Stakeholder Perceptions of the Acceptability of Peer-Mediated Intervention for Minimally Speaking Preschoolers on the Autism Spectrum

This is a qualitative study using focus groups and semi-structured interviews following the Consolidated Criteria for Reporting Qualitative Studies (COREQ) reporting guidelines (Tong et al., 2007; see Appendix A for checklist) and Ethical Code for Early Childhood Researchers (EECERA; Bertram et al., 2016). We aimed to collect the perspectives of stakeholders across various roles (ECEs, Speech and Language Pathologists (SLPs)) and contexts (autistic adults, parents of minimally speaking children and parents of non-autistic preschoolers) to better understand the acceptability of PMI from a variety of viewpoints (Aarons & Palinkas, 2007; Carey & Asbury, 2012). Focus groups allow for interactive discussion, with the potential for group interaction to prompt greater engagement with a topic (Carey & Asbury, 2012). Focus groups can be challenging for autistic people, as attending a new place, and interacting with new people can be anxiety-inducing (Gowen et al., 2019). Therefore, individual semi-structured interviews were used to gather the views of autistic adults. The interviews took place in a location of the participants’ choosing. Accommodations as recommended by Pellicano et al. (2017) were made, including providing the interview guide in advance, giving plenty of warning of changes to the setting or schedule and allowing the interviewee time to process what had been said before repeating a question. The data were analyzed qualitatively using reflexive thematic analysis (Braun & Clarke, 2006, 2019). This is the first study to focus solely on stakeholder views on peer-mediated intervention with minimally speaking children, and reflexive thematic analysis facilitated the researchers to adopt an inductive approach and work within a constructivist epistemology (consistent with Braun & Clarke, 2022). This study design was reviewed and accepted by the University of Limerick, Faculty of Education and Health Sciences Research Ethics Committee (2019_06_26_EHS). .

Each focus group comprised of only one category of stakeholder, i.e., all ECEs, all parents of minimally speaking preschoolers on the autism spectrum, all parents of non-autistic preschoolers and all SLPs. This was to facilitate the disclosure of attitudinal or organizational influences on behavior that may be challenging to disclose to a mixed group (Carey & Asbury, 2012).

The context for the current study was the Republic of Ireland where there is a universal two-year preschool program (Department of Children, Equality, Disability, Integration and Youth, 2021). The program is provided for three hours per day, five days per week over 38 weeks per year. A model of support is currently in place to ensure that children with disabilities can access the preschool program. SLPs are predominantly employed in health settings and provide input to preschool children directly and indirectly in clinical and educational contexts, working with parents, educators and others as required.

Focus groups with ECEs and SLPs progressed as planned, as did face-to-face interviews with autistic participants. COVID-19 restrictions were introduced before the focus groups with parents had been conducted. Early childhood education settings and schools were closed. Some workplaces were closed, and others remained open. Face to face meetings were prohibited. This was the first lock down in the Republic of Ireland and it was a time of uncertainty for many people. To facilitate the continuation of the study, we altered our data collection approach for these groups to the use of online, recorded, one-on-one semi-structured interviews. This was preferable to online focus groups as it was challenging for people to commit to a specific day and time in advance, so individual interviews allowed for more flexibility as interviews could be scheduled at a time that suited each participant. These changes were reviewed and approved by the ethics committee.

We sought to recruit participants from across five stakeholder groups: autistic adults, ECEs, parents of autistic children who are or were minimally speaking during the preschool years (i.e., using significantly fewer words than expected levels relative to age, as per Koegel et al., 2020), parents of non-autistic children who currently attend preschool and SLPs. The inclusion criteria required that participants were living in the Republic of Ireland, could express themselves using the English language and that ECEs and SLPs had at least 12 months experience working with preschoolers on the autism spectrum, to ensure the inclusion of sufficiently experienced participants. There is no sample size requirement for reflexive thematic analysis research (Braun & Clarke, 2022), instead sample size is determined by a mix of interpretative, situated, and pragmatic judgements (Braun & Clarke, 2019). We planned to conduct one focus group per stakeholder group. We estimated a provisional sample size of between 20 and 60 participants, based on focus group guidelines of 4–12 participants per focus group (Tong et al., 2007). Participants for semi-structured interviews and focus groups were invited via purposive and convenience sampling through the following channels: the national SLP Autism Special Interest Group (SIG), local preschool network, local parent organizations, and the university’s autism SIG. Emails were distributed via contact points in each organization.

