Keywords

Using Applied Behavior Analysis to Teach Adaptive Skills

Adaptive skills are those skills which are needed for everyday life and provide access to independence. While all individuals benefit from some systematic instruction to learn adaptive skills (learning to tie one’s shoes, for example), individuals with developmental disabilities may require additional, more intensive supports. These supports are often derived from the science of applied behavior analysis (ABA). In this chapter, we will first present a rationale for the importance of adaptive skills, then provide a review of the available literature on using interventions derived from the science of applied behavior analysis to teach adaptive skills. Finally, we will provide suggestions for practitioners and staff on methods of instruction that are effective for adaptive skills, as well as a brief conclusion with recommendations for future research and practice.

Adaptive Skills

For the purpose of this chapter, adaptive skills will be defined as skills resulting in independence for the learner, specifically in the following categories: (a) safety skills; (b) recreation skills; (c) skills needed to access the community; (d) hygiene and dressing skills; (e) skills needed to access technology; (f) skills needed to buy and prepare food; (g) skills needed to obtain and keep employment; and (h) housekeeping skills. For the purposes of this chapter we will not be considering the relatively large and independent bodies of literature on (a) toileting skills; (b) feeding skills (including addressing picky eating, food refusal, and sensory-based issues with food); (c) staff and personnel training; (d) communication; (e) challenging behavior; (f) sleep and sleep hygiene; and (g) choice making.

Importance of Adaptive Skills

All individuals require adaptive skills, also sometimes called self-help skills or life skills, to access all environments, obtain employment, and ultimately, survive. For example, most individuals learn to get dressed independently while they are in preschool. Learning to dress oneself allows access to school environments and selecting the appropriate clothes leads to increased safety and health. Failure to learn to get dressed independently would mean an inability to access school and work environments without the assistance of another individual. Therefore, for individuals who are unable to learn through brief modeling and practice provided by a caregiver in early childhood, vast areas of independent life are unavailable without systematic intervention. In fact, adaptive skills are some of the most predictive for future quality of life for individuals with intellectual and developmental disabilities (IDD; Tomaszewski et al., 2020).

In addition to individual quality of life, adaptive skills are directly tied to economic outcomes. Not only are individuals without a typical repertoire of adaptive skills likely unable to seek out and obtain sufficient employment, an inability to complete tasks of daily living signals the need for a high level of support, often meaning in-home services or group living, both of which are expensive (Buescher et al., 2014). A recent systematic review indicated that although the exact numbers differ depending on how the cost is calculated and what public support is available, the cost for an individual without basic adaptive skills can be up to 15 times that of an individual with the ability to feed, clothe, and transport themselves (Kozma et al., 2009). In a survey of parents on post-secondary outcomes for their children with developmental disabilities, the most frequently selected concern by far was the ability of their child to obtain gainful employment (Blustein et al., 2016).

Adaptive skills are also of importance for physical safety. Individuals with developmental disabilities have a shorter expected lifespan than typically developing individuals (Tyrer et al., 2007). While accidental deaths account for only a small percentage of these deaths, deaths from other causes like chronic disease and suicide could be prevented in part through support of adaptive skills including adherence with health regimes and increased self-efficacy. A recent systematic review found that life expectancy was an average of 20 years shorter for individuals with developmental disabilities, and that life expectancy was responsive to several interventions, many of which involved better adaptive skills (O’Leary et al., 2018; Cooper et al., 2020). Beyond mortality, adults with disabilities make up a disproportionate amount of emergency room visits, and that this high rate of visits can be described by factors related to adaptive skills including lifestyle changes, preventative medical care, and poverty (Cooper et al., 2020).

Previous Literature on Adaptive Skills

Compared to other domains affecting children and adults with IDD, there is relatively little literature on teaching adaptive skills. Recent reviews of adaptive literature include specific reviews on specific teaching strategies (e.g., Cullen et al., 2015; Ramdoss et al., 2012). As one example, Ramdoss and colleagues completed a systematic review on computer-based interventions to teach adaptive skills to individuals with intellectual disabilities (Ramdoss et al., 2012). Systematic reviews have also aggregated the current literature on adaptive skill interventions for distinct disabilities or other groups of learners (e.g., Scott et al., 2019; Chiang et al., 2017). One such review outlines the varying methods for teaching life skills for Middle and High School students with autism. Finally, previous reviews have focused on categories of adaptive skills (e.g., Doughty & Kane, 2010; Scott et al., 2019). Scott and colleagues conducted a systematic review of employment skills for individuals with ASD, as one example. Previous reviews have conducted general reviews of adaptive skills (e.g., Neely et al., 2020), but to our knowledge no recent review has directly examined interventions based in the science of applied behavior analysis and without specifying a particular population.

