Literature Review

write a Literature Review.

? Synthesize the journal articles that you read to provide background showing the previous research related to your study.
? Did you identify and weave the key themes of the research articles together? Do not just summarize what each study found.
? Does this conclude with a paragraph that connects the research reviewed to your research question?

RESEARCH ARTICLE
Choice as a Strategy to Enhance Engagement in
a Colouring Task in Children with Autism
Spectrum Disorders
Christine L. Lough1, Martin S. Rice2*† & Larry G. Lough3
1Toledo Hearing and Speech Center, Toledo, OH, USA
2Occupational Therapy, The University of Toledo, Toledo, OH, USA
3Retired, Port Charlotte, FL
Abstract
This study investigated the effect of choice on a colouring task in children with autism spectrum disorders (ASD).
Children with ASD typically have difficulty engaging in purposeful activities, which makes progress toward skill
development difficult in therapeutic or educational settings. Participants included 26 male and female children with
ASD, aged 8 to 15 years. In this counterbalanced design, participants either chose which picture to colour or were
given a picture to colour. When given a choice, participants spent more time colouring (p = 0.005) and used more
coloured markers (p = 0.016), but did not colour more of the page (p = 498). This study demonstrated that when
offering a choice in a colouring activity, children with ASD participated and engaged in the colouring task for a
longer period of time and used a larger array of markers while doing so. However, associated small effect sizes
require caution with generalization. Future research should focus upon offering choice with other age-appropriate
activities to determine its efficacy as a useful strategy for facilitating activity engagement for children with ASD.
Copyright © 2012 John Wiley & Sons, Ltd.
Received 15 March 2012; Revised 27 August 2012; Accepted 30 August 2012
Keywords
autism; paediatric occupational therapy
*Correspondence
Martin S. Rice, Occupational Therapy, The University of Toledo, Toledo, OH, USA.
†Email: [email protected]
Published online 27 September 2012 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/oti.1337
Effect of choice in a colouring occupation
in children with autism spectrum disorders
This study explores the concept of choice making upon
task engagement in children with autism spectrum
disorders (ASD). Promotion of choice is one of the
keys to the uniqueness of the occupational therapy
process (Yerxa, 1967). Self-initiated occupation is a
tenet of occupational therapy “stock and trade” because
we cannot force an individual to initiate occupation
unless he or she chooses to do so (Yerxa, 1967, p. 3).
Occupational therapists have an active role in providing
opportunities to help a client reach a larger goal;
however, the client should be an active participant in
the treatment process by choosing to engage within
and among specific occupations that have personal
significance.
A fundamental assumption upon which this study
rests is that providing options (i.e. a choice) is intrinsically
motivating. The ability to make a choice is believed
to be an essential component of self-determination
204 Occup. Ther. Int. 19 (2012) 204–211 © 2012 John Wiley & Sons, Ltd.
(Wehmeyer et al., 2007). Furthermore, it is believed that
when the opportunity for making a choice is provided,
people respond to the choice on the basis of their own
personal interests, motivation and capabilities. This
concept has been included in occupational therapy
literature since the founding of the profession. Specifically,
Baldwin argued that patients should be offered a
variety of equally desirable options from which to choose
(Baldwin, 1919). Moreover, King (1978) surmised that
offering a choice resulted in enhanced performance
because of an increase in motivation associated with
having been given the option to choose. Rice and Nelson
(1988) and LaMore and Nelson (1993) considered this
self-determination, or as they termed “locus of control”,
to be of paramount importance to be included in the
delivery of occupational therapy services to those with
intellectual and mental disabilities. Kielhofner (1992)
highlighted the importance that choice making has in
the development of personal causation. This concept of
personal causation is congruent with self-determination’s
inherent ideas of being able to determine one’s fate
without compulsion. The provision of choice-making
opportunities is particularly important for populations
with chronic disabilities who have historically been
denied “choice making” options as a default in their lives;
hence, it is apposite to explore the concept of choice
making in a population of children with ASD.
