Modification of the training environment to improve functional performance using blacklight conditions: a case study of a child with autism

Abstract

Objective: This retrospective case study of an eight year old female with autism illuminates how alteration of the training environment using florescent objects under blacklight conditions, may have been the facilitating impetus that increased her interaction with objects over time.

Methods: This study approach was chosen to best correspond with establishment of an individualized education plan for a child with limited functional skills. The complicated task of teaching toothbrushing was broken down into 34 action steps, grouped into six training clusters that were chained together, using a hierarchy of prompts that were faded on every step, until the child functioned on each step independently. Her progress was evaluated by four points of data.

Findings: The child interacted with objects and became independent in toothbrushing.

Conclusion: Backlighting brought previously ignored objects into the foreground, enabling a child with autism to develop or accentuate visual focus. Future research about the effect of blacklight paired with powerful instructional techniques is recommended.

Autism Spectrum Disorders are a group of neurodevelopmental disorders characterized by deficits in social communication and social interaction as well as “hyper- or hypo-reactivity to sensory input or unusual interest in sensory aspects of the environment” (American Psychiatric Association 2013, p. 50). Children with autism react differently to sensory aspects of the environment, varying from complete disregard to an insatiable desire for sensory input (Miller et al. 2007). For example, some children have been reported to have preferences for visual stimuli (Chevalier et al. 2016, Little et al. 2018).

Since many children with autism demonstrate severe delay or incompetence in acquiring functional performance of daily living skills such as grooming/hygiene, dressing, washing, and toileting, it is thought that they need to be trained to perform those functional skills in their early lives, in order to achieve independence, improve quality of life, and increase the potential to have positive outcomes in adulthood (Hong et al. 2015, Wertalik and Kubina 2017). It is believed that visual intervention might be useful for those known to have preferences for visual information and notable visual processing abilities, resulting in them being trained more effectively to perform functional skills (Chevalier et al. 2016, Little et al. 2018). This strengths in visual–spatial abilities and unique interaction with visual environment may be helpful in designing interventions that use visual cueing to facilitate learning to teach functional skills (Case-Smith and Arbesman 2008).

Typically implemented by pediatric rehabilitation practitioners, visual environmental supports have utilized picture prompts, photographic activity schedules, checklists, and videotaped modeling (Schneider and Goldstein 2010), activity sequences, color coding, or changing the sensory properties of the environment and materials used in a task (Shepherd 2010)to promote development of function-based skills. For instance, in one study, a mother of a child with autism reported that a visual schedule for toothbrushing routine assisted her son with brushing his teeth independently (Kientz and Dunn 2012).

Connection between visual processing and functional performance

Visual processing refers to “the entire process by which we receive visual information, integrate it, perform an action, and adjust behavior accordingly” (Cohen and Rein 1992, p.531). Habituation to visual stimuli in children with autism suggests that there might be a relationship between visual processing and functional performance (O'Brien et al. 2009). The reliance on visual cues was reported to be a crucial approach that had a positive effect on expansion of cognitive resources, thus improving performance through interaction with the surrounding environment (Chevalier et al. 2017). It was acknowledged that some children with autism, who tend to be more reliant on proprioceptive feedback compared to visual feedback, had limited functional performance as a result of restriction of interaction with the surrounding visual environment (Haswell et al. 2009).

Complexity of visual processing

Visual processing has been regarded as a complex, dynamic and multifaceted procedure that requires environmental stimuli, goal (intentional visual task), attention, motivation, and the person’s history of past meaningful experiences (Coté 2015). In fact, a child’s visual processing requires active observation (motivation for receiving visual information) plus consideration of the environmental stimuli (Chien et al. 2016). The act of observation could be an active and purposeful process that enables receipt of visual information from the environment and help the observer initiate meaningful functional task (Freeman 1999). Thus, a child’s pattern of searching the environment has roots that go deep in his/her prior meaningful experiences and wide in the number of components connected to this pattern (Coté 2015). Through this process, patterns of behaviors become self-organized as dynamic configurations of habits that form over time towards which a child has the propensity for seeking continued stimulation (Champagne et al. 2007). This might be the explanation as to why children with autism flap their hands in front of their face or repeatedly run their eyes over an object. Some clinicians tended to rate this type of behavioral manifestation as impairments of social behavior (i.e., avoiding eye contact), while others thought it was a stereotypic behavior (Moulton et al. 2016).

