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Alternative Seating for Young Children with Autism Spectrum Disorder: Effects on Classroom Behavior

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A single subject, withdrawal design was used to investigate the effects of therapy balls as seating on engagement and in-seat behavior of young children with Autism Spectrum Disorder (ASD). In addition, social validity was assessed to evaluate teachers' opinions regarding the intervention. During baseline and withdrawal (A phases) participants used their typical classroom seating device (chair, bench or carpet square). During the intervention (B phases) participants sat on therapy balls. Results indicated substantial improvements in engagement and in-seat behavior when participants were seated on therapy balls. Social validity findings indicated that the teachers' preferred the therapy balls. This study suggests therapy balls as classroom seating may facilitate engagement and in-seat behavior and create opportunities to provide effective instruction.
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Alternative Seating for Young Children with Autism Spectrum
Disorder: Effects on Classroom Behavior
Denise Lynn Schilling
1,2
and Ilene S. Schwartz
1
A single subject, withdrawal design was used to investigate the effects of therapy balls as
seating on engagement and in-seat behavior of young children with Autism Spectrum Dis-
order (ASD). In addition, social validity was assessed to evaluate teachers’ opinions regard-
ing the intervention. During baseline and withdrawal (A phases) participants used their
typical classroom seating device (chair, bench or carpet square). During the intervention (B
phases) participants sat on therapy balls. Results indicated substantial improvements in
engagement and in-seat behavior when participants were seated on therapy balls. Social
validity findings indicated that the teachers’ preferred the therapy balls. This study suggests
therapy balls as classroom seating may facilitate engagement and in-seat behavior and cre-
ate opportunities to provide effective instruction.
KEY WORDS: Autism; sensory strategies; school based interventions; classroom behavior; dynamic
seating; early childhood.
INTRODUCTION
Autism Spectrum Disorder (ASD) once consid-
ered a rare disorder is now one of the most prevalent
developmental disorders among children (Rogers,
1998). ASD occurs at a higher rate than Down syn-
drome, diabetes, and childhood cancer (Huebner,
2001). The Center for Disease Control reports the
prevalence of ASD 1 per 250 children (Bertrand
et al., 2001) and many epidemiologists consider this
to be a conservative estimate. This current increasing
rate of ASD, coupled with the intensity of interven-
tion required by children with ASD presents a
daunting challenge to public education. Although
children with ASD exhibit a wide variety of behav-
iors and developmental levels, difficulty with engage-
ment, attention, and appropriate behavior in the
classroom are common and interfere with students
ability to participate in the educational mainstream.
Most interventions conducted in classrooms to
increase engagement, attention and appropriate
behavior of children with ASD have been based on
traditional models of classroom management.
Although functional behavior assessments (FBAs)
are part of the law and are common practice, most
behavior intervention plans reflect ‘‘obtain’’ or
‘‘avoid’’ as the function of the behavior and often
ignore the sensory issues that may underlie the
behavior. Sensory needs as a possible motivator of
behavior may be ignored or not addressed due to
lack of knowledge in assessment and intervention
strategies. One reason that children with ASD may
have limited success with some intervention strate-
gies is that they do not address the sensory issues
that may underlie the behavior that is perceived to
be disruptive (Ayres, 1972; Dunn, 2000). In taking a
sensory processing approach to modifying the
behaviors associated with ASD, educators want to
provide children with an opportunity to modulate
sensory input, while maintaining the level of appro-
priate behavior required at school. Alth ough these
sensory-based treatments do not have an empirical
1
University of Washington, Seattle, WA.
2
Correspondence should be addressed to: Denise L. Schilling,
PhD, PT, Silverman Hall, 750 East Adams Street, Syracuse,
NY 13210; e-mail: PT@upstate.edu
Journal of Autism and Developmental Disorders, Vol. 34, No. 4, August 2004 (Ó 2004)
423
0162-3257/04/0800-0423/0 Ó 2004 Plenum Publishing Corporation
base of support in classroom use (Dawson &
Watling, 2000; National Research Council, 2001;
Watling, Deitz, Kanny, & McLaughlin, 1999), they
enjoy widespread popularity among field-based cli-
nicians and parents (Watling et al., 1999).