The ability of children with ASD to complete day-today
occupations can be enhanced by the occupational
therapy process. Children with ASD show delayed or
abnormal functioning by the age of three with social
interaction, language used in social communication or
social play (Morrison, 2006). Many children with ASD
have difficulty with engagement in occupation secondary
to decreased communication and interaction skills. A
number of different strategies have been developed to
address some of these issues, not the least of which
include the applied behavior analysis (Matson et al.,
2011) and the pivotal response treatment for children
(Renshaw and Kuriakose, 2011). Dunst et al. (2012)
completed a meta-analysis of 24 studies incorporating
the interests of 78 children aged 2–6 years with ASD
into early intervention practices. They found that when
the interests of the child were incorporated into early
intervention exercises, pro-social behaviour increased,
whereas excessive motion behaviour decreased. Furthermore,
these researchers found that when the interestrelated
behaviour focused on communication and
“personal core features of ASD”, favourable results
occurred more frequently than interventions focusing
on suppressed or repetitive motor actions.
Ulke-Kurkcuoglu and Kircaali-Iftar (2010) recognized
the importance of investigating the concept of providing
choice and its effects on the ability to stay on task. In their
study, they recruited four male participants aged 5 to
8 years with ASD. Within the context of a classroom
experience, choice and no-choice conditions were
provided. Using a repeated measures design, these
researchers found that when given a choice, the participants
were able to stay “on task” to a greater degree than
when not given a choice.
One of the challenges occupational therapists face
when working with children with ASD is finding a
method to increase engagement in occupation. One of
the most striking characteristics of children with ASD is
the relative lack of affective engagement and communication
with others (Wimpory et al., 2007).Many children
with ASD display stereotypic behaviours such as hand
flapping, body rocking, head rolling, oral/vocal repetitions,
repetitive object manipulations or self-injurious
behaviours (Lee et al., 2007). Stereotypic behaviours such
as this may prevent children with ASD from engaging
fully in occupation.
One strategy occupational therapists can use to
increase engagement when working on fine motor
coordination is to allow the children to make a choice
while engaged in occupations (Rice and Nelson, 1988).
When an occupation holds a special interest to a child,
there is a greater opportunity for adaptation to occur
on the child’s part (Nelson, 1984). To promote choice
in a treatment session, an occupational therapist can
provide an array of different objects and encourage the
client to actively choose one of the items. In doing so,
occupational therapists can structure the environment
while continuing to provide choice for the child. Several
researchers have investigated the effect of choice during a
variety of occupations (e.g. Taber et al., 1953; Rice and
Nelson, 1988; LaMore and Nelson, 1993; Schroeder Oxer
and Kopp Miller, 2001).
Taber et al. (1953) investigated the effects of a
free-choice craft group versus a task-directed craft group
in 50 patients living in a psychiatric facility. The
dependent variables in this study were social attitude,
work tolerance, work quality, organization, impulsiveness,
directability (i.e. being capable of receiving and
acting appropriately to receiving “direction”), interestedness
and cooperativeness. The results of this study
suggest that patients who participated in the free-choice
Lough et al. Choice as a Strategy to Enhance Engagement
Occup. Ther. Int. 19 (2012) 204–211 © 2012 John Wiley & Sons, Ltd. 205
craft group demonstrated work tolerance and psychosocial
behaviours closest to the norm. This was one of the
first studies to address the concept of “choice” and its
effects upon behaviour.
LaMore and Nelson (1993) completed a study that
examined the effect of choice on performance of an art
project in 22 adults with mental disabilities ranging
from severe to mild. The craft completed was painting
a ceramic figure. The results showed that the participant
painted significantly more in the choice condition than
in the no-choice condition. This suggests that choice
making can enhance occupational performance within
a population of adults with mental disabilities. In a
similar study, Schroeder Oxer and Kopp Miller (2001)
also investigated the effect of choice in an art project
involving painting a plastic figure. This study involved
32 adolescents diagnosed with psychiatric conditions.
The amount of dips into the paint and the time spent
painting were significantly higher in the choice condition
than in the no-choice condition. The authors concluded
that having a choice at the beginning of an art project can
enhance the performance of adolescents with psychiatric
conditions living in a residential facility.
