Research in Autism Spectrum Disorders 6 (2012) 271–276

Contents lists available at ScienceDirect

Research in Autism Spectrum Disorders

Journal homepage: http://ees.elsevier.com/RASD/default.asp

Review

Treating adaptive living skills of persons with autism using applied

behavior analysis: A review
Johnny L. Matson *, Megan A. Hattier, Brian Belva
Louisiana State University, USA

A R T I C L E I N F O A B S T R A C T

Article history: Work, self-help, leisure, and hygiene skill deficits are often associated with Autistic
Received 1 April 2011 Disorder, a neurodevelopmental disorder characterized by pervasive impairments in
Accepted 6 May 2011 socialization, communication, and repetitive and restricted behaviors or interests. A
Available online 14 June 2011 number of interventions have been established to assist individuals with these
impairments. This paper is a review of the use of techniques specific to applied behavior
Keywords: analysis (ABA) as an intervention for these adaptive living skill deficits for individuals with
Autism autism. The current status and future directions for research are discussed.
Applied behavior analysis
ß 2011 Elsevier Ltd. All rights reserved.
Self-help
Hygiene skills

Contents

1. History . . . . . . . . . . . . . ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272

2. Work skills . . . . . . . . . . ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272
3. Self-help and self-care . ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
4. Leisure . . . . . . . . . . . . . ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
5. Independent living and hygiene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
6. Feeding . . . . . . . . . . . . . ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274
7. Conclusions . . . . . . . . . ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274
References . . . . . . . . . . ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274

Autism spectrum disorders (ASD) are a group of neurodevelopmental conditions comprised of deficits in communication
and social skills and the occurring of rituals and stereotypies (Fernell & Gillberg, 2010; Matson & Boisjoli, 2007; Matson &
Dempsey, 2009; Matson, LoVullo, Rivet, & Boisjoli, 2009; Matson & Mahan, 2009; Matson & Wilkins, 2009a; Matson &
Wilkins, 2009b; Parks et al., 2009; Wilkins & Matson, 2009). These conditions are often accompanied by intellectual
disability, comorbid psychopathology, seizures, and/or challenging behaviors (Kuhn & Matson, 2004; LoVullo & Matson,
2009; Matson & Boisjoli, 2009a; Matson, Gonzalez, & Rivet, 2008; Matson & LoVullo, 2009; Matson & Minshawi, 2007;
Matson & Neal, 2009; Matson & Nebel-Schwalm, 2007; Matson & Shoemaker, 2009; Rojahn, Aman, Matson, & Mayville,
2003; Singh et al., 2009; Williams, 2010). These conditions have a lifelong course, but have proven to be responsive to
psychological interventions, particularly applied behavior analysis (ABA) and behavior therapy (Adcock & Cuvo, 2009;
Matson & Boisjoli, 2009a; Matson & Boisjoli, 2009b; Matson & Dempsey, 2009; Matson & Fodstad, 2009; Matson & LoVullo,

* Corresponding author at: Department of Psychology, Louisiana State University, Baton Rouge, LA 70803, USA.
E-mail address: johnmatson@aol.com (J.L. Matson).

1750-9467/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.rasd.2011.05.008
272 J.L. Matson et al. / Research in Autism Spectrum Disorders 6 (2012) 271–276

2008; Matson & LoVullo, 2009; Matson, Mahan, & LoVullo, 2009). These factors have led to efforts to identify these problems
as early as possible and to follow these individuals throughout the lifespan (Matson, Fodstad, & Boisjoli, 2008; Matson,
Fodstad, & Mahan, 2009; Matson, Wilkins, & Gonzalez, 2008; Matson, Wilkins, et al., 2009).

