INDIVIDUAL TOPIC SEARCH STRATEGY (ITSS) GUIDELINES

Vol:.(1234567890)

Journal of Autism and Developmental Disorders (2018) 48:2530–2541
https://doi.org/10.1007/s10803-018-3523-z

1 3

O R I G I N A L PA P E R

I Wanna Play Too: Factors Related to Changes in Social Behavior
for Children With and Without Autism Spectrum Disorder After
Implementation of a Structured Outdoor Play Curriculum

Michael J. Morrier1 · Sonja M. T. Ziegler1,2

Published online: 27 February 2018
© Springer Science+ Media, LLC, part of Springer Nature 2018

Abstract
Children with autism spectrum disorder (ASD) have difficulties interacting with same-aged peers during unstructured play
(e.g., on the playground). Thirty-five toddler and preschool children with and without ASD participated in a structured 15-min
outdoor play curriculum. The intervention, the Buddy Game, used familiar songs, movement, and games to promote peer
social interaction. A 2 × 3 ANOVA assessed changes in overall targeted social behaviors during baseline, the Buddy Game,
and generalization to free-pay. Multiple regression analyses examined factors related to increases in social interactions. Pre-
dictors were ASD status of child and age of child. Results indicated the Buddy Game increased overall social interactions
and that social interactions were influenced more by ASD status than age. Implications for practitioners are highlighted.

Keywords Autism spectrum disorder · Toddlers and preschoolers · Structured outdoor play curriculum · Peer interactions

Introduction

A diagnosis of autism spectrum disorder (ASD) requires
significant differences in the key developmental areas of
social communication and social interaction, as well as the
presence of restricted and repetitive interests and behaviors
(American Psychiatric Association [APA] 2013). Signifi-
cant deficits in a child’s ability to initiate and respond to
others, especially same-aged peers, are readily apparent in
children with ASD. Recent prevalence estimates for 8-year-
old children with ASD indicate that the rate of diagnosis
is increasing and the disorder is more common than pre-
viously believed (Christensen et al. 2016b). The Centers
for Disease Control and Prevention’s Autism and Devel-
opmental Disabilities Monitoring (ADDM) Network also
has investigated the prevalence rates for 4-year-old with

ASD (Christensen et al. 2016a). Recent estimates from the
ADDM Network indicate that for 4-year-old (i.e., preschool-
aged) children, the prevalence of ASD is 13.4 per 1000 (or 1
in 74). Thus, early educational and other childcare settings
will have increasing numbers of children with ASD in their
classrooms.

In early educational settings, a daily playground period is
usually offered for children to independently engage in social
interactions with peers in a more unstructured setting. The
social withdrawal of children with ASD can become most
obvious when children are participating in these unstruc-
tured times (Anderson et al. 2004). The lack of structured
planned activities lends to children with ASD spending the
majority of playground time isolated from peers, socially
disconnected, and engaging in non-functional, self-stimu-
latory behaviors (Peeters 1997; Veale 1998). Unstructured
periods of time during the school day are missed opportuni-
ties to teach children with ASD the peer-related social skills
they need. Previous research has demonstrated that increases
in social interactions of children with ASD can be accom-
plished by specifically teaching their typically developing
peers how to play with them (Harper et al. 2008; Kohler
et al. 2007; Laushey and Heflin 2000; McGee et al. 1992;
Owen-Deschryver et al. 2008).

Professionals from various fields have reached the
consensus that early intervention for children with ASD,

* Michael J. Morrier
[email protected]

1 Emory Autism Center, Department of Psychiatry &
Behavioral Sciences, Emory University School of Medicine,
1551 Shoup Court, Decatur, GA 30033, USA