Optimization of the visual environment

Brown and Dunn (2010) reported the correlation between sensory processing and environmental stimuli for children with autism. This correlation has the potential to be at the heart of optimizing the visual environment to design individualized intervention planning because it is believed that the most effective interventions for children with autism could be those that synchronize the child’s sensory processing capacity with his/her daily routines of the natural environment (Kientz and Dunn 2012). For example, the environmental factors such as location and type of sink, as well as the sensory properties of the materials related to toothbrushing, were reported to have contribution to effective or ineffective autistic children’s participation in toothbrushing (Kientz and Dunn 2012). Considering the environmental factors means “having more pieces of the autism puzzle [that] may help to provide more effective and individualized interventions” (Brown and Dunn 2010, p. 481).

To provide a child an opportunity to benefit from an optimized visual environment, it has been recommended that practitioners should arrange for the child to be surrounded by an individualized sensory environment (Casillas et al. 2008). Development of such a sensory environment could be incorporated into an individualized education plan (IEP) to provide support for a child with autism that reduces anxiety and deters atypical behavioral patterns (Davis 2009). For example, visual supports may serve to reduce anxiety about the unknown and facilitate predictive capabilities (Texas Statewide Leadership for Austin).

Use of blacklight environment

Recently, researchers have shown an increased interest in using the multi-sensory environment of the “Snoezelen” sensory room, as an environmental modification to address behavioral problems by providing a relaxed atmosphere with pleasant, calming surroundings. The Snoezelen multi-sensory environment “incorporates a specialized selection of sensory equipment and materials that can help clients adapt their responses to sensory stimulation and to advance education and therapy goals” (https://www.snoezelen.info/). On this basis, the use of alteration in lighting (i.e. blacklighting) as a kind of visual support is expected to promote engagement (https://www.snoezelen.info). Commercial marketing suggests that the blacklight environment provides a range of appealing, eye-catching, attention-grabbing visual materials and resources with lots of calming effects that provide ideal options for improving visual processing, as well as facilitating functional skills (https://www.sensorytoywarehouse.com), yet this seems to be an unsubstantiated claim of a sales website. In one study, by equipping a windowless room with some materials such as white walls, colored fiber-optic light spray, lighted bubble tubes, under a blacklight condition, some researchers reported a slight tendency for three males with autism to engage in more prosocial behaviors, while in the Snoezelen environment (McKee et al. 2007).

Objective of this study

Despite the importance of visual supports, there remains a paucity of evidence revealing how functional performance could be affected by the lighting environment. Usefulness of backlighting in children with autism has not been well investigated. Therefore, by using florescent objects under blacklight conditions, to optimize the visual environment of a child with profoundly limited functional skills, this study sought to improve the subject’s participation in her daily life routines, which was specified on her IEP and was easily measured by pretest–posttest tools. It is hoped that this article will contribute to improving the way practitioners instruct children with autism to perform personal daily living skills. The Institutional Review Board at the University of St. Augustine for Health Sciences approved this retrospective report.

Conceptual framework for the Study

The Neuro-occupation framework (Lazzarini 2004) considers a dynamic process as the source of the conflation of the brain, context, and occupation/task (Derakhshanrad and Piven 2019). On this basis, we hoped to observe connections between the brain’s visual processing, the lighting environment, and the functional task. In this theoretical lens, the environment and occupation/task have been postulated to shape the brain’s function (Lazzarini 2004), and the brain’s function was thought to regulate an individual’s behavior to direct his/her “sense organs toward a selected aspect of the world, [whereby the individual]… abstracts, interprets, and learns from the resulting sensory stimuli” (Freeman 1999, p. 146).