Literature Review Method

We conducted a literature review of teaching procedures for adaptive skills for individuals with IDD. We did not limit by age range, setting, or interventionist. We searched ERIC and PsychInfo with the following search terms: (a) life skills; (b) job skills; (c) activities of daily living; (d) self help; (e) self-care; (f) independent living; (g) food preparation; (h) safety; (i) transition; (j) vocational rehab (Akmanoglu & Tekin-Iftar, 2011; Allen et al., 2012, 2015; Bassette et al., 2018; Becerra et al., 2018; Bouck et al., 2014, 2016; Burton et al., 2013; Cakmak & Cakmak, 2015; Carson et al., 2008; Cavkaytar, 2012; Cavkaytar et al., 2017; Chang et al., 2011, 2014; Cihak et al., 2004, 2015; Choi et al., 2012; Coles et al., 2007; Collins et al., 2017; Cullen & Alber-Morgan, 2015; Fisher, 2014; Gardner & Wolfe, 2019; Goh & Bambara, 2013; Golisz et al., 2018; Honsberger et al., 2019; Johnson et al., 2013, 2019; Josman et al., 2008; Kearney et al., 2019; Klett & Turan, 2012; Kwon & Lee, 2016; Lancioni et al., 2011a, 2011b; Levy et al., 2017; McDuff et al., 2019; Mechling et al., 2010, 2014a, 2014b; Mechling & Collins, 2012; Morgan & Horrocks, 2011; Nittrouer et al., 2016; Nosik et al., 2013; O’Handley & Allen, 2017; Ohtake & Hatano, 2018; Pérez-Fuster et al., 2019; Price et al., 2018; Purrazzella & Mechling, 2013; Rehfeldt et al., 2003; Root et al., 2017; Sabielny & Cannella-Malone, 2014; Saloviita & Tuulkari, 2000; Smith et al., 2015; Spencer et al., 2015; Spivey & Mechling, 2016; Taber-Doughty et al., 2013; Uphold et al., 2016; Walser et al., 2012; Weng & Bouck, 2014); (k) adaptive AND (a) intervention; (b) instruction; (c) teach; (d) treatment; (e) training; (f) behavior skills training AND (a) disability. These results were limited to peer reviewed manuscripts, manuscripts written in the English language, and the dependent variable had to be an adaptive skill as defined in this chapter. Initial results returned 5981 articles from PsychInfo and 1851 from ERIC. After initial title and abstract review, the full text of 58 articles was reviewed. To be included, an article needed to have at least one participant with a developmental disability and an intervention with the expressed goal of increasing or teaching of an adaptive skill. Although the authors did not limit the research methodology, the vast majority of studies use single case methodology (n = 52).

Important Skills Excluded from the Current Review

There are large swaths of the literature that could be conceptualized as adaptive skills. However, due to the limited scope of this chapter and the focus on primarily ABA interventions, we excluded a few adaptive skill categories with bodies of literature we felt were complete on their own. We would like to briefly discuss the areas and how they impact adaptive skills and daily functioning of individuals with IDD. The areas excluded were: (a) toileting skills; (b) feeding skills (including addressing picky eating, food refusal, and sensory-based issues with food); (c) staff and personnel training; (d) communication; (e) challenging behavior; (f) sleep and sleep hygiene; and (g) choice making. While we have excluded these skills from this chapter in order to focus on general adaptive skills, we feel these skills meet our definition of adaptive skills and so should be mentioned briefly.

