Independence is the ultimate goal for the majority of individuals in our society. For many, this goal is attained sometime between 18 to 30 years of age. However, for other individuals, such as those diagnosed with Autism Spectrum Disorder (ASD), full independence may never be attained; the aim then becomes to minimize the dependency on caregivers and providers.
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According to Shattuch, Narendorf, Cooper, Sterzing, Wagner and Taylor (2012), about 80% of adults with autism live at home and only 6% have paid jobs. These statistics are alarming, clearly indicating that greater efforts are needed to design and use effective interventions that teach long-lasting functional daily living skills to individuals with disabilities.
Functional living skills are those necessary to be an independent and productive individual in society (Hong, Davis, Neely, Ganz, Morin, Ninci, Boles, 2017); they include a variety of skills, from toileting and personal care to grocery shopping, banking and social skills (Ayres, Mechling, & Sansosti, 2013). Given some of the core characteristics of ASD, such as repetitive and stereotypic behaviors, deficits in language and communication skills, and poor attending skills, individuals with autism heavily depend on others to accomplish daily living skills (Hong et al., 2017). According to Hume, Loftin, and Lantz (2009) there are three particular factors of ASD that hinder the acquisition and maintenance of skills: prompt dependence, initiation, and generalization of skills.
Prompt dependence refers to learners relying on their instructors or caregivers to help them complete a task (even after they have already learned the task) (Mays & Heflin, 2011). Initiation refers to the lack of motivation to initiate different tasks, such as chores, homework or even social interactions and, again, reliance on others to get started; Last, generalization refers to the individual’s ability to demonstrate learned skills with untrained stimuli and people, as well as in untrained settings (Hume et al., 2009).
Hume et al. (2009) also reviewed three intervention strategies that have been effective in increasing independence in individuals with autism: Self- monitoring, individual work systems and video- modeling. These interventions are believed to be successful because they all focus on shifting stimulus control from continuous adult prompts during tasks to alternative stimuli.
In self-monitoring, the individual learns to discriminate and record the occurrence or absence of a particular target behavior. In this intervention, the stimulus control remains within the individual; that is, the learner is the one who attends to his own behavior and determines if the behavior meets the requirement for reinforcement. When teaching self-monitoring skills (i.e., ability to monitor one’s own behavior) in individuals with autism, four steps are followed: (1) creating an operational definition for the target behavior, (2) determining reinforcers, (3) choosing a self-management method or device, and (4) teaching the learner to use the selected method (Hume et al., 2009). This strategy has been effective in changing a variety of behaviors seen in individuals with ASD. For example, when monitoring their own behaviors, individuals have improved on-task behavior (Callahan & Rademacher, 1999), reduced stereotypic behavior (Koegel & Koegel, 1990), increased pro-social behaviors (Morrison, Kamps, Garcia, & Parker, 2001), and, most importantly for the purpose of this study, increased the performance of daily living skills without prompts from the caregiver or provider (Pierce & Schreibman, 1994). With self-monitoring, the learner has greater autonomy and responsibility, which reduces the dependence on prompts from others in their environment (Hume et al., 2009).
Similarly, an individual work system is a teaching strategy that highlights visual supports and focuses on reducing the recurrent need for teacher prompts and feedback and increasing independent functioning (Hume et al., 2009). In individual work systems, the learner practices mastered skills in a visually organized setting. In this setting, the work system transmits four pieces of information: (1) the target task the learner is supposed to complete, (2) how much work the individual needs to do, (3) how the learner will know when he/she is finished with the task, and (4) what to do once the task has been completed. This strategy uses a left-to-right system where the learner completes all of the activities placed on their left and then moves them to the right (i.e., the finished pile) as they complete them. In this intervention, the stimulus control shifts from the caregiver’s or provider’s prompts to the visual stimuli presented.
Video modeling is another visual strategy that promotes teaching different skills with minimal prompts from others. This is the third intervention reviewed by Hume et al. (2009). With video modeling, the individual learns a skill by imitating the behavior modeled by another person in a video. This technique is appealing to individuals with ASD because it helps them attend to relevant information required for the task while blocking out distractions. Furthermore, watching videos is a pleasurable activity for most individuals with ASD (Hume et al., 2009).
One strategy not mentioned by Hume et al. (2009) that has also been effective in promoting independent skills and reducing prompt dependency is the use of visual activity schedules (VAS) (Koyama & Wang, 2011). This approach utilizes visual cues to teach the learner a sequence of activities or tasks independently (McClannahan & Krantz, 1999). The purpose of activity schedules is to give the learner a visual cue of what will come next in his or her schedule. The visual cues are pictures, photographs or textual prompts related to the task. For example, an image of a sink would signify it is time to wash hands and an image of a bed would represent time to go to sleep. Parallel to the interventions mentioned earlier, stimulus control can be transferred from the caregiver or provider to the picture. Once the learner masters responding to the picture cues alone, the pictures can then steer behavior in the absence of a caregiver (Koyama & Wang, 2011). Outcomes of existing research have shown that people with disabilities can learn to use picture cues so effectively that they can even follow successfully multiple long behavior chains (e.g., washing hands, brushing teeth and then dressing). These results are significant because they indicate that VAS can be a useful strategy in reducing prompt dependency in individuals with disabilities, while promoting independence. Furthermore, activity schedules are not limited to particular ages, intellectual functioning or diagnosis and can be adapted and individualized for all persons (Koyama & Wang, 2011).