Method

Case description

Mary (a pseudonym for anonymity) was an eight-year-old Caucasian girl, who resided in a privately funded residential school for children with autism. Mary developed normally until 14 months, when her developmental skills regressed. She lost all interest in objects of play and was diagnosed with autism by her pediatric psychiatrist. She ambulated with a wide base of support with her fingers tightly clasped together and nonfunctional for reach. Left standing, she would rock side to side clasping her hands into a fist together for hours. Mary’s eye contact was described as downcast and she smiled to herself most of the time.

The school psychologist had her on a “look at me” program with a continuous reinforcement schedule to train Mary to gaze at the trainer’s face. Popcorn proved to be the best reinforcer during each trial, delivered with the associated statement “Good looking!” She showed no interest in any object in the environment other than popcorn. The school psychologist was the sole provider of the operant conditioning program at the facility. It is unclear why this training was not duplicated by staff working with Mary. The psychologist referred the child to the second author, registered/licensed occupational therapist (OTR), to “evaluate and establish an IEP with functional treatment goals, to provide weekly supervision of a certified occupational therapist assistant (COTA), and to establish training for facility caregivers.” (Personal conversation with referral source). Consultation was biweekly for four hours/week for development of the self-care program. Supervision of the COTA for 2 hours/week was allocated for the client on her visual sensory treatment plan, and other staff. The COTA worked with the client daily for ½ hour in the treatment room. Every two weeks, the consultant provided whole group in-service training for all staff at the facility, and separately on a rotating basis with staff on 7.00am–3.00pm and 3.00pm–11.00pm shifts that were working with the client. The consultant changed her schedule accordingly, in order to provide extensive staff training needs for administration of the same duplicatable task analysis plan, as needed on day and evening shifts. The second author convinced the psychologist that consistency was required to teach Mary any task. Therefore, the author provided in-service training to all direct care personnel working with basic activity of daily living (BADL). Training was ordered on all shifts.

Measures

Before treatment began, the occupational therapist spent one week observing the client in all settings and shifts, including the night shift. Mary was noticed to have no interest or active interaction with objects in her environment, with one exception. Staff witnessed that she would pick up random pieces of popcorn and put them in her mouth. Standardized evaluations could not be done because she was unable to use her hands for purposeful activity at all, nor was she able to pass any tests given by the psychologist to pinpoint her intelligence, cognitive, social skills and lack of responsiveness to direction.

Four objective measures were used to assess baseline performance at the beginning of research and 4-month post-intervention to assess progress. Mary’s functional performance was assessed by Canadian Occupational Performance Measure (COPM). Since Mary had low visual interaction, it was impossible to measure her visual processing capacity. An ophthalmologist determined her vision was normal. Thus, to measure alteration in perception of environmental stimuli, the author decided to measure alternative sensory modules that included her perception of tactile stimuli. Accordingly, Semmes Weinstein Filament Test (SWMT) and a therapist-made stereognosis kit of familiar objects were used.

COPM (Law et al. 1990) was selected as a tool to help Mary’s mother prioritize goals for Mary by interview on the phone. The COPM was a norm-reference measure that was standardized in methods of administration, instruction, and scoring that assisted occupational therapists to conduct semi-structured interviews with clients about their self-perception of their ability to function in every day occupational performance. The most important occupations were rated on performance and satisfaction with performance, each based on the 10-point rating scale. Based on self-perception, the higher numbers signified highest performance or feeling very satisfied. Self-perception was numerically rated by importance, performance, and satisfaction, and was reported as mean averages over time by taking the number of goals divided into the ratings for pretest and posttest scores. Internal reliability, test retest reliability, content, criterion, convergent, divergent, and construct validity measures were deemed adequate and since then have been in reliability and validity studies. “The scores for performance and satisfaction remained independent of one another when completing the evaluation of the COPM. The concepts of performance and satisfaction with performance are very different and therefore the mixing of the two for one final score would confuse the outcomes” (Sue Baptiste, personal conversation, October 31, 2018).

The SWMT was administered because of the high interrater reliability scores (Bell-Krotoski and Tomancik 1987). The thickness of the monofilaments was graded from .086 to 448 g. The test ceased when the person reacted to the stimulus. On pretest, Mary scored red because she did not respond to any of the monofilaments, which indicated she was untestable at baseline and oblivious to the sensory stimuli.