Sensory process ing theory comes primarily
from the disciplines of occupational and physical
therapy and relates to ‘‘the brain’s ha ndling of sen-
sory information for the purpose of enabling a per-
son’s engageme nt in occupations’’ (Johnson-Ecker
& Parham, 2000, pp 494–495). The primary occupa-
tion, that is the normal daily activities of children,
is that of student. School and related activities such
as engagement to task, listening, and playing with
peers are examples of the primary occupations of
children. Sensory processing theory suggests that
typically developing individuals have the ability to
modulate sensory input as necessary to adapt to
and be successful in constantly changing environ-
ments. Research has found that children with ASD
respond differently to sensory stimuli than their typ-
ically developing peers (Baranek, 1998; Dunn, 2001;
Elliot, 1990; Kientz & Dunn, 1997; Watling, Deitz,
& White, 2001). Greenspan and Wieder (1997) in an
extensive chart review of 200 children with ASD,
found 95% exhibited sensory modulation difficul-
ties. These children often engage in perseveration or
stereotyped movements in an attempt regulate their
sensory systems (Baranek, Foster, & Berkson, 1997;
Lovaas, Newson, & Hickman, 1987; Quill, 2000). In
addition, sensory processing deficits in children with
ASD also appear to be associated with deficits in
their ability to attend, engage in play and sustain
interaction (Greenspan & Wieder, 1997a; Koomar
& Bundy; 1991; Wieder, 1996; Williamson & Anz-
alone, 1997). Furthermore, Greenspan and Wieder
(1997b) suggested that deficits in sensory processing
might be a causative factor for social disengagement
and off-task behavior. Therefore, a priority for chil-
dren with ASD and others with sensory processing
problems is to provide them successful strategies for
self-modulating sensory inp ut.
Sensory modulation strategies can provide the
central nervous system with the type of sensory
stimuli that bodies require to attain and maintain
an optimal state of arousal for learning (Huebner,
2001; Kimball, 1999; Mulligan, 2001; Trott M.,
Laurel, M., & Windeck, S., 1993; Williams & Shel-
lenberger, 1994). Arousal implies a continuum of
alertness from low arousal associated with mental
lethargy and drowsiness; to high arousal associated
with hyperactivity and distractibility (Huebner,
2001). Consequently, mo dulation of arousal is criti-
cal for optimal engagement, attention and learning
(Royeen & Lane, 1991; Williams & Shellenberger,
1996). A therapy ball for seating is one strategy that
may provide a child with ASD an opportunity to
attain and maintain an optimal state of arousal.
Therapy balls, because they are a type of
dynamic seating, may provide children with ASD
an opportunity to both actively move and maintain
an optimal arousal level while maintaining a
healthy, safe, and productive posture. Studies on
classroom seating suggest that sustained sitting in
regular classroom chairs is unhealthy for children’s
bodies, particularly their backs (Il li, 1994; Lear &
Pomeroy, 1994; Schroder, 1997; Witt & Talbot,
1998). European researchers investigating the ergo-
nomics of classroom furniture have found that
when children are in inflexible seating they often
assume extreme postures in their attempts to move
(Schroder, 1997). European schools have been using
therapy balls and other types of dynamic seating
devices in the classroom as chairs to improve back
health since at least 1988 (Illi, 1994). Currently, a
private school in Florida is making the transition to
therapy balls in place of chairs while conducting
longitudinal studies on the back health of their stu-
dents (Witt & Talbot, 1998).
Although all these studies using balls as chairs
have focused on posture and back health, most
include anecdotal reports of improvement in atten-
tion, maintained sitting, and school performance. In
Switzerland where therapy balls originated, they
have a program called ‘‘Moving students are better
learners’’. The program name is based on the phi-
losophy that students sitting on therapy balls are
less bored and better able to focus on classroom
activities. Swiss teachers report that when students
are seated on therapy balls ‘‘there is a decrease in
noise, hyper kids can jiggle without moving furni-
ture, and the class is generally calmer’’ (McBride,
1993, p 1A). Currently therapy balls are being used
as the primary seati ng in over 5,000 classrooms in
Switzerland (Spaudling, Kelly, Santopietro, & Pos-
ner-Mayer, 1999). In addition, Witt and Talbot
(1998) reported that children in a private Florida
school who began sitting on therapy balls demon-
strated overall improvements in work habits, partic-
ularly in attention and classroom behavior.
