Stephen Anderson, Ph.D., is the chief executive officer of Summit Educational Resources, which provides educational and therapeutic services to children with autism in Buffalo, New York. A child psychologist, Dr. Anderson is a national expert in the education and treatment of children with autism and related developmental disabilities. He has worked in the field of developmental disabilities for more than 25 years. Dr. Anderson holds appointments as adjunct assistant professor at the University of Kansas and the State University of New York at Buffalo and an adjunct with the Exceptional Education Department at Buffalo State College.
With much of the current emphasis on early intensive intervention and recovery, parents and teachers of young children with autism do not spend a lot of time talking about deficits in self-help skills. Most are more concerned with the child’s development of functional communication and early cognitive skills. Often, it is simpler to dress the child than it is to teach the child to dress him/herself. But dressing and the development of other basic self-help skills are important to success at school and work, making friends, and living independently.
As an individual develops self-care skills, her/his ability to live and function independently across multiple environments increases, and it influences the level of supports an individual will need. Vine and Hamilton (2005) examined the individual characteristics associated with community integration for 37 individuals of with developmental disabilities. Scores on daily living scales were found to correlate with objective aspects of quality of life such as community access, daily routines, and choice opportunities.
Self-help skills are part of a larger group of behaviors called “adaptive skills,” a collection of practical skills that enable individuals to function in everyday life. Adaptive skills include communication, community self-sufficiency, socialization, behavior, and activities of daily living (ADL). The basic skills of eating and drinking, dressing and undressing, toileting, and personal hygiene all fall within ADL.
Individuals with autism often experience a gap between intellectual functioning and adaptive functioning that is not evident in individuals with developmental disabilities without autism. Studies have also shown that children with autism often display poorer adaptive skills (including ADL) and significantly more maladaptive behaviors than a comparison group of individuals with developmental delays without autism. Because individuals with Asperger’s have intellectual abilities within the normal range, one might quickly conclude that this group would not present delays in ADL. However, at least one study showed that individuals with Asperger Syndrome also demonstrated moderate deficits in most adaptive skills, including ADL, in spite of their advanced vocabulary and normal IQ scores.
One of the challenges in working with individuals with autism is that it is a very diverse group. At one end of the autism spectrum are individuals with significant intellectual delays and at the other end are individuals with intellectual abilities within the normal range. It is fairly safe to assume that profiles of communication, social, and intellectual deficits may present broad challenges for teaching new skills. Specifically, deficits in attention, imitation, and symbolic play are very likely to impact the individual’s learning and the instructor’s choice of instructional strategies. Likewise, behavioral issues such as an interest in consistent routines, stereotypical behavior, and aggression may present unique challenges.
Imitation and Observational Learning. Little research exists to explain how typical children learn self-help skills. Children appear to learn largely from their parents’ coaching, demonstration, and frequent reminders. Simply showing and telling seems to be enough for most children without ASD. Through imitation, children learn a variety of basic and complex skills within a short period of time. Whether it is the reward of matching or the praise they receive from parents and teachers, the motivation to imitate is present very early. Many children with autism, however, do not learn to imitate naturally and are not likely to learn by simply observing their parents or listening to their parents’ instructions.
Communication. Communication, particularly the ability to understand and integrate information, is important for typical development. Once again, many children with autism experience significant delays in both the understanding and production of speech. As a result, methods that rely on verbal instructions and explanation may not work very well.
Adherence to Rituals and Routines. Individuals with ASD sometimes exhibit adherence to specific routines and stereotypic mannerisms (e.g., hand flapping). These behaviors can be particularly challenging because they may interfere with getting and sustaining the learner’s attention when teaching new skills.
Sensory and Motor Issues. Finally, a variety of sensory and motor concerns may interfere with learning self-help skills. These issues may be present at a very early age for some otherwise typically developing children but rarely persist beyond the first three or four years of life. In contrast, children with autism may have ongoing sensory and motor issues, such as an extreme sensitivity to the texture of toothpaste or a struggle with the fine motor skills needed for buttoning.
Arguably, deficits and excesses in these areas will make teaching and learning self-help skills more challenging; but there is no evidence that their absence predicts failure for the development of self-help skills. However, the instructor must find another way to teach and for children to learn. Many learners require an approach that relies heavily on breaking the target skills into very small steps and directly teaching the skill one step at a time – often accompanied by direct physical prompts for desired responses that later must be faded. Similarly, adherence to routines and sensory and motor deficits will make teaching more challenging and may extend the time it takes to learn a new skill; however, it does not mean that instruction will be unsuccessful.