The stereognosis pretest assessment occurred under normal light conditions. A kit was created using Mary’s familiar objects used in daily activities: a comb, hairbrush, electric-powered toothbrush, spoon, fork, and three “pop-it” beads (see description) were added because they were florescent under blacklight. Vision was occluded by a curtain hiding vision of an object. Mary scored 0 for stereognosis item recognition and did not explore objects placed in both hands, as would be expected for a child that was born with manipulative hand function.

Baseline status of daily routine activities

Mary was a passive participant for all undressing, dressing, bathing, toileting with pull up diapers, including wiping herself, washing face, tooth brushing, and hair washing. She showed no emotion or resistance to total physical assistance provided. Mary’s permanent teeth were loosening in her mouth and her dentist was concerned that she would lose them. It was observed that aides were brushing her teeth on every shift, using different task analyses that were inadequate for oral care.

COPM goal: brushing teeth

Mary’s mother had this singular focus, as she was worried that Mary would lose all her teeth. This goal seemed to be most unattainable at the time, but her mother insisted that this was the most important goal for her daughter. The toothbrushing goal was written as follows: Under blacklight conditions, Mary will brush her teeth in front of the mirror with set up and standby supervision three times or trials/day (breakfast, lunch, and dinner), with faded physical, verbal or gestural assistance on each step of the toothbrushing trial, for 60 consecutive trials with no errors (20 days). Errors were considered delivery of any type of prompt at any level at all.

Toothbrushing task analysis and recording sheet of progress

The toothbrushing task was written up as a typical task analysis and a task analysis recording sheet was developed (Table 1). The task was delineated into 6 clusters and 34 steps, using one action verb for each step. Each action step was chained into a cluster as a training strategy. As they were acquired, sequential clusters were chained together, after being taught separately. Indicating trial numbers 357–364, Table 1 is a sample task analysis recording sheet representing data from almost three days (days 119–121). In other words, Table 1 captures a snapshot of Mary’s progress during task performance during the 3 days of the last month, when the last cluster was in the process of becoming acquired. She continued to require more trials to reach the criterion of 60 consecutive trials with no errors, which was required to determine that she had the focus and skills to perform the task under the blacklight condition. Realistically, Mary continued to require setup and standby observation by staff, in order to maintain her ability to brush her teeth. She was unable to perform the task without blacklight conditions.

Table 1.

Recording sheet toothbrushing

Clusters	Steps in each cluster	Number of Trials	357†	358	359	360	361	362	363	364
6	Wipe mouth on towel
	Spit
	Swish
	Sip
5	Grasp cup, bringing to lips		30	30	30	30	30	30	30	30
	Replace brush in charger		29	29	29	29	29	29	29	29
	Rinse brush		28	28	28	28	28	28	28	28
	Replace cup on counter		27	27	27	27	27	27	27	27
4	Spit		26	26	26	26	26	26	26	26
	Fill cup		25	25	25	25	25	25	25	25
	Bring to lips		24	24	24	24	24	24	24	24
	Grasp cup		23	23	23	23	23	23	23	23
3	Brush tongue back to front twice		22	22	22	22	22	22	22	22
	… bottom row		21	21	21	21	21	21	21	21
2	Brush biting surface top row of teeth		20	20	20	20	20	20	20	20
	Spit		19	19	19	19	19	19	19	19
	… inside right lower quadrant		18	18	18	18	18	18	18	18
	… inside left lower quadrant		17	17	17	17	17	17	17	17
	… right lower quadrant		16	16	16	16	16	16	16	16
	… left lower quadrant		15	15	15	15	15	15	15	15
	Move brush across gums bottom left upper quadrant		14	14	14	14	14	14	14	14
	Spit		13	13	13	13	13	13	13	13
	… inside right upper quadrant		12	12	12	12	12	12	12	12
	… inside left upper quadrant		11	11	11	11	11	11	11	11
	… upper right quadrant		10	10	10	10	10	10	10	10
	Move brush across gums upper left quadrant		9	9	9	9	9	9	9	9
1	Insert toothbrushing in mouth		8	8	8	8	8	8	8	8
	Turn on		7	7	7	7	7	7	7	7
	Squeeze on brush		6	6	6	6	6	6	6	6
	Wet the brush		5	5	5	5	5	5	5	5
	Pick up toothbrushing		4	4	4	4	4	4	4	4
	Cap on counter		3	3	3	3	3	3	3	3
	Unscrew cap		2	2	2	2	2	2	2	2
	Pick up tube		1	1	1	1	1	1	1	1
	Total independent steps(%)		31//34 91%	31/34 91%	31/34 91%	34/34 100%	33/34 97%	34/34 100%	34/34 100%	34/34 100%

