1. + Effects of Therapy Cushions on Classroom Behaviors of Children with Autism Spectrum Disorder by Caroline Umeda and Jean Deitz Presented by Sarah Singalla, OTS

2. + Why do the study? Children with Autism Spectrum Disorder (ASD) have higher levels of: Inattention distractibility than their typically developing peers modulating incoming sensory input. This leads to difficulties focusing and learning information in the classroom. School-based occupational therapists focus on dealing with the challenging behaviors by examining the possible sensory roots of the inattention and distractibility demonstrated by students with ASD.

3. + Why do the study? cont’d The strategies often used by school-based occupational therapists are sensory-based strategies to increase: Students levels of attending On-task behavior And performance in the classroom. One of the sensory based strategies used are different seating options. There are benefits of therapy balls to the increase of previously mentioned behaviors, but more research needs to be done to understand the benefits of therapy cushions because: Commonly used More practical alternative seating choice then therapy balls Takes up little space for storage Portable Can be used discreetly in a classroom so that they are not singled out.

4. + What’s the purpose of this study? The purpose of this study was to examine the efficacy of using therapy cushions to promote in-seat and on-task behavior in kindergarten students with ASD and sensory processing differences. The authors examined student behavior during math time to determine the effects of using therapy cushions on the following variables: The percentage of intervals in which in-seat behavior was observed. The percentage of intervals in which on-task behavior was observed. Students seating preferences. Teachers seating preferences for students. Teachers perceptions of student behavior.

5. + Methods- Setting Setting: Integrated Kindergarten classroom at the University of Washington’s Experimental Education Unit (a school specifically geared towards developing special needs children). Staffed by a special education teacher, an assistant teacher, classroom aides, an occupational therapist, and a speech-language pathologist. Frequency: 4.5 days per week. Data Collection: Was done during the math time where group instruction time was 10- 15 minutes Students were required to: Follow teacher’s verbal instructions Answer teacher’s questions Participate in group responses to math questions.

6. + Methods- Participants Participants: 2 participants (5 year old boy and a 6 year old boy) were enrolled in a classroom of 18 students where 12 received special education. Both participants had an educational diagnosis of ASD. Demonstrated functional challenges with on-task behavior during math time. Demonstrated sensory processing differences by scoring “definite difference” range in at least one of the seven categories on the Short Sensory Profile.

7. + Methods- Participants 1 st participant: 5 year old boy demonstrating mild delays in cognitive and language development. On SSP, he scored “definite difference” range in five categories: tactile sensitivity, underresponsive/seeks sensation, auditory filtering, low energy/weak, and visual/auditory sensitivity. Scored “probable difference” in movement sensitivity category. Displayed disruptive self-stimulatory behaviors during math time (bouncing up and down or rocking back and forth forcefully in his seat, etc.)

8. + Methods-Participants Participant 2: 6 year old, 1 month old boy. Demonstrated mild cognitive delays and substantial delays in expressive language development. Had low muscle tone, fidgety, and had trouble keeping an upright position. On the SSP he scored a range of “definite difference” in three categories: taste/smell sensitivity, auditory filtering, and low energy/weak. Scored “probable difference” range in the underresponsive/seeks sensation category.

9. + Methods-Independent Variable Independent variable: The seating options used during math time. The standard classroom chairs were used where each chair had a hard plastic seat and black metal legs, which were used to determine the baseline Cushions used on the seating were Inflated Disc ‘o’ Sit Jr. therapy cushions and were measured for each participant so that participants hips and legs were approximately 90 degrees and their feet could rest flat on the floor. This was done before data collection.

10. + Methods- Dependent Variable Dependent variable: In-Seat Behavior (chair and cushion): chair- behavior that occurred when any portion of a participants buttocks was in contact with the seat portion of the chair and the four legs of the chair were in contact with the floor. Cushion- behavior that occurred when any portion of a participants buttocks was in contact with the cushion, when any portion of the cushion was in contact with the seat portion of the chair, and when the four legs of the chair were in contact with the floor. Out-of-Seat Behavior: any sitting behavior that failed to meet the criteria for in-seat behavior On-Task Behavior: engagement in the appropriate classroom activity and was demonstrated by visual orientation toward the appropriate classroom activity. Off-Task Behavior: behavior failing to meet the criteria for on-task behavior.