2 Department of Educational , Special Education,
and Communication Disorders, College of Education
and Human Development, Georgia State University, Atlanta,
GA, USA

http://crossmark.crossref.org/dialog/?doi=10.1007/s10803-018-3523-z&domain=pdf

2531Journal of Autism and Developmental Disorders (2018) 48:2530–2541

1 3

including targeting the areas of social communication and
social interactions, is most effective when started before
3 years of age (National Research Council 2001). In order to
make changes in the fundamental social deficits of children
with ASD social interventions need to be carefully planned
and consistently implemented (McGee et al. 1999, 2001;
Schreibman et al. 2015). Research has shown that effective
interventions for children with ASD can be embedded into
their natural play activities (Boyd et al. 2008; McGee et al.
1999, 2001; Stahmer et al. 2011; Strain and Bovey 2011).
The characteristics of these effective interventions have been
described by Schreibman et al. (2015), and include embed-
ding applied behavior analysis treatment within a develop-
mental framework, known as Naturalistic Developmental
Behavioral Intervention, or NDBI. NDBIs are especially
important for teaching socially meaningful skills within the
context that a child with ASD will use them.

Increasing Social Interactions During Unstructured
Preschool Activities

McGee and colleagues have demonstrated that by making
small changes to environmental arrangements and structures
in the classroom, teachers can significantly increase posi-
tive social behaviors and decrease negative social behaviors
between preschoolers with ASD and their typical peers
(McGee and Daly 1999; Morrier et al. 2009). Adding coop-
erative games to an educational setting has been shown to
be associated with generalized increases in positive social
behaviors and decreases in aggressive behaviors in typically
developing preschools (Bay-Hinitz et al. 1994; Orlick 1981).
In addition, McEvoy and colleagues (1988) have shown
that by embedding interactive songs and games that include
affection actions (e.g., giving your neighbor a hug, patting
a friend on the back) can increase the social interactions of
children with ASD.

Increasing Social Interactions During Outdoor
Recess Activities

Pairing children with ASD with previously trained typical
peers, or peer buddies, has been shown to increase appropri-
ate social skills in kindergarteners with ASD (Laushey and
Heflin 2000). Previous research on increasing social interac-
tions between children with ASD and their typical peers dur-
ing outdoor recess has primarily focused on elementary-aged
students, and has often targeted only a few children at a time
(Boyd et al. 2008; Harper et al. 2008; McEvoy et al. 1988;
Owen-DeSchryver et  al. 2008). Research conducted on
pre-school-aged children tends to focus solely on older pre-
schoolers (i.e., those aged 3–5 years; McGee et al. 1992),
and does not typically include toddler-aged or younger
preschool-aged children. Research in comprehensive early

intervention programs for children with ASD that include
typical peers has provided naturally occurring social interac-
tion times during more structured, planned small and large
group activities (McGee et al. 2001; Strain and Bovey 2011),
but unstructured free-play periods such as playground recess
are often ignored.

Adding structure to outdoor recess time in order to teach
pivotal responses during recess increases social interactions
between children with ASD and their typical peers (Harper
et  al. 2008; Keogel et  al. 2006). In addition, when child
choice is embedded within games, children with ASD can
make significant gains in language and social skills (Carter
2001; Miller and Almon 2009). Previous research has dem-
onstrated that the use of a structured, cooperative play recess
curriculum with a focus on natural modelling and imita-
tion, increased children with ASD’s frequency of social bids
received from and social bid initiations to peers (Morrier
et al. 2009; Ziegler and Morrier 2018). This study aimed
to examine factors that might be related to the increases in
social behaviors demonstrated by children with ASD and
their typical peers during a Buddy Game intervention. Spe-
cific hypotheses investigated were (a) that implementing the
Buddy Game intervention would have positive effects on
children’s overall social interactions during outdoor recess
and generalize to a different time and setting (i.e., free-play);
(b) although children with ASD would make significant
gains despite the social deficits inherent in the ASD diag-
nosis, the ASD status of the participating children (ASD
versus typical) would be a significant factor that influenced
the social gains observed, with typical children having sig-
nificantly greater gains than the children with ASD; and (c)
the age range of the child at study start, regardless of ASD
status, would be a significant factor, with younger children
displaying less increases in receipt of social bids and initia-
tions to both peers with ASD and typical peers due to the
maturation levels of the older children as well as the devel-
opmental level of social behavior expected for toddler-aged
children compared to pre-K aged children.