^†Trials: Three per day (breakfast, lunch, dinner), representing data from days 119 to 121, when the last cluster first began to be acquired at trial 360.

On the task analysis recording sheet (Table 1), steps were inverted showing the last step first and the first step last, to graph the highest number of independent steps per trial and to calculate an accurate percentage of independence. The task analysis recording sheet shows mastery of certain steps and errors on others. Any prompt at all that was given, be it verbal, gestural, demonstration, or physical was counted as an error, was indicated by a strike through the number of the step on the chart. Independent steps were not struck out. The trainer added the total number of steps done correctly and circled the number at the completion of each trial. Next, the learning graph was made connecting the circles together to show the fluctuation of Mary’s performance. The consecutive trials with no error were set as the final goal with the duration of trials indicating how long it might take to instill a habit, to insure learning continued over time. Calculation of percentages can be done for each step horizontally or vertically for the total task. The total number of steps was divided into the number of correct steps to calculate level of independence. For example, 18 independent steps out of 34 would be 53%, whereas 31 independent steps out of 34 would be 91%.

Environmental modification for the blacklight conditions

Environmental changes were made to the treatment environments by exchanging florescent light bulbs for blacklight bulbs of the same size. The key objects in the toothbrushing environment that were deemed essential for the task were: a mirror framed in white wood, the white sink, two faucets that were replaced with white ceramic handles, white cup for water, an electric toothbrush with a white toothbrush and white handle, the white toothpaste, and white towel for wiping, which were all be illuminated under blacklight. The blacklights covered the entire area and perimeter of the training where the toothbrushing task occurred. As a result, one backlight bulb placed above the bathroom sink, enabled features of the environment illuminate, thus facilitating focus on white objects: mint toothpaste (Mary seemed to prefer the taste best among the selections presented to her), electric toothbrush handle, cup, and teeth and white saliva and face seen in the white framed mirror, and white towel, all of which served to attract attention to salient features of the environment.

Try another way methodology

The Try Another Way methodology (Gold 1980) presented an instructional approach to provide powerful prompting techniques for training people who found it difficult to learn. It was selected because of Mark Gold’s work for his PhD, training adults with developmental disabilities to learn a complicated task of assembling 18-piece bicycle brake units with severe deficits in intelligence. Today, Mark Gold and Associates continues his work and provides certification (http://www.marcgold.com/).

In the Try Another Way system, any level of prompt no matter large or small challenged independence, and the trainer’s goal was to fade all prompts from a high-power levels (where the trainer does most of the action, if not all) to low-power levels (where the client does most of the action), so that all prompts could be faded away and the client independence would be achieved. Fading of prompts was done for each dependent step of a trial. The fading process involved giving the client less assistance, which elicited rudimentary problem-solving capacity because withdrawing prompts to a lower level allowed the client to take over more of a task. A higher prompt could be restored when a client did not respond to the fade. Only one action verb constituted a step. For example, a verbal prompt such as “Pick up cup” could be faded to provide less information by saying, “Pick it up” then to fade further by saying, “Pick.” Here is an example of a two-action step because the word “and” separates the two action verbs: “Pick up cup and sip water.”

