Nora Griffin-Shirley, PhD, COMS Devender Banda, PhD, BCBA-D Phoebe Okungu, MA

1. Teaching Orientation and Mobility Skills for Students with Autism and Visual Impairments in Public Schools Nora Griffin-Shirley, PhD, COMS Devender Banda, PhD, BCBA-D Phoebe Okungu, MA Texas Tech University International AER Conference 2014, San Antonio

2. Background • Children with autism and visual impairment represent a population of students with unique and varied educational needs. • The rising numbers of children with autism spectrum disorders (ASD) have received national attention and the Center for Disease Control and Prevention (CDC, 2014) estimates 1 in 68 children in the United States are identified with ASD.

3. Characteristics Associated with Autism • Deficits in communication, language, & social interactions. Behavioral excesses. • More recently associations with motor coordination have been made (Nayate, Bradshaw, & Rinehart, 2005). • Evidence suggests that cerebral dysfunction associated with ADS may cause difficulty with visual feedback during motor learning tasks (Johnson, Rinehart, White, Millist, & Fielding, 2013).

4. Literature Review • According to Carvill (2001) as early as 1958, Keeler looked at childhood schizophernia and found that 5 children who were blind had similar characteristics of those with infantile autism. • The severity of sensory impairments and the time of onset make it difficult to determine the exact number of individuals with ASD and sensory impairments (Mukaddes, Kilincaslan, Kuckyazici, Sevketoglu, and Tuncer, 2007) . • Lund and Troha (2008) mention that the prevalence of autism is higher in individuals with impairments (11.6%) and the risk of autism increases with the severity of visual impairment.

5. Literature Review… • More recently, Absoud, Parr, Salt, and Dale (2011) confirmed that young children with congenital severe visual impairment were at risk of early social communication difficulties by school age, and reported that 11 to 40% met criteria for autism. • Iketa, Davitt, Ultmann, Maxim, and Cruz (2013) examined 407 children diagnosed with autism and found that 40% participants with autism had ophthalmologic disorders.

6. Literature Review… • Professionals working with individuals, either with autism or sensory impairments, are often ill equipped to serve students with dual diagnosis because these children have unique needs due to their comorbid conditions (Gense & Gense, 2005). • With the existence of disabilities, more attention needs to be focused concerning research with this population (Goodman & Minnie, 1995; Parker, Davidson, & Banda, 2007)

7. Need for the Study A systematic data collection method is highly recommended to measure student progress, and outcomes, to monitor and evaluate educational plans, to determine the efficacy of O&M instruction, and to justify the need for O&M services to school administrators (Fazzi & Naimy, 2010; Jacobson, 2013; Pogrund, et al., 2012)

8. Need for the Study • Careful methodological design considerations are necessary in studies involving low-incidence disabilities. • According to the Council for Exceptional Children (CEC), single subject design has the benefit of sufficient methodological rigor to offer adequate evidence for guiding educational practice (Honer, et al., 2005; Kratchwill, et al., 2010).

9. Need for the Study • This design provides protection from many of the threats to internal validity and is especially effective (Odom et al., 2003) • This study involved a single subject, multiple-baseline design across participants to train students with autism and visual impairments to travel using their canes. (Bianco, 2013)

10. Purpose of the Study • To train two students with autism and visual impairment in orientation and mobility (O&M) to travel in school settings using their folding canes.

11. Method • The study included two participants who attended public schools in the Southwest of US. • The university Institutional Review (IRB) approved the study. • Parental consent was obtained prior to conducting the study.

12. Method-Participant 1 • Lana (pseudonym) • 12-year-old • Attends elementary school in a self-contained classroom and was included 50% of the time in a general education classroom • Exam in 2001 indicated congenitally blind, nysatgmus, probable Leber’s Congenital Amaurosis , and CVI • Limited use of vision; legally blind

13. Lana continued… • Meets criteria for autism • Severe receptive language impairment • Profound impairment in pragmatic/social language • Her assessment for intellectual functioning fell into the delayed range on all areas of the Developmental Profile-3 (DP-3) (Alpern, 2007). • Low range on the Vineland II Parent-Caregiver Rating Scale and The Teacher Rating Scale (Sparrow, Cicchetti, & Balla, 2005) • Standard score of less than 50 which falls into the delayed range of the Adaptive Behavior Scale (Lambert, Nihira, & Leland, 1993)

14. Lana continued… • Problem behaviors • Eye poking • Self stimulatory behavior (stamping feet, flapping hands) • Hugging • Running away

15. Lana-Target Behavior • The teacher and the O&M specialist indicated that Lana required training in independent travel with accompanying school personnel to and from her classroom to an outside gymnasium using her folding cane.

