Preschool children’s ideas about peer-mediated intervention for autistic children who use minimal speech: a qualitative study protocol

Inclusive early childhood education and care

Inclusive early childhood environments support learning and social development for all children (Cologon, 2014; Lynch & Irvine, 2009; National Council for Special Education (NCSE), 2016; United Nations, 2006; United Nations Educational, Scientific and Cultural Organisation (UNESCO), 2005) and children’s language development in the early years is influenced by their peers (Henry & Rickman, 2007; Justice et al., 2011; Mashburn et al., 2009; Ribeiro et al., 2017). Children with disabilities in Ireland increasingly attend mainstream early childhood education and care (ECEC) settings (Roberts & Callaghan, 2021), with three quarters of ECEC settings reporting that they have at least one child with a disability enrolled in their service (Pobal, 2022). Autistic children experience challenges engaging in social interactions with their peers (American Psychological Association (APA), 2013; World Health Organisation (WHO), 2019) and supports need to be put in place to ensure that they experience the potential gains proffered by inclusive environments (Banks et al., 2018; NCSE, 2016; Watkins et al., 2019).

In Ireland, all children aged between three and five years are eligible for a three-hour, five-day per week childcare scheme for 38 weeks of the year over two years. The Access and Inclusion Model (AIM) is a model of supports designed to ensure that children with disabilities can access this childcare scheme (Department of Children, Equality, Disability, Integration and Youth (DCEDIY), 2020). AIM supports may be provided on an individual basis, or at an organisational level, for example, staff training. Autistic children may also have access to healthcare professionals via state funded Children’s Disability services (Carroll et al., 2013).

Autism

The prevalence of autism in Ireland is estimated at 1.5% (Department of Health, 2018), or 1 in 65 children in education settings (NCSE, 2016). Diagnostic criteria include persistent difficulties in social communication and social interaction, and persistent restricted and repetitive patterns of behaviour, interests, or activities (APA, 2013; WHO, 2019). Up to 30 per cent of autistic people do not develop verbal expressive communication and use no or minimal speech (Anderson et al., 2007; Pickles et al., 2014; Rose et al., 2016). They may use an augmentative and alternative means of communication (AAC), such as gestures, sign language, picture communication, or a voice output device. Limited communicative speech and fewer opportunities to engage in social interactions lead to reduced opportunities to develop language and social skills (Watkins et al., 2017), which has the cyclical effect of reducing social opportunities further (DiStefano & Kasari, 2016). Autistic people experience difficulties forming and maintaining social relationships and friendships and may experience loneliness and isolation (Bauminger & Kasari, 2000; Connor, 2000; Deckers et al., 2017; Grace et al., 2022; Mattys et al., 2018; Müller et al., 2008; Murray et al., 2023). When addressing these challenges, the supports needed for children who use minimal speech may be different to those needed for autistic children who use language confidently (Brignell et al., 2018).

Peer-mediated Intervention

Peers can provide a natural source of support for autistic children as they are situated in the education context, and they understand how children interact with each other (Carter, 2018). PMIs aim to facilitate interaction between autistic children and their peers. Researchers may set up a facilitative environment and encourage and scaffold the children to interact with one another (see Wolfberg et al., 2015). PMI may involve direct skill building with peers, where they acquire strategies for extending the amount of time spent in interactions with an autistic play partner, role play potential play scripts, and troubleshoot when interactions do not proceed as planned (e.g., Goldstein et al., 1997; Ledford & Pustejovsky, 2023). Researchers may also teach social skills to the autistic child, such as how to initiate and maintain play with peers (e.g. Katz & Girolametto, 2013).

PMI has been used to increase the volume of interaction between autistic children and their preschool peers (Chapin et al., 2018; Watkins et al., 2015), including autistic children who use minimal speech (O’Donoghue et al., 2021) and AAC (Bourque, 2020; Therrien & Light, 2016). Quantitative behaviour change outcome measures are typically reported (Bourque, 2020), such as the length of time spent in interactions, and the number of initiations made by the autistic child and their peers. The experiences of the participants in PMI are rarely considered (Ezzamel & Bond, 2016).