To teach swishing water in mouth, it was broken down into two steps: (1) “Fill mouth” (with water), (2) “Swish” (water in mouth). To teach swishing required physical assistance where the trainer shook the client’s head, jiggling water passively in the client’s mouth. Physical assistance was faded by offering less head jiggling. To teach “Spit” in sink also required physical assistance at first. When mouth was full of water from the cup, the trainer leaned the client’s head forward towards the sink, then patted both cheeks simultaneously with trainer’s hands, forcing the spit action. To fade physical assistance, the trainer used lower power prompts on every step of a trial. A gestural prompt for putting a cup on the shelf might be to touch or tap the shelf. Fading this prompt would involve pointing to the shelf with one finger from 3 inches away. To fade even more (providing less information), the trainer would point from 6 inches away. A verbal prompt could be combined with a gestural prompt “Here” and a point to the shelf. All steps were trained in clusters. When clusters were mastered, they were chained together like links on a necklace. Once linked together, the command would be “Drink and Spit.”

COPM sub-goals: interaction with objects in the environment

Mary had one functional skill. She tracked popcorn anywhere in her environment and picked it up to eat, but this constituted her entire interaction with objects.

Interaction with other objects was preparatory for toothbrushing. Therefore, sub-goals were developed: Fisher-Price now makes “Snap-Lock Beads” that look very similar to the “Popit Beads” that were used because they became florescent under blacklight conditions. The beads were selected, without intention to infantilize Mary, who was not attending to any toys. They were readily available and suited the purpose. Goals were sequential after achieving one, the next was attempted.

1a. Under blacklight conditions, Mary will pick up a plastic ‘Popit Bead’ for 10 consecutive trials independently with no error.

1b. Under blacklight conditions, Mary will add beads to form a chain of ‘Popit Beads’, for 10 consecutive trials with no errors.

1c. Under blacklight conditions, Mary will select a ‘Popit Bead’ from the floor that matches the florescent bead painted on a black card and connect the bead to a chain of other ‘Popit Beads’, for 10 consecutive trials independently with no errors.

Fidelity of the training and data recording

A standard procedure was followed to be sure if training and data recording were implemented consistently across trainers as planned (fidelity). Following the development of the task analysis by the OTR, all staff at the facility and COTA were trained in implementation of the plan. Through a series of in-services, they were taught to use the same procedures, informing strategies, prompting, and reinforcement techniques of the Try Another Way training methodology. Since Mary’s participation was entirely passive, this detailed training was necessary to increase her participation in the steps of the task by fading prompts in incremental levels on every step of the toothbrushing task. Consistency among trainers was imperative using the methodology, which was the reason why so much training occurred and was regularly monitored. In-services were incremental, cumulative, and training was practiced first together on other staff under the blacklight environments. This was an effort to ensure exact duplication of the training procedures to assure trustworthiness and fidelity of the training and recording of accurate data.

The beauty of The Try Another Way training was exactness. There was little decision to be made, as any prompt indicated a need for more help. The recording sheet provided exact and accurate percentages of independence. In-service training occurred in this order: (1) How do you read the treatment plan? (2) A demonstration 4-hour workshop, to teach all trainers to use the hierarchy of prompts for training the child, fade prompting to provide less assistance, raise level of prompts to provide more information to the trainee as necessary, criterion for independence, proper use of the recording sheet, avoidance of using the forbidden word ‘No’ and substitution of more positive verbal prompts such as ‘Try again’, ‘Try another way.’ ‘Look again.’ ‘What is missing?’ ‘What is next?’, ‘Did you forget something?’ (3) Concept of providing too much help and too little help that fosters dependency longer than required. (4) Rating performance: The training concept of ‘No news is good news,’ to prevent the fostering dependency and reducing distraction. In other words, the message to the trainee was, “If I don’t stop you, assume you are doing everything correctly.” As such, the training prevented reliance on giving verbal prompts. Telling someone they are doing well is viewed as an unnecessary distraction. ‘No news is good news’ promotes decision making and problem-solving. (5) Timing strategies, important for giving the trainee time to think about what he/she need to do.

Once all staff was trained, the best staff were selected by the author and given the opportunity to work with Mary. As shifts were rotated and staff required days off, 36 people received training.

