Introduction
A 2024 Centers for Disease Control and Prevention (CDC) report indicates that children with autism spectrum disorder (ASD) may demonstrate several maladaptive social characteristics, such as the inability to reciprocate social-emotional cues in developing social relationships. Children with ASD have difficulty with peer relationships with reported more incidents of teasing and feelings of isolation (Feldman et al., 2022). They may be nonverbal and show impairments in social communication impairment and interaction skills, and restricted or repetitive patterns of behavior, limiting their ability to develop age-appropriate play skills (CDC, 2024) and interacting with neurotypical peers. Feldman et al. (2022) found that children with ASD who enhanced their social skills were more likely to experience increased peer acceptance.
Exposure to Different Forms of Disability
Research on neurotypical children’s perception of children with a disability has focused on physical disabilities (Demetriou, 2020; Hurst et al., 2012) due to the visibility of the disability. Hurst et al. (2012) compared responses before and after program’s implementation and found that children in second and third grade showed improved acceptance levels of children with disabilities after receiving a disability-simulation program. Most notably, when comparing whether prior exposure to someone with a disability influenced acceptance level, the authors found those who did not have previous exposure responded statistically significantly lower in acceptance level than those who had prior exposure to someone with a disability.
Demetriou (2020) explored the level of acceptance with typically developing children towards peers with disabilities using images. Children showed preference to have playmates with wheelchairs in three categories: activities requiring motor skills, activities not requiring motor skills, and invitation to birthday parties. The authors concluded that the children used charity and human-rights-based approaches to disability: empathy, morality, and functionality when deciding to play with a playmate in a wheelchair.
Although school and community-based programs for children with ASD exist, there is a notable absence of peer-reviewed literature specifically addressing programs that focus on exposure, education, and peer mentoring between neurotypical with neurodiverse students. Silton and Fogel (2012) found that providing all three conditions of learning through direct information, peer strategies, and promoting positive characteristics of children with autism, improved their willingness to participate in activities with children with autism (p=.003) as measured by the Shared Activities Questionnaire (SAQ). Although participants did not directly interact with children with autism, learning peer strategies was helpful in their willingness to interact with children with ASD.
Nikolaraisi et al. (2005) concluded that exposure to children with disabilities led to more acceptance between typically developing children and children with disabilities (F=8.824, p<0.01). Cameron et al. (2006) found a statistically significant difference (p<0.001) in improving non-disabled children’s attitude towards children with disabilities after exposure to having stories of friendship between disabled and non-disabled children read to them. Hurst et al. (2012), Demetriou (2020), and Silton & Fogel (2012) focused on physical disabilities and the use of hypothetical scenarios and found positive outcomes in typically developing children’s acceptance of children with disabilities.
Play as a Foundation for Interaction
Play is defined by American Occupational Therapy Association (2020) as “activities that are intrinsically motivated, internally controlled, and freely chosen and that may include suspension of reality”. Play is a foundational occupational activity of children and can impact peer acceptance toward children with ASD.(Lory et al., 2017) It is a common language for typically developing children and children with autism. Using play was found to be a beneficial method to deliver the intervention (Kent et al., 2021). The authors completed a randomized controlled trial of a 10-week play-based intervention. They found a statistical significance (p=.016) difference of improved interaction skills of children with ASD when peer modeling with their typically developing peers. Using play may be an effective modality to spark changes in the level of acceptance by typically developing children towards children with ASD.
The Integrated Play Group Model
Children with ASD experience challenges with peer-play interactions (Wolfberg et al., 2012). The Integrated Play Group (IPG) model developed by Wolberg et al (2012) provides evidence-based methods to develop play relationships between neurodiverse children (novice players) and neurotypical children (expert players). The model focuses on four intertwining strategies to support interaction between novice and expert players: Nurturing play initiations, Scaffolding play, Guiding social communication, and Guiding play within a just right challenge. Briet et al. (2023) found that using the IPG model for peer-mediated intervention improved variability in social skills and imitation of play skills with children with neurodiverse children. Using the IPG model, the pilot Building Respect for Autism Inclusiveness Now (B.R.A.I.N.) program aimed to create a diversity and inclusion curriculum for the neurotypical fifth grade students on building a supportive community for children with ASD using play as the model.