Toileting Skills

Toileting is a skill that some typically developing children struggle with, particularly defecation, and autism and IDD make toilet training success less likely (Baird et al., 2019). The skill of independent toileting is critical to everyday functioning and accessing independent living. There are logistical difficulties with changing diapers as children get older as changing stations are often only made for small children. There is also a lack of changing stations in men’s bathrooms, which can limit the ability of male caregivers to assist with this task. There is a movement to include changing stations for older individuals in public places such as stores and shopping malls (http://www.changingspacescampaign.org/). However, at this time, these are generally unavailable. This is a skill that can be addressed both at home and school for individuals with IDD. There is a growing body of research about the use of toilet training protocols including the use of phone-based applications and urine alarms (Levato et al., 2016; Mruzek et al., 2019; Saral & Ulke-Kurkcuoglu, 2020). An area commonly overlooked within this research is teaching individuals who menstruate to use menstrual hygiene products. Many individuals with IDD are not given the opportunity to learn hygiene skills (Rodgers & Lipscombe, 2005). There a few studies that do so, but only with menstrual pads and none with the use of tampons, menstrual cups, or underwear specifically designed to be worn during menstruation (Klett & Turan, 2012; Veazey et al., 2016). There is evidence to support the assertion that people with disabilities experience the same level of difficulties with menstruation as those without, however, little attention is paid to this issue in intervention research (Hamilton et al., 2012; Kaskowitz et al., 2016). A lack of toileting/menstrual hygiene skills can also lead to exclusion from school and social settings and limit access to community activities and travel outside of a certain distance from the home of the individual.

Feeding Skills

This is an area of research that is shared by many disciplines (Snider et al., 2011; Marshall et al., 2013, 2015; Smile et al., 2020). Occupational therapists, speech therapists, developmental pediatricians, and behavior analysts have addressed issues ranging from picky eating to complete food refusal that results in feeding tubes or other intrusive medical interventions. There is some disagreement over which specialty should be addressing feeding issues or specific kinds of feeding issues. For feeding issues, a differential diagnosis or an elimination of medical/physical reasons for the problem is required. Pediatricians will address medical concerns and speech therapists can address problems like apraxia. Once any physical or medical reason has been addressed or ruled out, behavioral intervention or may be appropriate (Zhu & Dalby-Payne, 2019). However, due to the different possible etiologies and complications of treatment and the cross-disciplinary nature of the treatments, we have excluded that literature from our review.

Staff and Personnel Training

Staff and personnel training are an area that ABA is uniquely situated to complete along with ensuring lasting treatment adherence through assessment of treatment fidelity. However, this area is not specific to adaptive skills. The majority of training research focuses on behavior skills training, which includes didactic teaching, modeling, rehearsal, and feedback (Cooper et al., 2020). These specific steps are repeated until the individual reaches a certain level of treatment fidelity. This can be used to teach staff and personnel who assist individuals with IDD in their daily lives including teachers, therapists, parents, and group home staff (Nosik et al., 2013; Rosales et al., 2009; Ward-Horner & Sturmey, 2012). This chapter will explore behavior skills training (BST) as an intervention later in a specific section.

Communication

Communication is a complex set of behaviors that all individuals can exhibit to some extent (Desouza et al., 2017). The focus of many early behavior interventions is to increase to communication to enable children with disabilities to get their basic needs met, an adaptive skill in that it is a behavioral cusp that allows the individual access to an expanded array of reinforcement. Communication is a topic that falls under the purview of many disciplines such as speech language pathologists and occupational therapists in addition to ABA therapists. Given the vast body of literature on teaching communication using the science of ABA as well as from other disciplines, we have not included it in this chapter.

Challenging Behavior Interventions

Challenging behavior certainly impacts children with IDD’s functional and adaptive capabilities and daily lives. Current research supports the use of functionally-matched interventions to address challenging behavior that teach a new or replacement behavior for the challenging behavior (NAC, 2015). These require specific assessments and the creation of a behavior intervention plan. These plans require team support and must be acceptable to parents and other specialists. However, many of the interventions used to address challenging behavior are combined with or contain teaching procedures for the acquisition of new skills. For example, instead of engaging in screaming to get a milkshake, a service provider could teach the person to help make or make a milkshake independently. This may eliminate the need for screaming and meet the functional needs of the individual. Some of the teaching procedures that we cover later in this chapter can potentially be used to teach appropriate replacement behaviors to address challenging behavior.

Sleep and Sleep Hygiene

Sleep and sleep hygiene (or lack thereof) can have serious impacts on individuals with IDD and their families (cite Matson studies and others on sleep and brain development). There is some research to support the connection between lack of sleep and brain development and an increase in challenging behavior. There are many different types of sleep interventions with varying success at addressing various sleep disorders with melatonin, behavioral interventions, and parent training showing the strongest effects for the most types of sleep problems (Cuomo et al., 2017; McLay et al., 2019). Interventions for sleep in individuals with IDD/ASD can be difficult for parents to complete, and research on them is scarce. As the ability to manage a bedtime routine independently as well as manage a reasonable sleep schedule is certainly necessary for an independent life, we are considering sleep an adaptive skill. Since there is a large body of literature specific to sleep, however, we are excluding it from this particular chapter.