16. Method-Participant 2 • Andrew (pseudonym) • 19-year-old male • Non-verbal • Diagnosed with autism • Functionally blind due to self-inflicted injury to eyes • Attended self-contained classroom 100% of day • Lives at residential facility • Eye report includes retinal detachment, glaucoma, & hyphemia of the right eye; retinal detachment, & traumatic cataract in the left eye • Diagnosed with autism and intellectual disability by educational agency in 1996

17. Andrew continued… • Problem behaviors • Self-injurious behaviors (hitting temples with fist) • Screaming • Striking the floor with his cane • Masturbating • Spitting

18. Andrew-Target Behavior • Overall IEP Goals • Increase functional communication • Improve social skills • Reduce self-injurious behavior • Learn to use folding cane

19. Settings-Lana • Lana’s self-contained classroom • Special education teacher • A paraprofessional • 6 students with disabilities (varying functioning levels) • Gymnasium located 200 feet from school building • Lana must walk 80 feet to double doors leading outside then another 120 feet along a sidewalk to reach the gymnasium

20. Settings-Andrew • Andrew’s self-contained classroom • Special education teacher • 3 paraprofessionals • 3 students with severe ad multiple disabilities • The physical arrangement includes multiple rooms: a main classroom with a kitchenette and laundry facilities, a bathroom, a supply room, and an activity room (e.g., bed swing, table for crafts, sofa and chairs) • A 67 foot corridor outside Andrew’s classroom was the training environment

21. Dependent Variable • Time taken to complete route • All sessions were videotaped. For each trial time was recorded from the videotapes when the students took their first step and ended with their last step. • Each sessions included at least five trials, but on some occasions, less than five were conducted. • Time was calculated for each trial using an average time per session.

22. Method-Design • A multiple-baseline across participants was used to determine the functional relationship. • Baseline data collected for both participants began concurrently. • Intervention began with Lana following 3 baseline sessions. • While Lana received intervention, Andrew continued baseline, 3 additional baseline sessions followed by intervention. • Visual analysis was used to determine relationship between independent and dependent variables.

23. Procedure-Lana • Lana • The COMS, classroom teacher, and the paraprofessional selected the training route based on functional needs prior to O&M instruction. • For preference assessment, 5 toys (clapper, noise putty, play dough, pair of magnets, and a rubber bracelet) were used • She first received all the toys then they were withdrawn to begin the test.

24. Procedure - Lana • Test were conducted for 3 days, each day had 3 trails/sessions. • During tests toys were arranged on a table in front of student • She was asked to pick 1 and allowed to play with it for 2 minutes this procedure was repeated until all the toys had been picked • Lana chose the noisy putty as the most preferred followed by the magnets

25. Procedure-Andrew • Andrew • The classroom teacher decided the training route based on the student’s needs as he never received formal O&M training prior to this study. • 4 items were used (rattle, music, body lotion, and teddy bear) for preference assessment • The same procedure was used for Andrews as was used with Lana. • His preferred object was the rattle, followed by the lotion because it was the second preferred item.

26. Baseline • Established by allowing the student to navigate an O&M route as typically completed during daily routines with some verbal and physical assistance. • Lana • Able to traverse outdoor section of the route if she can hear people near the gym, but quickly became disoriented if she did not hear other people. • Received verbal and physical reinforcement (i.e.,hugs, tickles, playing with noise putty) after completion

27. Baseline • Andrew • Instructed to travel with human guide and was never introduced to the cane • Reinforcement included high-five and lotion

28. Intervention-Lana • Greeted by COMS inside her classroom • COMS indicated the purpose of the training • Lana retrieved her cane and appropriate clothing for outdoors • Lana & COMS exited classroom into the corridor at the starting point

29. Intervention - Lana • COMS instructed Lana to walk to gym 5 times by herself using her cane • COMS provided verbal prompts when needed • Reinforcement was given following the completion of the 5 repetitions of the route, then session terminated

30. Intervention -Andrew • COMS greeted Andrew inside classroom • Was instructed to get cane and lotion (when he did not comply COMS gave these items to him) • COMS guided Andrew to the starting point of the training route (at the end of his classroom hallway) • COMS instructed using verbal communication

31. Intervention - Andrew • COMS provided verbal prompts when needed (when he did not comply COMS offered physical assistance such as hand under hand) • Upon completion of route positive reinforcement was used • After completion of 5 trials, the session was terminated (on some occasions less than 5 trials were conducted if problem behaviors were exhibited)

32. Interobserver Agreement • A trained graduate student viewed the videotapes independently and scored 30% of the sessions for each participant for baseline and intervention sessions. • The interobserver agreement was calculated by finding the percentage of agreement between the two observers and the percent of agreement was 94% (range 88% to 99%) for both participants.