Through literature review, a gap in research was found on developing a program for inclusive interactions between neurotypical students and children with autism, moving away from hypothetical scenarios, and providing hands-on mentoring support with children with ASD. The B.R.A.I.N.program attempts to expand on the knowledge of previous research by improving typically developing children’s acceptance and inclusivity for children with ASD. The program focuses on play through coursework and mentoring, facilitating direct interaction of children with autism in a preschool classroom. The aim of the pilot program was to determine if 5th-grade students who undergo an inclusivity program based on play with direct mentorship would be an effective means for improving peer attitudes and perception towards playing with children with ASD.
Methods
Design
The pilot study was a Pre-Experimental Design (One-Group Pretest-Posttest). The participants were recruited through convenience sampling with a small sample size.
Recruitment
Participants were recruited through the local elementary school’s fifth-grade ambassador program, where they served as role models and leaders during school events. While applying to be leaders through this established ambassador program, fifth-grade students also applied for the BRAIN program. In the application for the BRAIN program, students wrote a short explanation of why they wanted to be part of the program. The responses were reviewed by the principal and the investigator. The investigator then received the final list of student applicants from the principal.
Participants
The pilot study was approved by Rocky Mountain University of Health Professions in Provo, Utah Institutional Review Board. The site authorization was received from a local elementary school to participate in the program. Informed consent was obtained with parent permission for the twelve neurotypical fifth-grade students (eight females, four males). One participant identified as being Indian, eight participants identified themselves as being Asian, and three participants identified themselves as Caucasian. All twelve students attended the same local elementary school but attended three different 5th-grade classes.
Outcome Measures
The Shared Activity Questionnaire (SAQ) is a tool to assess individuals’ behavioral intentions or willingness to participate in certain activities with the target child. The questionnaire includes 24 items, appropriate for use among students who can read at the second to third grade level, addressing three domains: General Social, Academic, and Active Recreational (Campbell, 2008; Vignes et al., 2008). The SAQ demonstrate strong construct validity, with a comparative fit index of .95 and high internal consistency reliability with a coefficient alpha of .95 for the SAQ-A Total Score (Morgan et al., 2000). The children completed the SAQ, which consisted of statements about activities they would participate in with another person. They indicated their willingness to engage in each activity by selecting a number on a scale from one to three. The tool is designed for children aged between 8-12 and is intended to be filled out independently rather than by a parent.
The Adjective Checklist (ACL) measures cognitive attitudes used to examine elementary school children’s attitudes toward children with special needs. The checklist comprises 32 adjectives: half feature positive characteristics, and half feature negative characteristics. The ACL presents with good reliability with alpha coefficients average of .76 for males and .75 for females (Gough & Heilbrun, 1983). The participant will circle the adjective that reflects the target child. Scores above 20 indicate a more positive view of children with special needs, and a score below 20 indicates a negative view of the target children (Vignes et al., 2008). Children between 8-12 years of age can fill out the form independently rather than with a parent.
Implementation
The program was implemented adhering to the curriculum, lesson plans, and PowerPoint presentations. The pilot study ran for seven weeks, two days after school for one hour each.
Lessons included videos, book reading, story-based discussions, development of leadership skills through education to their peers, and ultimately, applying the skills in a special education class. Throughout the seven-week course, the participants listened to stories through literature and watched animation through carefully selected videos to build acceptance of children with autism. The courses were followed up with activities and discussions focusing on inclusivity, diversity, belonging, and acceptance. In addition, participants learned to communicate and build play activity plans to structure their play sessions. The participants were asked to play with their little buddies (preschool children with autism) at least four times during the seven weeks while being mentored and guided by the investigator, the teacher, and the teacher assistants. The fifth-grade students completed the SAQ and ACL before and after the completion of the seven-week program to determine differences in acceptance levels towards children with autism.