Stakeholder contributions to intervention design

End users of interventions offer unique insight and understanding into how interventions need to be designed and/or adapted to be implementable in real world contexts (Kasari & Smith, 2013; Thabrew et al., 2018). Interventions may be enhanced by access to a range of relevant ideas and a greater understanding of end users needs and preferences (Thabrew et al., 2018). Members of the autism community, and health and education professionals who support them, are increasingly involved in research (Chown et al., 2017; Fletcher-Watson et al., 2019; Nicolaidis et al., 2019), but children’s voices are often absent (McKinney et al., 2021; Tesfaye et al., 2019; Travers & Carter, 2022).

The current research team recently engaged with stakeholders to explore the prospective acceptability of implementing PMI in inclusive preschool settings with autistic children who use minimal speech (O’Donoghue et al., 2024a). Using a series of focus groups and semi-structured interviews we gained valuable insights into how PMI can be integrated into everyday practice from autistic people, early childhood educators (ECEs), speech and language therapists (SLTs) and parents of autistic and nonautistic children. PMI was considered to be a positive addition to children’s preschool experience, with the potential to support inclusion, and advance the social skills of autistic and non-autistic participants, “teaching a child social skills to interact with a child that is <autistic>… is going to aid the child learning social skills in the rest of their social interactions as well” (parent of a nonautistic preschool child; O’Donoghue et al., 2024a). Stakeholders described it as a complex intervention to implement, requiring training for ECEs, ongoing support as implementation queries arise, and individualisation for each participant. The proposed research extends these findings by considering the views of non-autistic preschool children.

Children are knowledgeable about their own experiences (Lyons et al., 2022), even those who are very young (Carroll & Sixsmith, 2016) and they have a right to be heard (Lundy, 2007; United Nations, 1989). Research that listens to children can enrich practice (Blanchet-Cohen & Elliott, 2011), nurture an inclusive mindset (Blaskova & Gibson, 2023) and identify child-relevant issues that would otherwise remain invisible (Charles & Haines, 2014; Gallagher et al., 2019). According to Lundy’s (2007) model of participation, children must be given the opportunity and support to express their views, and whatever they say must be listened to, and acted upon.

Nonautistic children’s voices in PMI research

Ezzamel & Bond (2016) reviewed the methods used to report on the impact of PMI in education settings and concluded that little attention has been given to exploring peers’ experiences of PMI. Quantitative measures relating to the nonautistic peers’ communicative behaviour (Parsons et al., 2020; Schaefer et al., 2016) or play performance (Kent et al., 2020) are more likely to be reported than qualitative information. Little attention has been paid to the effect PMI has on peers’ perspectives and attitudes (Schaefer et al., 2016) and there is no evidence of peers’ views being gathered in the intervention design phase of research or data on the acceptability of the intervention to potential peer participants.

Current study aim

This study aims to provide a qualitative, child-centred, description of non-autistic preschool children’s views on PMI and how to implement it.

Design

This is a qualitative study following the Consolidated Criteria for Reporting Qualitative Studies (COREQ) reporting guidelines (Tong et al., 2007; see extended data for checklist) and Ethical Code for Early Childhood Researchers (EECERA; Bertram et al., 2016). Focus groups will be conducted to facilitate interactive discussion (Carey & Asbury, 2012) in a safe peer environment (Adler et al., 2019). Consideration will be given to conducting the focus groups in a manner that is appropriate for preschool children, as per guidance in Adler et al. (2019) and Gibson (2007).

Research team roles and prior experience

The focus groups will be led by M.O.D., and C.A.M. will be present as the note-taker and assistant. M.O.D. and C.A.M. will take field notes, transcribe and analyse the data. N.K. will support data analysis by engaging in critical dialogue.

