with ASD using RCT.

10 intervention sessions that included therapist and peer mediation and video modelling.

Using RCT is possible for improving play skills

Koegel, Fredeen et al., 2012

    n = 3

Age: 11-14

Gender: Male  

Ethnicity: Not stated

Location: USA

Primary school

Quantitative: Single case experimental

multiple baseline

To assess if generalisation would occur after scaffolding (when the interventionist wasn’t present).

Lunchtime club based on students interests. Social facilitators on hand.

The students levels of engagement increased throughout the study.

Koegel, Vernon et al., 2012

    n = 3

Age: 11-14

Gender: 2 Male & 1 Female

Ethnicity: Not stated

Location: USA

Primary school

Quantitative : Single case experimental

 multiple baseline

To assess if students with ASD would improve engagement in natural settings with their peers.

Researcher initially facilitated the Lunchtime club

None of the children engaged with their peers initially, it increased throughout intervention.

Laushley et al., 2009

    n = 4

Age: 6-10

Gender:  Male

Ethnicity: Not stated

Location: USA

Primary school

Quantitative : Single case experimental multiple baseline

To determine if  Concept Mastery Routines (CMR) aid social skills.

CMR delivered at Lunchtime club

All social skills improved.

Follow up at 3 weeks, all students showed maintenance of skills.

Social validity questionnaires stated that teachers found the intervention beneficial.

Loftin et al., 2008

    n = 3

Age: 9-10

Gender: Male

Ethnicity: Not stated

Location: USA

Primary school

Quantitative:

Single case experimental multiple baseline

To increase social interactions between ASD children and their peers.

1:1 and small groups

All three children improved their social interactions

Maintenance found at one month follow up.

Social Validity-positive evaluations.

Mason et al., 2013

n =3

Age: 6-8

Gender: Male

Ethnicity: Not stated

   Location: USA

Primary School

Quantitative: Single case experimental

multiple baseline

To increase the students communicative acts by peer mediation.

 

Recess intervention by trained school staff.

All students experienced an increase in the number of communicative acts they displayed.

Rodríguez- Medina et al., 2016

n =17

ASD: 1

Peers: 16

Age: 8

Gender: Male & Female

Ethnicity: Spanish & Moroccan

Location: Spain

Primary School

Quantitative: Single case experimental

To increase the interactions of the student with his peers at recess.

Observation at recess. 14 sessions over 4 weeks. Guided by his

classroom teacher. His peers model social skills.

The intervention assisted the student to globally improve their social interaction skills.

Trembath et al., 2009

n = 9

ASD: 3

PEERS: 6

Age: 3-5

Gender: Mixed

Ethnicity: Not stated

Location: USA

Pre-schools

Quantitative: Single case experimental

multiple baseline

The assess the effectiveness of two communication interventions for preschool-aged children with autism.

Six peers were taught to use naturalistic

Peer-mediated teaching, with and without a speech generating device

All 3 students with ASD increased their communicative skills and were able to generalise these increases to mealtime interactions with their peers also.

Trottier et al., 2011

N= 2

Age: 11

Gender: Male

Ethnicity: Not stated

Location: Canada

Primary school

Quantitative: Single case experimental

multiple baseline

If the use of  Speech Generating Devices (SGD) would help with social interaction.

3 peers per class supported SGD use.

Effective in increase of communicative acts

Social Validity by peers was positive.

 

Summary of Key Findings

The results show that PMIs have proven to produce increases in communicative acts and social interaction skills and decreases in isolation. All fifteen studies in the review showed at least some level of success in their interventions. Therefore, there is empirical support for a variety of different interventions. The studies in this review focus mainly on students attending mainstream schools who have been diagnosed with ASD. The interventions utilise many different approaches, with the majority of the interventions being individualised and naturalistic.

There are eight different categories of interventions in the review. Interventions involving PECS, PRT, CMR, Robotics and Video modelling were utilised for one study. Speech Generating Devices and facilitated lunchtime clubs were supported by two studies each. Peer training was by far the most popular intervention as six studies out of the fifteen were focused on it (Jung et al., 2008; Kasari et al.,  2012; Kasari et al., 2015; Loftin et al., 2008; Mason et al., 2013; Rodríguez- Medina et al., 2016). Peer training is the most successful method of PMI according to the review. According to DiSalvo and Oswald (2002) increased peer effort encourages children with ASD to attend to their peers and hence enhances learning.

