Stereotyped behaviors and strategies to intervene stereotyped behaviors in children with autism spectrum disorders from 3 to 6 years old at special preschools

HNUE JOURNAL OF SCIENCE DOI: 10.18173/2354-1075.2017-0139 Educational Sci., 2017, Vol. 62, Iss. 6, pp. 147-157 This paper is available online at STEREOTYPED BEHAVIORS AND STRATEGIES TO INTERVENE STEREOTYPED BEHAVIORS IN CHILDRENWITH AUTISM SPECTRUM DISORDERS FROM 3 TO 6 YEARS OLD AT SPECIAL PRESCHOOLS Do Thi Thao1, Tran Xuan Kieu2 1Faculty of Special Education, Hanoi National University of Education 2Nam Dinh teachers’ training College Abstract. Stereotyped behavior is one of the most challenging behaviors commonly displayed in children with ASD to intervene. Educational interventions of behaviors should indicate a system of plans, methods, and purposes based on individual characteristics of the child to reduce unexpected behaviors and change them into expected ones, teach new behaviors and provide opportunities to maximize the development for children with ASD. The article aims to show the findings of (1) Stereotyped behaviors of children with ASD, (2) Causes of stereotyped behaviors in children with ASD, and (3) Intervention strategies for stereotyped behaviors of children with ASD, including: Enhancing practical capacity for teachers and parents about behavioral intervention strategies for children with ASD; Building appropriate behavioral intervention plans; Using positive reinforcement to adjust behaviors; Task analysis; and Making activity schedules to help children ready to participate in learning. Keywords: Autism Spectrum Disorders (ASD), stereotyped behavior, intervention, strategies 1. Introduction Many challenging behaviors of children with Autism Spectrum Disorders (ASD) affect to their learning, living and community inclusion and make their teachers and parents difficult in their child care and education such as stereotyped and repetitive, stimming, hyperactive, hypoactive, inattention, and aggressive behaviors. Among them, stereotyped behavioris the most typical in children with ASD. It is a corncerning challenge to limit their problem behaviors and have a full and active participation to the children’s learning and living for teachers and parents as well as professionals. Stereotyped behaviors are referred to diagnose ASD in ICD-10 [1], DSM-IV [2], DSM-5 [3]. Symptoms of stereotyped and repetitive behavior from low to high level were studied by Szatmari et al. (2006) [4]; Turner (1999) [5]. Stereotyped behavior in children with ASD was indicated to have a negative influence to their learning (Koegel and Covert 1972 [6]; Varni et al. 1979 [7]; Pierce and Courchesne 2001 [8]) and their social skills (Loftin et al. 2008 [9]; Nadig et al. 2010) [10]. Aggressive, destructive, stereotyped and self-stimulous behaviors are commonly displayed in children with ASD (C. Lord et al. 2001) [11]. The diversity of behaviors appear in children with ASD 3-6 years including challenging behaviors such as inattention and stereotyped Received date: 20/2/2017. Published date: 5/5/2017. Contact: Do Thi Thao, e-mail: thao2006trang@yahoo.com 147 Do Thi Thao, Tran Xuan Kieu behaviors become a barrier for their learning and social inclusion (Do Thi Thao, 2017) [12]. Despite of a growing number of studies in stereotyped behaviors of children with ASD, there is a limitation in the findings about intervention strategies for stereotyped behavior in children with ASD in Vietnam. The article aims to show the findings of stereotyped behaviors in children with ASD and causes of their stereotyped behaviors, and to recommend some intervention strategies for their stereotyped behaviors to reduce their challenging behaviors and improve their concentration in learning. 2. Content 2.1. Stereotyped behaviors and causes of stereotyped behaviors in children with ASD Stereotyped behaviors in children with ASD Leo Kanner (1943) indicated that stereotyped behaviors were typically shown in children with ASD. Symptoms of stereotyped behaviors in children with ASD are different, such as word repetition, stereotyped and repetitive body movements (spinning, rocking, hand flapping, whirling, etc.). Some children insist on the restricted habits and resist changing the habits. Children with ASD have very limited interests in some things and feel satisfied with them that do not want to change anything. They can only wear certain shirts, like to put on a pair of shoes or switch on close button of the television, etc. Baumeister (1978) showed that stereotyped behaviors are highly persistent and repetitious motor or posturing behaviors that seem to have little or no functional significance [13]. These behaviors interfere the child’s attention, limit the effectiveness of education and other programs. Stereotyped behaviors interfere the most common educational objectives in children with ASDor serious mental disorders: (a) Stereotyped