M.O.D. is a PhD candidate and assistant professor employed in the School of Allied Health at the University of Limerick. She has experience conducting qualitative research with a variety of stakeholder groups but is a novice to conducting research with children. She has four years of clinical experience working with young children as a speech and language therapist. She has clinical and research experience in the autism field and views neurodiversity and inclusion in a positive light. M.O.D. will be supported and supervised by C.A.M., an associate professor in speech and language therapy with clinical experience with children and experience in conducting research with children. She has particular interests in intervention development and implementation for children with communication difficulties including valid approaches for educational settings. N.K. is a senior academic with extensive research experience across multiple methodologies, who is active in intervention development and implementation.

Participants and recruitment

Children will be recruited via convenience sampling at a local preschool. To be included, children must be able to express themselves using English, be aged between 3:0 and 5:11 and not yet attending primary school. Children who do not have a consistent and reliable means of expressive communication will not be included in this study. No financial remuneration will be received by participants.

Following a detailed phone conversation between the gatekeeper (the owner of a local preschool) and M.O.D., where the inclusion and exclusion criteria and study procedure will be outlined, the information sheet (see extended data) will be circulated to guardians. This describes the purpose of the study, research team, procedure, and information regarding data protection. Interested parties can contact the gatekeeper or the researcher. M.O.D. will contact the interested parents and send them the consent form for consideration and an information sheet and an assent form for their child (see extended data). The children’s information sheet contains a description of the study in child-friendly language, with pictures to support understanding. Guardians will be advised to look at this with their child and support them in asking questions about the study. The researchers will offer to phone or meet the guardian to talk further about the study if requested. The information sheets will be discussed again with parents prior to signing the consent and assent forms on the day of the focus group, and they will have the opportunity to ask further questions. Parents can stay with their child for the duration of the session.

Minimal risks are anticipated for participants in this study. If children are showing any signs of discomfort, or unease which indicates that they no longer wish to take part in the focus group, then they will return to their preschool group. If children would like to keep any drawings or artwork generated during the group, then the researchers will photograph the material before they leave, and they can take it home with them.

Procedure

We propose to run two focus groups, each with four children. The recommended size for focus groups with young children is between four and six (Adler et al., 2019; Gibson, 2007). Given that the children here are in preschool, we have chosen the smaller focus group size. The focus groups will last between 20 and 30 minutes (as per Adler et al., 2019). The workshops will either take place in the preschool, or in a room in the local school, depending on availability. Children will sit around a table, or in a circle on the floor, depending on the equipment available in the room. One ECE that the children are familiar with will be present throughout the focus group to support the children to feel secure (Adler et al., 2019). They will also be available to take any child to the bathroom as needed, or to return the child to the main group if they wish to leave the focus group.

We are cognisant of the young age of our participants and will make all efforts to ensure that our methods are used in an appropriate manner. We will adopt a child-friendly approach demonstrating patience, warmth, and active listening (Gibson, 2007). We will ask direct questions, using concrete, simple language as much as possible (Adler et al., 2019). Questions will be rephrased if children do not understand some of the vocabulary used (Lund et al., 2016). Long pauses before children answer will not be interrupted (Lund et al., 2016). Adults may dominate and steer conversations with children (Lyons et al., 2022). If C.A.M. observes this during the workshop she will alert M.O.D. to address this immediately.

Once the consent and assent forms are completed there will be 10 minutes of unstructured play time before the focus group begins. This will provide the children with time to become comfortable in the space, and to understand that their ECE and/or guardian is not going to leave.

The focus group itself will begin with a brief ice-breaker activity of making name tags. The children will have the opportunity to choose a sticker to attach to their name tag. We will employ different types of activities (talk- and art-based) as these will create accessible, interactive, and fun ways to engage the children (Lyons et al., 2022). A visual schedule will be used to support the children to understand what is happening, what will happen next, and when the focus group will end (Watson & DiCarlo, 2016; see extended data).