Findings

IEP outcomes

Mary’s mother was thrilled with Mary’s progress and scored Performance and Satisfaction ratings on the COPM at 10/10 for toothbrushing, under blacklight. Mary’s performance fluctuated during the 4-month period, until she finally achieved 60 consecutive trials with no errors, at trial 426 (4 months and 24 days). Then, she was moved to a maintenance program with staff, whereby Mary brushed her teeth with set up and standby supervision.

This was accomplished by breaking down a 34-step task analysis into 6 training clusters that were chained together, using a hierarchy of prompts that were faded on every step, until Mary functioned on each step independently (Gold 1980). It should be noted that Mary’s performance at baseline and post-intervention equaled respectively to show progress from 0 and 100% toward independent steps. Once Mary demonstrated that she was successful in achieving her first trial without errors, training continued for another 20 consecutive days (3 times/day) written as 60 trials with no errors, before it was determined that the habit of toothbrushing was formed and could continue with standby supervision. Mary met each sequential goal (1a–1c) in the blacklighted therapy room environment by the end of the 4th month, demonstrating positive interaction with objects.

The SWMT

Mary reacted to the blue monofilament on the SWMT. This showed diminished sensation for light touch, which indicated she had advanced to protective sensation.

The post-test stereognosis

This assessment was administered under blacklight conditions. When Mary was presented with two florescent picture cards at a time and placed on top of the box, she pointed to two/three different shapes of “Popit Beads” and the electric toothbrush that were placed in both hands. Mary demonstrated rudimentary behavior indicating mass grasp and object recognition.

Secondary observations

One year following the post-intervention, Mary’s dental report reflected reduction of periodontal disease and tightening of Mary’s teeth that may have been the result of the consistently executed, dentist approved, training program. Due to the extensive training of school staff, the Try Another Way methodology that was first used with Mary was instituted with other children with autism at the school to teach BADL tasks. This necessitated that the second author became the training director at the school and continue to supervise the COTA at the school.

Discussion

The relationship between blacklighting environment and functional performance of children with autism has not been well explored yet. This study approach was chosen as Level 1 research to best corresponds with establishment of IEP goals for a child with limited functional skill. Learning to brush teeth through a system of instructional feedback, withdrawing levels of prompts from higher power faded to lower power prompts on all steps, allowed Mary to take over the task under blacklight conditions, to improve visual foreground/visual background discrimination and sustained task focus. The COPM performance and satisfaction goals were rated by Mary’s mother when it was determined that Mary had reached criterion at trial 426. Moreover, Mary interacted with objects and focused on her body, suggesting enhanced self-awareness and perceptual feedback as she was doing something to her body with objects (toothbrush, toothpaste, cup, water). Mary’s enhanced sensory awareness was evident in her improved object recognition indicated by the stereognosis assessment and her reaction to the blue monofilaments on the SWMT, which signified that she had advanced to the protective sensation filament.

Since Mary showed no visual attention to objects in her environment other than popcorn, the occupational therapist decided to alter the visual environment to affect change. This turned out to be a logical environmental modification that increased Mary’s attention to objects in the foreground. Blacklight conditions heightened her focus on objects that became florescent against the black background. The fact that Mary’s functional performance improved through optimizing the visual environment corroborated the findings of Little et al. (2018) who also found that modifications of the task and lighting in the training environment might improve visual processing of children with autism. The blacklight facilitated interaction with various objects in a purposeful way. The occupational therapist worked with the psychologist to develop an operant conditioning program to reinforce interaction with objects in the environment, which was deleted as soon as Mary began to link pictures with objects and construct chains of “Popit Beads,” thus showing intrinsic motivation and engagement in the visual task.

Theoretically, these results seem to be consistent with the Neuro-occupation framework principle that context and occupation can shape brain function (Derakhshanrad et al. 2017, Lazzarini 2004). Using this theoretical framework, one explanation why blacklight was a potential active ingredient in this intervention was that Mary might have become excited and attracted to perform the task under blacklight conditions. Accordingly, Mary’s brain might have interpreted blacklight as an attractive contextual situation that was perceived as pleasurable (Gutman and Schindler, 2007). McKee et al.’s (2007) single subject study indicated that the Snoezelen room appeared to excite and activate three male inpatients with autism to demonstrate more prosocial behaviors.