Likewise, Schilling and her colleagues demonstrated
improvements of both in-seat behavior and work
production of fourth graders with ADHD when
seated on therapy balls vs. chairs (Schilling, Wash-
424 Schilling and Schwartz
ington, Billingsley, & Deitz, 2003). In addition, the
teacher stated that she believed that the students
were much more productive when using the balls
and thought their test scores would be impacted in
a positive manner. These extremely positive findings
were pleasantly surprising to the research team, but
they also set the occasion for further investigation.
The purpose of this study was to extend the
findings by Schilling et al. (2003) by examining the
use of therapy balls for seating as an inter vention
for children with a diagnosis of ASD. Three specific
research questions were addressed. First, what effect
does using therapy balls as chairs have in-seat
behavior? Second, what are the effects of sitting on
therapy balls on engagement? Third, what were
teachers’ perceptions of the use of therapy balls for
classroom seating?
METHOD
Participants
All participants in this study were preschool
children with ASD who attended a public- school
funded preschool program located on a University
campus. All children participated in an integrated
preschool classroom for 12 hours a week and a spe-
cialized program for children with ASD 8 hours a
week. The participants, four males (three Caucasian
and one Asian) ranged in age from 3 years
11 months to 4 years 2 months. Each had a physi-
cian’s diagnosis of Autism Spectrum Disorder.
These children were selected to participate in this
study based on teacher reports that indicated diffi-
culty with in-seat behavior and maintained engage-
ment to task. Specific concerns regarding in-seat
behavior varied for each participant, thus the set-
ting and tasks wer e matched to the needs of the
individual students.
Ryan (all names are pseudonyms) age 4 years
2 months enjoyed decoding text and numbers. He
had an extensive vocabulary, would initiate conver-
sation with familiar adults and could accurately
respond to ‘‘how’’ and ‘‘why’’ questions pertaining
to social situations and emotional states. He dis-
played a sense of humor, and although he did not
initiate to peers, he would respond to their over-
tures. Ryan displayed difficulty remaining seated in
the classroom chair and would generally stand dur-
ing tabletop activities. While standing he would
often assume unhealthy postures, such as balancing
on one foot, standing on the tips of his toes, or
lying on the table with his feet dangling. In addi-
tion, while in these inappropriate positions he was
not able to attend to task or peers.
Sam, age 3 years 11 months, enjoyed imaginary
play with small cars or small animal figures. Cogni-
tively he displayed age-appropriate skills, however,
he demonstrated moderate delays in social and com-
munication skills. Sam required adult prompting to
facilitate peer interactions. He displayed generalized
low tone as demonstrated by poor lip closure,
drooling, and an overall flexed posturing. As a
result, his teachers had him sit on a bench without
a backrest in an attempt to facilitate upright sitting
posture. When using the bench, Sam would rarely
sit and instead would either stand or kneel on the
bench.
Luke, age 4 years 2 months enjoyed participat-
ing in movement activities such as chasing other
children, using the swing, and bouncing on the
small trampoline. Luke had mild cognitive delays
and could engage in conversation with adults if
motivated. However, oppositional behavior to rou-
tine and requests was a major concern for him.
Luke required visual supports to structure his day
and understand what was expected in a task. In
addition, adult supervision with high levels of
prompting was required during small group table
activities. Unlike the other study participants who
were frequently out-of -seat, Luke remained in seat
(buttocks in contact with the chair) but would lean
forward placing his upper body and head under the
table. Furtherm ore, if staff were not directly
engaged with Luke (working with another child)
during small group table time, he would frequently
leave the area. Luke had a specialized program to
address oppositional behavior. When he did not fol-
low a repeated request, he was given a verbal warn-
ing followed by a ‘‘3-count’’. If the oppositional
behavior continued, a contingent effort task (i.e.,
placing plastic bottle caps in a basket) was imple-
mented.
