academic performance on a young severe stroke 1986 ... - Europe PMC

JOURNAL OF APPLIED BEHAVIOR ANALYSIS

1986,199,425-430

NUMBER4 (wiNna

1986)

THE EFFECTS OF INTERSPERSED MAINTENANCE TASKS ON ACADEMIC PERFORMANCE IN A SEVERE CHILDHOOD STROKE VICTIM LYNN KERN KOEGEL AND ROBERT L. KOEGEL UNIVERSITY OF CALIFORNIA AT SANTA BARBARA

We examined the effects of task-sequencing variables on the academic performance of an 8-yearold severe stroke victim. Within a multiple baseline design, previously acquired (maintenance) task trials were systematically interspersed at designated points in treatment among new (acquisition) task trials. The results showed improvements in both academic responding and subjective ratings of motivation in each of four treated areas (spelling, reading, word-finding, and memory). Social validation data obtained from standardized school placement examinations suggested marked improvement in a variety of related areas of academic functioning. Results suggest that children suffering severe strokes may be capable of learning more than has previously been suspected, and that behavioral treatments may improve such children's functioning. DESCRIPTORS: interspersal training, motivation, stroke, task variation, social validation

In addition to emphasizing the importance of physiological variables (Stover & Zeiger, 1976), researchers have noted that psychological variables, such as motivation, influence the recovery of severe stroke victims (Alajouanine & Lhermitte, 1965; Edelstein & Couture, 1984; Gilchrist & Wilkinson, 1979; Klonoff, Low, & Clark, 1977). Although there have been few systematic treatment studies conducted with childhood stroke victims, research with other severely handicapped children suggests that performance can be influenced substantially by manipulating task-sequencing variables (Carr, Newsom, & Binkoff, 1980; Dunlap & Koegel, 1980; Homer, 1980). One variable that has been especially influential is the interspersal of previously acquired (maintenance) tasks among new (acquisition) tasks (cf. Dunlap, 1984; Neef, Iwata, & Page, 1980; Schroeder & Baer, 1972). The purpose of this study was to assess the effects of a constant acquisition task condition verThis research was supported by U.S. Department of Education, Special Education Program, Research Contract No. 300-82-0362, and by U.S. Public Health Service Research Grant No. MH28210 and MH28231 from the National Institute of Mental Health. The authors are grateful to Leslie Snitzer and Rondi Bloom for their assistance throughout the investigation. Requests for reprints should be sent to Robert L. Koegel, Speech and Hearing Center, University of California, Santa Barbara, California 93106.

sus a condition that interspersed maintenance trials among acquisition trials on the motivation and academic performance on a young severe stroke victim.

METHOD Subject and Setting The subject was an 8-year-old male with diabetes who suffered a large left-middle cerebral artery distribution stroke that resulted in a 10-day coma. The experiment was conducted approximately 1 year following the stroke. Therefore, improvements were not likely to be a result of spontaneous recovery. At the time of the investigation, the child was in a special education dass in a public school. Just prior to the stroke, his IQ was measured at 122 on the Otis-Lennon Test of Mental Ability, compared to a fill scale IQ of 69 on the Wechsler Intelligence Scale for Children-Revised just prior to the start of this study. In addition, he scored at least 1 to 2.5 years below grade level in all academic areas (see social validation measures section). All sessions were conducted on a one-to-one basis with the child by his speech/language pathologists in a small clinic room containing a table, chairs, and stimulus materials relevant to each task. Also present in the room was a reliability observer who was naive to the purpose of this study.

