Using Behavior Skills Training and Other Environmental Manipulations to Teach Safety Skills to Adolescents with ASD

Choosing the correct target behavior to teach is fundamental for parents, teachers, therapists and other professionals working with people with autism and other intellectual disabilities. While early intensive behavioral intervention (EIBI) for young children diagnosed with autism can produce large gains in social, cognitive, and language development, choosing the appropriate curriculum for adolescents and adults warrants some further reflections. Starting from puberty and adolescence, the focus of teaching should move from what the student is missing with respect to typically development peers to what the student needs to become an effective adult, with the final outcome of “making a life”. Applied Behavior Analysis is effective in teaching functional skills, adaptive skills, daily living skills, safety skills, sexuality, physical exercise, self-advocacy and other often overlooked skills that can contribute to the improvement of the quality of life of people with or without disabilities. Research suggests that working on functional skills provided through a meaningful curriculum leads to a more independent life. During this presentation the contribution ABA can offer in developing a meaningful curriculum for adolescents will be reviewed. Particular focus will be placed on using Behavior Skills Training (BST) and other environmental manipulations to teach safety skills to adolescents and young adults with autism spectrum disorders. Examples of safety skills include abduction prevention, seeking help if lost, inappropriate physical contact and information disclosure. The use of technology in teaching safety skills to students with a poor repertoire of verbal behavior will be discussed.

Those who work with people with ASD or other intellectual disabilities, such as parents, teachers and therapists, face, on a daily basis, the problem of selecting appropriate skills to target for skills acquisition with their children or students. While Early intervention programs based on ABA (e.g. Early Intensive Behavioral Intervention - EIBI) [25] are considered the one of the best examples of evidence-based behavioral health care [18], choosing targets for adolescents and adults warrant some reflection.

Research in ABA shows that adolescents and adults with ASD, with various levels of skills are able learn, using evidence based procedures and teaching strategies, a variety of academic skills or skills usually taught in one of the available teaching curriculum based on ABA (e.g. VBMAPP [31]; ABLLS, [21]; PEAK, [7]). Some of those students may also acquire skills proposed in a “standard” teaching curriculum, for example skills learned at school by their typically development peers. Even if we know that people with ASD can learn those targets behavior, a different question is raised: “At what cost do they learn these skills? Will these skills help the students find employment or housing, or activity participate in the community?” [1]. Starting from puberty and adolescence, the focus of teaching should move from what a student misses respect to a typically development peer to what a student needs to become an effective adult, with the final outcome of making a life [34].

Sharing this point of view, professionals should identify and teach skills that can help students with ASD to “function” independently in their community. ABA can contribute to  teaching skills that are not usually taught as “first targets”, such as adaptive skills [24; 29; 36], doctor visits [27], functional life skills [20; 22], nail and skin care [11], bedtime routines and sleep hygiene [8; 9; 35], safety skills [33], exercise [23] and self-advocacy [14; 26] with the final aim of improving the quality of life of individuals with ASD or other intellectual disabilities.

A large body of literature has investigated the importance of teaching individualized functional skills to students with intellectual disabilities with respect to a norm-referenced curriculum. To be effective, functional skills should be taught in the natural environment and in context. A common teaching strategy used to effectively teach functional skills is called community-based instruction [3]. Community-based instruction (CBI) is an instructional method that promotes the teaching and use of academic and functional skills in the student’s natural environment. The setting, as well as the tasks performed in these settings, should be relevant to the student, facilitate independence, and be age appropriate. In identifying individualized functional targets, Brown et al. [5] proposed a rule of thumb: asking if someone else would have to perform a task for a student, if the student themselves is unable to do it. If the skills taught are not individualized or functional, they may not be maintained because they may not contact sources for reinforcement in the natural environment and so they may not be used in the daily life.

To demonstrate this point let’s look at the example of Sara, a young lady with ASD. Sara received her diagnosis at the age of 2 years and 6 months. Sara’s family immediately started an ABA educational program based on evidence-based practice. Sara was lucky enough to have a team of trained and motivated professionals (teachers, behavioral technicians, BCBAs etc.) who really helped her to learn the highest number of skills in the shortest possible time. During her childhood and adolescence, she continued to receive high-quality training and improve her repertoire of skills, however when she reaches adulthood, her services will be less comprehensive, she will no longer attends school, and the amount of hours allocated in her educational program will dramatically decrease. As Sara ages so will Sara’s family, and one day, Sara will be an adult with ASD, with minimal or no support. At this point the question to ask is “Who will be Sara as an adult?”, “What will her future look like?”, “What will her quality of life be when the resources and support previously available are no longer available?”. It is the opinion of the authors of this paper is that, WHO Sara will be as an adult, is dependent on what we have been able to teach her when she was five, ten, and fifteen years old. A professional working with individuals with ASD and/or other intellectual disabilities should acquire the skills to select target behaviors that will ensure the individual’s independence in the future.