Method

Participants

Ten preschool-aged children with autism spectrum disorder
(ASD) and 25 of their typically developing peers partici-
pated in this study (N = 35). Mean age of the children with
ASD was 55.70 months (sd = 13.92; range = 29–78 months),
and mean age of the typical peers was 39.64 months
(sd = 12.77; range 24–66 months). All children enrolled
at Early Emory Center for Child Development and Enrich-
ment (Early Emory) were invited to participate in this study.
Children whose parents did not consent to their participation

2532 Journal of Autism and Developmental Disorders (2018) 48:2530–2541

1 3

in the study remained in the educational environment for
the study’s duration, though remaining in a different part
of the playground than the intervention setting during the
treatment phase. Just over half of the parents of children
with ASD consented to participate in this study, thus these
children were not representative of all children with ASD of
the same age. Prior to the study’s commencement, any chil-
dren with neurotypical development (NTD) who presented
with characteristics indicative of ASD were screened by the
Center’s clinical team.

All children whose parents’ consented to their participa-
tion were included in the study. For children whose parents
consented for research participation, mean time enrolled
in the program for children with ASD was 23.90 months
(sd = 13.77; range = 4–46 months), and mean enrollment
for typical peers was 13.58 months (sd = 11.67; range 0–48
months). All children with ASD received a pre-admission
assessment to confirm their diagnosis of ASD using the
Autism Diagnostic Observation Schedule, 2nd edition
(ADOS-2; Lord et  al. 2012a, b) and Autism Diagnostic

Interview-Revised (ADI-R; Rutter et  al. 2003). Prior to
study participation, parents of children with ASD com-
pleted the Vineland Adaptive Behavior Scales, 3rd edition
(Vineland-3; Sparrow et al. 2016). One-way ANOVA indi-
cated that there were no significant differences on any of
the assessment measures for children with ASD based on
gender of the child. No other assessments were conducted
in relation to this study. T-test analyses on gender, age, time
in program, racial/ethnic background, and ADOS-2, ADI-
R, and Vineland-3 scores indicated that there were no dif-
ferences in groups between those children whose parents
consented to participation in the study and those children
whose parents did not consent to participate. Characteristics
of the 35 participants can be found in Table 1.

Setting

The study was primarily conducted on the outdoor play-
ground of Early Emory, a component of the Emory Autism
Center. Early Emory is an integrated preschool environment,

Table 1 Characteristics of study
participants (N = 35)