self-injurious behaviors such as beating, biting or sucking on different parts of his/her body, pinching, scratching, pushing, or pulling, vomiting with a high intensity to make himself/herself injurious; (b) Stereotyped self-stimulatorybehaviors without hurting such as screaming, running, hopping, finger wiggling, masturbation, rattling and other repetitive movements. Lovaas, Newsom and Hickman (1987) thought that stimming behaviors such as body rocking, head nodding, object shocking, light staring, up-and-down jumping, and so on are not always harmful to the child and others [14]. Schreibman, Heyser, & Stahmer, (1999) found that stereotyped behaviors may be verbal or non-verbal, simple or comflex [15]. They may appear at any time, with or without others. One type of stereotyped behaviors is verbal using or repeating. Some typical symptoms of stereotyped behavior may be hand clapping, body rocking, toe-top walking, smelling, delayed or immediate echolalia and out of adult’s control. DSM-5 points out diagnostic criteria for ASD in term of restricted andrepetitive patterns of behaviors, interests and activities as manifested by at least 2 of 4 symptoms as follows: (a) Stereotyped or repetitive speech, motor movements, or use of objects; (such as simple motor stereotypies, echolalia, repetitive use of objects, or idiosyncratic phrases); (b) Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change; (such as motoric rituals, insistence on same route or food, repetitive questioning or extreme distress at small changes); (c) Highly restricted, fixated interests that are abnormal in intensity or focus; such as strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests; (d) Hyper or hypo reactivity to sensory input or unusual interest in sensory aspects of environment; (such as apparent indifference to pain/heat/cold, adverse response to specific sounds or textures, excessive smelling or touching of objects, fascination with lights or spinning objects) [3]. 148 Stereotyped behaviors and strategies to intervene stereotyped behaviors in children... In sum, stereotyped behaviors are repetitive behaviors and and highly persistent symptoms that seem to have little or no functional significance. Common stereotyped behaviors in children with ASD are hand flapping, finger flicking, spinning, pacing, head rocking, uncrossing of legs, and marching in place. Stereotypies usually begin before the age of three, involve more people, are more rhythmic and less random, and are associated more with engrossment in another activity rather than predictive urges. Causes ofstereotyped behaviors inchildren with ASD Stereotyped behaviors are triggered from these factors: (a) Attention: The child wants to get the adult’s attention without using verbal language to do this; (b) Tangible Access: Some childrenuse their behaviors to get a reward, such as playing with their favorite toy; (c) Escape: Using the behaviors, the child will escape a unexpected situation or avoid a difficult task; (d) Immediate Transition. The child should be noticed when an activity finishes and another starts; (e) Classroom Environment: Noise, stress and intensity of tasks may trigger his/her behaviors; (f) Sensory: The child’s behaviors are about hearing, seeing and touching stimuli.Stereotyped behaviors are related to one or more senses, for example: (i) Vision, staring at the light bulbs or glowing objects, squinting, or flicking his/her finger in front of his/her eyes, or clapping hands; (ii) Hearing, tapping on his/her hand, or fingers to make sounds, making sounds by mouth; (iii) Touch, using his/her hand or objects to rub on his/her skin or scratch him/her-self; (iv) Vestibular, rock his/her body forward to back or left to right; (v) Tasting, put his/her fingers or objects into mouth; (vi) Smelling, or sniffing objects, even others.Lovaas et al. (1987) found that stereotyped behaviorsare served as sensory stimuli [14]. Some authors analysed functions of stereotyped behaviors in similar conditions (Iwata et al., 1982; Northup et al., 1994; Sasso & Reimers, 1988; Wacker et al., 1990) [16]. They said that an intervention based on a functional behavior analysis was useful to reduce stereotyped behaviors in children with ASD. These findings supported the study byCarr, E.G. [17,18] about triggers of stereotyped behaviors. Horner (1980) [19] assumed that children in disadvantaged environment without a variety of activities, materials and toys would exhibit stereotyped behaviors. In sum, children with ASDshow more than one of behaviors mentioned above. The “rarely” frequency of occurrence is not strong enough to define the behavior. Educational intervention of behaviors could reduce, maintain and enhance behaviors to make them more expected and appropriate before they become more seriously to apply specific therapy methods. 