Rice and Nelson (1988) investigated the effect of
choice during an ironing occupation. The participants
in this study were 24 adolescent and adult males with
developmental delay. The participants where yoked into
pairs in a counterbalanced design. The choice condition
consisted of a participant choosing a t-shirt with a sports
team logo. The second member of the pair automatically
received the t-shirt with the logo the first member chose.
The shirts were systematically wrinkled and sprayed
with water. The results of the study demonstrated that
the participants ironed more thoroughly in the choice
condition. This was measured by weighing the shirt pre
and post occupation to see how much water had
evaporated from the heat of the iron. This showed that
having a choice in an ironing occupation enhanced the
level of participation in adolescent and adult males with
developmental delay.
While there have been only a handful of studies
regarding the effect of choice in occupational therapy,
there has also been a dearth of research regarding the
effect of choice in school aged children with ASD
(with the exception of Ulke-Kurkcuoglu and Kircaali-
Iftar (2010). The research that has been carried out,
collectively, suggests that offering choice can enhance
motivation and engagement in activity. The purpose of
this study is to investigate the effects of choice on the
quality and duration of a colouring activity in children
with ASD. A colouring activity was chosen for this
population as it is age appropriate and commonly
engaged in, both in school-related tasks as well as
therapeutic interventions. The hypotheses for this study
are as follows: 1) there will be an increase in the amount
of colouring in the choice versus no-choice condition; 2)
there will be more colours used in the choice versus
no-choice condition; and 3) there will be an increase in
the duration of the colouring in the choice versus
no-choice condition.
Method
Participants
The participants in this study were 22 male and 4 female
children with ASD from local area schools aged 8 to
15 years (M=12.2 years, SD= 2.3 years). By verbal
report, one participant was left hand dominant, 22 were
right hand dominant and one participant’s dominancy
was reportedly “undecided”. All participants had a diagnosis
of autism. They were required to have the cognitive
skills necessary to follow directions and make a choice to
participate in this study as determined by the child’s
parent or teacher. Participants were required to have
the ability to grasp and colour with markers.
Apparatus
Each participant completed a colouring occupation in a
no-choice and choice condition. Depending on the condition,
participants either chose from three pictures or were
assigned which picture to colour. The picture templates
were available on an 8.5in.11 in. sized piece of paper.
The pictures were coloured using Crayola Broadline
Markers-Classic-8 count (55-7708). The colours included
were red, orange, yellow, green, blue, purple, black and
brown. The templates offered to each participant were
developed with the same amount of surface area. The
pictures offered were four faces with different facial
expressions. See Figures 1–4. To calculate the amount
coloured, each picture was scanned into Photoshop with
a resolution of 300 pixels per in. The scanner was an Epson
Perfection, model number 4180 (Nagano-Ken, Japan).
Procedure
This study was approved by the second author’s Biomedical
Institutional Review Board. Data were collected from
Choice as a Strategy to Enhance Engagement Lough et al.
206 Occup. Ther. Int. 19 (2012) 204–211 © 2012 John Wiley & Sons, Ltd.
October through June of 2010. This study used a
counterbalanced design with the participants yoked into
dyads. Counterbalancing was achieved by allowing the
first member of the dyad to select one of the pictures to
colour and subsequently assigning the choice of the first
member of the dyad to the second member. The
assignment to the sequence of conditions (e.g. Choice,
No-Choice or No-Choice, Choice) depended upon the
order in which participants volunteered for the study.
There was 1week between each condition for any given
participant, and data collection occurred at approximately
the same time (i.e. mornings) for all participants.