Nineteen participants, across five stakeholder groups participated: autistic adults (n = 3), ECEs (n = 5), parents of autistic children who are or were minimally speaking during the preschool years (n = 4), parents of non-autistic children who currently attend preschool (n = 2), and SLPs (n = 5). Characteristics of the participants are provided in Table 1.

Before COVID-19 restrictions were introduced, five parents had signed up to each of the two planned parent’s focus groups. When contacted again post-COVID-19 restrictions, one parent of a minimally speaking autistic child did not respond, leaving a total of four participants in this stakeholder group. Of the five parents of typically developing preschoolers, three indicated by return email that they no longer had availability to participate in the study, leaving a total of two participants in this stakeholder group. We deemed it relevant to include the groups with smaller representation in the analysis as this is an exploratory study (Carey & Asbury, 2012), consideration of this topic is novel, and it was important to include these stakeholder perspectives. Our sample size of 19 is just short of our provisional sample size range, and balancing the impact of COVID-19 and the pragmatics of recruitment we are confident the data add to an understanding of this topic area.

The interviewer (first author) was known to six of the participants prior to study commencement due to her previous involvement with the groups in the various recruitment channels. All participants were aware that the interviewer was conducting this study in part fulfilment of her PhD, as per the Information Sheet (see Appendix B). Participants received no financial remuneration. Tea/coffee/water and light refreshments were available for participants where focus groups/interviews were face-to-face.

The researchers engaged in reflexive practice throughout the research process, interrogating and considering their positionality and influence (as per Holmes, 2020). The first author, an SLP with a Master of Science degree, has worked in preschool settings as an SLP for four years, and as a lecturer in SLP for 6 years. She is an active member of local and national autism SIGs. Her understanding of autism is shaped by the children and families with whom she has worked, her autistic collaborators, friends, and their families, and the concept of neurodiversity. She views inclusive education opportunities in a positive light and has research experience in qualitative methodologies including focus groups and interviews.

The final author, an SLP with a Doctoral Degree and wide research experience, has worked as a SLP with children with communication difficulties and as a lecturer and researcher in speech and language therapy for 19 years. She has particular interests in intervention development and implementation for children with communication difficulties including valid approaches for educational settings.

Both second and third authors are senior academics with extensive research experience across multiple methodologies. Both are active in intervention development and implementation.

The Participant Information Sheet (Appendix B) was supplied to potential participants during recruitment. Participants also had an opportunity to read the information sheet at the beginning of the focus group/interview and to ask questions. If the participants were happy to proceed, then they were provided with the consent form. No participants dropped out or decided not to participate at this stage.

The first author conducted the interviews and focus groups. The final author monitored the audio-recordings for adherence to the study procedure and engaged in transcript checking and theme development.

Focus groups lasted for 40 min (SLP) and 60 min (ECE) and were audio-recorded. Participants were encouraged to respect the privacy of others by agreeing not to disclose anything about the focus group discussion to others. Semi-structured interviews lasted from 10 to 40 min (median = 29 min) and were audio-recorded. One interview was particularly short (10 min). This interview was with an autistic participant, who had considered the interview script in advance and provided answers to all the questions asked. Their rate of speech is fast and there was little deviation from the questions in the interview script. When engaging with people from various sociocultural backgrounds it can be necessary to challenge some of the beliefs that we hold about what is appropriate or sufficient when using qualitative methods (Chauhan & Sehgal, 2022). The first author conducted each interview. The face-to-face focus groups and interviews took place in a space mutually agreed between the participant(s) and researcher and consisted of a mix of workplace and neutral environments (see Table 1). Only the participants and researchers were present. The online interviews were conducted using Microsoft Teams.