As in our study, Brown and Dunn found, “behavior is influenced by context” (2010, p.475) for children with autism. Accordingly, the findings showed how optimizing the lighting environment enabled focus on specific objects that increased the child’s repertoire of functional skills. The blacklight helped Mary regulate her visual processing, thus expanding her functional skill of interaction from one object to multiple objects, which enabled her to achieve the functional occupation of toothbrushing. Our results reflected those of Little et al. (2018), who also found that children with autism used their visual processing as an effective strategy to engage with their environments. Incorporating blacklight conditions into Mary’s environment enabled her to experience a state of readiness that directed her attention toward the selected aspect of her visual environment that created her increased capacity to acquire functional outcomes (Freeman 1999).

In line with Coté’s (2015) visual processing model, it could be argued that Mary’s visual processing seemed to have benefited from a complex, dynamic, multifaceted procedure that required visual supports of blacklight conditions to enable Mary to seek attractive visual information in the environment to activate intentional visual activity, attention, and motivation to achieve meaning. Thus, Mary’s pattern of engagement in toothbrushing under blacklight conditions, seemed to be shaped by the attractive visual environment (Chien et al. 2016, Coté 2015). This was the process whereby patterns of Mary’s new self-organized behaviors formed over 4 months, became a chain of linked behaviors and formed a habit. It can also be argued that the vibratory sense and sensation of tasting toothpaste may have also been attractors that maintained the behavior.

Implications

The evidence from this study suggests that using instructional prompting through Try Another Way methodology may contribute to instructing children with autism to perform BADL; however, information from one single case study can hardly be generalized. Another important implication of this research is the possibility that the task analysis system used in this study may be useful for development of directed performance assessments in children with developmental disabilities such as autism, because the graphing system visually shows exact percentages of independence. The Try Another Way method can only be effective when great effort is made to be sure training is duplicated by all that interact with the client. When a task is performed the same way and client instruction is the same, no matter who executes the training, the client progresses, and a complicated skill can be learned.

Further, it is important to emphasize that alteration of the visual environment may include other familiar modifications such as use of self-help devices, grading tasks, and use of florescent objects under blacklight conditions, to enable a child with autism to accentuate visual focus. Therefore, therapists must consider lighting when making visual environmental modifications. However, we argue that only those modifications that incorporate the child’s sensory processing capacity into his/her daily routines of the natural environment would be of great practical value to the child. The Snoezelen room might be a potential training environment (McKee et al. 2007) if it helps “transform spaces into meaningful places” (Loukas 2011, p. 2) by challenging functional performance opportunities and magnifying or accentuating naturally embedded features of the environment to increase visual focus.

Limitations and Future research

The most important limitation is the single case research method. Sadly, there was limited evidence of carryover because the occupational therapist relocated. One consideration is that perhaps this training was successful because of the task analysis break down and training approach used (regardless of the blacklight). Therefore, it is recommended that future research with follow-up strategies and more participants considers randomized controlled trials to compare the outcomes between blacklight conditions and without it. Future research to discover the neurological mechanisms involved in visual focus (i.e. visual processing) is warranted. Determination of the effect of blacklight conditions on task performance and purposeful interaction with objects will help practitioners tailor the visual environment for children with autism. One way to clinically increase outcomes would be to continue to test toys with florescent qualities that could be seen under blacklight to work on bringing the background to the foreground.

Conclusions

The IEP using instructional prompting through Try Another Way methodology for a case with autism seemed promising. The results of this study indicated that how the child’s participation in the functional occupation of toothbrushing may have been affected by her lighting environment. Overall, the findings of this study suggest that:

• Considering the linkage between lighting environment, functional performance, and visual processing may be warranted.

• Self-care routines may be improved through an optimizing visual environment, using florescent objects under blacklight conditions.

• Task analysis recording sheet used in this study may show potential as a direct performance assessment.

Disclosure Statement

The authors confirm that there is no conflict of interest.

Funding

We have no financial interests related to the material in the manuscript.