In each condition, data collection occurred in the same
quiet room for all participants. The participants did not
know the research investigator. Participants were seen
individually and were seated in a chair with large markers
in front of them. The child was then given a choice of
three template pictures on paper. After the child indicated
his or her choice, the picture chosen was placed
in front of him or her. The participants were given verbal
instructions to take as much time as needed to colour the
picture with the markers. They were provided with
pictures of a red light and a green light to use for indicating
if they are still colouring or all finished throughout the
occupation. They were instructed to get up from the table
when they were finished colouring the picture. The
participants were timed with the use of a stopwatch
throughout the colouring occupation. The start time
began as soon as the marker touched the paper. If the
participant stopped colouring, he or she was asked “are
you finished coloring your picture?” If the child indicated
verbally, physically or by pointing to the red light that he
or she was finished, the stop time was recorded. If the
child indicated more time was needed, more time was
given. The child was asked this each time he or she
stopped colouring until the child indicated he or she
was finished. After the child completed the colouring,
the amount coloured was calculated for each condition.
Each picture was scanned into the computer in order
to calculate the amount of pixels coloured by each child.
The process for calculating the amount coloured is
Figure 1 Face number one
Figure 2 Face number two
Figure 3 Face number three
Figure 4 Face number four
Lough et al. Choice as a Strategy to Enhance Engagement
Occup. Ther. Int. 19 (2012) 204–211 © 2012 John Wiley & Sons, Ltd. 207
explained in the following sections. Once the scanning
process was completed, the child was given the coloured
picture as well as the package of markers to keep as a
“thank you”.
Dependent variables and statistical analyses
Dependent variables included the amount the page was
coloured, the number of colours used and time on task.
The amount the page was coloured was defined as the
number of different coloured markers used and the
amount of pixels filled with colour within the object that
was coloured. Each choice of object had the same
amount of available surface area to colour as each picture
offered was developed using a circle with a diameter of
16.67 cm. The amount of pixels filled was reported as
an error score; therefore, a picture coloured and given a
lower score would be coloured with higher quality. Time
on task was derived using a digital stop watch that was
operated as long as the child was colouring as per the
aforementioned protocol.
The amount of pixels for each figure was calculated
using the following process. After the child coloured
the picture, the amount of colour was calculated in
pixels. The amount of template pixels was subtracted
from the amount of pixels coloured by each child. The
amount of pixels was calculated using the select and
histogram features within the Photoshop program. This
process allows one to calculate the amount of pixels
coloured by each child. The scans of the figures were
saved into a Tiff file in Photoshop. One file was made
to represent the exact circle size used for the original
prints. This file was used throughout to standardize
the circle size for all children’s drawings. This will be
referred to as the circle layer in the following. The
original scan was cropped to 8.5 in.11 in. at 300 dots
per in. The white point for the background was set to
255. The circle layer was added, and original scan is
scaled to the exact same size. The background layer
was duplicated, and the original was deleted. This layer
was then duplicated and titled background copy. A new
layer was made and named circle. At this point, there
were four layers: reference circle, circle, background
and background copy. A selection was made just
outside the circle from the background layer. The
selection was adjusted to just touch the outside of the
original and saved. This selection was cut and pasted
to the circle layer. The magic wand tool was used to
select a clear white area from the background layer. The
number of white pixels in the histogram tab was read
and recorded. This was the total number of white pixels
remaining in the figure. The same procedure was
completed in the circle. This number was the number
of white pixels remaining inside the circle. There were a
total of 131,747 pixels in the original file. There were a
total of 44,272 pixels inside the circle of the original file.
The total number of pixels each participant added to
the figure was calculated by subtracting the number of
white pixels remaining in each figure and the number
of black pixels from the original figure from the total
number of white pixels in the original figure.
Data for each of the three dependent variables were
skewed; therefore, a nonparametric one-tailed, paired
Wilcoxon signed rank test was used for each of the
statistical analyses. Alpha was set at 0.05.
Results
There was no significant difference of the amounts of
pixels coloured in the choice condition versus the
amount of pixels coloured in the no-choice condition
(p = 0.498). However, children used significantly more
colours (p = 0.016), and they spent significantly more
time (p = 0.005) during the choice colouring condition
than in the no-choice colouring condition. The effect
sizes for both the number of markers used and the
duration of time while colouring were small. Table I
exhibits the Wilcoxon statistics, and Table II is a tabulation
of the means and standard deviations for each of
the dependent variables. Figures 5 and 6 are colouring
examples by the same participant while in the choice
and no-choice conditions, respectively.
