The Use of Routines in Skill Building 

One of the hallmark features of people with Autism Spectrum Disorders is a strong preference for routine behavior.  The routines can appear nonsensical and interfering for outside viewers, but may hold significant importance for the person with ASD.   Routines frequently allow the person with ASD to engage in established behavior patterns without having to integrate much new information, which can be potentially overwhelming.  From what I've observed over the years, I believe that the need for routine is so strong for people with ASD that it cannot and should not be extinguished.  Instead, the need for routine can be used as a strength in skill building, independent behavior, and eventually employment.    

One of the easiest ways to incorporate routines in a positive way is with the establishment of morning and bed-time routines.  Building on the last post about task analysis, set up a stepwise procedure for getting ready in the morning for school or work and for getting ready in the evening for bed.  The steps should be consistent with the person's abilities and preferences so the individual will be able to complete the procedure with little to no resistance.  Help can be provided when needed until the person feels more comfortable completing the steps independently.  A routine is established when these procedures are repeated daily.  The repetition over time will allow the person to have comfort and familiarity with what is expected, typically resulting in less resistance and more independence.  Routines can be used for a multitude of behaviors including self-care, homework, and work related tasks.  

Some care must be used in establishing routines, however, as once a routine is established it is very difficult to break or modify.   Make sure that the routine is set up in a way that it can be carried out consistently.  For example, if the morning routine takes a specific amount of time then it is imperative that the necessary amount of time is available in the person's schedule for completion of the routine.  Consistency of routines needs to be across settings and people as well as time.  A new job coach or supervisor needs to allow the employee with Autism to work within their regular routine.  The same with a new teacher or caregiver.  

That does not mean that routines are unchangeable.  Sometimes routines need to be altered for legitimate reasons.  For altering the timing of a routine, show the person with ASD the proposed time change on their calendar and explain and reasons and logistics of the change.  For example, if a morning routine needs to start earlier in the day, the person may need some assistance in resetting their alarm or be shown on a clock the new time for the routine.  If the steps of the routine need to be altered, review the new task analysis (list of steps) and show the person with ASD how it is different.  Some practice sessions may be needed with the new routine before it is formally adopted.    

There are many jobs and activities in society that require repetition and routine for success.    Since people with Autism have a natural tendency for this type of behavior,  using routines for developing skills and independence can not only be helpful for the person with Autism individually, but can help the people with Autism get more opportunities to make greater contributions to society in general.    

Steven C. Altabet, Ph.D.

                                                Task Analysis - Breaking it Down

Many people with Autism have deficits in Executive Function (EF).  EF refers tot he brain's ability to organize information and regulate your thoughts and actions.  Some people refer to EF as the 'brain's secretary.'  Without a well developed EF, people are unable to organize all of the information they receive and thus have difficulty planning out and completing even the most activities without becoming overwhelmed.  This can lead to individuals resisting activities even when there is positive incentive for completion.  for people with a poorly developed EF, the effort and emotional stress associated with doing activities requiring organization and planning exceeds and positive consequence they may receive for completion.  This avoidance is often more powerful and negative consequences for incompletion as well.

Fortunately, there is a method helping people with poorly developed EF to complete activities and develop skills.  Applied Behavior Analysis (ABA) therapist call this a Task Analysis.  A task analysis refers to breaking an activity down into a series of short discreet steps.  These steps are then put on a picture or word list for the person to use as a reference.  This allows the person with an EF deficit to only have to think about one small step at a time.  Organizing thoughts or keeping track of multiple steps is not required saving the individual from being overwhelmed and making them more likely to attempt and complete the activity.  For example if one wanted to make a task analysis for washing your hands, it look like this:

1. Turn on cold water 1/2 turn 
2. Turn on hot water 1/2 turn
3. Place both hands under faucet.
4. Squirt soap on hands.
5. Rub hands with soap.
6. Place hands under faucet again.
7.  When soap is off, dry hands with towel.
8. Turn off water.