Focus Groups and Interviews followed guides (see Appendix C). These guides were informed by Duda's implementation science in education framework (Duda & Wilson, 2018) and the contextual factors identified in the Practical, Robust Implementation and Sustainability Model (PRISM) by McCreight et al. (2019). The guides were also influenced by the systematic review of PMI with minimally speaking children on the autism spectrum conducted by the current research team (O’Donoghue et al., 2021). There were slight differences in the questions that were put to the professionals (SLPs and ECEs) and to parents and autistic adults. This was to allow for the exploration of issues that are of particular relevance to each group, for example, the lived experience of an autistic adult. There were no further differences in the guides across focus groups and interviews. All guides began with the first author providing a description of PMI and asking participants whether they had experience of this intervention. No participants had been involved in a PMI as described.

The first author transcribed the focus groups/interviews verbatim. Participants were assigned pseudonyms to protect anonymity. Once the audio recording of each focus group/interview was transcribed, verified (four transcripts were double checked for procedural and transcription accuracy by the final author), and cleaned (participant identifiers removed), the original audio recordings were permanently deleted. Short, keyword field notes were handwritten during the interviews and focus groups and stored with study data.

Braun and Clarke’s (2021) six-phase analytical process was used: (1) data familiarization; (2) systematic data coding; (3) generating initial themes; (4) developing and reviewing themes; (5) refining, defining, and naming themes; and (6) writing the report. In the initial stages of the analysis, the first author engaged in an in-depth reading of the transcripts to become attuned to key issues and ideas arising from the perspectives of participants. NVivo software was used to manage the dataset. A semantic approach to coding was adopted in order to describe the experiences of the participants, with themes considered in terms of their broader meaning and implications (Braun & Clarke, 2006). In reflexive thematic analysis coding quality is not dependent on multiple coders, and a single analyst is common (Braun & Clarke, 2022). Forty-six data codes were identified during systematic data coding. These were organized into preliminary thematic areas. The first and last author discussed and developed these themes over a series of three meetings. The meetings facilitated the primary analyst (first author) to enhance interpretative depth and for authors to ensure that alternative interpretations and possibilities were considered. Conversations centered around reflecting on the inductive nature of the analysis, ensuring that theme generation was not the provision of a summary of the answers provided to the questions asked during the focus groups/interviews and that codes that challenge predominant views in the literature on PMI were addressed. Candidate themes were identified that captured how some codes were clustering together. This is a subjective and interpretative process in which the authors take an active role in knowledge production (Braun & Clarke, 2019). These themes were reviewed and analyzed until each theme was clearly defined. Analytical memos were created within the software to document key insights and decisions made, as a strategy to enhance the overall trustworthiness and transparency of the analytical process. The first author prepared a Microsoft Word document detailing each theme, with illustrative examples from the text. This was shared with co-authors and discussed in a peer debriefing session. Transcripts were not returned to participants to comment on, but a summary of the themes was shared with participants.

PMI was conceptualized as being embedded within the preschool’s philosophy, rather than as a stand-alone intervention that takes place at specific times of the day. It needs to become the “norm” for the preschool and “part of their ethos” (parent of NA child 1). It is not a “nice, charitable thing to do”, it is “fulfilling the (autistic) child’s human rights” (autistic adult 3).

If your peers and those around you were taught how to interact with you and how to support you and how to meet you where you are (you) wouldn’t have to … go the full way, you could meet at halfway. All of the work wouldn’t be on one side. (Autistic adult 3).

To achieve this, staff need to be “on board”, if not “they’ll do it every so often … and then it just won’t work” (autistic adult 2).