David age 3 years 11 months enjoyed music,
movement activities and numbers. He pr eferred to
play alone and required adult facilitation for peer
interactions, such as turn taking or requesting toys.
Although David had limited verbal skills and used
visual supports for communication he could iden-
tify, count and recite numbers up to 25. David dem-
onstrated the greatest difficulty with in-seat
behavior and engagement when seated on the floor
during circle time in the classroom. David required
425Alternative Seating for ASD
a staff member seated nearby or he would roll on
the floor, face outside the circle away from the
teaching activity, or roam about the room.
Setting
The intervention was implemented at school in
settings individualized for each participant. School
settings included an integrated preschool classroom
(nine children with a diagnosis of developmental
delay and six children with a diagnosis of ASD) and
an extended day program serving only children with
a diagnosis of autism spectrum disorder. The teacher
to student ratio in the integrated preschool was 1–4
and the teacher to student ratio in the extended day
program 1–2. Data on two of the participants were
collected during participation in the extended day
program while data for the other two participants
was conducted in their integrated preschool class .
Intervention for Ryan was implemented in the
extended day program during art activities. This art
session occurred at the same time every day, imme-
diately following his recess. However, the length of
time required to complete each art activity varied
daily. Therefore, data collection sessions ranged
from a minimum of 5 minutes to a maximum of
10 minutes per session.
For Sam, intervention was implemented in the
extended day program during reciprocal play activi-
ties that occurred while seated at a table with one
other child and the teacher. This table time for Sam
was immediately before his recess. Although the
type of activities varied daily, all of Sam’s data col-
lection sessions were consistently 10 minutes in
length.
Luke’s intervention occurred during small
group table time in his integrated preschool class
(seven peers and two adults) that occurred immedi-
ately following his lunch. Activities at this time were
generally art, however, one day a week was cook-
ing, that involved turn taking wi th pouring and stir-
ring. The group activities varied daily, however, all
data collection sessions were 10 minutes in length.
David’s intervention was implemented during
circle time in the classroom, the final activity in his
school day. During circle the entire class including
teaching staff sat on the floor, the children on car-
pet squares. Circle activities included listening to
the teacher reading a picture book and/or music
activities. Circle time varied in length and therefore
the data collection sessions ranged from a minimum
of 5 minutes to maximum of 10 minutes.
Design
This study used a single subject withdrawal
design (Kazdin, 1982) within the natural classroom
setting across four students with a diagnosis of
ASD. The intervention was delivered in an A-B-A-
B design for three participants and a B-A-B for 1.
The B-A-B design was us ed to demonstrate the
effectiveness of this intervention without an initial
baseline, a situation more similar to how a class-
room teacher might implement the intervention
(Cooper, Heron, & Heward, 1987).
Procedures
Pre-baseline Activities
After parental consents were obtained, each
participant was individually fitted for a therapy ball.
Therapy balls were individually fitted to a diameter
that assured each child could sit comfortably with
his feet flat on the floor with knees and hips flexed
at 90°. The therapy balls used in this study had
molded feet (Sit ‘n’ Gym ä by Gymnic) that
extended when the ball was not in use to prevent
rolling away.
Next, the time of the day and the activity in
which each of the participants would use the ball
for seating were determined via teacher interview.
Each participant’s teacher was asked to identify the
activity and time of day that seemed to be most dif-
ficult for the child in the areas of in-seat behavior
and engagement. Since participants’ schedules and
curriculum were not altered, the duration of the
activity varied in length of time. In addition, all
staff within each participant’s classroom were
instructed to give no prompts on sitting behavior
throughout the duration of the study. Staff interven-
tion would occur, however, if a student exhibited a
behavior that would be potentially harmful to the
child, his peers, or teacher (e.g., throwing materials,
aggression). Otherwise, the teachers’ classroom
management style, expectations, and activities were
not altered.
Baseline and Withdrawal Phases
During baseline and withdrawal phases (A)
classroom activities, teacher behaviors, and seating
devices were not altered. Each child was observed
at the same time daily and data were collected on
seating behavior and engagement. Once baselines
for both variables were stable, the participant’s
426 Schilling and Schwartz
commonly used seating device (chair, bench, or car-
pet square on the floor) was removed and the inter-
vention initiated.