This can be modified to meet the person's needs.  Some may need pictures or less words, but this type of approach can be used for not only simple tasks like this, but for more complicated tasks as well (.e.g. school assignments, chores, work activities, finances, etc.).  In general if a person with EF deficits is resisting a task it is likely because they perceive the task as either too larger or too difficult.  Often times a task analysis can make the activity seem less daunting.

The other key aspect of the task analysis is the list itself.  Having the reference list with the individual steps is highly important.  It allows the person to see the steps so they do not have to think about them.  It also helps because the person realizes that if they forget a step they can refer to the list.  This further creates a sense of independence because if the person has access to the list (and understands it) they do not have to rely on others to tell them what to do.  If a person can complete a task independently that they were once not able to do, the sense of accomplishment is often greater than any reward or incentive that is given.

Steven C. Altabet, Ph.D.         

                                                            Positive Use of Routines

The strong need for routine by most people with Autism can often lead to distress and challenging behavior whenever a routine is interrupted, postponed or changed in some way.  However, this same need for routine can also be used to  help people with Autism learn new skills and increase their independence.  Many people use routines in their everyday lives to help get ready in the morning for work or school and in the evening to get ready for bed or the next days activities.  

Hi all,
Thanks again for coming back. For those of you who are new to this series, the first seven posts focused on interaction techniques aimed at better connecting to people with Autism Spectrum Disorders. The next several sessions will focus on Positive Behavior Support that I consider the behavioral foundation for working with people who have Autism.  Today's  post will review what Positive Behavior Support is, along with a general philosophy of the approaches.  The more specific/technical aspects of the approaches will come in later posts. 

Positive Behavior Support is a form of Applied Behavior Analysis (ABA) that focuses on strategies primarily aimed at preventing problem behaviors and correcting inappropriate behavior by emphasizing appropriate alternatives.  The strategies are set up to be consistent with the way a person with Autism frequently thinks and processes information. In general Positive Behavior Support are driven by the following guidelines.


Key Aspects of Positive Behavior Support

Prevention - The majority of strategies discussed will be aimed at preventing problem behaviors from occurring, either by setting up the environment for a successful interaction or by teaching alternative behaviors that may reduced the need for or take the place of a problem behavior. 

Predictability - All strategies discussed will be presented in a way the is consistent with the person with Autism's need for predictability.    People with Autism tend to respond much better when they can anticipate an action or predict an outcome.

Expectations - A major focus of the approaches will center on letting the person with Autism know what to expect.  People with Autism typically thrive on expectation when the expectation is clear and is presented in a way that attainable (see section on Teaching and Gradual).

Consistency - Consistency is very important with any type of intervention, because consistency allows for a sense of predictability, which is important for reducing anxiety and resistance. 

Positive - Nobody likes to experience negative news, feedback, or consequences.  However, people with Autism tend to be more emotionally sensitive than most (even if they have difficulty expressing it) and the negative feedback or consequence tends to result in such an intense reaction that the person with Autism is often unable to process the situation and learn from result.

Teaching - Once a calm and predictable environment with positive expectations can be gained through the teaching of skills.  The assumption in most cases is the person with Autism is behaving inappropriately because they do not know of a better that way will work for them.  It is our job to teach them that better way.   

Gradual - Because of a person with Autism's sensory and neurological sensitivities, the teaching typically has to be done gradually to be effective.  Information that is presented too quickly or is too large in scope will be overwhelming and met with resistance.  A gradual approaches ensures a positive experience and greater willingness to participate in the next lesson. 

Physical - Because Autism is a neurologically based disorder, helping the person achieve an optimal physical state is important for helping the person concentrate and control their impulses/emotional reactions.  It takes quite a bit of effort for a person with Autism to concentrate and control their behavior and fatigue can certainly impair that ability.  Factors that can positively or negative affect physical functioning are sleep, nutrition, exercise, and stress. 

Natural - All behavior has consequences, some immediate and some long term.  Either way, Positive Behavior Support emphasizes the natural consequences that go along with every behavior.  It also helps the person with Autism understand those consequences so they can act in a way that best benefits them.  

That is all for now.  Again, this was just a philosophical overview.  Next week's post will begin to explore specific Positive Behavior Support strategies.

Steven C. Altabet, Ph.D.