ASD autism spectrum disorder, sd standard deviation, ADOS-2 autism diagnostic observation schedule, 2nd
edition, RRB restricted, repetitive behavior, ADI-R autism diagnostic interview-revised, Vineland-3 Vine-
land Adaptive Behavior Scales, 3rd edition
*p < .05; **p < .001 Description Children with ASD Typical children N 10 25 Male (%) 6 (60%) 15 (60%) Mean age in months (sd)** 55.70 (13.92) 39.64 (12.77) Mean months in program (sd)* 23.90 (13.77) 13.58 (11.67) Parent reported racial background  Asian 0% 9%  Black/African American 33% 9%  White/Caucasian 67% 64%  2 or more races 0% 18% Mean ADOS-2 scores at program entry (sd)  Social affect 16.44 (3.36)  RRBs 5.33 (2.29)  Overall score 21.78 (4.44) Mean ADI-R scores at program entry (sd)  Social 18 (3.93)  Verbal (n = 2) 19 (2.83)  Nonverbal (n = 8) 12.17 (1.94)  RRB 3.63 (1.85)  Development 3.5 (0.76) Mean Vineland-3 domain scores (sd) at time of study  Communication 70.78 (20.17)  Daily living skills 71.33 (12.69)  Social 68.78 (16.88)  Motor 73.22 (9.76)  Adaptive behavior composite 70.11 (11.19) 2533Journal of Autism and Developmental Disorders (2018) 48:2530–2541 1 3 which supports the social communication development of both children with ASD and their typical peers through embedding applied behaviour analysis (ABA) techniques within natural preschool activities. The primary ABA technique used during the study was incidental teaching (McGee et al. 1992, 1999), which has been described as an NDBI (Schreibman et al. 2015). Incidental teaching uses a child’s interest in a particular item, topic, or activity to determine the timing and content of teaching opportunities (Hart and Risley 1968; McGee 2003a, b). Adults utilize the child’s interests to target their cognitive, language, or social development. Adults are aware of what concepts need to be taught, but the child determines the timing and context of their teaching. The intervention occurred daily on the outdoor play- ground during each classroom’s regularly scheduled, 45-min recess period. The duration of the study’s phases for each classroom can be seen in Fig. 1. The intervention, referred to as the Buddy Game, was implemented during the second 15-min of the recess period. All participating classrooms opened directly onto the playground, which measured 139-ft by 34-ft. The playground was divided into three main sec- tions, called “zones”. The zones consisted of (a) swings and a plastic play house, a sandbox with sand toys, two bounc- ing ride-on toys, secured in the ground, (b) a wooden play structure with two stairwells, two plastic slides, a balance beam, and a multiseat Spring-a-Bout™, and (c) an open area referred to as “the field”, that contained a plastic play kitchen and a plastic play house. Additional playground toys were available, and the entire organic surface of the play- ground was covered in 6-in of mulch, as specified by state childcare licensing guidelines. The Buddy Game was conducted on the 37-ft × 34-ft por- tion of the playground described as “the field”. Apart from the materials described in this study, no other playground activities were located in this section. Generalization data were collected inside each classroom during their afternoon free-play sessions (known as Generalization Free-Play). Fig. 1 Duration of each study condition during the multiple baseline across classrooms design CWA children with autism spectrum disorder; BL baseline; IV The Buddy Game intervention; MAIN maintenance; PK pre-kindergarten classroom; EPS early preschool classroom; PS preschool classroom 2534 Journal of Autism and Developmental Disorders (2018) 48:2530–2541 1 3 The free-play area of each classroom contained cubbies for the children’s belongings, shelves, age appropriate toys and books, a small vinyl coach, small vinyl chairs, a reading center, a block center, an art center, and a dramatic play center. Study Conditions Pre‑baseline One month prior to the start of the study, all teachers were instructed to discontinue any organized activities, games, or curriculum that they may have been implementing during their outside recess time. They were also instructed to stop singing all of the movement songs chosen for the treatment condition, and to not sing these songs during any part of the day. These songs were already part of the regular song repertoire in each classroom. Teachers were provided with an extensive list of new non-movement songs that could be added to their classroom’s repertoire. Teachers were instructed to make these changes to minimize confounding variables to the study. Baseline Condition Baseline occurred outside on the playground during the sec- ond 15-min of each classes’ 45-min recess time. During this condition, children were free to engage in any outdoor activ- ity that was available to them. Each teacher was assigned to facilitate one zone on the playground, and to contact children in their zone using normal program procedures (e.g., contact children engaged at a rate, which provides approximately 13–15 contacts in total, within a 5-min period). Unengaged children were matter-of-factly redirected to an ongoing play- ground activity. Teachers also routinely prompted verbal language expansions and ensured that safety and behavior management procedures were followed. During baseline, teachers were instructed not to prompt, to teach, or to rein- force any child to child interactions, except those required to settle a sharing dispute over materials or physical space. Pre‑Buddy Game