Choice Making

Choice making is often conceptualized as a cognitive skill, but certainly also an adaptive skill since having the discriminative ability to select the desired item or option from an array is certainly important for access to independent life. Many of the interventions we’ve included also involve choice making, but there is little literature on instruction on this skill (Sparks & Cote, 2012; Stephenson, 2016). We recognize the ability to make a choice as critical for independence, but will not be directly discussing it in this chapter due to lack of research and the available literature being situated in the skill acquisition domain.

Data Extraction

These articles were coded for the following data: (a) category of adaptive skill, (b) intervention; (c) dependent variable; (d) research methodology; (e) participant demographics (age and disability); (f) setting; (g) change agent/implementer; (h) generalization; and (i) maintenance. This information is summarized in Table 1. The resulting articles included the following categories of adaptive skills: (a) safety skills; (b) food access and preparation; (c) employment; (d) housekeeping; (e) hygiene; (f) technology; (g) medical procedure tolerance/participation; and (h) technology use—recreational. While these classifications are not exhaustive, they are areas of concern and intervention targeting across the lifespan and all disability categories.

Table 1 Studies included in the review of literature
Full size table

Results

As with most developmental disability research, the many studies featured participants with ASD (n = 21), however another common disability was some level of intellectual disability. There was a surprising diversity of change agents with parents and caregivers (n = 5) and special education teachers (n = 12) being most common. Interventionists also included nurses and nursing students (n = 1), job coaches (n = 5), peer tutors (n = 1), speech language pathologist (n = 1), and researchers (n = 19). The single case designs included multiple baseline (n = 15), multiple probe (n = 23), reversal or withdrawal (n = 6), and alternating treatment design (n = 6). The majority of studies did not include generalization (64%) or maintenance assessment (52%). The following will be a summary of the studies included in each category of research.

Summary of Intervention Domains

Safety Skills

Safety skills are skills needed to avoid hazards or injury in the natural environment. The knowledge of what to do in emergency situations, such as a fire safety, water safety, abduction, and what to do when you are lost, etc. prevent individuals with ID or ASD in accessing their communities independently. Nine articles were included in this category. While some of these skills can be taught in role play situations, behavior skills training, and other methods, these are mostly abstract concepts to learn. Bassette et al. (2018) suggested using Video modeling (VM) and a system of least prompts (SLP) to teach individuals with ID how to take and send a picture of their environment on a cell phone in the event they were lost. All participants were able to complete 100% of the steps at least once, and were able to generalize in unfamiliar areas, such as the grocery store.

Technology and Recreation Skills

Technology skills are skills needed to access the technology important for daily life. Much of the research found in this review in this is focused on adaptive technology, which is technology used to make a task or tasks easier or manageable by the individual. In that sense, technology plays a large role across domains in facilitating access to adaptive skills (see Damianidou et al., 2019 for examples). Despite frequent use of technology to support acquisition of adaptive skills, however, comparatively little attention has been paid to teaching individuals with disabilities to use technology for leisure. Two examples of recreation training include Walser et al. (2012), where authors used video modeling to successfully teach individuals with moderate intellectual disability to access features of an iPhone including the camera function, slideshow function, and video viewing function. Uphold and colleagues taught six adults with intellectual disabilities and autism how to manage recreation tasks using an iPod application (Uphold et al., 2016).

Food Access and Preparation

In contrast, much attention has been paid to teaching students food preparation and acquisition skills. As a skill fundamental to independence and survival, food acquisition and preparation deserves enhanced recognition as a basic functional skill for most individuals. Utilizing strategies such as self-monitoring systems (Bouck et al., 2014), video self-modeling (Allen et al., 2015), high-tech and low-tech price comparison (Bouck et al., 2016; Weng & Bouck, 2014), and video prompting (Johnson et al., 2013), skills associated with preparing and buying food have been successfully supported.