1. History

Learning based interventions often referred to as applied behavior analysis, behavior therapy, behavior modification, and
cognitive behavior therapy have been in use for persons with autism since the 1960s. Ferster (1961) for example, described
the use of operant method including reinforcement, extinction, and punishment. Similarly, Risley and Wolf (1967)
demonstrated the ability to teach language, and Risley (1968) successfully treated stereotypies. By 1970 over 100
behaviorally based treatment studies were available in the literature and by 1980 this total of studies had doubled (DeMyer,
Hingtgen, & Jackson, 1981). And, these numbers have continued to rise (Matson, Benavidez, Compton, Paclawskyj, & Baglio,
1996). The trend has continued upward to the point that what has typically been lumped under the term ABA is considered
standard practice by most professionals in the field of autism and the broader field of developmental disabilities (Goin-
Kochel, Mackintosh, & Myers, 2009; Lancioni, Bellini, Oliva, Singh, O’Reilly, & Sigafoos, 2010; Matson, Bamburg, Smalls, &
Smiroldo, 1997; Matson & Fodstad, 2009; Matson, LoVullo, Boisjoli, & Gonzalez, 2008; Matson, Smalls, Hampff, Smiroldo, &
Anderson, 1998; Peters-Scheffer, Didden, Mulders, Korzilius, 2010; Shimizu, Yoon, & McDonough, 2010; Simer & Cuvo, 2009;
Rose, 2010). At this point, the volume of research is such, that covering the breath of topics described by Matson et al. (1996)
in a single review paper is no longer feasible. Additionally, developments with specific treatment packages such as early
intensive behavioral interventions or treatments for adolescents and young adults with Asperger’s Syndrome have become
subfields (Matson, 2007; Matson, Matson, & Rivet, 2007).
For this review we have chosen commonly studied adaptive living skills. This topic is an area where persons with autism
have marked deficits in these essential skills (Matson, Dempsey, & Fodstad, 2009). Some of these skill areas include work,
self-help, leisure, and hygiene. Factors that are particularly critical in all of these areas include cognitive functioning and
communication skills (White, Scahil, Khin, Koenig, & Volkmar, 2007). These topics are essential to the tasks we will cover
here, but both cognitive and communication skills are major topics in their own right. These topics have been covered
extensively elsewhere. Additionally, we have chosen to focus on adults and adolescents since they have been the most
underserved of those persons with ASD. As McClannahan, MacDuff, and Krantz (2002) point out, due to the diversity of skills
displayed by this group, program models that address an array of options from training centers to support employment are
necessary.

2. Work skills

Unlike for persons with intellectual disability (ID), little emphasis has been placed on employment programs for persons
with autism (Howlin, Alcock, & Burkin, 2005). People in this ASD group have also been the most neglected with respect to
program development. Howlin et al. (2005) found that, only 68% of adults with ASD who were specifically targeted for work
placement found a job. For the vast majority of people with ASD, where such placement efforts are not in place,
unemployment is likely to be much higher. These data are in line with results reported by Mawhood and Howlin (1999). They
also found that supported employment was important for helping persons with autism find a job. However, in total numbers,
such programs are very limited. This type of data has led Bennett, Bradly, Scott, Dukes, and Frain (2010) to point out that the
rates of unemployment for persons with developmental disabilities is staggering.
Given that supported employment improves work performance, much more effort in this area is warranted. Having said
that, some promising research has been reported. Garcia-Villamisar and Hughes (2007) for example, found that 44 adults
with autism in competitive employment improved in cognitive skills over a 30-month period of time, while adults with
autism who were unemployed did not improve.
How training is provided has also been addressed to some degree. For example, Lattimore, Parsons, and Reid (2006)
trained four adults with autism to work in a small publishing company. They also worked on on-site skills at an adult
education center. A job coach used a variety of applied behavior analysis methods including breaking the skills into steps,
shadowing the workers movement, and using physical guidance, interruption of incorrect actions, and vocal and gestural
prompts. Three of the four workers responded positively to this training, with improved work performance.
Durán (1985) in one of the earliest work study papers with autism, taught janitorial skills to an adolescent with ID and
autism. The task was an 18-step sequence on restroom cleaning. In addition to the task analysis, verbal and physical prompts
were used to effectively teach these skills. Conversely, Hume and Odom (2007) decreased the need for supervisor prompts
and increased on-task with behavior for three persons with autism. Through the division of TEACCH program in North
Carolina, they employed an organizational training model using visual information that informed students about work
participation activities.
Research efforts are disappointing with respect to competitive employment, and work skills training in general for
persons with autism. Much more can and should be done. Rather than reinvent the flat tire, replication of many of the
existing methods and procedures developed for the ID population are in order. With some modifications, a host of effective
strategies could be rapidly developed.
 J.L. Matson et al. / Research in Autism Spectrum Disorders 6 (2012) 271–276 273

