The Impact of Air Sit Cushioned and Ball Chair on Classroom Behavior of Students with Autism Spectrum Disorder (ASD)
Nader Matin Sadr1, Hojjat Allah Haghgoo2, Sayyed Ali Samadi3, Mehdi Rassafiani2, Enayat Allah Bakhshi 2
1. Ph.D Candidate of Occupational therapy
2. PhD
3. Ph.D University of Ulster

Abstract
Introduction: Educational achievements are disturbed in autistic students because of their repetitive restlessness and disruptive behaviors. Therefore the effectiveness of sitting on ball and cushion instead of simple chairs was investigated on classroom behavior of students with Autism Spectrum Disorder (ASD).
Methods: Class behavior of four students was monitored in a single-subject A-B-A-C design study during four weeks. Students behavior was recorded by camera in three phases; sitting on their 1) Own chairs during A phases, 2) Air cushioned chairs in B phase and 3) Ball chairs in C phase. Sitting times and on task behavior were quantified by momentary real-time sampling every 10 seconds compared during different phases for relevant changes. Social and communication skills evaluated by GARS II and Vineland tests before and after intervention.
Results: Findings demonstrated increases in on task behavior for four students when seated on air cushioned and increase in-seat behavior for two students with ASD when seated on therapy balls. Social validity findings indicated that the teacher preferred use of ball and air cushion chairs for some of the students in class.
Conclusion: The results showed unique responses per student with ASD. Therapy balls/cushioned chairs for students with ASD may facilitate in-seat and on task behavior.

Keywords: Stability ball, Sit cushion, Ball therapy, Autism, Attention, Classroom engagement.

Introduction: Increasing number of children with autism spectrum disorder is 1 case per 110 Students is a great challenge for education system (1). Difficulty in engagement in class tasks, low attention span, and inappropriate behaviors are common in these students, which interfere with student’s ability to participate in the educational mainstream (2).

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One reason that children with ASD have limited success in educational improvement with some intervention strategies is that these strategies do not address the sensory issues that may underlie the disruptive behavior (Ayres, 1972; Dunn, 2000). In an extensive research on 200 children with autism, %95 had difficulties in sensory modulation. Physiological need for proper sensory stimulation leads to spending most of student time on stereotype and repetitive movements to adjust their sensory system. Therefore, their attention would not be concentrated on learning and assignments in class. Greenspan and Wieder argued that the decrease in sensory processing may resulted in social isolation and inattention to class tasks (2).Viola and Noddings stated that children with low sensory sensibility require additional sensory stimulation to accomplish the tasks which require attention and concentration (3). Therefore, one of the prominent approaches to address the behavioral problems in these children is sensory integration approach.
Sensory integration approach includes integration of three essential sensory systems: the proprioceptive, the vestibular, and the tactile systems. These systems, regulate the awareness of the body in space, joint and limbs positions, control sensations of gravity and movement, and perceives the sense of touch (4). Sensory Integration theory is focused on these special key sensory systems which are useful in person’s interpretation and application of sensory information. Proper sensory integration is a gate to successful educational learning through successful application of sensory and perceptual systems which would lead to forming vital skills for doing on task behaviors (4). Occupational therapists who work in school often use sensory techniques to increase students’ levels of attending, on-task behavior, and performance in the classroom. Many clinicians perceive these approaches to be successful in promoting functional classroom behavior. According to previous findings, 99% of occupational therapists use sensory integration techniques (5). Smith and Miller had been in contact with 292 occupational therapists in 1992 and found that Sensory Integration based-therapy was the most common applied technique among all of them (6). The effects of proper sensory integration, improve students ability to educational achievements and success by goal directed use of sensory and perceptual systems. This method can lead to success in learning (Gilman). Furthermore, formal research conducted on sensory-based interventions has supported this belief (Schilling, 2004; Schilling & Schwartz, 2004; Schilling, Washington, Billingsley, & Deitz, 2003).
Hemmingsson and Borel in their investigations emphasized on lack of environmental modification in the classroom that directly refers to the limitation of student’s engagement. So, lack of proper changes in environment can lead to restriction in learning. Furthermore, previous emphasis in pediatric occupational therapy has been on modifying the individual’s behavior with less emphasis placed on changing the environment, but focus is now shifting to ergonomic and sensory modifications to promote academic success (Asher, 2010). Various sensory-based strategies, including the use of alternative seating devices, have been examined by researchers and in many cases have been found to promote functional classroom behavior (Fertel-Daly, Bedell, & Hinojosa, 2001; Schilling et al., 2003; Schilling & Schwartz, 2004; Zissermann, 1992). Two of these functional methods are the using of balls and air cushions rather than common chairs. The use of therapeutic balls have been lead to marked improvements in the in-seat behavior and legible word production, in school age children with attention deficit hyperactivity disorder (ADHD; Schilling, 2004; Schilling et al., 2003) and to increase in engagement and in-seat behavior of preschoolers with ASD (Schilling & Schwartz, 2004) (7). Clinicians have been using dynamic seating systems such as the Disc ‘O’ Sit cushion for many years to assist students to increase their attention span. While clinical evidence that these systems can lead to desired results, but very little research has been completed and published to support their use.
Sitting on a ball allows the child to pay more attention to activities while receiving stimulation in a passive form, rather than seeking stimulation from disruptive activities. Gamache-Hulsmans (2007) stated that students said they feel better when sitting on ball chairs. Students also felt more comfortable and said their backs did not hurt when sitting. The ball chairs are soft compared to regular classroom seats and are more fun to sit on (3).
To what extent, dynamic seating chairs will effect on attention to on task behaviors and in-seat behavior? Therefore, in this research, the effects of sitting on ball and air cushion were investigated. With regards to thousands of special students with difficulty in sitting and classroom performance, these devices may be optional selection for solving the mentioned class behavior problems.
Materials and Method