During morning programming, before each classes’ outside time, teachers informed all the child participants that they would be playing the Buddy Game when they went outside, and to play game, they first needed to have buddies. Teach- ers then randomly paired each child with ASD with a typical peer. This was done by choosing a name out of a shaken con- tainer of names of children with ASD; then a name was cho- sen from a shaken identical container with the names of the typical children. This procedure continued until all children with ASD were paired with a typical peer. The remaining typical peers were paired together in the same manner. If there was a typical child who was not paired with a peer due to an odd number of class members, they were paired with a typical dyad. The buddy pairs were announced and placed together using each child’s nametag on a black poster board with Velcro™ dots titled the “Buddy Board”. Children were informed that when they were told that it was time for the Buddy Game, they should go to the field, find their buddy, and that they needed to stay together because they are going to do some movement songs. Children were reminded who their buddies were before going outside and what they should do when they heard a teacher say, “It’s time for the Buddy Game.” Just before the intervention, the children were informed that they were about to play, they needed to come to the field, find their buddy, and stay with them. They were reminded who their buddies were, both visually through the “Buddy Board” and verbally by the teachers. In all class- rooms, the ratio of children with ASD to peers with NTD was 1–3. As part of the center-wide culture, children with ASD were integrated throughout the day in all activities. No child was identified as having a diagnosis, and learning and skill differences were never highlighted. It was a typical practice of each classroom to have children with differing neurodevelopment participate in each activity, and paring of children to help one another or to transition from one activ- ity to the next was common. If a child protested playing the Buddy Game either vocally or gesturally, this would have been considered the revocation of the child’s assent to par- ticipate for that session. This did not occur during the study. Buddy Game Intervention Condition The Buddy Game was a novel intervention designed by the second author, based on tenants identified from the ABA and NDBI literature, with materials previously familiar to all study participants. When all children had gathered “at the field”, the lead teacher informed them that they were going to play the Buddy Game. The intervention consisted of child dyads singing songs with gestures and movements in front of one another in a larger group setting. Songs were randomly chosen from a selection of laminated 4-in × 6-in cards with the song’s title and related pictorial depiction. The lead teacher randomly chose a different child to select each song (see Table 2). After the children gathered in the field, they were given the instructions: “Friends, we are going to sing some of our favourite songs with our buddies. They are here on these cards. (The lead teacher randomly chose a child to pick a card; the child picked a card). Oh, X chose song Y. Ok, we are going to stand in front of our buddies to sing. Remember we are dancing and singing with our buddies.” Both the lead teacher and assistant teachers supported the children to stand in front of their buddies in two lines, by gently leading them 2535Journal of Autism and Developmental Disorders (2018) 48:2530–2541 1 3 by the hands or gently applying pressure to the children’s upper backs to guide them into position, if needed. All teach- ers then stood behind the line of children they had supported. The lead teacher began the chosen song with movements and assistant teachers followed in singing and moving. Once a song was completed everyone cheered, and the process was repeated with song cards that had not been previously chosen. Before each song the children were instructed to, and if needed, supported to stand front of their buddy. If the 15-min intervention period had not ended before all song cards were chosen, the song cards were placed together again, shuffled, and the process continued until the 15-min period had ended. At that time, the lead teacher told the children, “We are all done singing. You can go play now.” The nametags used on the Buddy Board closely resem- bled the nametags that each child used during the school day to identify their place at meals. The song cards used in the intervention closely resembled the children’s nametags in their design. Similar cards had been utilized in some class- rooms to visually support children in choosing songs to sing during circle time, prior to the study’s commencement. If a child left “the field” during the 15-min intervention, an assistant teacher followed them, gently taking him or her by the hand and said “It’s time to sing song X with your buddy” in a matter-of-fact manner, brought child back to the field, and supported child them to face their buddy. If during a song, the lines dispersed and a group formed, the Buddy Game continued in that manner. Behavior management plans for child aggression towards another child, as defined in the ongoing curriculum, remained in place. Generalization to Free‑Play Condition In a 15-min free-play session following the Buddy Game, teacher behavior mirrored that of the baseline