Evaluation of two instruction methods to increase employment options for young adults with autism spectrum disorders

Abstract

We evaluated the efficacy of a vocational training program including behavioral skills training, and a “performance cue system” (i.e., a proprietary iPhone application adapted for the study) to teach targeted social-vocational skills to six young adults with an Autism Spectrum Disorder. In two separate studies, participants were employed to assist in the delivery of a fire safety education program. Participants were asked to wear an inflatable firefighter WalkAround^® mascot costume and to perform 63 scripted behaviors in coordination with a fire prevention specialist who was the lead program presenter. In Study 1, three participants were initially exposed to established company training procedures comprised of behavioral skills training components to determine whether they met mastery of the skills. If necessary to reach criteria, participants were then exposed to a performance cue system. In Study 2, three additional participants were provided with the performance cue system alone, and then behavioral skills training if required. A single case, multiple-baseline design across subjects was used to evaluate efficacy of each intervention. Results indicate that 5 of 6 participants reached criterion only after introduction of the cue system while the sixth reached criterion with behavioral skills training alone. The program received high satisfaction ratings from participants, their parents, and consumers. Implications and potential use of the PCS in other employment settings are discussed.

Introduction

Among employment-age adults with disabilities, some of the lowest employment rates are for individuals on the autism spectrum. For example, Engstrom, Ekstrom, and Emilsson (2003) found that only 2% of participants with Asperger's Syndrome or High Functioning Autism were employed. Results from a longitudinal study of social and employment outcomes in 120 individuals with autism indicated that over 90% were unemployed and not living independently (Bellstedt, Gillberg, & Gillberg, 2005). Barnard et al. (2001) analysis of employment age individuals with an Autism Spectrum Disorder (ASD), found that only 6% of adults with ASD were employed full-time and 4% were employed part-time. In contrast, Benz et al. (2000) study of 709 students with disabilities (the majority of whom were diagnosed with learning disabilities) indicated that 35% were employed full-time at 2 years post high school graduation. The gap is even more disparate between employment age individuals with ASD and their working age peers without disabilities, 70% of whom are employed (Bureau of Labor Statistics, 2010).

Individuals with ASD are characterized by marked and sustained impairments in social and communicative functioning that can impact every aspect of adaptive functioning (American Psychiatric Association, 2000). Although some individuals on the autism spectrum have fewer cognitive and language impairments, most still have continuing difficulties with interpreting nonverbal cues and engaging in reciprocal social exchanges (Müller, Schuler, & Yates, 2008). In addition, because individuals with ASD have limited ranges of interest (Neisworth & Wolfe, 2005), many can become preoccupied with nonfunctional routines and patterns of behaviors that may interfere with work completion. It should not be surprising then that a large percentage of employment-age individuals with ASD experience unemployment and underemployment (Nesbitt, 2000).

Due to the social-communicative deficits associated with the disability, traditional job training and coaching methods (e.g., lengthy verbal instruction) are often counterproductive to helping individuals with ASD find and keep a job. Fortunately, there are evidence-based practices for individuals with ASD that can be used to improve employment training and support systems.

Behavioral skills training (BST) has been used extensively to teach skills to individuals with and without disabilities but few published studies have examined BST with individuals with ASD in the workplace. BST has been used to teach a parent and child how to teach social skills to a sibling with ASD (Stewart, Carr, & LeBlanc, 2007) and children with autism how to avoid being abducted (Gunby, Carr, & LeBlanc, 2010). BST also has been used to teach adults with mental retardation how to escape from a burning building (Knudson et al., 2009), how to construct shipping boxes (Maciag, Schuster, Collins, & Cooper, 2000), and how to self-monitor and complete tasks in competitive employment (Browder & Minarovic, 2000). In one of the few studies evaluating BST to address vocational skills in individuals with ASD, Hillier et al. (2007) reported increases in time in employment and earnings using an intervention that focused on pre-placement skills, such as completing applications and interviews and post-placement skills, such as completing job tasks and understanding workplace rules.

One of the reasons why there may be so few studies evaluating behavioral skills training with individuals with ASD in the workplace is that the approach can be relatively labor intensive. In the Hillier study, participants spent up to six months engaged in behavioral skills training with job coaches for up to 20 h per week. So, while BST can be highly effective in teaching new and complex skills, it also can be cost-prohibitive for many potential employers.

A cost effective alternative to behavioral skills training is to use prompts or cues that signal an individual both what to do and when to do it. Numerous studies have used video, picture, text, or verbal cuing to teach clients with developmental disabilities (DD) daily living skills such as how to set a table (Goodson, Sigafoos, O’Reilly, Cannella, & Lancioni, 2007), attend to personal hygiene (Garff & Storey, 1998), make peanut butter and jelly sandwiches (Rehfeldt, Dahman, Young, Cherry, & Davis, 2003), make microwave popcorn (Sigafoos et al., 2005), and unpack groceries (Cannella-Malone et al., 2006). There also is a long history of using cuing to teach individuals with DD basic computer skills (Frank, Wacker, Berg, & McMahon, 1985) and how to access preferred Internet sites (Jerome, Frantino, & Sturmey, 2007). Minarovic and Bambara (2007) successfully used sight-word checklists as cues to teach non-reading adults with moderate intellectual disabilities to complete a variety of job tasks. Prompting and cuing also have been used individually and in combination with other strategies to help children with autism initiate and respond to interactions with peers (Licciardello, Harchik, & Luiselli, 2008), imitate peers’ play activities (Ganz, Bourgeois, Flores, & Campos, 2008), and be more empathetic to peers (Schrandt, Townsend, & Poulson, 2009). A review of related research literature found only one published study that used cuing to teach young adults with ASD job skills. Hume and Odom (2007) effectively used cuing to help a 20-year-old male increase his time on task, increase task completion (i.e., scanning document pages), and decrease the number of prompts needed to complete tasks over time.

There is a small but expanding body of research examining the use of personal digital assistants (PDAs) to prompt students and adults as a means of increasing completion of daily living tasks and academic tasks in school, and developing social, emotional, and behavioral skills. For example, Gentry et al. (2010) trained transition-age high school students with autism to use PDAs as task management tools. Results indicated that the majority of participants used PDAs as trained and reported an increase in daily living task completion. In a study examining the use of PDAs with audio, video, picture, and voice-over capabilities, teen students with autism were found to increase completion of lesson tasks and their ability to adjust prompting levels to meet their needs (Mechling, Gast, & Seid, 2009). Published studies of PDA use as a prompting aid for completing job tasks are far less available. One promising study examined the use of a PDA to improve decision making and task completion of individuals with cognitive disabilities when completing two, 11- and 12-step packing tasks, e.g., putting product and materials in a container for shipment. Results indicated higher accuracy of decisions and task completion and fewer requests for assistance when participants used the PDA than when not using the prompting device (Davies, Stock, & Wehmeyer, 2003).

Although both behavioral skills training and cuing procedures offer potentially effective and complimentary approaches to teaching vocational skills, there are few studies that have assessed the effectiveness of these approaches with adults with ASD in the workplace. Additionally, PDAs hold promise as an effective means of providing cues in a wide variety of job settings, thereby increasing the possibility of employment for individuals on the autism spectrum. As a result, the two current studies were designed to evaluate the efficacy of behavioral skills training and a novel PDA-based performance cue system on the ability of individuals with ASD to perform a complex chain of workplace behaviors.