What About Life Skills? Tailoring Interventions for Autism and Beyond

Nearly 50 years of research have carefully documented daily living skills (DLS) deficits in individuals with autism spectrum disorder, which emerge early in life, appear to persist across development, and seem to affect people across this very heterogeneous condition.¹ The terminology and measures used to quantify life skills challenges vary across conditions, but such deficits are also common in people with intellectual disability, attention-deficit/hyperactivity disorder, internalizing and externalizing disorders, and schizophrenia and related psychotic disorders.² Though deficits in life skills are not a diagnostic criterion for autism, they should be a focus of support and treatment across the life span.

Developing age-appropriate DLS in childhood and adolescence predicts success in adulthood for autistic individuals and individuals with intellectual disability.¹ In contrast to cognitive behavior and other talk therapies, which are typically accessible only to individuals with average or better IQ, individuals with diverse cognitive and language abilities can learn DLS. In short, life skills are a seemingly obvious target for intervention efforts. However, they are often not prioritized until it becomes clear that they may be inhibiting a person’s ability to meet their goals.³

Evidence-based strategies, such as reinforcement, chaining, task analysis, visual supports, peer and video modeling, and technology, have been shown to support life skills development in autistic children and adolescents. However, intervention packages or curricula available for clinicians to teach DLS are lacking. Though many clinicians who specialize in autism and related developmental conditions have a general awareness of the importance of DLS, outside of occupational therapists, few clinicians receive formalized training in how to use evidence-based strategies to improve DLS. Further, clinicians who do not specialize in developmental conditions may receive little or no exposure to this construct in their professional training.

Recent randomized controlled trials for 2 intervention programs, Building Confidence and Surviving and Thriving in the Real World (STRW), have made important headway, demonstrating statistically and clinically significant DLS improvements in autistic children and adolescents without intellectual disability.^4,5 The STRW intervention targets critical age-appropriate DLS in autistic adolescents with average cognitive abilities who have significant challenges in DLS (eg, are typically at least 2-3 years behind peers). In this article, we summarize lessons learned from the implementation of STRW and use a fictionalized case study to illustrate potential applications for clinical practice.

CLINICAL STRATEGIES FOR IMPROVING LIFE SKILLS

Feedback from STRW therapists, autistic adolescents, and their caregivers has clarified essential treatment components that support this population in learning and practicing life skills. As with many therapeutic interventions, motivation and treatment buy-in are crucial to successful implementation. Clinicians collaborate with patients and their caregivers at treatment onset to create meaningful and individualized life skills goals that patients and caregivers can see are helpful to them. Once this baseline assumption is met, clinicians can leverage the following strategies to support DLS development:

1. Use a written contract to specify life skills goals, clearly define goal expectations (eg, how many steps, use of reminders, prompting), and identify positive reinforcement (eg, external rewards, verbal praise, natural consequences) if the goal is met (Figure 1). The contract motivates patients to practice newly learned DLS and scaffolds independence.

2. Allow patients to learn and practice skills (eg, laundry) in the actual setting that they will be performed (eg, using their own detergent and washing machine to wash their clothing). Telehealth can be used so that therapists can provide active support and coaching to patients and their caregivers as they get instruction and hands-on practice in the home environment, rather than having to generalize skills from a clinic or school setting to their home.

3. Prioritize goals that can be easily incorporated into the everyday lives of patients and their families (eg, cooking skills such as chopping vegetables and boiling water that can be learned and practiced while a caregiver is preparing dinner).

FIGURE 1. Sample Written Contract for Ethan’s Surviving and Thriving in the Real World Intervention Plan.

Note: This case study is a fictionalized composite based on the authors’ extensive clinical experience with autistic youth. Please note color figures are available online.

WHO SHOULD IMPLEMENT LIFE SKILLS INTERVENTIONS?

Ideally, clinicians need to understand age-appropriate expectations for DLS (eg, simple chores for a preschool-age child, making simple snacks or meals for a school-age child, doing laundry and cleaning one’s room for an adolescent) and should be comfortable using evidence-based strategies that may be effective for autistic children and adolescents across age and language and cognitive abilities (eg, increasing ability to get ready for school independently by using a checklist with visual aids, visuals and words, or just words). Finally, it is often critical for clinicians to have expertise in supporting the caregiver and family system. Clinicians may need to address family issues such as commitment to prioritizing and building DLS, motivation, managing expectations, and caregiver stress and emotional well-being. Clinicians who may be particularly well suited to providing life skills interventions include psychologists, occupational therapists, and behavioral therapists. Whereas there is value to providing instruction on DLS in school and outpatient settings, autistic children and adolescents clearly benefit from learning and practicing DLS in the home and community (ie, grocery stores, restaurants, public transit) settings whenever possible.