2.2. Current status ofbehavioral interventions forchildren with ASD 2.2.1. Organizing the survey Purpose: To conduct an assessment the current status of behaviors in children with ASD and strategies to intervene their behaviors to have a base to outline some strategies to intervene stereotyped behaviors in children with ASD from 3-6 yearls old at special preschools. Content: (1) Stereotyped behaviors commonly displayed in children with ASD; (2) Levels of frequency và effectiveness that parents and teachers used the strategies to intervene stereotyped behaviors. Participants: (1) Children with ASD: 35 children with ASD from 3 to 6 years, the rate of male and female is 26:4, (male: 86.6%; and female: 13.3%). Severity level of autism: All children with ASD diagnosed in Vietnam National Hospital of Pediatrics by CARS (Childhood Autism Rating Scale) with different severity levels. Among 35 children with ASD, there were 19 children with ASD at moderate level (accounts for 54.3%), 11 at severe level (31.4%) and 5 at mild level(14.3%). Placement/Setting: 35 children at special preschools; (2)Teachers: 31 of 149 Do Thi Thao, Tran Xuan Kieu 33 teachers are female, 2 other teaches are male, aged 25 to 40. Qualification: 25 of 33 teachers were bachelors(75.8%); 8 other teaches were college graduates (24.2%). Speciality of education: Special education, preschool education, primary education, psychology, social works. Working experiences with children with ASD: 48.5% of teachers worked with children with ASDin 1 - 2 years (16 teachers), 39.4% of teachers worked with children with ASD in 2 – 4 years (13 teachers) và 12.1% of teachers worked with children with ASD more than 4 years (4 teachers); (3) Parents of children with ASD: 30 people, aged 28 – 40.86, 7% of them graduated from technical schools to university (26 people) and 4 other people graduated from high schools (13.3%) Methods: (1) Observation: Observing stereotyped behaviors in children with ASD, the organization of stereotyped behaviors interventions in children with ASD from teachers and parents. Participants: 35 children with ASD and their teachers in learning sessions and playtime; (2) Interview: Collect more information about the study. Interviewee: teachers and parents of children with ASD at special schools; (3) Statistics: Data analysis from the answers of teachers and parents using some statistical formulas such as mean, percentage, rank, correlation. Four frequency levels of stereotyped behaviors: Often = 1 point, Sometimes = 2 points, Never = 3 points 2.2.2. Findings of practical survey on intervention strategies for stereotyped behaviors a. Current status about stereotyped behaviors in children with ASD from 3 to 6 years Table 1. Frequency levels of stereotyped behaviors in children with ASD at 3-6 years old according to theirparents, teachers and survey team No. Behaviors Frequency levels of stereotyped behaviors in children with ASD Teachers Parents Survey team Average (N=33) (N=30) (N=35) (N=98) M Rank M Rank M Rank M Rank 1 Beating, biting or sucking on different parts of the body 1.0 1 1.0 1 0.9 1 1.0 1 2 Playing with certain toys 1.1 2 1.1 2 1.4 3 1.1 2 3 Eating some specific types of food 1.8 8 1.6 7 2.1 10 1.8 8 4 Rocking the body 1.1 2 1.9 9 1.6 5 1.4 5 5 Holding and spinning an object 1.4 5 1.4 5 1.5 4 1.3 4 6 Doing a task in a way (e.g, lining in a horizonal or vertical line) 1.6 6 2.1 10 1.8 7 1.1 2 7 Waving or flapping hands consistently 1.3 4 1.5 6 1.7 6 1.2 3 8 Jumping and clapping hands 1.2 3 1.2 3 1.1 2 1.7 7 9 Flicking fingers 1.9 9 2.1 10 2.0 9 1.9 9 10 Staring at a moving object (e.g,fan, wheel) 1.7 7 1.3 4 1.8 7 1.5 6 11 Attaching to old clothes or socks 2.1 10 1.7 8 1.9 8 2.0 10 150 Stereotyped behaviors and strategies to intervene stereotyped behaviors in children... The table shows some stereotyped behaviors commonly displayed in children with ASD. “Beating, biting or sucking on different parts of the body” rank in the first position (M = 1.0). Second are“Playing with certain toys” and “Doing a task in a way (e.g, lining in a horizonal or vertical line)” (M=1.1). Third is “Waving or flapping hands consistently” (M= 1.2). Fouth is “Holding and spinning an object” (M=1.3) Teachers and parentssaid in the interviews that children with ASDoften displayed these behaviors becausethe schedules had been changed but not noticed in advance for children or when the children had not met their demands, or when a new task begins. Q.T.T, the mom of Q said “At home, Q often jumped and clapped his hands, then everyone thought that he requested something and took it for him. As a result, his behaviors became more and more”. Teachers reported that stereotyped behaviors were commonly displayed in the class and learning activities (individual, group and play time). As a result, children were difficult to attend in the classroom activities and interfere to peers. Teachers and parents also reported that children explicited these behavior at home