Table I. Wilcoxon signed rank tests comparing the choice versus no-choice conditions for percent coloured and time colouring
Dependent variable Sum of positive ranks Sum of negative ranks Sum of signed ranks p-value Effect size d
Percent coloured 176.0 175.0 1.0 0.4975 0.06
Markers used 57.0 9.0 48.0 0.0161 0.20
Time coloured 277.0 74.0 203.0 0.0051 0.30
Choice as a Strategy to Enhance Engagement Lough et al.
208 Occup. Ther. Int. 19 (2012) 204–211 © 2012 John Wiley & Sons, Ltd.
Discussion
The purpose of this study was to investigate the
effects of choice on the quality and duration of a
colouring occupation in children with ASD. Whereas
there was no support for Hypothesis 1, in that there
was no difference in the amount of pixels coloured
between the two conditions, there was support for
Hypotheses 2 and 3. Specifically, there were significantly
more different colours used, and a greater
duration colouring occurred in the choice condition
versus the no-choice condition.
Contrary to Hypothesis 1, the amount of pixels
coloured in the choice condition versus the no-choice
condition yielded no significant results. One reason this
could have occurred is that children with ASD often
have difficulty with fine motor tasks. It may be that
the amount of colouring was similar for both the
choice condition and the no-choice condition because
the participants were not so much concerned with the
quantity of colour they placed on the page, but rather
were perhaps more concerned with the location of their
marks; in other words, the participants may not have
equated quality with quantity in this colouring occupation.
It is also possible that the participants did not
perceive the occupation of colouring (these pictures) to
be meaningful. If the pictures were perceived as such,
it is possible that anymotivating effect frombeing offered
a choice was diminished, thereby resulting in no
significant difference in the quantity of colouring.
The use of more colours may be a reflection of being
more engaged in the colouring activity than if fewer
colours were used. This may be true on several levels.
It has been shown that normally developing children
associate emotions with specific colours (Boyatzis and
Varghese, 1994). It is possible that children with ASD
can also, at some level, associate emotions with colours.
Additionally, the use of colour can enhance the
cognitive response time of children when searching for
a target on a page (Thistle and Wilkinson, 2009). Given
these two premises, the use of colour can have an impact
upon the cognitive processes in children. Although it is
unknown what was in the minds of the children during
Table II. Means and standard deviations and ranges for percentage of the page coloured, number of markers used and duration
for colouring
Dependent variable
Choice No choice
Mean SD Range Mean SD Range
Percent coloured 0.22 0.19 0.82 0.21 0.17 0.51
Markers used 2.58 1.81 6.0 2.23 1.73 6.0
Time coloured (seconds) 202.65 183.43 670.89 154.62 137.24 467.66
Figure 5 Choice condition colouring example. Note that the face is
yellow, the right eye is brown, the left eye is purple, and the mouth
and nose are red
Figure 6 No-choice condition colouring example. Note that only
green was used to colour this picture
Lough et al. Choice as a Strategy to Enhance Engagement
Occup. Ther. Int. 19 (2012) 204–211 © 2012 John Wiley & Sons, Ltd. 209
this colouring activity, it is possible that during the choice
condition, the children thought about the picture in a
more dynamic way than when not given a choice. When
colouring, the child must first think about which colour
to use where to place that colour. When using multiple
colours, these two tasks may occur in sequence with each
other as subsequent coloured markers are chosen and
used; however, it is also possible that the child may be
planning where to apply additional colour(s) before
actually colouring or while using a given coloured
marker. The first strategy requires fewer cognitive
demands but is still arguably cognitively more complex
than if using only one colour for the whole picture. The
second strategy involves simultaneously thinking about
multiple colours and where to place those colours using
motor and spatial planning to a greater degree than when
using fewer colours.
Many children with autism struggle to maintain
engagement in purposeful occupation secondary to decreased
interaction and communication skills (Wimpory
et al., 2007). In order to develop and learn new skills, it
is imperative that children with ASD be engaged with
teachers, therapists and parents. Children with ASD
commonly show impairment with social interaction,
social play and communication (Morrison, 2006).