Staff need to engage in both “opportunism and orchestration” (parent of minimally speaking (MS) child 1), setting up PMI at pre-determined points during the preschool day, but also taking advantage of naturally occurring opportunities as they arise, “tweaking what's there naturally” (parent of NA child 1). Participants described how an observer would not notice PMI overtly: “It wouldn’t stand out, it would just be like the other interactions taking place in the room: the playing, the disagreements, the turn taking, the crying, the laughing … you wouldn’t really notice that this is something that’s going on” (autistic adult 3). This removes any need to single out the child on the autism spectrum, “that’s the worst thing, to single them out” (autistic adult 1).

Embedding PMI in this fashion could negate the need to wait for specialist support to implement it. Participants described “missing the key opportunity” (SLP 1) to intervene early and waiting a significant amount of time for a diagnosis “there’s children coming in … and there’s a year there of a gap before they’re getting assessed” (ECE 2). Nevertheless, outside of specialist services, a lack of understanding of autism limits the ability of preschool staff and parents to successfully implement strategies such as PMI: “In the last five years the children that have come into our service that are non-speaking has increased … and we’re only learning now really to change our ways” (ECE 3). Without specialist support there is an “insecurity” (parent of MS child 3) in decision-making and a “fear of doing the wrong thing” (autistic adult 3).

A complex picture emerged of the role of the adult(s) responsible for implementing PMI, typically identified as a preschool staff member. The level of parental support or buy-in will depend on the trust that parents have in the person telling them about PMI, “if you have a parent in a good place, they’re much more open then when you’re coming with a suggestion, saying ‘I’d like to try this’ or ‘I’d like to try that’, they’re less cautious of you” (ECE 5). Trust must also exist between the PMI interventionist and the children involved, “that relationship has to be there between the teacher and the child” (parent of MS child 4); “trust has to be built up” (ECE 3).

When implementing PMI, the adults responsible need to set up opportunities for interaction, while also facilitating naturally occurring interactions as they arise. They provide support for both the child on the autism spectrum and the peer(s) in the interaction, modify this support depending on the situation, modify the intervention to suit an individual child’s needs, explain the children’s behavior, provide praise, and also coach the children through when the interaction “fails” (parent of MS child 1). This occurs in the context of collaboration and consultation with other team members, including the child themselves, caregivers, and specialists. The PMI interventionist needs to communicate how PMI is progressing to other team members and understand that change may be “a slow process” (ECE 2) and not “an overnight thing” (autistic adult 3). Beyond direct PMI itself, preschool staff also have an active role in supporting their colleagues to engage in PMI and providing encouragement in order “to keep that morale up” (ECE 5).

Participants warned against PMI being the remit of one member of staff, or a specialist member of staff (e.g., Special Needs Assistant), while also proposing appointing a PMI “champion” (autistic adult 2) who would build their own knowledge and expertise of PMI and then support other staff members in its implementation. Staff training is necessary to build capacity and understanding: “if it was to be done properly, you have to have the teacher trained” (parent of MS child 4), “there’s a lot of training involved obviously of staff” (SLP 2), “you need a level of expertise for a child … to do justice for the child, to do justice to the parent” (ECE 5). Currently, training opportunities are limited “[there is] so little support for preschool educators both in terms of training and the cost” (autistic adult 3).

Stakeholders described peer selection for PMI as happening over time, mirroring natural friendship development. Early childhood educators described letting children “find their own way” (ECE 4), and how all children may be drawn to particular peers, “certain children gravitated straight away … the children who naturally gravitated were the children who wanted to be there … and they gravitated not because they saw the child as different, they gravitated because they like something about that child” (ECE 5). Similarly, the child on the autism spectrum may also choose the children with whom they want to interact.

We had one little boy, he would eat his lunch at the windowsill, and…over time … he graduated bit by bit and would stand at the edge of the table before he sat down. But, he still picked the table he liked the children at. You know, so then we said, ok now we have a group, now we have a group to work with. (ECE 4)

At times, this process may involve adult involvement and trial and error, “You would try and see people that you think would match together, personality wise, and try and get them in the same area. Maybe with a similar activity that they enjoyed. And try to see would it happen organically” (ECE 1).