Employment Skills

Employment skills are another important and well researched subject for individuals with disabilities. A large variety of tasks can be considered job skills, but they broadly fall into the categories of acquiring a job or doing the work necessary for employment. In the first category, it is evident that job application and interview skills are of great importance to individuals looking to earn an income. However, the research included in this chapter are primarily representative of training individuals with disabilities like ASD to complete work tasks in jobs they have already acquired. Strategies implemented for this goal include video prompting (Smith et al., 2015), video self-modeling (Goh & Bambara, 2013), peer mediation of literacy-based behavioral interventions (Honsberger et al., 2019), graphic and video supports (Becerra et al., 2018; Johnson et al., 2019), computer-based interactive games (Chang et al., 2014), and numerous others. Skills taught ranged from making coffee and recycling to sending e-mails across multiple platforms.

Housekeeping

Housekeeping is yet another vital skill for independence in individuals with disabilities. Chores such as washing dishes and folding laundry have been the focus of numerous studies. Strategies that have shown success include video modeling (O’Handley & Allen, 2017; Cannella-Malone et al. 2011), video prompting (Cannella-Malone et al., 2011; Gardner & Wolfe, 2019) and other prompting strategies (Sabielny & Cannella-Malone, 2014).

Dressing and Hygiene Skills

The ability to dress oneself, is a crucial part on the road to live independently. Dressing, which is one of the basic daily living skills, can range in the amount of support needed by caregivers and/or parents. Teaching this skill to individuals can greatly increase their independence. The use of ABA principles in teaching these skills “utilizes behavioral principles such as positive reinforcement to teach individuals with special needs skills in planned, systemic manner, and offers repeated opportunities across the day, settings, people, and materials to practice their new skills.” (Cavkaytar & Pollard, 2009). Cullen and Alber-Morgan (2015) suggested that learning of life skills, such as dressing, through video modeling, self-prompting, either through pictures and/or technology, can lead to increased generalization and maintenance of the skill. The range of which this method can be implemented allows it to be accessible to individuals regardless of their access to technology.

Individuals with ID often need a varying level of support when preforming self-care and daily living skills. These tasks include, but are not limited to, toothbrushing, feminine hygiene, toileting, bathing, and getting dressed. While some of these skills, such as bathing, require another subset of skills, such as water safety, most of these skills have the potential to taught to individuals with IDD. The consequence of learning these types of skills, increase the individual’s level of independence and decreases the amount of support and aid by caregivers and family members. Previous research has required the use of a person-based learning approach to practice and teach a series of visual and verbal prompts to teach a new skill. Golisz et al. (2018) suggested using technology instead of people to deliver these types of prompts, in hopes to maximize independence of the individual. In this study, adults with IDD, decreased the amount of support needed from others to perform tasks such as toothbrushing, getting dressed, and tying a knot via technology.

Community Access Skills

Being able to safely and independently navigate within the community is a skill we take for granted. However, individuals with IDD need to be explicitly be taught how to perform certain task such as knowing how to read signs for safety reasons and navigating public transportation (Price et al., 2018). The study conducted by Price et al. (2018) capitalized on the already self-prompting application of Google Maps to teach young adults with IDD how to navigate their college campus via public transportation. Results showed that by teaching the students to use Google Maps by total task chaining, three out of the four students were able to complete the steps independently and navigate public transportation. The results were generalized to a public setting, and were not limited to just navigating the college campus.

Teaching Strategies

Video Modeling and Video Self-modeling

One successful intervention used to teach adaptive skills is video modeling or video self-modeling. Video modeling can consist of videos of the person (self-modeling) or another individual completing the targeted skill/action. There are factors that can make a model more likely to be successful such as using someone matched to the age and sex of the individual and is preferably someone the individual admires or wants to emulate (Tuong et al., 2014). Video modeling can also be completed using point-of-view of the individual or from another angle. Spencer and colleagues compared two perspectives and both perspectives combined (Spencer et al., 2015). They found that there were minimal differences between the perspectives and that all three participants reached mastery criterion in all three tasks (gift wrapping presents and decorating, boxing presents and decorating, and bagging a gift and decorating). Video models may also incorporate verbal or written instructions.