Intervention Phases
All intervention phases were implemented for a
minimum of two school weeks. During the interven-
tion phases (B), each participant continued to be
observed at the same time daily and data continued
to be collected on seating behavior and engagement.
The only change during this phase was the imple-
mentation of the therapy balls for classroom seat-
ing. No specialized training was provided to the
students or teachers. Teachers were instructed to
prompt children to sit on their balls only if behavior
was deemed dangerous or destructive. No changes
in schedules or activities were made to accommo-
date the intervention.
Data Collection
Data were collected on two variables: sitting
and engagement. Data on these behaviors were
collected using momentary real time sampling
(Richards, Taylor, Ramasamy, & Richards, 1999).
In-seat behavior as either in-seat or out-of-seat
and engaged or nonengaged. In-seat behavior for
chair and bench were defined as any portion of
the participants’ buttocks in contact with the seat
portion of the chair (Sugai & Rowe, 1984) and the
four legs of the chair in contact with the floor.
For the one participant sitting on the floor for cir-
cle in-seat behavior was defined as the child being
in an upright position with any portion of his but-
tocks in contact with the floor. On-ball behavior
included any portio n of the participants’ buttocks
in contact wi th the ball, the ball in contact with
the floor, and a minimum of one foot in contact
with the floor.
Engagement was defined as when the student
was oriented towards the appropriate classroom
activity such as instructional materials, activity, or
teacher and either interacting with the materials,
responding to the speaker, or looking at the
speaker. In group activities, engagement also
included orientation and responding to peers in the
activity. Nonengagement was defined as when the
student was not oriented toward the appropriate
classroom activity, such as instructional materials,
activity, or teacher. For example, staring at persons
or objects not related to instruction.
For Luke, one additional variable, frequency
of oppositional behavior was measured. Opposi-
tional behavior was defined as refusal to follow a
routine teacher request that resulted in the staff to
employing Luke’s individualized consequence. The
consequence for oppositional behavior was a warn-
ing, a teacher counting out loud to three, and then
the implementation of a mild aversive procedure,
contingent effort (e.g., placing plastic bottle caps
into a basket.). Data on this variable were col-
lected using a frequency count across the entire
session.
All other data were collected using momentary
real time sampling in which the recorders wore
wireless headsets to hear a pre-programmed 10 min-
ute tape that announced ‘‘record’’ and the interval
every 10 seconds. Wireless headsets allowed the
recorders freedom of movement for observing and
for recording signals to be heard at the exact same
moment by two data collectors. Session times varied
since data were collected in the natural environment
without curriculum changes and the length of time
teachers remained at tasks varied. As a result data
collection sessions ranged from a minimum of
5 minutes to a maximum of 10 minutes. Three data
collection sessions were scheduled each week, how-
ever student absences or changes in the school sche-
dule (e.g., holidays, field trips) resulted in variability
in the number of sessions (data points) that
occurred in a week. During the intervention phases,
the staff implemented the intervention even though
no data were being collected.
Reliability
Inter-observer agreement was examined a mini-
mum of once per phase for each of the participants.
Inter-rater agreement for in-seat behavior ranged
from 95% to 100% (
X = 98%) and for engagement
ranged from 82% to 100% (
X = 90%), as calcu-
lated by point-by-point agreement.
Social Validity
Social validity was determined via a staff ques-
tionnaire that was completed at the conclusion of
the study. For each participant their classroom tea-
cher and the teaching assistant completed the brief
questionnaire regarding the typical classroom seat-
ing device (chair, bench, or carpet square) vs. the
ball. A total of eight questionnaires were com-
pleted.
427Alternative Seating for ASD
RESULTS
In-seat Behavior
The results for the participants are shown in
Figs. 1–4. These results indicate that all participants
displayed marked improvement in classroom behav-
ior during the use of therapy balls for classroom
seating. For Sam, Ryan, and David the positive
changes in in-seat behavior were both immediate
and substantial. Likewise upon withdrawal of the
therapy balls and return to typical classroom seat-
ing participants displayed an immediate decline in
in-seat behavior returning to their respective base-
lines.
