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TEACHERS’ EXPERIENCES OF DEVELOPING JOINT ATTENTION SKILLS IN CHILDREN WITH AUTISM USING IPADS C. Mangafa, L. Moody, A. Woodcock, A. Woolner Coventry School of Art and Design, Coventry (UNITED KINGDOM)
Abstract Mobile devices such as tablets are increasingly used in primary schools with reported benefits in communication, independent learning and creativity. Children with autism spectrum disorder have an affinity with tablets, which is recognised by the autism research community with many studies gradually emerging in this field. This qualitative study aims to explore primary school teachers’ experiences of developing joint attention skills in children with autism using strategies and iPads. Joint attention (JA) can be defined as the act of sharing, sustaining and shifting attention between two social partners and an object, activity or another person. It is an essential life skill which can indicate the later development of social communication, language acquisition and behaviour. It is usually absent or impaired in children with autism, which means that they often find it difficult to share attention with an adult or peer about a toy by following gaze, pointing and alternating gaze, but also showing interest to the other person. Joint attention difficulties can also be a prognostic indicator of autism. Research on the use of tablets to develop skills in autism is limited. In order to understand current practice, semi structured interviews with 16 school staff members and non-obtrusive observations of 12 pupils interacting with the teacher using iPads were held in three UK schools (one mainstream and two special needs). All teachers used teaching strategies to promote joint attention on a daily basis, a few used targeted interventions for joint attention and even less used iPads in general in their classroom. Participants expressed different opinions about the effectiveness of teaching strategies and iPad use in developing joint attention skills since it relied on their ability to implement them appropriately and their knowledge of each child. The observations showed that teachers used a variety of evidence-based strategies to engage their pupils with autism in joint attention opportunities but that there was little use of iPads. The iPad was mainly used as a reward, a motivator to direct and sustain pupils’ attention, to practice turn-taking and waiting skills and to teach the curriculum. The research points to the need to provide schools with guidance on how to use tablets to teach joint attention skills and that teachers would welcome opportunities to share knowledge with colleagues and parents so that they can work together. Keywords: Tablets/iPads, autism spectrum disorder, joint attention skills.
1 1.1
INTRODUCTION Joint Attention Skills in Autism
Autism Spectrum Disorder is a neuro-developmental disorder characterized by persistent deficits in social communication, interaction and restricted, repetitive patterns of behaviours [1]. The core impairments are explained by the two latest and most prevalent diagnostic criteria, the fifth revision of ‘Diagnostic and Statistical Manual of Mental Disorders’ (DSM-V) [2] and the tenth revision of the International Classification of Diseases and Related Health Problems (ICD-10) [3]. In DSM V the term autism spectrum disorder has recently replaced the terms autistic disorder, pervasive developmental disorder- not otherwise specified (PDD-NOS), childhood disintegrative disorder and Asperger’s syndrome that were considered subtypes of autism spectrum disorders. The fact that a single definition is now used to describe the symptoms, shows that emphasis is given to individual needs rather than labelling the condition which may change over the course of the individual’s life [4]. In ICD 10 the term used is Childhood Autism under the overarching term ‘pervasive developmental disorders’. For clarity and consistency reasons, the term autism will be used throughout the paper to refer to individuals with autism spectrum disorder and childhood autism.