condition. During this condition, children were free to engage in any activity or with any of the toys that were available to them in their indoor free-play area. Teachers were instructed to contact children using regular classroom procedures. The normally occurring program procedure that teachers matter- of-factly redirect children who were unengaged to an activ- ity or to functionally play remained in place, and teachers continued to prompt for verbal language expansion and ensured that safety and behaviour management procedures were followed. Teachers were instructed to not prompt or teach to, or reinforce any child to child interactions, except those required to settle a sharing dispute over materials of physical space. Response Definitions A multiple baseline across classrooms design was used to investigate the effect of a structured outdoor play curricu- lum on social communication behaviors between children with ASD and peers with NTD. Data were collected in vivo using a 120-s observe; 30-s record, partial interval system. Observe and record intervals were specified to each data col- lector through an individually worn ear bud attached to an Olympus Digital Voice Recorder (VN-100) so that only the data collector could hear the intervals. Each data collector developed their reliability of observation of the response def- initions through scoring videos of non-participants at play, and observing non-participants at play in situ. The study commenced when all observers demonstrated an interob- server agreement with the principle investigator of 80% or more over three consecutive observations. Data were collected on three main behaviors during all study conditions. These three behaviors were also broken down by child status (i.e., ASD and non-ASD) to determine the effects of the Buddy Game on each population of child. Specific response definitions are provided below. Overall proximity to peers (proximity) was defined as the target child being within 3-ft of another child, or a distance in which an item could be easily given by one to the other. Proximity to a typical peer (typical proximity) was defined as the target child being within 3-ft of a typical peer, or a distance in which an item could be easily given by one to the other. Proximity to a peer with ASD (ASD proximity) was defined as the target child being within 3-ft of a peer with ASD, or a distance in which an item could be easily given by one to the other. Overall social bid received from a peer (receives) was defined as the target child having facial orientation toward another child and receiving a verbal, non-verbal, or com- bined social initiation from that child; accidental bumping into each other was not counted as a social bid. Social bid received from a typical peer (typical receives) was defined as the target child having facial orientation toward a typical peer and receiving a verbal, non-verbal, or combined social initiation from that peer; accidental bump- ing into each other was not counted as a social bid. Social bid received from a peer with ASD (ASD receives) was defined as the target child having facial orientation toward a peer with ASD and receiving a verbal, non-verbal, Table 2 Interactive songs used during the Buddy Game curriculum ● Baby Shark ● Head, Shoulders, Knees and Toes ● If You’re Happy and You Know It ● The Banana Song ● The Itsy-Bitsy Spider ● Wheels on the Bus ● The Hokey Pokey 2536 Journal of Autism and Developmental Disorders (2018) 48:2530–2541 1 3 or combined social initiation from that peer; accidental bumping into each other was not counted as a social bid. Overall social bid initiated by target child towards a peer (gives) was defined as the target child having facial orienta- tion towards another child and actively engaging in a (verbal, nonverbal, or combined) social interaction with that child. Social bid initiated by target child towards a typical peer (typical gives) was defined as the target child having facial orientation towards a typical peer and actively engaging in a (verbal, nonverbal, or combined) social interaction with that peer. Social bid initiated by target child towards a peer with ASD (ASD gives) was defined as the target child having facial orientation towards a peer with ASD and actively engaging in a (verbal, nonverbal, or combined) social inter- action with that peer. Interobserver Agreement Two independent observers simultaneously coded a total of 38% of sessions across all study conditions to determine the degree of accuracy in behaviors recorded. Interobserver agreement (IOA) was calculate using a Total Count IOA formula (Cooper et al. 2007, p. 115; Landis and Koch 1977). Both observers independently scored data using individual Olympus Digital Voice Recorders (VN-100) which were synchronized to play intervals at the same time. Observers were free to move around each setting in which data was col- lected in order to get the best view of children and to stay at minimum of 4-ft apart from each other. Specifically, agree- ment between the total frequency of responses recorded by the two independent observers was calculated by dividing the smaller frequency of behaviors recorded by the larger frequency of behaviors recorded and multiplying by 100. Percent agreement for overall proximity was 87% (range: 64–100%). Percent agreement for overall receives was 78% (range: 0–100%) Percent agreement for overall gives was 85% (range: 50–100%). Data Analyses Data analyses were conducted using IBM SPSS 24 …