Chaining and Task Analysis

Chaining is a method of teaching that can take several forms. The basic idea is that complex tasks can be taught by breaking the task down into relatively simple behaviors known as task analysis, which can be taught to be performed in a fluent sequence. In serial chaining, each step is taught to mastery criteria before moving on to the next step. The order of steps can be forward or reverse. In concurrent chaining, steps can be taught all at once and performed in each trial (McDonnell & McFarland, 1988). Chaining has been used to teach many different adaptive skills, including leisure skills such as internet usage (Jerome et al., 2007) and daily living skills such as using the laundromat (McDonnell & McFarland, 1988).

Chaining is often paired with a task analysis, or a visual and/or text-based list of the steps in the behavior chain. Task analyses are often left in the setting where the skill is most likely to be performed in order to serve as a passive prompt for the learner (Cooper et al. 2007). Visual prompts and task analyses were used in several of the studies included in this review as a component of a packaged intervention (e.g, Akmanoglu & Tekin-Iftar, 2011; Collins et al., 2017).

Audio Cueing and Audio Prompting

Audio cueing or prompting utilizes technology to deliver training to a person learning a new skill. It can be as simple as listening to an audio recording on a smart phone or tablet that cues the person on each step of the task (Mechling & Gast, 1997). While often paired with video modeling, it is not always necessary to have a visual component for each individual. It may be a more socially valid or simpler process to provide the individual with appropriate prompts for the task through an audio recording. Such audio cues may be easier than picture cues for people with physical or motor disabilities.

Self-Monitoring

Self-monitoring is a category of teaching strategy that requires the learner to keep track of their own behaviors. By having the learner take an active role in their own skill acquisition, they often become more invested in the learning task. This buy-in is advantageous to the learning goal. Self-monitoring can take the form of a learner using picture tokens to keep track of their progress in any number of goals, or it can be as simple as a checklist. While often used in academic and behavioral goals, self-monitoring can be a valuable tool for learners who need to acquire adaptive skills. It should be noted that self-monitoring does require certain skills of the learner before it can take place. For instance, the learner must know when a task or step has been completed correctly or incorrectly and the learner must be able to manipulate the self-monitoring system, whether it be electronic, tactile, or visual (Rusch & Dattilo, 2012).

Visual Schedules

Visual schedules are a well-researched strategy for educating learners both with and without disabilities. They consist of a system of pictures or symbols which are ordered to correspond with a series of events, usually a daily schedule (Preis, 2007). The predictability of events allows the learner to feel more comfortable and helps with compliance in many cases. The visual nature of the schedule allows the information to be easily and readily accessed throughout the duration of the time period (such as a school day). While visual schedules can help a learner to prepare for an adaptive skill’s implementation (such as a scheduled bathroom break during the school day), they can also be adapted into a task analysis which serves to prompt the learner for each step.

Game-Based/Virtual Reality

Game-based teaching methods include a wide variety of strategies and tools which can serve a number of functions in teaching adaptive skills to learners. A game can be primarily physical in nature, such as sports or dexterity games. A game can also have visual and tactile representation, such as board games and tabletop games. One promising vein of research focuses on electronic games—video games—as a method of instruction. Virtual reality presents a number of opportunities for teaching adaptive skills, as it allows the user to assume a virtual persona and interact with real or computer-generated people and objects. Learners with intellectual and developmental disorder were taught interviewing skills through virtual reality in a study by Walker et al. (2019). Technology such as video games and virtual reality can allow students to learn at an appropriate pace for them, as well as revisit areas of confusion (Walker et al., 2019).

Behavior Skills Training

Behavior skills training (BST) is a common teaching method including instruction, modeling, rehearsal with role play and coaching or prompting (Rizzi & Dibari, 2019). Behavior skills training has been used to successfully teach a variety of learners a variety of skills. The instructions portion refers to an instructor delivering information—usually verbally—about the skill being taught. Modeling occurs next, in which the instructor replicates the skill, with or without comments, so that it can be witnessed by the learner. Next is rehearsal, where the skill is practiced by the learner in a simulated or real context, after which feedback is given on correct and incorrect rehearsal performance. BST is effective for learners of various abilities in many cases, as evidenced by its frequent usage in teacher and parent trainings. This technique has been used to teach safety skills to adolescents with disabilities ranging from abduction prevention skills to making video calls when lost (Rizzi & Dibari, 2019). It is important to note that there are cognitive prerequisite skills needed for this type of instruction to be successful, such as basic communication practices like joint attention, mimicry, and in most cases, functional language.