Over the last 25 years of research, instructional strategies have emerged for teaching self-help skills. The general approach for teaching self-help skills has included various combinations of behaviorally based principles that include stimulus control procedures, task analysis, chaining, reinforcement, and prompting.
Stimulus Control Procedures. One of the first questions to consider when beginning instruction is: What stimuli should control the learner’s behavior? For example, the stimuli that control washing hands should be the presence of noticeably dirty hands or learned sequences such as washing hands before you eat. For a preschool child, a verbal instruction from the teacher or parent to wash their hands before eating is normal. When a prompt is still necessary when the individual reaches adolescence or young adulthood, it is no longer normal.
Chaining and Task Analysis. A behavior chain is a sequence of discrete behaviors that make up more complex behavior. A chain allows the simplification of complex behaviors into a series of steps for learning. Examples of chaining are plentiful, such as chaining together simple steps to form the skill of “putting on a t-shirt.” Once learned, this simple skill can be combined with all other articles of clothing to form the act of dressing (an even longer chain). The job of breaking down complex behaviors into a series of teachable steps is called a task analysis.
Prompting. Because many individuals with autism may not have any of the component steps of the task analysis, the instructor often must rely on prompting to occasion the behavior so that it can be reinforced. There are three basic ways to prompt desired behavior: verbal, model, and physical guidance.
Verbal prompts involve specific instructions (e.g., “get dressed”) to help the child begin or continue the target task. Modeling involves demonstrating the desired behavior while the child observes. It may be effective for learners who can imitate and who have some of the component skills prior to instruction. Physical guidance prompts are often used with children with severe disabilities. Physical guidance may involve the instructor fully guiding the learner or partial prompts such as touching the learner’s elbow to encourage picking up a toothbrush.
Prompts, although very effective for teaching new skills and maximizing the instructional time, present a risk that the learner may become dependent on them. Thus, the instructor or parent must introduce prompts only if absolutely needed, then fade them quickly and systematically. One of the most common approaches to using prompts systematically is most-to-least prompting. When most-to-least prompting is applied, the instructor provides physical guidance at the level where the child is likely to correctly perform the step. Over trials or sessions, the instructor slowly reduces the amount of help as the child begins to independently perform the task (e.g., reducing the amount of effort needed to guide the child).
Other Strategies. A variety of creative visual and tactile strategies have been employed to minimize dependence on adults and to maximize the strengths of learners with autism. For example, the use of pictures, activity schedules, and videotape has all been reported. Visually cued instruction in the form of activity schedules and video modeling have been used to teach a variety of skills and hold great promise for teaching self-help skills. Tactile prompts such as the use of a beeper’s vibrating function also have been used to cue learners to respond without an adult verbal or physical prompt.
Given the pace of today’s society, asking parents to do much more seems daunting. The good news is that as individuals acquire skills, it means independence for the parents as well as the learners. In most cases, parents will be able to build on things they are doing already. For example, instead of taking the time to dress her son each day, a mother can use that time to introduce a program to teach him to dress himself. It may take a little more time initially, but eventually both gain greater freedom.
Whether a child is in a general or special education setting in a public or private school, school personnel also have a responsibility to provide a comprehensive program that addresses all areas of development, including self-help (Individuals with Disabilities Education Improvement Act – Revised, 2006). But if a child with autism is in a general education classroom, most teachers are focused on teaching required academic curricula and testing them on content – not teaching self-help skills. At a minimum, school district personnel should be involved to ensure transfer of skills from home to school. If your child attends a special education classroom for some or all of the day, the school district should be directly teaching self-help skills and these activities should be written into the child’s Individual Education Plan.
In summary, the acquisition of self-help skills is critical for individuals with ASD. Research has shown that children with autism often experience moderate to significant deficits in this area regardless of their intellectual abilities. Deficits in daily living skills have been demonstrated to significantly impact on quality of life related to community integration, work, and personal choices. Fortunately, there exists a body of scientifically proven methods for teaching self-help skills to individuals with ASD. When applied systematically, most individuals with autism can learn to be more independent and achieve a lifetime of greater success.
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