Data collection

Vignettes will be used to explore children’s ideas on how to include children who have complex communication needs (see extended data for the focus group outline). Vignettes deal with a fictional character in a scenario engaging in some form of activity or experience relevant to the topic under study (Palaiologou, 2017). The vignettes are the same as the examples provided to adults in a previous study (O’Donoghue et al., 2024a) but have been modified in order to engage the children in defining what the challenges for the child with complex communication needs are, and what their role as peers could be to support them. Each vignette will be accompanied by a picture of the ‘child’ in order to make the task more concrete for the children (see extended data). Role play, visual supports and card-making activities will be used. We will draw on a multimodal perspective, which posits that all forms of meaning-making play an important role in understanding, not just language (Streelaskey, 2020). To facilitate this, the focus group will be video recorded to make sure that all forms of communication used by the children are captured. Any materials, e.g. cards completed by the children, will be included in the analysis. If clarity is required as to the meaning of a child’s words or their artwork, then M.O.D. or C.A.M. will check the intended meaning with them.

A copy of the video and audio recordings will be saved in a secure server of the University of Limerick. No children’s names or contact details will be stored with these data. Hard copies of data developed during the workshops by participants will be stored in a locked filing cabinet in an office in the School of Allied Health at the University of Limerick. The researchers will be the only people who can access these data.

Data analysis

The material will be analysed qualitatively using thematic analysis (Braun & Clarke, 2006; Braun & Clarke, 2019). This is the first study to focus solely on nonautistic preschool children’s views on PMI with children who use minimal speech, and reflexive thematic analysis will facilitate the researchers to adopt an inductive approach and work within a constructivist epistemology (consistent with Braun & Clarke, 2022). Braun and Clarke’s (2021) six-phase analytical process will be used: (1) data familiarisation; (2) systematic data coding; (3) generating initial themes; (4) developing and reviewing themes; (5) refining, defining, and naming themes; and (6) writing the report. M.O.D. and C.A.M. will engage in data familiarisation, systematic data coding and generating initial themes. These will be developed, reviewed, and refined with N.K. and J.F. We will adopt a critical lens when analysing the data to ensure that we do not make assumptions about the children’s intended messages (Facca et al., 2020). All members of the research team will contribute to writing the final report. NVivo software (Lumivero, 2023) will be used to assist in analysis. QualCoder is a free-to-use alternative to NVivo for data analysis.

Pre-test

The materials and procedures were pre-tested with four preschool children, as recommended by Adler et al. (2019). This provided confirmation that the materials and activities are age-appropriate and were well received by the children and the timing was realistic and appropriate for the participants. One issue arising was that at times the ECE was prompting the children to respond. To address this, we will include guidance for the ECE not to prompt the children and will use a laminated card during the focus group to remind the ECE (and parents if needed) not to prompt the children. We also encountered a technical issue as the video recording of the pretest did not work, we had only the audio from the session. This would not support our planned multimodal analysis and so we will need to ensure that the video camera is working satisfactorily before commencing the focus group.

Ethical approval and consent

This study design was reviewed and accepted by the University of Limerick, Faculty Education and Health Sciences (EHS) Research Ethics Committee (2024_04_05_EHS) on May 16, 2024. All work undertaken will conform to the Declaration of Helsinki ethical principles for research involving human subjects (World Medical Association, 2013). M.O.D. will ensure that all participants and their guardians have time to consider the opportunity to participate in this study. The consent form, information sheet and child assent form (see extended data file) will be sent to guardians in advance of the workshop for their consideration. M.O.D. will offer to meet with the parent and child to talk further about the study if requested. The information sheet will be read to guardians in advance of the session with their children, and they will have an opportunity to ask questions before signing the written consent form. This will take place in the same room as the workshop so that parents have a clear visual of the workshop setup, with recording and art equipment present. At the beginning of the workshop M.O.D. will read through the assent form with the children. We will listen for, and respond to, any indication from the children that they no longer assent to being involved in the workshop, for example, if they express dissatisfaction with the notetaker recording their actions, or with the video recorder (Palaiologou, 2014).

Dissemination

Findings will be disseminated via journal publication and a lay summary and an infographic will be disseminated to organisations for early childhood education in Ireland (Early Childhood Ireland, Better Start National Early Years Quality Development, City and County Childcare Committees). The children’s ideas will be shared, including any ideas that may disrupt or challenge existing intervention supports (Alderson & Morrow, 2011).