Research Design: A single subject multiple treatments withdrawal design A-B-A-C was used to investigate the effects of 3 seating options including common chairs, therapy balls, & air cushions on the in-seat, on class task behavior, communication and social behavior of four students with ASD. During the 2 A phases students were sitting on common chairs, in B phase on air cushions, and during C phase they were sitting on therapeutic balls.
Participants: This investigation performed in an especial school for ASD students. A convenience sample including four participants was recruited from the Preschool students in autism elementary school in Mashhad, Iran. Participants were diagnosed as ASD by specialists and taking their own medications regularly throughout the study. According to teachers’ report, all children were identified as having difficulty with in-seat behavior and on task behavior.
Procedures: Informed consents were obtained prior to experiment and contents were comprehended and signed by students’ legal representative.

Data collection: Gilliam Autism Rating Scale-Second Edition (GARS II) and Vineland testes were given and were used to examine social and communication skills of students in the first and final of research for all students of class. To assess the students’ class behavior, staff was instructed to give no additional feedback on students’ sitting behavior either positive or negative throughout the duration of the study. But, if a student exhibited behavior that could be potentially harmful to him, peers, or the staff must have been prevented by staff. To remove any novelty effects, students were introduced with stability balls and air cushion instead of their chairs for 2 full days, before baseline data collection.

Video recording: Setting camera recorders in class, Students’ behaviors during class task (sitting period and attention performance related to class tasks) were recorded all the day-time. Students’ behaviors were quantified three times per week, one day after another, with an overall of 12 sessions. Two occupational therapists were trained as observer of videos. In-seat data were collected via momentary real time sampling (MTS); the observers coded the student’s behavior on the basis of several behavioral classifications. The mean score across raters was used to calculate weekly on-task and in seat behavior. Videos were regularly checked throughout the study to determine inter and intra rater reliability agreement. Observers individually, watched videos every 10-s intervals, stopped it and marked the observation on each child’s designated worksheet, thus resulting in 60 observations per session per participant. This MTS interval would serve to make the observations more valid and representative of the child’s behavior throughout the baseline and interventions periods. Additionally, GARS II and Vineland testes were given and were used to examine social and communication skills of students in the first and final phases of research for all students of class. Students’ class behaviors during two intervention phases (each 1 week) were compared with class behavior during baseline and withdrawal phases (each one week).
Teacher Social Validity Scale: Social validity questionnaire was used at the end of the study to evaluate teacher opinion regarding the intervention. The questionnaire consisted of 8 questions and assessed effects of intervention on sitting and activity participation as well as the extent of preference of stability balls or air cushion instead of chairs. Questions were answered on a 5-point Likert scale that ranged from strongly disagree (1) to strongly agree (5).
On-Task Behavior:” Engagement was defined as “oriented towards appropriate classroom activity or teacher and either interacting with materials, responding to the speaker or looking at the speaker” (Schilling & Schwartz, 2004, p. 427). This definition included reading, and writing as well.
In-Seat Behavior: Data on in-seat behavior was defined according to Schilling and Schwartz (2004) and quantified during video review. “Any portion of the child’s buttocks in contact with the seat portion of the chair” (Schillling & Schwartz, 2004, p. 427) and “the four legs of the chair in contact with the floor” (p. 427). For the intervention phase (B), any portion of the participant’s buttocks in contact with the air cushion, air cushion in contact with the chair and the four legs of the chair in contact with the floor. For the intervention phase (C), in-seat behavior was defined as “any portion of the participant’s buttocks in contact with the ball, the ball in contact with the floor, and at least one foot in contact with the floor” (Schilling & Schwartz, 2004, p. 427).