33. Procedural Integrity • A checklist of the intervention procedure was developed. A graduate student independently rated the item “yes” when that particular item was implemented correctly and “no” when not followed. • Procedural integrity was calculated using the number of steps completed by the total number of steps multiplied by 100. • The procedural integrity for Lana was 91% (range 86% to 100%) and for Andrew was 95% (range 86% to 100%).

34. Results

35. Description of Results • The previous figure displays the baseline and intervention graph for both students. On average, Lana travelled 152 sec during baseline while during intervention she took 120 sec. • Furthermore, the graph shows that the trend was highly varied at baseline and more stable (almost flat) towards the end of the intervention. • On average, Andrew travelled 64 sec during baseline while during intervention he took 42 sec. Furthermore, the graph shows that the trend was highly varied at baseline and more stable (almost flat) towards the end of the intervention. • Overall, the participants reduced their travel time from baseline to intervention.

36. Discussion • Results show that both participants took less time post intervention. • Anecdotal reports from the special education teachers indicated that the intervention was beneficial for the participants. (Strechay, 2013)

37. Discussion • The COMS reported that Lana was able to make choices about her reinforcers at the end of the intervention during several sessions. • Andrew’s teacher mentioned that he was walking with his folding cane under supervision and was more willing to express himself using his communication board and was happy while walking.

38. Discussion Plausible reasons for participants’ improvement may have been the use of: • Reinforcers through preference assessment • Systematic instruction including task analysis, modeling, prompting, reinforcement, fading • O&M instruction focusing on cane travel • Continuous monitoring through data collection However, robust results were not evident in this study because of the participants’ problem behaviors during O&M training

39. Recommedations • Replication of the current study as well as more intervention studies with children with autism and visual impairments using single-subject designs are recommended. The use of single-subject design is prevalent in special education (Horner et al., 2005) but not evident in the O&M field. • We need to move beyond anecdotal reports and case studies to document the efficacy of O&M instruction. This endeavor will provide a much needed foundation for evidence-based practices in O&M instruction due to the lack of experimental research in the field. (Daigle, 2008)

40. Recommendations • Prior to O&M interventions, preference assessments are necessary to determine reinforcers to enhance the impact of training. • The O&M specialists working with children with autism and visual impairments should collect data and make data-based decisions while providing O&M instruction.

41. Limitations • Data collection during baseline was not stable before we introduced the intervention to Lana. However, the intervention was necessary because of time constraints and teachers’ requests. • No strong functional relation between dependent and independent variables was established, but overall, participants took less time to travel during intervention session. • Finally, no data was collected on maintenance and generalization because of the end of the school year.

42. Conclusion • The results of the study should be considered preliminary • More research is needed to confirm or replicate the results. • In the field of O&M, interventions using the experimental designs are in its infancy, and the current study is an attempt to provide a basis for future researchers. (Gomez, 2013)

43. Contact Information Texas Tech University • Nora Griffin-Shirley – n.griffin-shirley@ttu.edu 806-834-0225 • Devender Banda – devender.banda@ttu.edu 806-834 4827 • Phoebe Okungu – phoebe.okungu@ttu.edu 806-834 0225

44. References Absoud, M., Parr, J.R., Salt, A., & Dale, N. (2011). Developing a schedule to identify social communication difficulties and autism spectrum disorder in young children with visual impairment. Developmental Medicine & Child Neurology, 53, 285-288. doi:10.1111/j.1469-8749.2010.03846.x Alpern, G.D. (2007). Developmental Profile 3 (DP-3). Los Angeles, CA: Western Psychological Services. Carvill, S. (2001). Sensory impairments, intellectual disability and psychiatry. Journal of Intellectual Disability Research, 45, 467-483. doi:10.1046/j.1365- 2788.2001.00366.x Centers for Disease Control and Prevention. (2012). Autism Spectrum Disorders — Data and Statistics. Retrived, from http://www.cdc.gov/ncbddd/autism/data.html