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LYNN KERN KOEGEL and ROBERT L. KOEGEL

Procedures The presentation of task instructions (e.g., "point to . . ."), prompts (e.g., saying the first sound of a target expressive word) during prompted trials following an incorrect response, and social consequences (e.g., "Good job" for a correct response and "No" for an incorrect response) were used in all conditions of the experiment. Sessions were conducted 2 days per week for 8 weeks. Each session was divided into four 1 5-min segments to provide work in four areas (memory, spelling, word-finding, and reading). The order of the four areas was randomly varied each session. The number of target task trials per session varied slightly according to the child's rate of responding, but did not differ consistently across the experimental conditions. The average number of target task trials per session was 28 (range, 5-47) across the four skill areas. Task Materials All four target areas were selected based upon the child's performance on the task in his school environment. The target items for all tasks had been acquired prior to the stroke but were lost as a result of the brain damage caused by the stroke. In order to determine the specific words for the selected target areas (spelling, word-finding, reading, and memory tasks), a large number of items was presented prior to t start of the study. Spelling words were read aloud to the child and he was asked to write (spell) the word on a piece of paper placed in front of him. Reading words were printed on index cards (3 in. X 5 in.) and the child was asked to read the word. Vocabulary words (nouns) were assessed by presenting commercially drawn pictures (3 in. X 5 in.) that the child was asked to name. Memory tasks consisted of placing on the table five common items that the child knew receptively. The clinician then asked the child to point to the items in a specified order (varied randomly from trial to trial). For each of the four targeted academic areas, items to which the child responded correctly (incorrectly) on 2 consecutive days were selected as maintenance (acquisition) items.

Independent Variable and Experimental Design Performance was assessed under two conditions of task sequencing in the context of a multiple baseline design across the four academic behaviors. During the acquisition only trials condition, target task trials were presented successively for 15 min for each of the four academic areas. During the acquisition with interspersed maintenance trials condition, procedures were identical to the acquisition only trials condition, except that no more than two acquisition (target) trials were presented consecutively. Instead, the acquisition trials were interspersed with an equal number of maintenance trials. Dependent Variables Percent correct unprompted responses. The number of correct unprompted responses for each task in each session was divided by the total number of responses for that task in that session, and then multiplied by 100 to yield a percentage score. Subjective ratings of affect. The speech/language pathologist and reliability observer sampled the child's behavior on half of the days in the experiment (randomly selected, with some sessions occurring for all four academic areas in both conditions), and then independently assigned an average subjective rating for each target task in each condition. The observers used a 6-point rating scale (Dunlap, 1984; Dunlap & Koegel, 1980; Koegel & Egel, 1979) to rate the child's interest, enthusiasm, happiness, and general behavior. Scores could range from 0 to 5 points, with scores of 0 to 1.6 representing degrees of extremely low interest, low enthusiasm, low happiness, and extremely poor general behavior. Scores of 1.7 to 3.3 represented neutral affect (i.e., neither high nor low interest, enthusiasm, nor happiness, and neither exceptionally good nor poor general behavior). Scores of 3.4 to 5.0 represented degrees of extremely high interest, enthusiasm, and happiness, and extremely good general behavior. Social validation. We assessed the social significance or academic impact of the intervention by examining the results of school placement ex-

INTERSPERSED MAINTENANCE TASKS

aminations, administered by public school officials not associated with the present investigation, prior to and after the completion of this study. Two sets of standardized examinations, the Peabody Individualized Achievement Test (PIKE) and the Wide Range Achievement Test (WRAT), were administered in four academic areas. Three of the areas related to the behaviors treated in the present study and the other served as an untreated control measure. The four areas tested were (a) reading, which was related to our direct reading measure; (b) reading comprehension, which was related to our reading measure, our word-finding measure, and our memory measure; (c) spelling, which was related to our direct spelling measure; and (d) math, which served as an untreated control measure.

Reliability Reliability for percent correct unprompted responses and incorrect responses was assessed on 46 (71.9%) of the 64 sessions in this experiment on a trial-by-trial basis by having the clinician and the naive reliability observer independently record the outcome of each trial. Percent agreement for both categories was calculated by dividing the number of exact agreements between the two observers by the number of agreements plus disagreements in each session, and then multiplying by 100. Interobserver agreement averaged 99% for correct responses (range, 87%-100%) and 99% for incorrect responses (range, 67%-100%). Reliability for the subjective affect measure was assessed by having the two observers independently assign affect ratings in all of the sessions in which that measure was recorded. In every instance the two observers' scores closely corresponded, with the average difference between their scores being only 0.54 (range, 0-0.8) on the 6-point scale. RESULTS The percent correct unprompted responses are shown in Figure 1. Consistent increases in correct responding on the targeted acquisition tasks occurred only during the maintenance task inter-