Luke presented differently from the other three
participants. Out-of-seat behavior was never a con-
cern for Luke, and is substantiated by his data.
Staff were extremely concerned, however, about his
extreme oppositional behavior. During the interven-
tion phases Luke demonstrated improvements by an
increase in his engagement and a decrease in oppo-
sitional behavior. Oppositional behavior was mea-
sured by the frequency of the administration of the
contingent effort task. These data are displayed at
the bottom of Fig. 4. During use of the ball for
seating (15 sessions) Luke demonstrated no occur-
rence of oppositional behavior that resulted in the
implementation of his specially designed behavior
plan. However, during use of the chair for seating
(withdrawal phase) Luke was oppositional and
required implementation of his behavior plan on
one or more times per session (in three of four ses-
sions). In addition, while on the ball during small
Sam
0
20
40
60
80
100
Bench Ball
Bench
Ball
Sessions
engaged
in-seat
Percentage of intervals
Fig. 1. Percent of intervals Sam was in-seat and engaged during reciprocal play activities.
Ryan
0
20
40
60
80
100
Sessions
engaged
in-seat
Chair Ball Chair Ball
Percentage of intervals
Fig. 2. Percent of intervals Ryan was in-seat and engaged during art activities.
428 Schilling and Schwartz
group he did not leave the table area even when not
engaged directly with the staff. Although Luke
remained seated when on the ball, he bounced con-
tinuously. The bouncing did not appear to interfer e
with engage ment and he would independently stop
bouncing to perform more complex tasks, such as
stirring or pouring during cooking.
Engagement
The second area assessed was engagement. As
noted in Figs. 1–4, engagement for all four partici-
pants increased substantially during therapy ball
phases. Although participants bounced or gently
rocked while seated on the ball, they all displayed
improvement in engagement. As reflected in the
data, the movement while seated on the therapy ball
did not interfere with the participants’ engagement
to task. Upon withdrawal of the therapy balls and
return to typical classroom seating, all parti cipants
demonstrated an immediate decline in engagement
and returned to their respective baseline levels.
Social Validity
Teachers and staff working with the partici-
pants were given a satisfaction survey questionnaire
at the completion of the study. All staff responses
strongly supported the use of balls for classroom
seating.
Staff working with David reported increased
independence and noted him self correcting,
David
0
20
40
60
80
100
engaged
in-seat
Ball
Carpet Square
on Floor
Carpet Square
on Floor
Ball
Percentage of intervals
Sessions
Fig. 3. Percent of intervals David was in-seat and engaged during circle time.
Luke
0
20
40
60
80
100
Ball
Chair
Ball
Number of applied
warnings followed by
contingent effort
engaged
in-seat
Sessions
0 0 0 0 0 0 0 0 0
0 2 1 2
0 0 0
0 0 0
Percentage of intervals
Fig. 4. Percent of intervals Luke was in-seat and engaged during small group table
activities and the number of applied warnings followed by a contingent effort task as
the result of oppositional behavior per session.
429Alternative Seating for ASD
demonstrated to staff when hearing David severa l
times tell himself ‘‘sit down’’ during the use of
the ball for seating. Additionally, David appeared
to demonstrate a preference for the ball as he
would immediately upon presentation of the ball,
take it and sit without request or prompting.
The staff working with Ryan had the greatest
range of responses. Although they supported the
use of the ball for seating they felt that Ryan
showed no difference in his restlessness, whether
seated on the ball or the chair. However, they
reported that Ryan completed tasks better when
seated on the ball, but that the bouncing was some-
times distracting.
Similarly, staff working with Sam supported
the use of therapy balls for seating but reported
that although ‘‘verbal thinking increased’’ at times
Sam would start a sentence over at each new
bounce. All staff working with Sam reported an
increase in his attending, completion of tasks, and
interaction with peers when seated on the ball. In
addition, staff noted strengthening of Sam’s trunk
and a decrease in his drooling.
Luke’s teacher commented that ‘‘student did
not escape by going under the table at all while on
the ball’’. One staff member reported that initially
she found it difficult to work with Luke on the ball
since he was continually bouncing, but was able to
adapt as she also found Luke to be more engaged
and socially responsive during nonpr eferred table
tasks.