Proceedings of EDULEARN15 Conference 6th-8th July 2015, Barcelona, Spain
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The symptoms are similarly described in both classifications. Deficits in social interaction and communication include the children’s difficulty in forming peer relationships due to deficits in sustaining a conversation, understanding the communicative partner’s intentions and feelings, and misreading social cues such as eye contact and gestures in interactions. In addition, children may be preoccupied with restricted interests so interactions outside of this range may not start or develop. Children may also not be able to cope with changes in their routine and will show their discomfort through repetitive movements and sensitivity to outside stimuli. They may not want to share their toys with peers or adults and may not be interested in sharing their enjoyment or have a difficulty in expressing their emotions. Typically developing children may sometimes show some of these difficulties if they have not met the development milestone, but for a child to be diagnosed with autism the deficits should be persistent in multiple contexts and limit everyday functioning [5]. However, research refers to reduced or absent joint attention in pre-schoolers and children as a symptom for diagnosing autism [6]. Joint attention (JA) can be defined as the act of sharing, sustaining and shifting attention between two social partners and an object, activity or another person [7]. Joint attention deficits are defined as a lack in following another’s pointing and gaze and showing or pointing to share interest. The lack of joint attention skills can be a prognostic indicator of autism [9].It has been suggested that deficits in attention can have a negative impact upon communication, social interaction and repetitive, restricted behaviour [1]. While joint attention (JA) initiation bids start after 18 months of age in the case of children with autism JA is usually delayed or absent [10]. From the 1970s studies have shown that atypical or lack of eye contact is a predictor of a diagnosis of autism, but it is not until recently that JA has gained momentum as an area of research and intervention goal [9].
1.2
Interventions for Developing Joint Attention Skills
In autism, interventions can be used to develop and enhance certain skills, such as social or communication skills, to reduce negative patterns of behaviour, such as self-harm and to improve the quality of life of children and adults with autism and their family [11]. There is no universal classification of the forms of interventions but they can be broadly grouped into educational, pharmacological, technology-based, behavioural and developmental, dietary and psychotherapeutic. Taking into consideration the heterogeneity within the spectrum and the individual differences, each child may receive more than one intervention at a time since no single intervention may be sufficient to meet all their needs.
1.2.1
Educational Interventions
Educational interventions for children with autism have long been reported for their contribution in enhancing the children’s ability to grow and develop new skills. The role of the school in the development of interventions is of high importance since education is the fundamental experience children have early in their life. It is the place where the child spends most of time interacting with others and forming relationships. The social demands are more apparent in primary school years when children are usually expected to regulate emotions, develop empathy and take turns in meaningful interactions [5]. Schools have shown an interest in strengthening the effectiveness of their teaching strategies around autism by using evidence based practice. Evidence based practices derive from high quality research studies that have been peer reviewed in scientific journals. They are judged ‘well-established’ if a more than nine single subject designs are used, an experimental design is followed, the participants are clearly described, the intervention is compared to existing ones and a manual is created. A treatment is judged ‘emerging’ if less than three single cases are used in the design and its effectiveness is still not clear. Table 1 lists the evidence based strategies and interventions according to systematic reviews of the research literature [12].
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Table 1 Evidence- based strategies and interventions in autism. No
Evidence-based strategies
Evidence-based interventions Well- established
Emerging
1
Computer-‐Aided Instruction
Behavioural Interventions
Peer-‐led Interventions
2
Peer-‐Mediated Instructions
Joint Attention Interventions
Family- led Interventions
3
Prompting
Naturalistic Interventions
Augmentative and Alternative Communication Devices
4
Reinforcement
Pivotal Response Training
Developmental Relationship-‐based Treatment
5
Redirection
Discrete Trial Training
Imitation-‐based Interaction
6
Self-‐Management
Massage/Touch Therapy
7
Social Skills Groups
Music Therapy
8
Task Modifications
Picture Exchange Communication System
9
Time Delay
Technology-‐based Treatment
10
Video Modeling
11
Visual Supports
12
Play Scripts
13
Social Stories
14
Schedules
15
Family Involvement
As shown above, it has been proven that joint attention interventions are well established in terms of their effectiveness in supporting children with autism when compared to other forms of interventions. However, it is difficult to compare the effectiveness among studies targeting joint attention because of differences in sampling size, the demographics of the participant population, the setup and process [13]. A search was made on six databases (PubMed, Psych INFO, Medline, ERIC, SINAHL, Google Scholar) to find the most recent studies (from 2000 to date) about joint attention interventions for primary school aged children with autism. It was found that a very small number of studies target the age group of 5-11 year olds. The results are promising in promoting joint attention skills since evidence based strategies were used and follow ups were conducted. However, they were conducted in a clinical not natural setting, such as the classroom. In addition, the strategies and methodologies could only be applied by trained professionals, which make the interventions difficult to be implemented by unfamiliar agents, such as teachers or parents.