Literature Review Discussion

The results of the literature review show the research has been conducted on each of the areas of adaptive skills we selected, across the lifespan, across disability categories, settings, and change agents. We found that the parameters of current evidence-based practices such as video modeling, prompting, behavior skills training and others are being strengthened and expanded. However, what we did not find were novel interventions that show promise in this area. This is of great concern due to the critical nature of adaptive skills for success across the lifespan. These skills are life-saving in the case of safety skills and medical procedure tolerance and life-changing in the case of independence skills like shopping, meal preparation, and job skills. Many families report that achieving the greatest level of independence is an important goal (Henninger & Taylor, 2014). and these skills also enable individuals with disabilities to engage in greater self-determination (Taylor et al., 2019).

While technology was ubiquitous in the studies included in our review, research should continue to capitalize on ever evolving technology. Smart phones, smart watches, and even smart glasses are becoming more available and cost effective. These devices that are readily available in many learning environments can be used for leisure, problem solving (asking ‘Siri’ or ‘Alexa’ for information), communication, prompting (auditory, visual, or touch). While there is certainly research taking place in these areas, the research literature we reviewed does not reflect the full scope of potential applications. Similarly, there was very little literature found in this review that supports the modern adaptive skill of accessing technology. Skills like looking up bus times or ordering on a food delivery application are very much adaptive skills, but little research exists on how best to support effective use of smart phone technology.

In addition, little research exists on how best to support adaptive skills in young children. Without early systematic instruction on adaptive skills, many individuals will fail to acquire early skills that are exclusionary. For example, many individuals with IDD fail to learn to use the toilet independently or without accidents. Many daycares and preschools will not allow students to enroll who are not able to go to the bathroom independently when they need to, meaning they are excluded from early and beneficial inclusive settings. Consistent interventions that grow with individuals with developmental and intellectual disabilities are needed. We may teach a child to tie their shoes, but we may not teach them to check the weather to know what kind of shoe to wear to match their shoe to the activity they have planned for the day. We may teach a child to make a snack, but we have not addressed what to do if you are missing an ingredient for your recipe or if someone is coming for dinner and you need to make food for more than just yourself. Technology, and early intervention taken together may allow for interventions that can teach big picture adaptive skills such as problem solving or planning.

The majority of the studies reviewed were conducted in contrived environments in which the individual may not be able to access natural reinforcement (i.e., a clinic or life skills classroom; Neely et al., 2020). Experimental analysis of the generalization of skills is needed across the literature base in applied behavior analysis, however there are some examples of training in the natural environment included in this review (e.g., Cihak et al., 2015). Adaptive skills should be taught and assessed as often as possible in the natural environment where the naturally occurring discriminative stimuli are located. Teaching adaptive skills in the natural environment may also increase the efficiency of the intervention because generalization is not required or generalization could be used to assess other targets rather than spending time moving the intervention from a contrived environment to a natural one. Since these are skills that should come under the control of natural contingencies because they are embedded in daily routines and are critical to daily life, maintenance needs to be assessed (Neely et al., 2020). Several studies included in this review featured special education teachers. Special education teachers, while traditionally considered natural change agents, will not play a role in the individual’s life after they reach the age of 21, as there is no similar role in the life of the individual once they are not attending school (e.g., Akmanoglu & Tekin-Iftar, 2011). Thus, this position then may not be the best person/role to carry out these interventions, especially if they are not school-related. Research is needed to assess whether these skills are generalized to parents, siblings, group home staff, or whomever assumes care of the individual after they leave the public-school system.

Potentially dangerous gaps exist on the literature on using ABA to teach adaptive skills. For example, in the medical tolerance research, there were no studies looking at cancer prevention procedures such as pelvic examinations for pap smears or prostate/testicular cancer screenings. Research has found that women with intellectual disabilities are two times and 1.5 times as likely to not have routine cervical and breast cancer screenings regardless of insurance status (Cobigo et al., 2013). Cooperation with medical procedures like these is a set of skills that deserves more attention from the ABA practitioners. In the past, common wisdom of medical practitioners was that individuals with disabilities did not need these screenings because they did not live as long as typically developing individuals. Current research shows that individuals with disabilities are experiencing continually longer lifespans and there is no reason to believe that they are at a decreased risk for these cancers/conditions. There is, however, misinformation and stigma about these screenings and the likelihood of cancer risk (Wilkinson et al., 2011). Teachers and practitioners need to plan for these eventualities beginning early in children’s lives in a systematic and comprehensive way.