GARS-2: The GARS is a screening instrument used for the assessment of individuals’ ages 3–22 years old who exhibit behavioral characteristics that may be indicative of autism. This is a standardized instrument, which consists of 42 items divided into three subscales that describe specific, observable and measurable behaviors. The items included in this instrument are based on the definition of autism adopted by the Autism Society of America (2003) and on the diagnostic criteria for autistic disorder published in DSM-IV-TR.
Vineland

Materials:
Therapy balls: The selected therapy balls to be used in classroom use, had 55-cm-diameter (‘n’ Sit ball by …) with five little feet to prevent it from moving or rolling when used as a sitting ball. Therapy balls were individually fitted with air pressure into the ball (at different degrees of inflation) that confirm the student could sit comfortably with his feet flat on the floor with knees and hips flexed at 90 degrees.
Air cushion: The Disc ‘O’ Sit cushion is a round and widely available. The Disc ‘O’ Sit, are instability cushions, strong enough to sit. It is designed to fit on a classroom chair and provide movement while seated (7).
Chair: A general wooden with iron frame classroom chair without armrests (height, 72 cm; depth, 34 cm; width, 39 cm; seat height, 36 cm).
1. Participant 1, speak with himself slowly and repeatedly with low attention and cannot tolerate sitting on chair.
Participant 2 an 8-yr-old boy, he has low level endurance for performing occupation and sitting. He was hyperactive.
Participant 3 an 8-yr-old boy, he has visual perceptual problem with low attention and endurance.
Participant 4 a 11-yr-old boy, auditory problem, he likes,
Results:
During Phase A1 the number of times Hossin was on seat ranged from 11 to 18 (mean [M] = 14). During Phase B, the range was 30–36 (M = 34). During Phase A2, (chair) 15-38 (M = 23). During Phase C, (ball) the range was 2-10 (M = 6). The number of on seat for Hossin shows increase on air cushion and decrease in sitting on ball.
During Phase A1 the number of times Hossin was on task ranged from 23 to 32 (mean [M] = 27.5). During Phase B, the range was 42-56 (M = 50). During Phase A2, (chair) 33-44 (M = 39). During Phase C, (ball) the range was 47-51 (M = 48). The number of on seat for Hossin shows increase on air cushion and decrease in sitting on ball.
Each child’s data are presented in separate graphs in Figure
(A) Total number of times that Hossin was on seat each phases.

(B) Total number of times that Hassan was on seat and engaged each session.

(C) Total number of times that Parsa was on seat and engaged each session.
(D) Total number of times that Amir was on seat and engaged each session.
Films was regularly checked throughout the study for determining inter and intra rater reliability agreement. Final inter rater agreement percentages ranged from 93% to 100% for in-seat behavior and from 80% to 90% for on-task behavior. They had a mean age of 8.75 ± 1.9 years, mean height 132.5 ± 9 cm, and mean weight 29.25 ± 8.5 kg.
Each child demonstrated a unique response to the use of the therapy ball chair and air cushion.
Discussion:
Conclusions: This investigation suggests that dynamic seating in the classroom, increases in-seat behavior & on task behavior for children with ASD. However no one type of seating was found appropriate for all children with ASD. For some forms of classroom behavior, the use of dynamic seating appears proactive, serving as a positive behavior support strategy to assist in creating an opportunity for learning.
References
1.Koegel L, Matos-Fredeen R, Lang R, Koegel R. Interventions for children with autism spectrum disorders in inclusive school settings. Cognitive and Behavioral Practice. 2011.
2.Schilling DL, Schwartz IS. Alternative seating for young children with autism spectrum disorder: Effects on classroom behavior. Journal of autism and developmental disorders. 2004;34(4):423-32.
3.Horgen KM, Kathryn M. Utilization of an Exercise Ball in the Classroom:
Its Effect on Off-task Behavior of a Student with ADHD [thesis]: University of Wisconsin; 2009.
4.Wu W-L, Wang C-C, Chen C-h, Lai C-L. Influence of Therapy Ball Seats on Attentional Ability in Children with Attention Deficit/Hyperactivity Disorder. 2011.
5.Tunstall H.R. Effects of Alternative Seating on the Academic Engagement of Children With Autism 2010.
6.Lang R, O’Reilly M, Healy O, Rispoli M, Lydon H, Streusand W, et al. Sensory integration therapy for autism spectrum disorders: A systematic review. Research in Autism Spectrum Disorders. 2012;6(3):1004-18.
7.Schilling DL. Alternative seating devices for children with ADHD: Effects on classroom behavior. Pediatric Physical Therapy. 2006;18(1):81.