1.2.2
Technology based Interventions
The use of technology based interventions for supporting children with autism is a relatively new and emerging field. It is widely agreed that children with autism have a high interest in technology devices and an affinity in using them [14, 15]. Technologies create a predictable environment with consistency where children can interact without worrying about the unpredictability of human interactions. They offer multisensory stimulation through touch, visual effects, sound and movement. It is argued that the children, who use technologies that motivate them and they find easy to use, can better focus and sustain their attention on tasks [16]. Research on the use of technology is essential since, in September 2014, a new computing curriculum was introduced in the UK primary schools that require all children to improve their ICT skills at school. In terms of the technologies used for joint attention purposes, virtual reality, robots and mobile applications are the most prevalent [16]. What makes mobile applications favourable to other types of technologies is the fact that they are of low cost when compared to robots and virtual reality table top surfaces. They can be used in parallel with other equipment in the classroom such as picture cards,
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books and board games. They are accessible and portable and can be used in the home environment. To date, though, there is no empirical evidence of the effectiveness of the tablets beyond the results generated from individual cases [15]. However, mobile devices are a way to engage children with autism in meaningful face-to-face interactions by practising activities that are enjoyable and tailored to each child [16]. Depending on the children’s interests any mobile application can be used as long as joint attention opportunities are created with the support of the adult.
1.3
Overarching Aim of PhD Study
The overall aim of the study is to explore ways in which iPads can be used in the classroom and home to support children with autism in the area of joint attention skills. The objectives are a) to develop an understanding of the nature and importance of joint attention skills in children with autism, b) to disseminate effective strategies and interventions that target joint attention skills to teachers and parents and c) to investigate the potential of iPads to contribute to the development of joint attention skills. In order to achieve these, the research is divided into four studies; interviews with teachers, observations in schools, interviews with parents and an evaluation of the suggestions. This paper will present the results of the first two studies.
2 2.1
METHODS Semi-structured Interviews
Interviews were held with sixteen teachers in three schools in UK in order to examine the ways in which educational interventions, strategies and iPads are used in the school to support children with autism in the area of JA. Table 2 shows the interviews’ research objectives. Table 2 Interviews’ Research Objectives. No
Interviews Research Objectives
1
To explore teachers’ and teaching assistants’ opinions and experience of the manifestation of joint attention deficits in pupils with autism
2
To investigate what strategies school staff use to promote joint attention skills
3
To examine how technology is used to support pupils’ learning with regard to joint attention skills
4
To evaluate the effectiveness, from the teachers and teaching assistants perspectives, of the interventions and assess the extent to which iPads are used in promoting joint attention
2.2
Participants
Representative primary school teachers in mainstream and special schools in UK were recruited. The inclusion criteria were participants should have at least one pupil with a diagnosis of autism in their classroom of 5-7 years olds (Key Stage 1), have at least one month of experience working with pupils with autism and some use of iPads in the classroom would be preferable. Three schools met the criteria. However, the restrictions were relaxed in order to achieve a larger sample size. Teachers and teaching assistants from both lower (Early Years Foundation Stage: 3-5 years old) and higher key stage (Key Stage 2: 7-11years old) were selected. Finally, 16 participants were recruited - six from one special school, three from another and seven from a mainstream school. Table 3 shows participants’ characteristics.