The parents of minimally speaking children cautioned against relying solely on one special friend “the one person that he seems to click with” (parent of MS child 4), as over time “friendships may drift apart” (parent of MS child 1), and the autistic child may become isolated. Parents proposed that extending the number of children who understand their child’s behavior would lead to greater participation in preschool activities. The parent of a non-autistic preschooler hypothesized that peers would influence one another and seeing one child engaging in PMI would lead other children to seek it out.

Participants foregrounded the importance of individualizing and adapting PMI to meet the needs of each child. “Every one of them is going to be different” (parent of MS child 4) so “[PMI] has to be tailored to the child’s abilities and what the child wants” (autistic adult 2). Children may be ready for different levels of peer interaction, and the kind of support that they need in these interactions may vary, for example, “it may be a very sociable child, who perhaps needs … some boundaries put in place” (autistic adult 3). Children’s receptive language level and sensory requirements will influence the implementation of PMI. One parent described how their child finds noisy environments challenging, and therefore PMI with their child would need to be facilitated in a quiet environment, separate to the main preschool space (parent of MS child 2).

Children also need to have a choice to opt-out, “maybe preschool is already overwhelming enough” (autistic adult 3) and “we don’t know what the kid thinks” (parent of a MS child 1). This may involve some “trial and error” (autistic adult 3), as there may be particular times of day that suit the child better than others do and “there will be days when you just can’t do it” (autistic adult 2). Engaging in PMI may be tiring for the autistic child:

I think you've … got to understand just how much of a challenge it is for the child that is speaking or non-speaking, that it potentially may take a whole lot out of them. It may be that after that they feel like they want to be on their own for 45 minutes, and that’s okay. (Parent of MS child 2)

One avenue to individualize PMI is to incorporate the child on the autism spectrum’s interests. This can provide an avenue for communication (“the reason I didn’t communicate is because I wasn’t interested in what they were talking about”), connection (“I would have liked to be involved more if the people were interested in what I was interested in … I would have liked to connect with them”) and shared enjoyment (“they love talking about their things”) (autistic adult 1). This could involve individualizing the activities used, for example, setting up a pretend play opportunity based on pirates for one child, but for another child it is based on zoo animals. This engagement with the child’s interest was described as a “nice bridge” (parent of MS child 2), while the parents of non-autistic preschoolers predicted that once the activity was play-based it would be of sufficient interest to their child to hold their attention.

The PMI interventionist would benefit from open communication with other stakeholders to identify how best to individualize the approach and to discuss challenges that arise: “We took advice from everyone, and we kind of tweaked it a little bit ourselves as well, and it worked” (parent of MS child 3).

Participants identified potential positive changes (both immediate and long term) for both the minimally speaking children and their non-autistic peers, because of their involvement in PMI.

For the child on the autism spectrum, participants described them as experiencing an increased level of inclusion “bringing them into the social circle” (parent of NA child 2), and their enjoyment of this inclusion “[being] there with others and happy to be there” (parent of MV child 4). This has potential long-term benefits: “he’s not going to be alone in his life. The more he is exposed to others the better” (parent of MS child 1). Increased interaction presents an opportunity for learning language from their peers, and for learning generally, “it would bring them on” (autistic adult 2). This learning is mutual “she learns from them, and they learn from her” (parent of MS child 3).

For the peers, stakeholders identified PMI as an opportunity to develop empathy, “put themselves in the other child’s shoes” (SLP 2) and to learn about people’s differences, “the more knowledge that they have about differences then they’re … more comfortable” (SLP 1). PMI also provides chances to advance children’s social skills, “teaching a child social skills to interact with a child that is < on the autism spectrum > … is going to aid the child learning social skills in the rest of their social interactions as well” (parent of NA child 1). These skills have the potential to generalize to other settings, such as the playground, “the hope is that they’ll bring that with them going forward” (SLP 1). Parents would need information about how to make this happen, “if they were to be at a playground with their child, and they bumped into a child with additional needs…these skills are generalized … as parents can you support your child to deal with that situation?” (Parent of NA child 1).