In their seminal article, Bannerman et al. [2] provide a rationale about the importance of teaching choice-making behavior to people with intellectual disabilities. One of their points is that choice making has been seen more “as a permissible activity, rather than a teaching target” [28]. The authors describe the effects of choice-making in different areas of functioning, such as preference, participation in activities, task-performance or problem behavior. They conclude, emphasizing the need to insert choice-making in a student’s learning curriculum in order to evaluate student’s preferences when choosing teaching targets and to provide an appropriate number of opportunities to choose on a daily basis.

Another important area of teaching is safety skills. As individuals with disabilities become increasingly independent at home, in the community, and in work settings, they are exposed to greater risk [32]. One strategy often used in the ABA literature to teach safety skills (as well as skills from different domains) is Behavioral Skills Training (BST). The purpose of this article is to present to the reader a review of some examples of applications of BST and other environmental manipulations in teaching safety skills to students with ASD. In the subsequent part of the article some clinical suggestion on teaching objectives, related to safety skills, will be provided.

Teaching strategies used in teaching safety skills

Behavioral skills training (BST) is a multi-component intervention that consists of instructions, modeling, rehearsal, and feedback [19]. The instruction component of BST describes the appropriate behavior for the learner. Instructions can either be written or verbal. With modeling, the skill is demonstrated to the learner, so that the learner can observe and imitate the modeled behavior. After instructions and modeling have been provided, the learner is given the opportunity to practice the skill. The rehearsal component is an important part of BST because it represents an opportunity to provide feedback for the behavior. The feedback component involves giving praise or other reinforcers (e.g. points in a point system) for correct behavior or a form of correction for incorrect behavior. A component that is often added to BST is called in-situ training [10]. With in-situ training, the trainer assesses and teaches the skill in the natural environment.

One of the areas in which researchers have successfully used BST is in teaching safety skills. In one of the first studies on this topic [15], the researchers evaluated teaching children abduction prevention skills (e.g. not going with a stranger). This study used the four components of BST to teach the children the skill and all of the children learned and maintained the skill, except for one who required in-situ training in order to perform the skill correctly.

In another study, Johnson et al. [17] taught to 13 preschool children to say “no” and run away from a stranger, and then report the incident to a familiar adult. The researchers used BST plus in-situ training to teach this skill. During the BST component of the training, the researchers provided instructions about how to respond to an abduction lure, modeled and provided opportunities for the learners to rehearse the target behavior, and provided descriptive or corrective feedback based on the student’s responses. During the in-situ training component, the students were approached in the natural setting by a confederate. If they didn’t correctly engage in the three target responses, the researcher, previously out of sight from the student, entered the situation and provided corrective feedback. All 13 participants involved in the research learned the skills and all but three maintained them at the 3-month follow up. In 2006, Johnson et al. compared BST to BST plus in situ-training to teach abduction prevention skills to a small group of children. Results showed that both strategies were effective in teaching the skills, but the group who received also the in-situ component showed better results at the 3-month follow-up. A study by Gunby et al. [13] showed similar results, in teaching abduction prevention skills to three children with autism.

Fisher et al. [12] extended these previous findings teaching the same abduction prevention skills to five adults with mild intellectual disabilities. During a preliminary assessment the participants of this study did not walk away from strangers who approached them. Participants acquired skills in a classroom setting in just a few sessions, but in-situ training was needed for the participants to generalize the skills to the natural environment. Responding was variable for some participants during maintenance trials for some of the responses, however, all of them continued to say “no” to strangers.

Another line of research related to safety skills involves teaching students with intellectual disabilities to seek assistance when lost in public. Taber et al. [32] used BST and chaining to teach middle school students with moderate cognitive disabilities to make phone calls when they were lost. Participants learned to identify when they were lost and make a phone call for assistance, even if some of them showed difficulties in describing a specific location effectively to the adult during the phone call.

Taylor et al. [33] taught three teenagers with autism to respond to a vibrating pager, which served as a prompt, to seek assistance when lost by handing a card to a community member.  Using a multiple baseline probe design across participants the researchers evaluated the ability of the participants to hand the card to a nearby adult when the pager was activated. During probe trials, conducted in community locations, the adult left the student’s line of sight and activated the pager, simulating a situation in which the student may be lost. If the students approached an adult with the communication card, the researchers provided descriptive feedback. If the students failed to engage in the target response, the researcher kept activating the pager every 30” until the target behavior occurred or 2 minutes elapsed. At the end of the study all the students acquired the target skill and generalized it across different locations.