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Table 3 Participants’ Characteristics. No
Participant
Professional Experience
Type of School
Classroom
1
Higher Level Teaching Assistant
8 years
Special School 1
Y 5/6
2
Teacher
4 years
Special School 1
Y3
3
Higher Level Teaching Assistant
3 years
Special School 1
Reception class
4
Teacher
2 months
Special School 1
Y1/2
5
Teacher
13 years
Special School 1
Y1/2
6
Teacher
3 years
Special School 1
Y1/2
7
Teacher
1 year
Mainstream School
Reception class
8
Teacher
10 years
Mainstream School
Y2
9
Teacher
9 years
Mainstream School
Y1
10
Teacher
12 years
Mainstream school
Y3
11
Teacher
4 years
Mainstream school
Y1
12
Teacher
1 year
Mainstream school
Nursery Class
13
Teacher
1 year
Mainstream school
Y4
14
Teacher
12 years
Special School 2
Y4
15
Teacher
25 years
Special School 2
Reception Class
16
Teaching Assistant
7 years
Special School 2
Y1/2
The interview was divided into six categories; 1) Biographical information, 2) Knowledge and Experience of ASD, 3) Understanding of the nature of joint attention skills in children with autism,4) Discussion of the interventions used at school that target joint attention, 5) The use of technology/iPads in the school setting, 6) The use of technology/iPads in the home setting. The interviews lasted between 20-60 minutes and were audio recorded while the first author was also taking notes. The interviews were fully transcribed following the Interpretative Phenomenological Analysis approach [17].
2.3
Non- obtrusive Observations
Interviews were followed by observations in the schools. These aimed to investigate the use of iPads in the school setting by the children and teachers with the purpose of developing joint attention skills. Table 4 shows the subordinate objectives of the study. Table 4 Observations’ research objectives. No
Observations Research Objectives
1
To investigate what strategies and educational interventions school staff puts in practice to promote joint attention skills.
2
To examine how technology is embedded in the pupils’ learning to promote joint attention skills
3
To draw comparisons between the use of iPads and interventions for encouraging joint attention opportunities.
The teachers and teaching assistants, who participated in the first study, were also asked to be observed as a follow up study. Consent forms were signed and observations were conducted in two schools (one special and one mainstream school). The observation checklist was informed by the background literature and research questions. The observation checklist was divided into two sections; one being the use of technology and the other the non-technology use. Each section was
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further divided into child’s activities and teacher’s activities since they were both observed interacting. In the child’s activities social interaction (initiating and responding to turn-taking) and joint attention behaviours (initiating and responding to JA) were listed and the teacher’s activities included strategies to gain attention, sustain attention and shift child’s attention. Joint attention behaviours from teachers and children were observed with the use of technology and non-technological devices in various locations in the school setting any time during the day without interrupting the child’s timetable. A video camera recorded the participants interacting while the researcher was also taking notes. The data from the observations were analysed both manually by looking at the field notes and observation checklists and digitally by using the video editing software Transana Standard 2.61. Table 5 summarises the observations. Table 5 Summary of Observations. Observations
Class
Subject(s)
Location
Y3
-Literacy
-Classroom
Y3
-Literacy -PE -Numeracy -Fine Motor Skills Activities -ICT
-Classroom -PE Hall -PC Suite
Y1/2
-Register -Numeracy -PE -Snack Time -Soft Play Activities -Literacy
-Classroom -PE Hall -Soft Play Room
Y1/2
-ICT -Sensory Play Activities
-Classroom -Sensory Room
Y5/6
Numeracy
-Classroom
Y3/4
-Literacy -ICT -Numeracy -Fine Motor Skills Activities
-Classroom -ICT Suite
EYFS
-Sensory Play Activities -ICT - Soft Play Activities -Creative Play Activities -Play Time
-Sensory Room -PC Suite -Soft Play Area -Classroom -Playground
Y1
-Social Skills Lesson
-Classroom
Y2
-Numeracy
-Classroom
Y3
-Literacy
-Classroom
EYFS
-ICT
-Classroom
Special Needs School 8 sessions 5 teachers 9 children
Mainstream School 3 sessions 3 teachers 3 children
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3 3.1
RESULTS Interviews
Through the analysis of data derived from the interviews, four major themes were developed; ‘Teachers’ understanding of joint attention’, ‘Teachers’ strategies and interventions for developing joint attention skills’, ‘The use of technology at school’ and ‘Teachers’ future steps’. On the first theme regarding teachers’ understanding of joint attention skills almost all teachers gave a similar description of how these skills are demonstrated in the classroom. The teaching staff were familiar with the terms ‘shared attention’ and ‘social interaction’ when they were referring to joint attention behaviours. This difficulty in identifying a single definition of attention has been acknowledged in the research literature [8]. The fact that the research community uses different definitions from the school teachers shows a gap that future studies need to address when doing research in schools. In the current study, during the interview process the participants became familiar with the term joint attention which they used to describe behaviours such as sharing, turntaking, keeping eye contact, focusing and interacting by using symbols, gaze or gestures. On the second theme regarding teachers’ strategies for overcoming the barriers to joint attention, most of the strategies mentioned have been acknowledged for their effectiveness in promoting joint attention skills [18]. Among the strategies mentioned that target joint