A NOTE ON ASSESSMENT

Assessment is a vital component of any effective intervention plan to identify areas of need before treatment and track progress over time. Yet not all measures of life skills are equal. The Vineland Adaptive Behavior Scales (VABS-3)⁶ clinician interview is often considered the gold standard for assessing DLS in individuals with autism and related developmental conditions. However, VABS-3 is costly, is time-intensive, and requires some familiarity to administer smoothly. The Adaptive Behavior Assessment System (ABAS-3) has a validated self-report form, making it ideal for assessing DLS in adolescents and adults, and a caregiver report form that eliminates the need for an interview. Still, it is also costly and lengthy (though shorter than the VABS-3).⁷ Finally, the World Health Organization Disability Assessment Schedule (WHODAS 2.0) is free, relatively brief, and designed for transdiagnostic use.⁸ However, the broad questions and scores of the WHODAS 2.0 may make it challenging to identify life skills that would be meaningful to target in treatment. The WHODAS 2.0 also does not produce age-equivalent scores, which are helpful for explaining life skills deficits to patients and their families in easily understandable terms and tracking treatment change (see “Case Study”). These are only a few examples of the many existing measures that quantify life skills and the broader constructs of adaptive function and disability.

Clinicians should be thoughtful in choosing life skills measures that will be most effective for intervention planning with the populations that they serve. In the context of comprehensive evaluations and treatment planning, particularly with children, the clinician interview form of the VABS-3 is preferable and may be less likely to overestimate or underestimate a client’s DLS than caregiver questionnaires. Notably, the clinician interview and caregiver survey versions of the VABS-3 should not be considered interchangeable. Recent evidence suggests that the caregiver-report survey version of the VABS-3 may have poor measurement invariance in autistic samples, which brings the interpretability of scores attained from this format of the measure into question.⁹ If a clinician has limited time, does not feel sufficiently familiar with the VABS-3 to administer the interview version reliably, or is working with adolescent or adult clients who can provide self-report, the ABAS-3 may be preferable. Brief survey measures such as the WHODAS 2.0 are less suited to clinical use when working with individuals with developmental conditions, but could be informative screening tools when working with other clinical populations that may also experience DLS deficits.

CASE STUDY

Ethan is a 16-year-old autistic boy with above-average cognitive abilities who is in the 11th grade at a mainstream high school. He participated in STRW with both of his parents. Before treatment, Ethan received a standard score of 65 on the DLS domain of the VABS-3. On the Personal, Domestic, and Community subdomains of DLS, Ethan received age-equivalent scores ranging from 6 to 9 years of age. Ethan and his family reported DLS challenges with personal hygiene (showering, brushing teeth), doing laundry, using a stove or oven for cooking, and spending and saving money. When asked why he was motivated to improve his life skills, Ethan noted that he knows what he needs to do (eg, get ready for school) but struggles because he has not yet learned some DLS (eg, cooking breakfast, packing his lunch) and is lacking a system to help him get started, remember the steps, and finish a task (eg, taking medications, packing his backpack). A written DLS contract was implemented (Figure 1) to set up a system to help Ethan become independent as he worked toward goals in the areas of morning routine (eg, packing his lunch, hygiene tasks such as putting on deodorant), laundry (eg, doing his laundry, putting his clothing away), cooking (eg, cutting vegetables for a fajita dinner, baking brownies), and money management (eg, adding items to a grocery list, saving up for a new laptop). Ethan and his family identified a range of rewards he could earn for progressing toward his goals (Figure 1). At the final session, Ethan noted the link between his newly learned DLS and his long-term goals of going to community college, living on his own, and being able to take care of himself. At posttreatment evaluation, Ethan’s standard score on the DLS domain of the VABS-3 increased to 88, meaning his life skills were now in the average range. This was an improvement of 23 points over Ethan’s baseline DLS standard score of 65. He also narrowed the gap between his chronological age and DLS age-equivalent scores from baseline to posttreatment evaluation in all 3 subdomains—Personal (7-14 years), Domestic (6-12 years), and Community subdomains (9-16 years).

Data Sharing:

No original data are presented in this manuscript.