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spersal condition. For example, during the acquisition trials only condition for the memory task, the child averaged 35% correct responding; when maintenance trials were interspersed, his responding on the acquisition task averaged 72.7%. Similar improvements were shown in the other three categories (spelling, word-finding, and reading). That is, results for all four academic areas are consistent in that improvements always and only occurred following the interspersal of maintenance trials with the acquisition tasks. Subjective affect ratings were consistent across each subscale (happiness, interest, enthusiasm, and general behavior); therefore, the composite score (cf. Dunlap & Koegel, 1980) is presented alone. The ratings for all the academic areas were in the middle of the neutral range during the acquisition only condition (3.0, 2.5, 3.1, and 2.2 for memory, reading, word-finding, and spelling tasks, respectively). That is, the child showed relatively flat affect with neither high nor low interest, enthusiasm, nor happiness and neither exceptionally good nor poor general behavior. In contrast, during the acquisition with interspersed maintenance trials condition, the child's affect was rated well up into the high category (4.1-4.2 for each of the four tasks). Social validation. Results of the standardized school placement test batteries are shown in Table 1. The upper portion of the table shows the results for the untreated control measures (math as tested by both the PIAT and the WRAT). Neither of these measures showed any improvement. Specfically, math declined on the PIAT from grade level 2.1 to grade level 1.8, and showed unchanged performance from one test administration to the next on the WRAT. These results suggest that there was no improvement in an area that did not receive specific treatment, and that there was no improvement from one test administration to the next merely as a function of having tested the child more than once. In contrast to the results for the control measures, all five test measures that related to the target behaviors being treated reflected marked im-

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LYNN KERN KOEGEL and ROBERT L. KOEGEL

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Sessions Figure 1. Percent correct unprompted responses on acquisition tasks for the two conditions.

INTERSPERSED MAINTENANCE TASKS

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Table 1 Social Validation Measures: Results of Standardized School Placement Examinations Administered Immediately Prior to and Following Our Investigation Untreated control measures

Math (PIAT) Math (WRAT)

Test 1

Test 2

Gain (or loss)

Grade 2.1 Grade 2.9

Grade 1.8 Grade 2.9

-0.3 years 0 years

Measures related to the present treatment

Reading (PIAT) Reading (WRAT) Reading comprehension (PIAT) Spelling (PIAT) Spelling (WRAT)

Pretreatment

Posttreatment

Grade 1.6 Grade 2.4 Grade 0 Grade 2.2 Grade 2.4

Grade Grade Grade Grade Grade

provement from the pretest to the posttest. The improvements ranged from 0.1 academic years (PIAT spelling examination) to 2.0 years (PIAT reading comprehension examination). Overall, the five examinations reflected an average improvement of 0.7 academic years over the 8-week duration of this investigation. Thus, the standardized school placement examinations showed results that were consistent with the direct measures of improvement. In addition, follow-up measures taken 1 year 8 months after termination of this experiment indicate that the subject has continued to show improvements; it has been recommended that he be mainstreamed into the regular fifth grade program at the start of the next school year. DISCUSSION Results of this study, demonstrating consistent improvements in motivation and correct responding when maintenance trials were interspersed with acquisition trials, relate to several theoretical and applied issues. Although the generality of the findings to other stroke victims remains to be demonstrated, the fact that academic performance improved so rapidly (within one or two sessions) and so greatly (up to 2 years improvement on standardized tests within 2 months of treatment), sug-

2.2 2.8 2.0 2.3 2.8

Gain (or loss)

