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Activity Schedules for children with autism

Efficacy of Activity Schedules as Intervention for Children with Autism

 Children with autism have difficulty with the concept of time, experience anxiety relating to what events come next and have difficulty in independently planning and engaging in appropriate activities. Activity schedules visually represent a set of tasks or activities. Pictures are used for visual learners and words are used for children who have reading abilities. Sometimes it is seen that children with autism, even while competently doing their activities keep looking at an adult for a prompt to move to next or continue to stay on task. Visual schedules can help reduce dependence on adults or other people.

Activity schedules can be for a simple three or four step activity ( Dressing – wear underpants, wear vest, wear shirt, wear trouser)  they could cover a series of activities the child need to perform ( make a toast, play with iphone, finish a worksheet), it could cover events throughout the day ( breakfast,  get dressed, go to school, return by bus from school, evening meal, TV time, play at park, homework, supper, sleep) and with children that have advanced at learning schedules  even events during a month can be visually presented (  Grandma visit, long weekend stay at beach , going to a marriage…).

In my practice I come across several children who  would start their next activity which could be fixing a puzzle or going and playing on the swing only after an adult gestures or prompts.  They could move from one activity to another in a span of 3- 4 minutes but would be dependent on parent or trainer to stop an activity or start the next activity. Even in seemingly simple functional routines where they are  fluent in all the steps they could need prompts such as open the tap, rinse mouth, take toothbrush, squeeze paste on to the brush etc.,  Further, there are children who can complete the parts of the chain but will look at adult for some kind of a prompt to move on. In the context of helping such children  become atleast partly independent,  I started looking at a combination of visual schedule which can prompt the next activity to move to and and a  timer which can tell them when to stop ( in case the activity is a open ended activity like playing with ipad as opposed a closed ended activity like completing a 25 piece jigwas puzzle). I had to start with research on work that has already happened and felt I’ll share what I learnt while studying literature-  I’ll try to lighten the technical heaviness of what I am going to write but do bear with me if I am not entirely successful as I am trying to look at technical research..

According to Schopler, Mesibov (1995),  activity schedules reduce the need for adult prompts, help children transition between activities and provide a structured teaching environment. Further, the use of visual schedules also  help given the auditory deficits  of children with autism Schopler, Mesibov, and Hearsey (1995) .

Thus activity schedules are expected to transfer  control from verbal or imitative or gestural prompts  given by adults to pictures, symbols or photographs thus reducing the child’s dependence on adult prompts. Further, if correctly designed and implemented, activity schedules visually let children know their rate of progress, estimate time remaining to complete allotted activities and thus can reduce frustration.

One of the early studies by Applied Behavior Anlaysts examined teaching children with autism to be independent in emitting complex  response chains (Macduff, Krantz, & Mcclannahan, 1993).

The authors selected four youth whose interventions involved staff giving verbal instructions and physical prompts. The instructions rate were as high as 2 per minute ( Look at the level of dependence on adults and possible aversion to voice that may arise?) . The authors further reported that most of the responses had to be prompted and there was  no spontaneous emission of previously taught chains of activities. The study, after a baseline measurement went on to use photographic activity schedule depicting 6 leisure and homework activities.  The teachers stood behind and used  graduated guidance ( a procedure where initially trainers provide prompt to the extent required and reduce or fade as the child begins to gain independence)  from behind the participants to teach them to follow a schedule and be on task ( i.e., they had to teach the use of visual schedules using prompting and prompt fading procedures so that the actual performance of chain of activities may be dependent only on the photo schedules).

In terms of results, all the participants , after the training phase ( 13- 27 sessions) were found to be independent , i.e., not reliant on any teacher prompts , were on task and on schedule. They also generalized schedule following to novel chains. Anecdotally, the authors record a reduction in aberrant behavior from the participants. The effectiveness of photographic schedule training with graduated guidance was evidenced by the fact that the participants were able to independently engage in complex leisure and daily living activity chains for one full hour ( Quite a dramatic achievement is’nt it , considering the children needed 2 adult prompts per minute at baseline ).

Referring to the above study and replicating  it  Bryan & Gast (2000) taught four children with autism in a public elementary school program to  use visual activity schedules using a Graduated Guidance procedure. They measured on-task and on-schedule behaviors of the children after teaching them the mechanics of using activity schedule. The children carried the activity schedule in a book. The students not only learnt how  to use an activity schedule (with graduated guidance support from experimenters) but also maintained high levels of independent on-task and on-schedule behaviors with just the support of picture books . This had an automatic effect on reducing non-scheduled behaviors.

