Running head: EFFECTIVE STRATEGIES FOR WORKERS

What Types of Strategies are Effective with Young Adult Workers who have Intellectual Disabilities? Sylvia Niemyjski & Lauren Hoppe Touro University Nevada

Effective Strategies for Workers

Occupational Therapists utilize a variety of strategies for effective treatment. However, it is important to know what effective treatment is. An important part of being an occupational therapist means using Evidence Based Practice. Evidence based practice means that using prior techniques that have been shown to have significant results. The current research question at hand is: What type of cuing (or strategies) are effective with young adult workers who have intellectual disabilities? The study of Allen , Burke , Howard,

Wallace & Bowen (2012) relates to the research question, for in the study, various techniques that would increase job performance for adolescents who have intellectual disabilities were investigated. The research question was created during a level I fieldwork of 2 occupational therapy students. The placement was in a thrift store that employed individuals with intellectual disabilities. Although the workers were very hard working, it was apparent that job performance was not at a level where it needed to be. This fueled a search for techniques that would increase job performance. The purpose of the study was to specifically look at covert audio cuing to aid individuals working with WalkArounds, these individuals had ASD or ID. The research question of the study investigated what techniques would be best to use with workers who had ASD as well as ID. Extensive research has been done on this subject. In the previous literature it was evident that employment is extremely difficult for those who have ASD. In fact, nearly 90% of employment aged individuals who can work are not employed. A big challenge that was pointed out was that those individuals with ASD often struggle with social skills which makes it difficult to obtain and keep a job. Research shows that through the use of technology, job performance can increase for those with ID and ASD. One example of this is a technique called

Effective Strategies for Workers

videomodeling while wearing the WalkAround (a costume). Another technology driven technique was using an iPod. The iPod was utilized in the sense that the workers received textual cues. The study suggested that although the use of the iPod improves social skills for individuals with ASD, it does not necessarily improve vocational skills. However, audio-cueing is seen as the most promising technique. Research has found that pre-recorded prompts assists those with ID to perform vocational tasks. Given this information, it can be seen that many individuals who have ASD or ID are not employed but can be employed; therefore, it is important to investigate alternative ways or to provide more research to support these techniques. The study design was an experiment with an evidence level of IIb-which included evidence from at least one well designed experimental trial. Two interventions were evaluated in an interrupted time series withdrawal design during training and later in the real job setting. The study consisted of individuals who ranged in age from 16-20 years old. These participants were recruited from a developmental/behavioral clinic at the University Center for Excellence in Developmental Disabilities. Four adolescents with ASD and ID agreed to participate. 18 year old Ned was a Caucasian male who had ASD. It was noted that he had gotten behavioral services in the past for: noncompliance, enuresis and mild aggression. 17 year old Trace was also a Caucasian male who was diagnosed with ASD, a seizure disorder and moderate Mental Retardation (today referred to as Intellectual disability). At the time of the experiment, Trace was receiving behavioral services to deal with his aggression and noncompliance. 16 year old Emma was a Caucasian female who was diagnosed with ASD as well as moderate mental retardation. Matthew, was a 17 year old male who was diagnosed with ASD

Effective Strategies for Workers

as well as ADHD, he later refused to participate in the study which brought the total number of participants down to three. Prior to the participation in the study, none of the individuals had experience with supported employment. However, it is important to note that each had already begun prevocational training through transitional employment or the young adult programs which were started at their public schools. All information concerning the participants intellectual disabilities was extracted via their case files. Each of the participants had always been enrolled in special education throughout their school careers. The participation was voluntary and informed consent was obtained from the parents or the guardians of the participants. The study was approved by the IRB at the University of Nebraska Medical care. In the study, a total of two different walk around costumes were used. The first was a Rocky the Raccoon costume while the other was a Chester the Cheetah costume. The independent variables came into play with the help of 3-5 volunteers who would expose the workers to various scenarios. These 6 scenarios were as follows: Ignore the Walkaround, ask a question, respond to any initiation by the walkaround, walk past the walkaround while talking on their cellphone, look at items on the shelves and lastly, ask for a hug. The dependent measures were grouped into 3 categories looking for target skills, but coded separately. These included: Head actions (nodding, shaking head, moving ears, and wagging tongue), arm/hand actions (waving, shaking hands, giving high fives, clapping), and leg/torso actions posing for pictures, shaking tail, shaking body and jumping up and down. The primary dependent measure included the occurrence of multiple target skills (listed above) in a single interval. The

Effective Strategies for Workers

parents of the participants also completed an 8 item measure to show their satisfaction with their child wearing the costume. For the intervention, both video modeling and audio cueing were utilized. The videomodeling consisted of the participants sitting down in front of a laptop and watching a standard training video that had been used by previous employers. For audio cueing, an FM Tran receiver was used with a microphone and earphones. An attendant was on the other end of the receiver and would cue the participants with what to do in order to reach certain criterion. The statistical analysis used consisted of Poisson loglinear regression within a generalized estimating equations. The results concluded that audio cueing produced immediate and sustained improvements in the job setting. It was noted that the participants were able to do a combination of the skills 30% of the time. An important finding is that now the effectiveness of audio cueing was extended to a new setting and used with a new walk around costume. The findings do in fact provide more support for audio cueing. The findings of this article supported previous research that showed the use of video modeling is not an effective when teaching job or vocational skills to adolescents with autism and intellectual disabilities. After exposure to a standard video modeling program none of the participants showed substantial evidence of multiple skill use. Previous studies completed on the use of audio cuing showed an increase in job performance when prompting individuals with intellectual disabilities in a supported work environment. The study conducted found that continuous cueing was effective in improving job performance. However, job performance was not maintained if cueing was not constant and quickly declined if cuing ceased.