more clearly than in class. This is understood that the environment at home had more triggers of a child’s behaviors and made his/her parents difficult to manage the behaviors of their child. Most of teachers and parents found that these behaviors affected very much to children’s learning and playing. b. Current status aboutbehavioral intervention strategies that teachers used to reduce stereotyped behaviors in children with ASD *Levels of frequency Table 2 below shows that teachers used all of strategies to intervene stereotyped behaviors for children with ASD with different levels of frequency. The strategy used most frequently sush as “Use reinforcement system: reward and punishment” and “Arrange classroom environment: sounds and lights” (M=1.1). Next are “Create opportunities to engage the child in daily living activities” (M=1.4); Let the child be noticed before changing daily routines (M=2.0); and make appropriate behavioral intervention plan according to the child’s cognition and behavior problem (M=2.9). These strategies were used most frequently such as: Arrange classroom environment: sounds and lights; Use reinforcement system: reward and punishment; Implement sensory intergration activities/exercises. Teachers said that they knew well and used more often. Teachers rarely used the strategies such as Make appropriate behavioral intervention plan according to the child’s cognition and behavior problems or Let the child be noticed before changing daily routines because they need more experiences. Table 2. Levels of frequencyand effectiveness of the intervention strategies that teachers used to reduce stereotyped behaviors in children with ASD No. Strategies Levels of frequency Levels of effectiveness M Rank M Rank 1 Implement sensory intergration activities/exercises 1.2 2 1.1 1 2 Use reinforcement system: reward and punishment 1.1 1 1.3 2 3 Arrange classroom environment: sounds and lights 1.1 1 1.5 4 151 Do Thi Thao, Tran Xuan Kieu 4 Create opportunities to engage the child in daily living activities 1.4 3 1.4 3 5 Let the child be noticed before changing daily routines 2.0 4 1,7 5 6 Make appropriate behavioral intervention plan according to the child’s cognition and behavior problems 2.9 5 1.9 6 *Levels of effectiveness The results show the different levels of effectiveness of the strategies that teachers used to intervene stereotyped behaviors for children with ASD. The first rank is “Implement sensory intergration activities/exercises” (M=1.1), second positions are “Use reinforcement system: reward and punishment” (M=1.3); “Make appropriate behavioral intervention plan according to the child’s cognition and behavior problems” and “Arrange classroom environment: sounds and lights” (M = 1.4) và (M= 1.5) and the last are “Let the child be noticed before changing daily routines” and “Make appropriate behavioral intervention plan according to the child’s cognition and behavior problems” với (M=1.7). The strategy “Implement sensory intergration activities/exercises” was ranked in the highest position. The strategies such as “Make appropriate behavioral intervention plan according to the child’s cognition and behavior problems” were rarely used because teachers did not have experiences. Table 3.Levels of frequency and effectiveness of the intervention strategies that parents used to reduce stereotyped behaviors in children with ASD No. Strategies Levels of frequency Levels of effectiveness M Rank M Rank 1 Implement sensory intergration activities/exercises 1.8 4 1.3 2 2 Use reinforcement system: reward and punishment 1.1 1 1.1 1 3 Arrange classroom environment: sounds and lights 1.5 2 1.4 3 4 Create opportunities to engage the child in daily living activities 1.1 1 2 5 5 Let the child be noticed before changing daily routines 1.7 3 1.6 4 6 Make appropriate behavioral intervention plan according to the child’s cognition and behavior problems. 2.1 5 2.2 6 Levels of frequency: The strategies were often used and familiar including Use reinforcement system: reward and punishment and Create opportunities to engage the child in 152 Stereotyped behaviors and strategies to intervene stereotyped behaviors in children... daily living activities (M = 1.1); Let the child be noticed before changing daily routines (M = 1.7). Other strategies used but not familiar to the parents included Implement sensory intergration activities/exercises and Make appropriate behavioral intervention plan according to the child’s cognition and behavior problems. The parents often use the strategy Use reinforcement system: reward and punishment because it was said to be easy and effective. For example, most parents said that for their children with behavior problems, they had simple and useful tasks to engage them to prevent unexpected behaviors; then they used the strategy “Use reinforcement system: reward and punishment” including a reward for good behaviors and a punish