+0.6 years +0.4 years +2.0 years +0.1 years +0.4 years

gests that such children may be capable of functioning at a higher level than their poststroke performance usually indicates. The sudden and extreme intellectual impairment after the child's stroke may have exacerbated his other deficits. Similar results have been shown with other severely impaired populations (cf. Churchill, 1971; Goetz, Schuler, & Sailor, 1983; Koegel & Mentis, 1985; MacMillan, 1971), and suggest the possibility of learned helplessness that may impair the children's functioning (cf. Miller & Seligman, 1975; Seligman, 1972). Improved performance may also relate to the density of reinforcement. When maintenance variables are interspersed in the sessions, more correct responses and, therefore, more rewards are likely to occur if the child is on task. However, although high-density reinforcement may improve performance, interspersal training has been shown to be superior to high-density reinforcement in terms of acquisition rate and short- and long-term retention (Neef et al., 1980). Thus, the density of reinforcement may not be entirely responsible for the improvements. Another possible interpretation of the results may relate to the limited attention and concentration spans of persons with brain impairments. That is, breaking up the task into smaller components

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LYNN KERN KOEGEL and ROBERT L. KOEGEL

capped students. In M. Hersen, V. Van Hasselt, & J. through the use of other maintenance activities may Matson (Eds.), Behavior therapyfor the developmentalhelp to keep the material more manageable for the ly and physically disabled (pp. 57-77). New York: patient whose attention span is not 15 min long. Academic Press. Our experiment was essentially a beginning ef- Homer, D. R. (1980). The effects of an environmental "enrichment" program on the behavior of institutionfort that lacked any systematic attempt to manipalized, profoundly retarded children. Journal of Applied ulate the exact type of interspersed tasks, the denBehavior Analysis, 13, 473-49 1. sity of interspersed tasks, or the similarity between Klonoff, H., Low, M. D., & Clark, C. (1977). Head injuries in children: A prospective five year follow-up. acquisition and maintenance tasks. Thus, it is likeJournal of Neurology, Neurosurgery, and Psychiatry, ly that additional efforts in this direction may fur40, 1211-1219. ther enhance the power of this treatment. Koegel, R. L., & Egel, A. (1979). Motivating autistic

REFERENCES Alajouanine, T. H., & Lhermitte, F. (1965). Acquired aphasia in children. Brain, 88, 653-662. Carr, E. G., Newsom, C. D., & Binkoff, J. A. (1980). Escape as a factor in the aggressive behavior of two retarded children. Journal of Applied Behavior Analysis, 13, 101-117. Churchill, D. W. (1971). Effects of success and failure in psychotic children. Archives of General Psychiatry, 25, 208-214. Dunlap, G. (1984). The influence of task variation and maintenance tasks on the learning and affect of autistic children. Journal of Experimental Child Psychology,

37, 41-64. Dunlap, G., & Koegel, R. L. (1980). Motivating autistic children through stimulus variation. Journal of Applied Behavior Analysis, 13, 619-627. Edelstein, B. A., & Couture, E. T. (1984). Behavioral assessment and rehabilitation of the traumatically brain damaged. New York: Plenum Press. Gilchrist, E., & Wilkinson, D. M. (1979). Some factors determining prognosis in young people with severe head injuries. Archives of Neurology, 36, 355-359. Goetz, L., Schuler, A., & Sailor, W. (1983). Motivational considerations in teaching language to severely handi-

children. Journal of Abnormal Psychology, 88, 418426. Koegel, R. L., & Mentis, M. (1985). Motivation in childhood autism: Can they or won't they? Journal of Child Psychology and Psychiatry, 26, 185-191. MacMillan, D. L. (1971). The problem of motivation in the education of the mentally retarded. Exceptional Children, 37, 579-586. Miller, W. R., & Seligman, M. E. P. (1975). Depression and learned helplessness in man. Journal of Abnormal Psychology, 84, 228-238. Neef, N. A., Iwata, B. A., & Page, T. J. (1980). The effects of interspersal training versus high density reinforcement on spelling acquisition and retention. Journal of Applied Behavior Analysis, 13, 153-158. Schroeder, G. L., & Baer, D. M. (1972). Effects of concurrent and serial learning on generalized vocal imitation in retarded children. Developmental Psychology, 6, 293301. Seligman, M. E. P. (1972). Learned helplessness. Annual Review of Medicine, 23, 407-412. Stover, S. L., & Zeigler, M. D. (1976). Head injury in children and teenagers: Functional recovery correlated with the duration of coma. Archives of Physical Medicine and Rehabilitation, 57, 201-205. Received March 31, 1986 Final acceptance July 18, 1986