Three studies showed positive changes were maintained in their follow up observations (Kasari et al., 2012; Laushley et al., 2009; Loftin et al., 2008). The interventions also showed some promise for generalisation during probe observations (Harper, Symon & Frea, 2008; Laushley et al., 2009). All four of the studies that provide evidence of social validity were very positive (Jung et al, 2008, Laushley et al., 2009; Loftin et al., 2008; Trottier et al., 2011).


 

Discussion

The majority of studies in the literature review have utilised single case experimental with multiple baseline as well as three randomised control trials (RCTs). A lack of qualitative studies evaluating PMI’s was found, it seems researchers in this field have a clear bias for experimental design and the quantitative methodology. The strengths and limitations are discussed below.

Experimental

The single subject methodology involves placing emphasis on careful control over environmental-experimental conditions. It is a popular design for displaying causal relations between interventions and changes in behaviour, this is one advantage over large-sample designs, as it allows the researcher to focus on an individual behaviour (Nock, Michel, & Photos, 2007). Other advantages over larger designs are the amount of time needed, as well as the resources and staff to support the intervention, these are all much lower for a single subject design (Nock et al., 2007). As they are small samples it is easier to modify the interventions and quick to obtain feedback from the participants, thus being able to come to conclusions in regards to the effect one variable has on another. Often investigators use the single subject method because they are not able to accrue a large amount of participants (Punch, 2014).  

There are some limitations to the single subject design in that smaller samples have difficulty with their results being generalised to a wider community (Kazdin, 2011; Punch, 2014). Single subject design cannot be used to answer actuarial types of questions, whereas a qualitative method would need to be utilised in this scenario. Nor can it be used to compare two or more different interventions on the same behavioural measure, or for utilising for a large group of participants in the same way (Punch, 2014).

There can be threats to the internal validity of the study including maturation of the participants, selection of the peers and the participants, instrumentation utilised (Tuckman & Harper, 2012). It is essential that there is rigorous control in order for these threats not to derail a study. Fidelity implementation measures are utilised to ensure interventions are implemented with consistency across different practitioners and settings. Hence, the need for observations and self-reporting on the practical implementation of a intervention (Perepletchikova, 2007).

Twelve of the studies reviewed used experimental designs (Cannella-Malone et al., 2010; Harper et al., 2008; Huskens et al., 2014; Jung et al., 2008; Koegel, Fredeen et al., 2012; Koegel, Vernon et al., 2012; Laushley et al., 2009; Loftin et al., 2008; Mason et al., 2013; Rodríguez-Medina et al., 2016; Trembath et al., 2009; Trottier et al., 2011).  

Single-subject designs were used for assessing the effects of PMI implementation. Eleven of the studies analyzed utilised a multiple-baseline design across participants, settings and activities (Cannella-Malone et al., 2010; Harper et al., 2008; Huskens et al., 2014; Jung et al., 2008; Koegel, Fredeen et al., 2012; Koegel, Vernon et al., 2012; Laushley et al., 2009; Loftin et al., 2008; Mason et al., 2013; Rodríguez-Medina et al., 2016; Trembath et al., 2009; Trottier et al., 2011).

Other designs such as qualitative or mixed method studies could have been used which would have given us greater detail, more data which might lead to a deeper understanding, more fluid structures and it would be an open ended process (Punch, 2014). 

   

Randomized Controlled Trial (RCTs)

Three of the studies used Randomized Controlled Trial’s (Kasari et al., 2012; Kasari et al., 2015; Kent et al., 2018). An RCT involves participants being randomly assigned to receive an educational intervention (Sullivan, 2011).

 Randomized controlled trials are quantitative, comparative, controlled experiments in which treatment effect sizes may be determined with less bias than observational trials. Randomization is considered the most powerful experimental design in clinical trials: with other variables equal between groups, on average, any differences in outcome can be attributed to the intervention.

Many of the studies just focused on males with ASD which links to the higher percentage of males being affected by Autism (Kasari et al.,  2012; Koegel, Fredeen et al., 2012; Laushley et al., 2009: Loftin et al., 2008; Mason et al., 2013; Trottier et al., 2011).

The ratio of male to female students with ASD has been found to be closer to 3:1 (Loomes, Hull, & Mandy, 2017).

Many of the peer mediation interventions can be utilised by

Looking for interventions that can be practically implemented in the classroom…

Conclusion

In summation the research into PMI for students with ASD has shown that all fifteen of the studies chosen had positive effects on the students concerned. This intervention has been shown to be effective in mainstream school environments. There is a need to add research from the New Zealand context and for further research to be completed to understand the perceptions of the participants-both peers and students who participate in the interventions. The lack of qualitative or mixed method research on PMIs proposes a need for investigators to explore how interventions are functioning in the classroom and how they might be enhanced or indeed developed.

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