attention were the use of items that have been chosen by the children and are motivating and engaging to them, the teacher showing enthusiasm for what the child is doing, using a high pitched voice to show their interest and get children’s attention, the use of praise, prompts and visual aids as well as turn-taking tasks that are stimulating for the children. In terms of the interventions used in school settings, the participants expressed contrasting views about their contribution to the development of joint attention skills. Overall, the Picture Exchange Communication System (PECS) and Speech and Language Therapy were agreed to promote language development and communication skills. In contrast, interventions, such as Pivotal Response Training and Discrete Trial Training that specifically promote joint attention were not applied in the three schools. In addition to this, many teachers mentioned that some evidence-based interventions are not implemented the way they were designed but modified and adapted to their school practices and children’s needs, which is also noted in the literature [19]. With regards to the effectiveness of the strategies and interventions used at the school, the participants mentioned that it depends on the teacher’s ability to implement them appropriately and their knowledge of each child. In addition, when asked what assessments they used to measure effectiveness, participants admitted that they were more interested in reflecting on their own practice and learning more about the children than evaluating the children’s progress against standards. On the third theme regarding the use of technology in the classroom all teachers said that they use the interactive whiteboard almost every day while some others said that they also use iPads several times a week. Both devices were mentioned as being used for teaching the curriculum, for teaching turn taking skills and for engaging children in learning. In terms of the iPads being used to teach joint attention skills the participants mentioned that the iPad can be used for sharing activities, turn-taking tasks and small group projects since children are motivated to use it and therefore they can stay focused for a prolonged period of time and interact with peers. On the fourth theme about teachers’ future steps, the participants mentioned that they would like to become confident in using the iPads in the classroom via staff training, reflecting on their practice and discussing new strategies for improving joint attention skills. Participants also mentioned that they wished to have more resources available for use whenever needed as well as to build stronger links with parents with whom they can discover techniques to use the iPads in an interactive and engaging way.
3.2
Observations
The analysis of the observations followed a qualitative approach using the data collected from the field notes and video recordings supported by more structured observation checklists. From the analysis a number of themes emerged based on the study’s aim and objectives. The major themes were ‘Teachers’ strategies and interventions for JA purposes’, ‘The use of technology in the classroom’ and ‘Comparison of iPad use and strategies’.
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On the first theme regarding teachers’ strategies and interventions for JA purposes almost all teachers were observed using a variety of evidence-based strategies to gain, sustain and direct child’s attention. For example, teachers were observed creating opportunities for developing turntaking and joint attention skills with the use of visual supports. In particular, the teachers in the special school extensively used a turn-taking board where the photos of the children rotated under the picture of the game they would each play as shown in fig. 1. Symbols and communication boards were also used in order to encourage communication and joint attention, as shown in fig. 2. Apart from the use of visual supports that have been reported in the literature as an evidence based approach [19], teachers also used positive reinforcement and rewards straight after the child had responded or initiated a social interaction. In addition, teachers allowed time for the children to respond or ask for help which encouraged the children to participate more in the classroom. A teacher in the special school was observed running a social skills group lesson where children work in small groups to complete a range of tasks based on the curriculum with the aim to encourage joint attention opportunities and communication among them. Another teacher in the mainstream school was observed assigning learning partners in the classroom where children had to work in pairs and narrate to each other the story of their lesson shown in fig. 3. Overall, teachers in both schools used strategies to develop JA, but only in the special were teachers observed delivering one to one interventions with the pupil. This can be explained by the fact that the children in the mainstream school were not in the need of an intervention. Interventions, such as PECS and TEACCH were part of the children’s daily routine when pupils were encouraged to use communication boards to interact during snack time (fig. 4) and do their literacy and numeracy tasks using workboxes (fig. 5). Depending on the child’s cognitive level, tasks were modified and tailored for each child with autism in the classroom as revealed in the teacher’s lesson plan. However, with the exception of the delivery of the TEACCH intervention where the adults annotated the child’s work straight after each task, teachers were not observed assessing children’s progress after each lesson so it is not clear whether the strategies and interventions used developed joint attention skills. As teachers reported in the interviews, children’s progress is measured termly which means that future research investigating the long term effects of the strategies in joint attention improvements is advised.