Benefits may be experienced at a societal level as peers become more understanding and accepting of difference, “one of the main [barriers] is the judgement and attitudes of others … there is a huge benefit to other people being more open minded” (autistic adult 3). PMI provides a way to address this societal barrier “this is a nice way to plant the seed in parents of young children … that … it’s their children [who] are going to be the ones to support anybody with extra needs in the society” (parent of NA child 1). The youthful status of the children was important in this regard “it’s a lot harder to teach them the older they get, whereas if they are brought up with it … it’s going to be a lot easier” (autistic adult 2). One parent of a non-autistic preschooler described their child’s acceptance of the “different” behavior of their friend who is on the autism spectrum.

He was at a party here a few months back, it was very noisy, there were kids everywhere going bananas and he couldn’t cope, and he had to go home. And the lads are just like, ‘that’s Billy, he doesn’t like noise, you know’. So, he’s a little different but they don’t have any bias or anything towards him, you know. That’s the good thing about that age group … they don't recognize differences as much as older groups you know? (Parent of NA child 2)

One parent identified capturing these changes as a “challenge [because PMI] is about the relationship” and so it may need consideration “over time” (parent of NA child 1).

In an effort to appreciate the acceptability of PMI from a variety of viewpoints, participants from a range of stakeholder groups (autistic adults, ECEs, parents, SLPs) were invited to participate. The authors make no claims as to the sample being representative, but there are certain characteristics of the participants that may affect the interpretation of the results. None of the participants of the current study has participated in PMI, and their perceptions of its acceptability may change if they were to experience it. That said, prospective, or anticipated, acceptability remains worthy of investigation as it highlights aspects of an intervention that can be modified to enhance acceptability, and thus participation (Sekhon et al., 2021). The focus of the current study is on minimally speaking children on the autism spectrum, but only one of the three autistic participants had experience of being minimally speaking. The ECEs were all highly experienced. Perhaps less experienced ECEs would not have the confidence to take on the complex role of PMI interventionist, and this may act as a barrier to participation in PMI. The first author was known to six of the participants. While this is not inherently problematic (Carey & Asbury, 2012) it is possible that this prior relationship may have influenced the participants’ responses. The views of preschool children, both autistic and non-autistic, are not represented here. Children have important and highly relevant ideas and insight about their life experiences that we can learn from (Lyons et al., 2022). The authors intended to conduct a small group workshop with four preschool children using vignettes to explore the children’s ideas about interacting with children who have complex communication needs. Due to the onset of COVID-19 the workshop was not conducted, and the research team agreed that moving the session to an online forum was inappropriate given the young age of the participants, and the multimodal nature of the planned workshop.

According to the participants in the current study, PMI is an approach that is embedded in a preschool’s philosophy, and led by members of the preschool team, who implement it as opportunities arise throughout the school day. They described PMI as facilitating inclusion, and the children as learning from one another. This conceptualization may be better described as peer-mediated accommodations, rather than peer-mediated intervention, which may assume that the non-autistic children’s social interaction skills are in some way superior to the children on the autism spectrum. In line with guidance on developing complex interventions (O'Cathain et al., 2019), we propose conducting intervention development workshops with stakeholders to generate a protocol for an embedded PMI that is cognizant of implementation challenges and supports. Further investigation is required to determine whether this approach to PMI is as efficacious as more traditional approaches. This will involve data-gathering at multiple levels, including consideration of the preschool’s ethos and the communication environment, individual staff skills and knowledge, approaches to peer involvement and measuring the benefits as well as the costs to the children involved. Continued work with stakeholders may not only inform PMI development and implementation but may also reshape and reconfigure what is prioritized in PMI, in light of stakeholder views.