Recommendations for Research

Based on the results of the review included in this chapter, there are several exciting potential directions for future research in adaptive skills. Foremost, the advancement of technology means that interventions can push further outside clinical environments and can be implemented by natural change agents. We recommend capitalizing on commonly available technology to build prompts and instruction into independent interactions in the natural environment. Consequently, we also recommend directly evaluating the transfer of interventionist role from a job coach or teacher to a smart phone or AR device. In addition to capitalizing on rapidly evolving technology, we have identified several gaps in the existing research in need of further evaluation. Intervention on adaptive skills in early childhood, job attainment skills rather than just employment skills, and preventative medical skills are all areas in need of substantially more research.

Putting It Into Practice

In this section we will provide some practical ideas and tools for putting information gained from research into practice. Adaptive skills are best taught in the natural environment, so we will provide some specific suggestions for embedding instruction and practice into daily routines.

Start Early

The literature review included in this chapter indicated almost no early intervention or early childhood special education studies focusing on adaptive skills. While all young children certainly need more support than adolescents or adults, providing targeted intervention early on can prevent major skill deficits later on that might exclude individuals from independent lives later on. Appropriate early skills may include getting dressed, toileting, completing simple food tasks, and helping to clean the house or classroom. For example, teachers might use visual supports and video modeling to teach preschoolers to wash their hands before snack.

Make the Most of Technology

Although there are growing bodies of literature to support the use of certain basic technologies to implement the teaching of adaptive skills, the rapid advances of technology may be overlooked in day to day practice. Smart phones, for example, have become affordable and ubiquitous and have vast ability to support learning in the everyday environment. Some researchers, for example, have incorporated Augmentative Reality (AR) or Virtual Reality (VR) into daily living interventions as this technology allows for live and situation-based prompting without the presence of a trainer, which may limit the social validity of the intervention. AR interventions and ubiquity of smart phones and smart watches would allow, for example, an individual to encounter a bus schedule, her watch to understand she was at the bus stop, and a video model of how to pay her fare to play on her smart watch. Thoughtfully including prompts available by commonly used technology in interventions will allow for generalization and maintenance of new skills as well as the ability for skills to grow to meet changing environments.

Train the Trainer

Another key thing to think about in practice is who is putting interventions into place and whether the interventionist is natural to the context the skills will be used in. Because adaptive skills are so connected to independence, and so tied to success in generalized environments, they can be at risk failure to generalize, in large part because they skill becomes contingent on the trainer being present. For this reason, it is especially important to be mindful of transferring instruction to those agents most likely to be present in the environment where the skill is needed. For example, a teacher may support a parent to implement a chaining intervention for “getting dressed” since at least while the child is young, a parent is more likely to be present during dressing than a teacher. For some skills, the agent that needs to trained is the individual themselves, and this is when creative interventions capitalizing on technology and self-monitoring can be useful. For example, it is important that an individual living independently is able to prepare food without another individual present. Tools like video modeling or self-prompting can be helpful to allow the individual to become their own trainer.

Be Flexible

Similarly, sometimes the environment or specific items used in an intervention can accidentally become the cues for behavior and can lead to individuals unsure of how to complete the task without specific items or environments present. For example, if instruction for how to make a sandwich always includes a red cutting board, wheat bread, and the same brand of peanut butter, the learner might have difficulty making a sandwich when the cutting board is dirty or the store was out of the correct bread or peanut butter. For these reasons, we suggest training loosely or incorporating flexibility into your training of adaptive skills. This will allow for problem solving by the individual rather than getting stuck if the grocery store is rearranged or they need to use a public restroom.

Conclusion

Adaptive skills are those that allow individuals to access the world independently. While we argue that almost all skills can be considered adaptive per that definition, we have focused here on several categories of adaptive skills that applied behavior analysis has addressed. We present the results of a review of the recent literature on teaching adaptive skills. Results of this review indicate that there are several evidence-based strategies available for intervention on adaptive skills. While this is promising, this review also indicated that adaptive skills are sometimes overshadowed by work on other important domains like communication or challenging behavior. This review also made it clear that there are obvious gaps in the literature on adaptive skills including support for young children, innovative plans to generalize learned skills, and adaptive skills related to medical outcomes. We have made some suggestions for practitioners to overcome these barriers.