45. References Fazzi, D.L., & Naimy, B.J. (2010). Teaching orientation and mobility to school-age children. In W. R. Weiner, R. L. Welsh & B. B. Blasch (Eds.), Foundations of Orientation and Mobility (Vol. 2, pp. 208-262). New York: AFB Press. Gense, M.H., & Gense, D.J. (2005). Autism spectrum disoders and visual impairment: Meeting students' learning needs. NY: AFB Press. Goodman, R., & Minnie, C. (1995). Questionnaire screening for comorbid pervasive developmental disorders in congenitally blind children: A pilot study. Journal of Autism and Developmental Disorders, 25 Horner, R.H., Carr, E.G., Halle, J., McGee, G., Odom, S., & Wolery, M. (2005). The use of single-subject research to identify evidence-based practice in special education. Exceptional Children, 71, 165-179. Ikeda, J., Davitt, B.V., Ultmann, M., Maxim, R., & Cruz, O.A. (2013). Brief report: Incidence of ophthalmologic disorders in children with autism. Journal of Autism and Developmental Disorders, 43(6), 1447-1451.

46. Reference Jacobson, W.H. (2013). The art and science of teaching orientation and mobility to persons with visual impairments. New York: AFB Press. Johnson, B.P., Rinehart, N.J., White, O., Millist, L., & Fielding, J.(2013). Saccade adaptation in autism and Asperger’s disorder. Neuroscience, 243, 76- 87.doi:10.1016/j.neuroscience.2013.03.051 Kratochwill, T.R., Hitchcock, J., Horner, R.H., Levin, J.R., Odom, S.L., Rindskopf, D.M., & Shadish, W.R. (2010). Single- case designs technical documentation. What Works Clearinghouse Retrieved from http://ies.ed.gov/ncee/wwc/pdf/wwc_scd.pdf Lambert, N., Nihira, K., & Leland, H. (1993). AAMR Adaptive Behavior Scale - School (2nd ed.). Austin, TX: PRO-ED. Lund, S.K., & Troha, J.M. (2008). Teaching young people who are blind and have autism to make requests using a variation on the picture exchange communication system with tactile symbols: A preliminary investigation. Journal of Autism and Developmental Disorders, 38, 719-730. doi: 10.1007/s10803-007-0439-4

47. References Mukaddes, N.M., Kilincaslan, A., Kucukyazici, G., Sevketoglu, T., & Tuncer, S. (2007). Autism in Visually impaired individual. Psychiatry and Clinical Neurosciences, 61, 39-44. doi: 10.1111/j.1440-1819.2007.01608 Nayate, A., Bradshaw, J.L., & Rinehart, N.J. (2005). Autism and Asperger's disorder: Are they movement disorders involving the cerebellum and/or basal ganglia? Brain Research Bulletin, 67(4), 327-334. doi: 10.1016/j.brainresbull.2005.07.011 Odom, S.L., Brown, W.H., Frey, T., Karasu, N., Smith-Canter, L.L., & Strain, P.S. (2003). Evidence-based practices for young children with autism: Contributions for single- subject design research. Focus on Autism & Other Developmental Disabilities, 18(3), 166-175. Parker, A.T., Davidson, R., & Banda, D.R. (2007). Emerging evidence from single-subject research in the field of deaf- blindness. Journal of Visual Impairment & Blindness, 101(11), 690-700.

48. References Pogrund, R., Sewell, D., Anderson, H., Calaci, L., Cowart, M.F., Gonzalez, C.M., . . . Roberson-Smith, B. (2012). TAPS-Teaching age-appropriate purposeful skills: An orientation and mobility curriculum for students with visual impairments (3rd ed.). Austin: Texas School for the Blind and Visually Impaired. Sparrow, S., Cicchetti, D., & Balla, D. (2005). Vineland-II: Vineland adaptive behavior scales: Survey forms manual(2nd ed.). Circle Pines, MN: American Guidance Services.

49. Reference-Images Collected from Google Image Bianco, B., (2013). White Walking Stick Project in Senegal and Togo. retrieved from www.amoaonlus.org Daigle, C., (2008). logic defying sighting. retrieved from www.cathrine.daigle.com/ Gomez, K., (2013). Multi-sensor navigation gadget for people who are blind. retrieved from www.electronicsnews.com.au/news/ Strechay, J., (2013). This White Cane Day, Slim and I are Ready to Strut our Stuff. retrieved from www.afb.org