The act of movement between locations, environments, people, routines and activities is commonly known as ‘transitioning’. Individuals with autism often find transitioning difficult (Hendricks and Wehman, 2009; Cihak et al., 2010; Mechling and Savidge, 2011) as it requires the ability to be flexible; accept change; regulate emotion and react appropriately to unknown events. This study aims to identify useful strategies to support individuals with autism to develop transitioning skills by using a case study of a young adult learning to independently use transportation
Transportation involves the practice of transitioning between locations and also requires the individual to transition on and off the transportation device. The use of transportation is an essential skill without which individuals could not independently function throughout the day or access fundamental services such as education, employment, conveniences (e.g. food shopping) and social events. This paper describes transitional strategies used in the support of one adolescent with autism who was experiencing difficulties related to her educational placement and transportation.
Methods and Participants
This case study concentrates on one female, aged sixteen years and eight months, who was referred to Middletown Centre for Autism (MCA) for intervention as she was experiencing difficulty being included in her educational placement. This method was chosen because it offered researchers the ability to make significant design decisions regarding length of baseline data collection and when to implement intervention strategies depending on the participant and her unique presentation, circumstances and behaviour. The participant and her parents consented to take part in the study. All information has been anonymised.
G. H. is a sixteen year eight month old female with a formal diagnosis of Autism Spectrum Disorder, learning difficulties and language delay. She has been out of school for approximately two years and is currently living in residential care. G.H’s school placement broke down due to her challenging and at times aggressive behaviour
Direct standardised assessment of G.H was not appropriate due to her level of anxiety regarding new people in her environment. Given G.H’s difficulties, assessment of G.H’s strengths and needs occurred through observation and information gathering from G.H’s family, education and health professionals by an Autism Intervention Officer from MCA. A functional behavioural assessment of challenging behaviours was conducted and focused on observing and understanding the environmental conditions most commonly associated with such behaviour – the antecedent; how the behaviour manifested; and finally what happened as a result of the behaviour – the consequence. Additionally, risk assessments regarding challenging behaviour, transportation, staff, G.H and the community were completed.
Results from the risk assessments identified that G.H had a ‘Low’ severity of risk (minor injury but no first aid requirement) with an ‘almost certain’ (daily basis) chance of occurrence.
Functional behavioural assessments, observation and information gathering identified that G.H’s anxiety was heightened and her behaviour was particularly challenging during transportation.In particular, during baseline measurement G.H had successfully transitioned from her home environment onto the transportation, however, had never successfully transitioned from the transportation to a community area, which in turn resulted in limited interactions with the wider social community. At baseline, verbal instructions to transition off transportation to the community area were given by those working with G.H using no visual supports. Functional assessments identified that these instructions consistently preceded instances of challenging behaviour and the consequence resulted in staff members returning G.H to her home environment.
It was therefore possible that with the right strategies in place that supported G.H’s visual learning style, addressed her receptive language differences and reinforced her progress, the severity of risk and occurrence of challenging behaviours could be reduced.
An individualised intervention programme blending a range of best practice strategies was designed for G.H. Focusing specifically on transportation, the following strategies were implemented:
Care staff were taught to make an individualised visual schedule for G.H, this involved taking pictures of the bus and various locations were G.H would be attending. The care staff were instructed to communicate through pictures what G.H would be doing each day, i.e. where the bus would be taking her. Appropriate use of visual schedules are thought to reduce anxiety for individuals with autism (Rao and Gagie, 2006).
Care staff were encouraged to use G.H’s favourite toys to model the desired behaviour (e.g. G.H calmly getting off the bus and walking to the duck pond). Modelling, or learning through observation, was first introduced by Albert Bandura as part of his seminal work on social learning theory more than forty years ago. It is recognised to this day as a useful learning strategy for individuals with autism to acquire new skills and imitate desired behaviours (Bellini et al., 2007; Reichow and Volkmar, 2010).
Care staff were instructed to take G.H to the same location for at least seven days in a row.
Care staff instructed to:
- Stop the bus at the preferred location
- Model the desired behaviour
- Wait – preferably in silence, until G.H exited the bus or until ten minutes had passed. If G.H did not exit the bus within the specified time, the bus would take G.H and carers back to the residential home.
If G.H successfully exited the bus she was to be praised by the care staff. Equally, if G.H presented with the desired behaviour off the bus she was also to be praised.
These strategies were broken down into a seven step process for G.H and the care staff to follow, described in Table 1.
Quantitative data was collected on the completion of the seven step intervention process described in Table 1. G.H was scored out of a total of seven for each transition on and off the bus, were seven out of seven indicated that G.H had successfully completed all seven steps correctly, and zero out of seven indicated that none of the steps had been successfully completed. Completion of steps was monitored over two months from 25th May 2016 – 28th July 2016.
Over the course of two months, G.H was transported a total of fifty times. G.H performed a complete correct sequence (seven out of seven times) of desired behaviour on fifty eight per cent (twenty nine out of fifty) of occasions; on these occasions, G.H. remained calm and did not demonstrate any challenging behaviour.
During the two months of intervention, G.H performed four out of seven steps correctly on twenty eight per cent (fourteen out of fifty) of occasions, however, G.H was still learning to imitate the desired behaviour during eight per cent (four out of fifty) of these occasions. That said, the same amount of steps were not performed or performed incorrectly during both months (Chart 1 and 2).
Transitioning via transportation from one location to another is an essential skill for functional independence (Carnahan et al., 2009), however this critical skill can be compromised in individuals with autism (Dudley et al., 2012). In order to gain independence and greater access to life’s essential amenities it is essential that professionals working with individuals with autism ensure those individuals can use transportation services effectively and safely.
Previous research has noted that the transport needs of those with learning difficulties has received little, if any, societal attention (Gentry, 2011), which limits an individual’s functional independence and impacts on quality of life (Dudley et al, 2012). This case study highlighted that transitioning on and off transportation was causing heightened anxiety for the adolescent which resulted in challenging behaviour. Without appropriate intervention, challenging behaviours tend to persist across an individual’s lifespan (Murphy et al., 2005).
This study illustrated how professionals can support an adolescent with autism and learning difficulties overcome her anxiety and learn appropriate behaviour for gaining access to community services through supported use of transportation. It is important to note that as with the heterogeneity of autism, transport issues vary significantly across individuals, therefore some individuals will require minimal guidance or modified transportation training, whilst others will require more assistance as in the case described in this study.
Rachel Ferguson is research officer with Middletown Centre for Autism. Rachel qualified as an Occupational Therapist in 2010 at the University of Ulster and completed her doctorate in Health and Life Sciences at the University of Ulster in 2014. Her research interests include children and young people with autism, sensory processing and issues around quality of life. She has presented her research both locally and internationally.
Deirdre O’Shea is an Autism Intervention Specialist at Middletown Centre for Autism. Deirdre has worked as a Tutor for children with Autism at the Saplings School, Goresbridge, and as a Home Tutor providing early intervention programs. Deirdre has extensive experience in working with children and young people with Autism who display complex challenging behaviours. Deirdre has a Degree in Psychology with the Open University and has recently completed the Registered Behaviour Technician course with Queens University. Deirdre is also studying for her Masters in Autism.
Dr Fiona McCaffrey is Head of Research and Development at Middletown Centre for Autism. Fiona has worked individually and in-group sessions with older children and young adults with autism and their parents. Her PhD research addressed the area of managing anxiety in young adults with autism; she also holds an MSc in Counselling and a Postgraduate qualification in autism. Fiona is a Chartered Psychologist and has previously worked for Autism NI and the University of Birmingham.