A contra indicator is the study by Waters, Lerman, & Hovanetz ( 2009). Transitioning from a one task to another, often from a high preference task to a low preference task can be accompanied by emotional reactions and inappropriate behaviors. A treatment package consisting of extinction plus differential reinforcement of other Behavior (DRO) was tried with and without visual schedules. In this study the authors found that problem behaviors reduced with extinction plus DRO regardless of whether a visual scheduled was used or not.

This study calls into question the usefulness of activity schedules in facilitating transitions especially preferred to non-preferred. However, I would still like to examine the value of removing adult mediation during the transition.

Bryan & Gast (2000) also report a number of prior studies which found the use of activity schedules effective . They are tabulated below:
Betz, Higbee, & Reagon ( 2008) made a first of its kind study when they studied the effect of two children ( a social pair) following the same activity schedule to play  a series of interactive games. The three pairs of children with autism chosen for the study were between 4 and 5 years of age and they were assessed to be able to follow activity schedules independently. Activities or games were chosen for them to engage in that allowed  two people to take turns ( don’t spill the beans, crocodile dentist etc.,)  and the children were taught how to play these games fluently.  While in baseline condition no joint activity schedule was used, in the intervention phase teaching was given for each of the paired children to refer to the joint activity schedule, say brief lines from script and enagage in an activity or game collaboratively.  This study found that for every pair the engagement level ( defined as being on task and taking one’s turn appropriately) that was very low in baseline phase reached to 80% in the teaching phase and was sustained in the maintenance, re-sequencing and generalization phases.  This is a higher order training method and demonstrates the utility of activity schedules in promoting peer engagement in children with autism.Heres another big breakthrough possible with activity schedules: They can be used to teach joint activities, peer play etc., especially where turn taking is involved?

As  elaborated with several examples in this paper, activity schedules have proven to be effective in teaching children to be on task, on schedule, to be independent to a higher degree, in reducing inappropriate behaviors, in facilitating peer play without adult prompts, in teaching vocational skills, home living skills, leisure skills, play skills etc.

From the foregoing discussion it can be discerned that research on activity schedules had started in the 1980s and is continuing till date. It is important to note that though the dozen odd studies referred to in this article have demonstrated effectiveness barring the study by Walters etal., ( 2009), the volume of research and replication in the three decades does not seem to be high. This relatively low volume of research activity is surprisingly at variance with widespread use of activity schedules in one form or other across special schools catering to children with autism and other learning disabilities.

In terms of recommendations, activity schedules along with training to use them should be considered as a treatment of choice to promote independence , reduce dependence on adult prompts and to promote generalization. This is on account of the fact that the studies that have been done have reported success and the treatment will gain more favour with increasing replications and novel variations.

References

Bryan, L. C., & Gast, D. L. (2000). Teaching on-task and on-schedule behaviors to high-functioning children with autism via picture activity schedules. Journal of autism and developmental disorders, 30(6), 553–67.

Betz, A., Higbee, T. S., & Reagon, K. a. (2008). Using Joint Activity Schedules to Promote Peer Engagement in Preschoolers with Autism. (G. Hanley, Ed.)Journal of Applied Behavior Analysis, 41(2), 237–241. doi:10.1901/jaba.2008.41-237

MacDuff, G. S., Krantz, P. J., & McClannahan, L. E. (1993). Teaching children with autism to use photographic activity schedules: Maintenance and generalization of complex response chains. Journal of Applied Behavior Analysis, 26, 89–97.

Miguel, C. F., Yang, H. G., Finn, H. E., & Ahearn, W. H. (2009). Establishing derived textual control in activity schedules with children with autism. Journal of applied behavior analysis, 42(3), 703–9. doi:10.1901/jaba.2009.42-703

Neitzel, J., & Wolery, M. (2009). Steps for implementation: Graduated guidance. Chapel Hill, NC: The National Professional Development Center on Autism Spectrum Disorders, FPG Child Development Institute, The University of North Carolina.

Schopler E, Mesibov G, eds. Learning and Cognition in Autism. New York: Plenum Press, 1995:311–334.

Schopler, E., Mesibov, G., & Hearsey, K. (1995). Structured teaching in the TEACCH system. In E. Schopler & G. Mesibov (Eds.), Learning and Cognition in Autism (pp. 243-268). New York: Plenum Press.

Waters, M. B., Lerman, D. C., & Hovanetz, A. N. (2009). Separate and combined effects of visual schedules and extinction plus differential reinforcement on problem behavior occasioned by transitions. Journal of applied behavior analysis, 42(2), 309–13. doi:10.1901/jaba.2009.42-309

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