Statistical Methods
The data were analyzed through descriptive and inferential statistics. A paired t-test was conducted for all comparisons to determine significant differences between the pre- and post-test responses. The addition of the Wilcoxon signed rank test was conducted for the ACL unfavorable adjective responses (unfav) due to results of the paired t-test results indicating a lack of homogeneity of variance. Alpha was set at 0.05 (Portney, 2020). The two-tailed Wilcoxon signed rank test is a non-parametric alternative to the paired samples t-test when the condition of nonnormal populations is met (Zimmerman, 1996).
Results
Pre- and post-SAQ assessments were completed by all twelve participants. The analysis sought to determine the extent and direction of participants’ attitudes towards children with autism. SAQ group means for total, general social, academic, and active recreational scores were compiled. The scale interpretation was from one to five, with a higher score indicating greater acceptance. Table 1 provides a summary of the group mean change for total scores and its subscales. There was a decrease in mean change with acceptance towards participating in academic activities with children with autism decreased by -1.34 (M = 31.17 & 29.83). The mean change towards acceptance in recreational activities improved by 2.16 (M = 26.92 & 29.08). A two-tailed paired sample t-test was conducted for comparison of all the subscales pre and posttest. However, no statistical significance was found between the subscales pre and posttest.
Pre- and post-ACL assessments were completed for all 12 participants. This assessment sought to determine the participants’ perception of qualities related to children with autism. ACL group means for favorable (fav) and unfavorable (unfav) adjectives were compiled. As in Table 2, the participants chose more favorable qualities with a mean difference of 6.17 (M = 37.5 & 43.67) after completing the inclusivity program. In addition, participants chose less unfavorable adjectives with a mean difference of -4.2 (M = 57.67 & 53.50) after completing the inclusivity program. The two-tailed Wilcoxon signed rank test was used due to a lack of homogeneity in the Pre-Post Unfav scores and demonstrated a significant decrease in participants choosing unfavorable characteristics post-intervention (p = .048).
Conclusions
The pilot study aimed to explore whether neurotypical fifth grade students who underwent a seven-week program focused on education on acceptance and inclusivity and mentorship through play would be more accepting of children with ASD. The participants indicated increased acceptance towards participating in activities with children with autism with increased SAQ raw scores. In addition, participants chose more favorable qualities in children with autism after they participated in the inclusivity program. Statistical significance (p=.048) was found with participants choosing less negative or unfavorable qualities towards children with autism after they participated in the inclusivity program. Therefore, fifth grade neurotypical students who participated in this seven-week pilot study were more accepting of children with ASD by attributing less negative qualities towards children with ASD. This pilot study supports previous research using exposure (Hurst et al., 2012), education through books (Nikolaraizi et al., 2005) and videos (Silton & Fogel, 2012), and direct peer mentoring ((Kent et al., 2021) to enhance acceptance of children with ASD. Implementing a multifaceted program during this pilot study extends our understanding of the importance of offering various learning techniques to improve social acceptance of children with ASD.
According to the National Center for Education Statistics, 95% of school-aged students served under IDEA in fall 2022 were enrolled in regular schools. Twenty to twenty-five percent of occupational therapy practitioners (OTP) work in the school setting (Franco, 2023). School-based OTP have an opportunity to develop programs that support children at a Tier II level by educating peers to support children with ASD through a multifaceted learning environment. Equipping neurotypical children with these skills may enable OTPs to implement broader changes within the classroom.
Some limitations were noted when considering the interpretation of the results. The small sample size limits the generalizability of the findings to the broader population. Additionally, we relied solely on self-report measure to assess intervention outcomes. A performance-based or observational measure would enhance the objectivity of findings. These limitations suggest that further research with larger, more diverse samples and objective measures is needed to confirm the findings.
The preliminary findings from the pilot study suggest the potential for expanding programs that promote acceptance among individuals. Establishing a foundational community of acceptance can lead to branching effects, influencing interactions that changes mindsets towards acceptance and inclusivity of neurodiverse individuals with ASD. Despite the limitations, the pilot study highlights the importance of reducing stigma surrounding ASD and improved peer support among school-aged children. In addition, the pilot study provides support for evidence-based practices to develop programs in other school districts that target peer mentoring relationships between neurotypical and neurodiverse students at the elementary school level. The widespread impact includes the development of socio-emotional skills in neurodiverse students and increased acceptance of children with ASD among neurotypical students.