11. + Methods-Design The study used a single-subject A-B-A-B-C interrupted time series design. A are the baseline phases where participants used standard classroom chairs during math time. B are the intervention phases where participants used standard classroom chairs with therapy cushions during math time. C is a choice phase lasting 1.5 week after second intervention phase to assess participants seating preferences. Each phase was 2-3 weeks long, and data was collected on in-seat and on-task behavior during four math sessions each week. 1 week acclimation phase occurred before first intervention phase (B) in order for the participants to get use to the cushion and there being a video camera.

12. + Methods-Data Collection Indirect classroom observations (video recording) were performed to observe participants in-seat and on-task behaviors in all phases during math time. Video recording would occur 30 seconds after math time began to allow participants to get settled in. Two coders that were blind to the study’s purpose viewed the video recordings and recorded data for in-seat and on-task behavior. Coders were licensed Occupational Therapists with pediatric experience and were randomly assigned to each participant. In-seat and on-task behavior were rated separately and one at a time. Interrater agreement was established before data collection that began with a minimum agreement of 80% for both in-seat and on-task behavior.

13. + Results-Participant 1 There was a low percentage for in-seat behavior in the first intervention due to the participant placing their foot underneath one of the legs of the chairs. In the second phase of intervention and baseline there was higher and less variable in-seat variables and during the choice phase the participant chose the standard chair. On-task percentages the baseline phase never passed 50% and the intervention phase ranged from 20%-63%. No changes were evident in second baseline, but there was an increase in the second intervention. Less variability was apparent in choice phase where on the 1 st day he chose to sit on the cushion and the rest on the standard classroom chair. The teacher noticed better attentiveness when sitting on the classroom chair, but no increase in changes in terms of sitting behavior and level of disruptiveness. Participant displayed day-to- day variability with both seating options.

14. + Results- Participant 2 In-seat behavior percentages did not differ greatly during baseline and intervention phases. Although at first there was an increase when the cushion was first introduced and then dropped. During the choice phase the participant chose the cushion but there were no differences in in-seat behavior. On-Task Behavior, again there was no substantial differences during baseline and intervention phases. The percentages were low and variable across all phases of the study. Highest percentages of on-task behavior, 52% and 46% and his lowest percentage, 0% during intervention. Teachers Perceptions: Attention to task appeared better when using the therapy cushion, although there was no substantial difference in sitting behavior and level of disruptiveness for both seating options.

15. + Discussion Data did not reveal substantial changes in sitting or task-related behavior for either study participant when seated on cushions. In other studies examined there were substantial increases in classroom behaviors when using a therapy ball. In comparison with a therapy ball and cushions, previous studies suggest cushions are less effective than balls in promoting functional change. This could be attributed the therapy ball requiring postural demands to promote positive changes in functional behaviors. The cushion does not provide enough sensory stimulation in order for the child to have any positive behavioral changes. Instead the child sought out to get more sensory stimulation then what the cushion provided, thus making it more distracting.

16. + Limitations and Strengths Limitations include: Small sample size. The use of a single classroom. Strengths include: Data collection in natural environment Interrater agreement Procedural reliability checks

17. + Conclusion There is a limited body of research on sensory-based intervention specifically alternative seating and how it can produce positive behavioral changes. Results show that effective seating devices can provide intense amounts of sensory feedbacks such as therapy balls.

18. + References Jumping Balls (2010). Retrieved from http://www.jumpingballs.com/us/disc-o-sit-jr-cushion-by- gymnic.html http://www.jumpingballs.com/us/disc-o-sit-jr-cushion-by- gymnic.html Retrieved from http://www.pearsonassessments.com/hai/Images/resource/ samprpts/Sensory_profile_Sample_rpt.pdf http://www.pearsonassessments.com/hai/Images/resource/ samprpts/Sensory_profile_Sample_rpt.pdf Umeda, C. & Deitz, J. (2011). Effects of therapy cushions on classroom behaviors of children with autism spectrum disorder. The American Journal of Occupational Therapy 65(2), 152-159.