Effective Strategies for Workers

Some limitations of this study include the participants were only provided with one chance to view the standard video model used in the beginning of the training. This could not give the participants enough time to fully understand and learn the job requirements leading to poor baseline performance. Also, the participants showed a vast decrease in performance after the audio cues were ceased. The author stated this could be considered a limitation because it shows that individuals with ASD are often prompt dependent. This is also consistent with previous research showing constant cueing is required to perform job skills. This could provide a limitation to generalizability because the job performed in the study allowed for easy accessibility to cueing which may not be present in other job situations. The sample size in this study only included three participants, which is extremely small. In order to make the evidence stronger a larger sample size is needed with a wider range of ethnic, geographical and gender differences. There was one drop-out in the study. One initial participant did not like being in the Walk Around costume and could only tolerate wearing it for 15 minutes. He was not included in the study. Since this was such a small sample size, the dropout participant could have influenced the outcomes. Although I dont believe it would have made a huge impression on the results. There was also no control or comparison group in the study, each participant was provided with the same job training and the same amount of audio cues during the job. For future research, the authors of this study suggested working for more than one hour at a time in order to represent more of a full time employment. The participants were only required to work for one hour at a time, and therefore could only represent part time employment. Other research should consider the use of cueing in a full time job position. Future research

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should also be done to discover if audio cueing can be used in a job that requires more complex skills associated with it. This study used a unique job opportunity that made cueing extremely easy and accessible and did not require complex skills to perform. Finally, future research should continue to explore ways to improve vocational and job skills for individuals with Autism Spectrum Disorder and Intellectual Disabilities. Factors that could contribute to or influence the study outcomes include the type of job the participants were engaged in and the easy accessibility it had for cueing. The job was very unique and did not require much social skills or direct interaction with customers, something individuals with ASD tend to struggle with the most. Therefore the skills required for this job may not be generalizable to other potential jobs for individuals with ASD. Also, because the participants were in a costume with their face covered, they were not required to verbally communicate with the customers or other employers leaving all their attention to be focused on the attendant providing cues through the audio piece in their ear. This could greatly impact individuals in other jobs that may have to interact with others during their job and the cueing could cause distractions and lead to poor job performance. If coaches are constantly cueing them while they are communicating with others it could cause frustration for the individual and also influence job performance. Also, the amount of training time could have greatly impacted the job performance. The participants were only given one chance to watch the standardized training video and may needed to have seen it more than once to fully understand the job requirements and how to perform the job well. Another factor that could influence outcomes of the study are the frequency of prompts given by the attendant. The attendant prompts were given on average 6 times per minute. This

Effective Strategies for Workers

requires constant cueing from another individual which may not be possible in different environments. They also conducted the study with a trial (Job 1) where prompts were given followed by another trial (Job 2) when prompts were not given for a 10 minute duration to see if any job skills had been retained by the participants. The trial (Job 1) with prompts showed a tremendous increase in job performance while the job without prompts declined back to baseline level. If there was a slow decline in prompts given over a longer period of time instead of an abruptly halted it may have led to better results. Strengths of the study included using a two different costumes in two different locations, showing generalizability. It demonstrated that the skills the participants learned could be used in new environments with different gear on. Another strength of the study included using the same attendant to give cueing and prompts to the participants during all of the jobs. This kept the cueing consistent and did not allow for discrepancies in cueing. Furthermore, the researchers also tested for overall satisfaction from the participants and their parents. This showed that they not only wanted to see the benefit from the strategies but also make sure the participants were satisfied in the job as well. The weaknesses in this study included a small sample size, which may have caused difficulty in finding significant relationships from the data. The small sample size will limit the availability to generalize the results of the data to the entire ASD and Intellectual disability populations. Another weakness was the job the participants were trained in was very specific and unique that the type and amount of cueing received by the participants may not be possible in other jobs available to individuals with ASD or intellectual disabilities. Furthermore, all participants were exposed to two types of testing, audio cueing and video modeling, which

Effective Strategies for Workers

could have skewed the results since the participants already had one type of exposure to their task. Instead of exposing the participants to two different training strategies the authors of the study could have tested three different groups of participants and exposed the groups to one type of strategy and then compared the results between the two groups. The third group could then have been a combination of the two strategies, this could have given the researchers a better understanding of their results. Also, the researchers did not address reliability and validity;
this is still an important aspect of research. Reliability assesses consistent results within a study, while validity assesses how accurate a measurement is.

An occupational therapist could incorporate these findings into practice by using audio cueing to help improve job skill performance for clients with ASD and intellectual disabilities. This study also suggests that audio cueing provided better results over video modeling and indicates a therapist should use audio cueing instead of video modeling when working with this specific population on improving vocational skills. This article supports the field of occupational therapy by providing research to help improve strategies for vocational and job skills for individuals with ASD and Intellectual disabilities. This is an area that occupational therapists can definitely work in and help implement strategies for their clients to excel in the workforce with the use of clinical reasoning and evidence based practice.

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References Allen , D., Burke , V., Howard, R., Wallace , P., & Bowen, L. (2012). Use of audio cuing to expand employment opportunities for adolescents with autism spectrum disorders and intellectual disabilities. J Autism Dev Disord, 42(11), 2410-2419.