In a similar study Bergstrom et al. [4] used a treatment package composed of rules, role-playing and feedback to teach three students with ASD to seek assistance when lost in a store. Three target responses were taught: calling for “mom” or “dad” above conversational level, looking for a store employee, and approaching the employee telling him or her that they were lost. The procedure was effective in teaching the skills in the specific training location, as well as in novel stores.

In a more recent study, Carlile et al. [6] taught a low-tech (handing a communication card) and a hi-tech (making or responding to a Video Call) help-seeking response to students with ASD to be used when they were lost. The purpose of the study was to assess the efficiency of the two types of responses taught using an intervention package composed of video modeling, programming for common stimuli and error correction procedures. Interestingly, the authors differentiated target responses taught based on the students’ ability to determine if they were lost or not. They taught those students were able to identify they were lost to approach a store employee and to hand a communication card (low-tech response) or to make a video call (hi-tech response), while they taught students were not able to identify they were lost, to respond by handing the card to an employee who approached them to ask them if they were lost or to respond to a video call. The skills were taught in a school setting and the stimuli used were those that would have been present in the natural environment in which the behavior should be displayed to promote generalization [30]. After the students acquired both the low-tech and the hi-tech responses, they generalized the skills during post-intervention probes in community settings. Teaching both low-tech and hi-tech responses may be useful in case technology relying on batteries or electricity isn’t always available (e.g. smartphone battery dies).

Other clinical examples

Another way to help students learn safety skills is by using technology during teaching may be an effective way to help students with more severe intellectual disabilities or with low levels of verbal behavior. The authors of the present article, during their clinical practice, taught students with severe intellectual disabilities to share their location using the Whatsapp application on their smartphone. Using task analysis and chaining strategies, the authors taught the participants to respond to a vocal message sent via Whatsapp by a familiar adult (a parent or a therapist) by accessing Whatsapp and clicking on “sharing location” tab. Multiple exemplars of vocal messages were presented (e.g. “Where are you?”, “Send me your location”, “Can you tell me where you are”) in order to enhance generalization. The steps of the task analysis consisted of unlocking the smartphone, opening the the Whatsapp application, pressing on the vocal message icon to listen to the message, opening the Whatsapp menu, clicking on the “sharing location” tab, and then locking the smartphone. A critical component of this chain is the first response. It is essential that the sound from the phone indicating that there was a message become the discriminative stimulus rather than an adult instruction to check the message. If a particular student did not respond to the phone ringing, indicating that the phone ringing was not exerting stimulus control on the student’s behavior, a pre-training phase, consisting of sending vocal instructions for which the student’s responses directly resulted in positive reinforcement (e.g. “you can eat your snack now”; “it’s time to play your videogame” etc.) was implemented. Using this strategy the approaching response should be reinforced while the reinforcement process may start to change the function of the phone ringing into a discriminative stimulus.

Another clinical example is teaching high-functioning adolescents with ASD to discriminate between family members, friends, and strangers. The authors used BST to teach a list of behaviors that would be acceptable if displayed by a family member, but not by a friend or a stranger. For example, only a family member can help the student in the bathroom, or ask him or her personal information such as his or her credit card number or his or her address. In contrast, students should recognize inappropriate behavior exhibited by strangers (e.g. asking personal information or inappropriate touching). After the BST component the authors implemented an in vivo component, during which adults left the students’ sight in a safe location (e.g. a cafè) with a confederate present and asked people the students did not know to approach them and ask for personal information (e.g. “can you tell me your phone number”, “I’d like to bring you a present”, “where do you live?” etc.). As shown in previous studies, the teaching target was to say “no”, run away, and report the inappropriate contact to a familiar adult.

Conclusion

In the current paper we provided evidence to support the need to adopt an individualized teaching curriculum with a strong emphasis on functional and adaptive skills, with the aim to improve students’ lives not only in the classroom, but in their community and the natural environment. While a student gets older, the quantity of time allocated to educational programs usually decreases; in this scenario choosing targets that can help students to live the best and the most independent possible life is of utmost importance. In choosing teaching targets professionals should be asking themselves questions such as “Why are we teaching this skill?”, “Could my student act effectively as an adult without this skill?”, “Can we adapt/modify a too difficult skill?”, “Will learning this skill improve student’s quality of life?” (Gloria Satriale, personal communication). We presented a summary of the literature on the topic of using BST to teach safety skills, especially abduction prevention and seeking help if lost. Next, we shared some clinical practices in teaching safety skills based on the published literature. Our goal was to present the reader examples of evidence-based teaching strategies and procedures that can be applied in a clinical setting. Only by incorporating meaningful skills in daily teaching we can help our students to be prepared to live a meaningful life. Given that we often are tasked with teaching a large number of skills in a very short period of time, it’s our responsibility use this time wisely.

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