The children with ASD in this study were engaged
significantly longer when given a choice of what
picture to colour. Giving choice in a task can increase
occupational engagement in order to teach children
with ASD new skills.
It is possible that the children with ASD may have
coloured longer when given a choice because they
enjoyed the occupation of colouring. The goal of the
participants may have been different in the choice
condition versus the no-choice condition. As mentioned
earlier, it is possible that participants did not see covering
the page as important, and they just enjoyed being “in”
the activity. The amount of colour covering the page
may not have been part of their strategy. In some
instances, participants drew on to the pictures of faces
versus colouring in the faces. Participants may have been
more thoughtful about “how” they coloured instead of
mass colour coverage. This idea offers another explanation
of why the amount of pixels may not have changed;
however, the duration of time after having been given a
choice showed a marked increase.
The only difference between the choice condition and
the no-choice condition was the presence of choice
in what facial expression was to be coloured. The
occupational form was the same in each condition for
each participant. Giving choice can increase an individual’s
perception of locus of control. This perception of
locus of control may be something that these participants
do not often experience. Having this perception may
increase the amount of meaning that an individual
ascribes to an occupation and its associated occupational
forms. When this occurs, an individual may be more
motivated to participate in an occupation. Motivation
and engagement in occupation are major issues facing
children with ASD (Wimpory et al., 2007). This study
shows that providing a choice may be a strategy to
increase motivation and engagement in purposeful
occupation. Providing children with ASD choices may
be a way to increase the “potency” of an occupational
therapy session.
Occupational therapists can utilize choices within
treatment sessions by using creativity when planning
sessions. For example, an occupational therapistmay give
a child a choice of two occupations that require the use of
the same skill, such as fine motor coordination. The child
could be working toward the same goal; however, he or
she would be more motivated to engage for a longer
period of time when given a choice within an occupation.
This strategy could be utilized in many ways when
completing occupational therapy with individuals with
ASD and other developmental disabilities.
The increase in the number of colours used and the
duration of engagement in a colouring occupation is
supported by similar results from previous studies
involving individuals with cognitive impairments (e.g.
Rice and Nelson, 1988; LaMore and Nelson, 1993;
Schroeder Oxer and Kopp Miller, 2001). In each of
these studies, individuals with cognitive impairments
were more successful in a task when given a choice of
task. The results of this study build upon the evidence
that individuals with disabilities benefit from having
some control over the occupations they complete.
Sources of potential bias include the primary investigator
who completed data collection and the data
analyzer. Although the primary investigator strictly
followed the research protocol, she was aware of the
hypotheses and could have inadvertently influenced
the participants in a biased way. Additionally, timing
the children’s engagement in a colouring occupation
was completed using a computerized stop watch. Although
the stop watch was very precise and measured
the time to the 10th decimal, it is possible that statistical
error could have been introduced by the subjective
Choice as a Strategy to Enhance Engagement Lough et al.
210 Occup. Ther. Int. 19 (2012) 204–211 © 2012 John Wiley & Sons, Ltd.
nature of the human interaction to initiate and stop the
stop watch. This study had a relatively small number of
participants from a relatively small community in the
Midwest portion of the United States, which could limit
the generalization of the results. Results may have been
different if participants were for another community or
had been integrated in school with children without
disabilities. Lastly, it is possible that the colouring task
was not age appropriate for all of the participants.
In conclusion, this study has demonstrated that by
offering a choice in a colouring occupation, children
with ASD used a greater number of coloured markers
and engaged in the colouring task for a longer period
of time. Although statistical significance was found,
the effect sizes were small, meaning that these conclusions
must be conservatively accepted. When working
with individuals with ASD, it is important to understand
and to be aware of effective strategies for increasing
participation and engagement in occupations. This
study suggests that incorporating “choice” as a part of
the therapeutic occupation may be an effective strategy
for increasing participation and engagement. There is
also a need for continued research investigating choice
in children with ASD. Research investigating the
relationship of choice and occupational performance
may be an integral part of understanding the most
successful interventions for teaching children and young
adults who have ASD. There is also a need to investigate
the effect choice has on occupational performance in
adults with ASD.
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