Teachers and staff unanimously reported via
the questionnaire that they would like to have the
balls available for seating in their classroom, and
following completion of this study they continued
to use therapy balls for seating not only for the
study participants but other students in their class.
In addition, the parents of at least two of the par-
ticipants have also ordered balls for use at home.
DISCUSSION
Findings of this study indicated substantial
improvements in in-seat behavior and engagement
across all four participants when seated on therapy
balls. In addition, the teachers and students consis-
tently reported a preference for therapy balls vs.
other seating devices. This study also demonstrated
that the intervention was effective across partici-
pants with varied ability levels, across a variety of
classroom settings, and activities. It is impor tant to
note that not all students responded in the same
manner. Variations in movement on the ball
occurred both between students and within an indi-
vidual not only day to day but possibly within the
same session. Luke for example bounced vigorously
throughout the study when seated on the ball, stop-
ping and sitting still only during complex motor
tasks. Whereas, Ryan when seated on the therapy
ball, was either very still or gently rocking. How-
ever, regardless of the amount or type of movement
demonstrated by children when seate d on the ther-
apy balls, their engagement improved.
In addition to the pos itive outcomes docu-
mented by the observational data, teacher and par-
ents reported many positive behaviors. Sam’s school
therapist reported toward the completion of the
study that Sam’s trunk strength had increased and
his drooling had decreased. However, it should be
noted that when Sam initially used the ball for seat-
ing his drooling appeared to increase. Sam’s teacher
reported that when seated on the therapy ball, he
was more responsive. Also, at the completion of the
study Sam’s mom reported when he would see a
ball, he would immediately and independently get
the ball and sit on it.
Although not directly measured there were
repeated indicators that David preferred the ball to
sitting on the floor during circle. First, when
David’s ball moved off of the carpet square he
would get off the ball, adjust it and sit down inde-
pendently. This was periodically accompanied by
his saying ‘‘Sit’’. This verbal self-correction did not
occur when he was sitting on the floor. Second, on
more than one occasion when David saw the ball
he would immediately and without prompting get
the ball, take it to his sitting area, sit and remain
seated wai ting for the activity to begin. Third, when
using the ball David was able to sit independently
during circle time and did not need on-going adult
supervision. In addition he would raise his hand
without prompting and participate appropriately
with his peers in activities such as singing songs or
listening to a story.
Ryan would also adjust the ball without
prompting while working at the table. However,
when not engaged in the activity (e.g., task com-
pleted or waiting for materials/instruction) he would
often rock on the ball and appear to be exploring
and playing with his balance and the movement of
the ball. For Ryan, sitting on the therapy ball not
only increased his engagement but also, appeared to
increase the speed at which he responded to and
430 Schilling and Schwartz
completed tasks. The teacher woul d often expand
the task for Ryan when seated on the therapy ball,
whereas, when using the chair Ryan completed
fewer activities and required more prompting.
Luke, unlike the other participants, bounced
continuously while seated on the ball. Although
Luke bounced throughout each sessi on, and
appeared nonengaged, he appropriately participated
in the activities and accurately responded to peers
and staff. In addition, the staff noted that through-
out the duration of this study, when on the therapy
ball, Luke no longer required continuous adult
interaction and the need for prompting during non-
preferred activities decreased.
Although the results of this study provide one
of the first empirically validated uses of sensory-
based treatment for children with ASD in a class-
room setting, one must be cautious not to over-gen-
eralize the findings. The substantial improvements
in in-seat behavior and engagement support the
need for broad-based replication. Additionally, the
study raised the following questions.
The effect of this intervention overtime must be
investigated. Children in this study sat on the ther-
apy balls for a maximum of 10 minutes a day, for a
period of 3 weeks. What if children used therapy
balls for an extended period of time? Future
research might examine the effects of extending the
daily 10 minute session time to 30 minutes daily.
Similarly, future studies might examine the effects
of extending the use of the ball beyond 3 weeks to
an entire school year. Is there a possibility that par-
ticipants might acco mmodate and return to baseline
behaviors? Therefore, a next step would be to
extend the length of the intervention session and the
duration of the phases. In an extended study, one
might also examine children’s seating preferences by
offering children a choice of seating devices (typical
seating vs. a therapy ball). If given a choice would
children be consistent and would they choose to use
the ball for a portion of the day or the entire school
day?