A review of the literature by Knight, Sartini, and Spriggs (2015) examined 16 studies to determine if visual activity schedules can be considered an evidence-based practice. Interventions are believed to be evidence-based when they have consistently shown to be effective in at least five research studies, three geographical locations, and with a minimum of 20 participants (Knight et al., 2015). Based on the studies reviewed, the authors determined that visual activity schedules meet the criteria to be called an evidence-based practice and can be used to maintain, expand and generalize a variety of skills in multiple settings. Further, their results suggested that VAS can be used to (1) teach on-task behavior and appropriate transitions, (2) decrease latency to begin tasks, and (3) decrease the need of prompts during transitions.
Similar to the results of Knight et al. (2015), in a literature review by Koyama and Wang (2015), they found that activity schedules increased engagement and on-task behavior. They also suggested that one reason why disruptive behaviors may decrease with activity schedules is that as individuals allocate more time on on-task behavior less time is allocated to maladaptive behaviors. One caveat they discovered from different studies is that when the researchers removed the activity schedules, on-task performance declined to baselines rates. However, as soon as they represented the activity schedules, performance increased back to post-treatment levels. This finding is important because the mode of presentation may have higher significance than we think; in other words, the way in which the visual schedule is presented to the individual (e.g., binder, book, Velcro strips, or portable device) may be a crucial variable in determining the success the individual will have with following the schedule. Due to the previously mentioned deficits observed in individuals with autism such as stereotypic behaviors and poor attending skills, activity schedules that require the individual to carry a binder or book with multiple pictures may be cumbersome. In a situation where the child loses one picture from the schedule or misplaces the entire binder, then he/she will not be able to follow independently the activities scheduled in his day. Thus, other devices that are easier to carry and can be easily accessed may be better alternatives to individuals with attending deficits.
In the last years, a couple of studies have embedded activity schedules within different portable devices including a tablet and an iPod touch (Brodhead, Courtney, & Thaxton, (2018); Carlile, Reeve, & Debar, 2013). For example, Brodhead et al. (2018) evaluated the effects of using a visual activity schedule embedded within an iPad to vary the play across different applications in three children with autism (age range 4-9). The activity schedule was a six-slide presentation created with the keynote application (similar to PowerPoint). The first page showed the participant’s name and the second through the fourth page depicted two pictures on each slide: one of a timer application and one of the application they had to play during that slide. The fifth slide showed the picture of the YouTube application and a timer, and the sixth slide said, “The end.” Brodhead et al. (2018) used manual guidance to teach each participant how to follow the schedule and did not provide any praise or tangible reinforcers during teaching sessions. Nonetheless, they programmed the YouTube application to be at the end of each sequence to potentially serve as a reinforcer for the completion of the previous three tasks. Results showed that all participants varied their play from one application during baseline to an average of four applications during treatment.
In the same way, Carlile et al. (2013) taught four children (ages 8-12) with autism to independently organize their spare time by using a visual activity schedule embedded within an iPod touch and in the absence of a supervisor or reinforcement. The researchers added five pictures (of different activities) to the photo icon on the iPod touch, and the participants followed the schedule in the order of the pictures. Similar to Brodhead et al. (2018), Carlile et al. (2013) used manual guidance to teach the participants how to complete the activity schedule; however, they faded prompts using a progressive-time delay procedure instead of using graduated guidance. They also used nine different levels to fade the proximity of the experimenter and thin the schedule of reinforcement from FR-2 (i.e., reinforcer delivered after every two correct responses) to no reinforcement at all. Before the intervention, none of the participants were able to correctly follow any of the components in the activity schedule provided on the iPod Touch. After the intervention, the percentage of correctly completed components increased from 0% to an average of 95% in all participants. The percentage of intervals scored on-task also increased for all participant from an average of 15% to an average of 90%. Both studies, Brodhead et al. (2018) and Carlile (2013) demonstrated that activity schedules were effective in increasing on-task behavior, the percentage of correctly completed steps and improving independence altogether.
To date, there have not been any published studies examining the use of activity schedules embedded within a watch to increase the task completion of self-care skills in children with autism. Thus, the present study will assess the effect of the Octopus Watch on the task completion of three self-care skills in four children diagnosed with ASD. The dependent variables will include the latency and duration of completing tasks and the percentage of correctly completed activity schedule components in the absence of a caregiver or provider.
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