Fig.1 Turn Taking Board.
Fig.2 Use of Symbols to Encourage JA.
Fig. 4 Communication Board for Snack Time.
Fig. 3 Learning Partners.
Fig. 5 Numeracy Tasks Using Workboxes.
With regards to the second theme, both the interactive whiteboard and iPad use were observed in the classroom. The interactive whiteboard was used to teach the curriculum and signal the transition between the lessons. However, joint attention opportunities were not observed. On the contrary, despite teachers’ lack of confidence in using the iPad, the device was observed being used by the children with their teacher in an interactive way. iPads were used to practice fine motor skills, turn taking skills among peers and to sustain pupils’ attention during literacy work. In some cases, teachers used the iPad in combination with visual supports in order to teach the curriculum (fig 6). Most of the children responded to joint attention opportunities, less initiated JA but all were able to
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wait for their turn to use the iPad. Nonetheless, a number of challenges were observed in the two schools when the iPads were planned to be used. First of all, due to lack of resources the iPads were not available when scheduled, due to use in other classrooms. In addition, children were not able to print their work or search for information due to failure to the school’s network, which caused frustration to the children and teachers. Finally, some teachers could not lock specific apps on the iPad for the children to access, which meant that pupils could instantly switch through apps making it difficult for the teacher to gain or sustain child’s attention. The observations showed that joint attention opportunities were created and could be fostered as long as the challenges are addressed before the iPads are given to the children.
Fig. 6 iPad and visual support to teach the curriculum. On the third theme which derived from the study’s objectives, it was noticed that teachers did not only favour the use of one method over the other, meaning strategies or iPad, but they combined both approaches in their practice. Especially the teachers who were reluctant in using the iPad were observed supplementing the device with symbols and worksheets.
4
CONCLUSION
The study explored how three UK schools promote joint attention skills in their children with autism with and without the use of iPads. All teachers mentioned that they used teaching strategies (such as using children’s personal interests as motivators, sharing and turn-taking play activities, visual prompts, social skills groups and role models) to promote joint attention along with other skills on a daily basis, while a few used interventions for joint attention (PECS and TEACCH) and even less used iPads (to teach the curriculum, turn-taking skills and as a motivator/incentive) in their classroom. In addition, the participants’ opinions were similar with regards to the nature of joint attentions skills and difficulties of their pupils, the strategies they use and the future steps they want to take. On the other hand, participants expressed different opinions about the effectiveness of interventions and iPad use in developing joint attention skills. There was no difference in the teaching practice between mainstream and special schools with the exception that the special schools used more interventions for their children with autism, which can be explained by the fact that the children in the special schools have more complex difficulties. Also the mainstream school teachers reported that they can approach and engage parents more easily, which can be explained by the fact that special schools use school bus transportation with limited opportunities to meet parents face to face. It should be noted that the findings cannot be generalised as the sample size was small and there was variability in the sample in terms of age and ability levels. However the aim of this qualitative study was not to draw general conclusions but to explore the experiences of representative schools in UK. Future studies that use a bigger sample and measure children’s communication and cognitive abilities can provide a clearer picture of the current situation in schools that use iPads for joint attention purposes To sum up, it is proposed that while teachers start to become more confident in using iPads in the classroom more opportunities for joint attention can be created as long as research provides evidence based strategies and good practice recommendations.
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