In addition, a sample size of four was not
extensive enough to establish the generality of
effects observed in this investigation across a broad
range of children with ASD. Children with ASD are
complex and exhibit a wide variety of beh aviors,
developmental levels, and sensory needs. How do
we choose which children with ASD will most bene-
fit from the use of a therapy ball for classroom seat-
ing? To date, no single intervention has been
identified that is appropriate for all children with
ASD. The children included in this study were
selected by their teachers and all demonstrated diffi-
culty with appropriate classroom behaviors such as
engagement, attention and sitting behavior. Further
investigation is necessary to identify the criteria for
identifying which children with ASD this interven-
tion will be most effective.
This study indicated that the therapy balls were
an effective intervention for improving both in-seat
behavior and engagement for young ch ildren with
ASD, but did not address why they were effective.
Therapy balls for seating is a sensory-based inter-
vention that appeared to address some of the
sensory deficits of children with ASD. As sensory-
based strategies are based on theory, we can only
hypothesize as to why this intervention was effec-
tive. Therapy balls for seating appeared to provide
children with ASD an opportunity to move while
seated and therefore, attain and maintain an opti-
mal state of arousal for learning.
This intervention is an example of how the sen-
sory-processing theory embraced by many physical
and occupational therapists can be translated into
effective practi ce in a classroom context. This study
also demonstrated how the integration of basic the-
ories from two disciplines, specifically occupational
and physical therapy and education, can create an
effective behavioral support strategy that can be
easily implemented by classroom teachers.
In conclusion, it is important to note that this
study was conducted at a setting in which high
quality instructional strategies for children with
ASD were employed. Sitting on therapy balls does
not replace those, but may provide increased oppor-
tunities for teachi ng. We neither advocate sitting on
therapy balls as a replacement for highly structured
intervention using evidence-based practice, nor are
we suggesting that this intervention is appropriate
for all children with ASD. Therapy balls for seating
in the classroom are not teaching children with
ASD, but appear to have created opportunities for
high quality instruction to be effective for children
with ASD.
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432 Schilling and Schwartz
Reproducedwithpermissionofthecopyrightowner.Furtherreproductionprohibitedwithoutpermission.
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... The focus was on its effect on behavior and participation in the special education classroom. The majority of these studies were applied on attention deficit hyperactivity disorder [8,[12][13][14] and autism spectrum disorder [9,11]. Also, other studies were done on normal students to assess the effect of therapy ball seating on sitting discomforts, task behavior, and academic achievement [8,10,15]. ...
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Young children with severe communication and relationship disorders, often diagnosed with pervasive developmental disorders, respond to intensive intervention started at early ages. These disorders may be secondary to various sensory and motor processing deficits which can be conceptualized as Multisystem Developmental Disorder (MSDD). Diagnostic understanding of variations in multisystem disorders can now be linked to integrated treatment models that take into account the individual differences and developmental level of each child. Clinical vignettes describe different patterns typical of MSDD, a familybased interactive-relationship model needed by all children, and related intervention approaches to consider for each pattern. Keywords: autistic spectrum disorder, behavioral models, floor time, integrated intervention, multisystem developmental disorder, pervasive developmental disorder, relationship-based treatment (C)1996Aspen Publishers, Inc.
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Evidence is reviewed on the prevalence of sensory and motor abnormalities in autism and the effectiveness of three interventions designed to address such abnormalities—sensory integration therapy, traditional occupational therapy, and auditory integration training. Although sensory processing and motor abnormalities are neither universal nor specific to autism, the prevalence of such abnormalities in autism is relatively high. There is, however, little controlled research on the effectiveness of interventions designed to address these abnormalities. Four objective outcome studies of sensory integration therapy were identified. These were of such small scale that no firm conclusions regarding efficacy could be made. No empirical studies of traditional occupational therapy in autism were found. Five studies of auditory integration training were found. Results of these studies provided no, or at best equivocal, support for the use of auditory integration training in autism.