3. Self-help and self-care

Independence is a vital goal for every person. Given the multiple handicaps evinced by persons with autism, this
challenge is greater than for the general population. Adaptive behavior is quite variable but related to diagnosis (Mazefsky,
Williams, & Mineshew, 2008). The more severe the symptoms of autism, the greater the deficits in adaptive behavior. As a
result, systemized training is needed in many instances. This has motivated researchers to develop interventions to teach
these skills.
Cihak and Grim (2008) give one important example. They taught basic math skills to four students with autism ranging
from 15 to 17 years of age to assist them in shopping. With the aid of a teacher they practiced making purchases in a
classroom format. The teacher served as the cashier and taught a counting strategy with verbal descriptions and modeling.
For purchases between 5 and 10 dollars, the student began the purchase with a 5-dollar bill, for 10–15 dollar purchases the
student began the purchase with a 10-dollar bill, and so on. From the classroom setting, the purchasing skills successfully
generalized to a book store and other venues in the community.
In a second paper, Goodson, Sigafoos, O’Reilly, Cannella, and Lancioni (2007) taught four persons ranging in age from 33 to
36 years with intellectual disability (three also had autism) to set a table. Participants used plates, utensils, glasses, and
napkins. Students watched video clips of a trainer using a series of task analyzed steps to set the table. The viewing by
students was done in the proximity of the table. When the participants set the table, errors were corrected by the trainer. All
four participants learned the task. Video modeling alone was sufficient for one person, but error correction was necessary for
the other three people. These data parallel studies on vocational placement which underscores the need to have on the job
support and formal training to be successful in competitive employment (Lawer, Brusilovskiy, Salzer, & Mandell, 2009).
Unfortunately, they also parallel the vocational literature in the paucity of data available about how to teach these vital self-
help and core skills.

4. Leisure

Persons with autism are more likely to be less involved in a host of leisure activities including social, physical, and
informal activities (Hochhauser & Engel-Yeger, 2010). Researchers have demonstrated a positive relationship between
participation in leisure activities and decreases in stress and overall improvement in quality of life (Garcia-Villamisar &
Dattillo, 2010). These authors were able to achieve these goals by using a leisure skills program over a year and including
facilitating interactions with media, exercise programs, playing games, engaging in crafts and attending events.
Machalicek et al. (2009) describe teaching independent play and social skills to three autistic children, 6–12 years of age.
Color photographs were taken of the eight major playground activities including slides, swings, monkey bars, rock climbing
wall, climbing tires, sand areas, cars, and ramps and tunnels. A separate photo of each playground activity was presented via
a laminated picture. The teacher randomly affixed four playground activities to each child’s activity schedule. Graduated
guidance was used to prompt play. If a child began playing in a nondesignated play area, the teacher again used play
activities to play in the planned area. This treatment was effective for enhancing play.
Snoezelen multisensory equipment has also proven to be an effective leisure method. Hogg, Cavet, Lambe, and Smeddle
(2001) provide an interesting review of the multisensory method which includes visual, auditory, tactile, and olfactory
sensations. They describe seven studies; all involving persons with developmental disabilities. The results were generally
positive in terms of improved affect, and decreases in challenging behaviors.
Garcia-Villamisar and Dattillo (2011) worked with 11 males and nine females who were 27–38 years old and who evinced
autism. The leisure program lasted 12 months and focused on interests and abilities of participants while providing structure
and support for 2 h per day, 5 days a week. Participants played CDs or a radio, and looked at magazines. Other leisure
activities included swimming, playing catch, throwing a Frisbee, hiking or bowling. A variety of other tasks included
computer games, puzzles, attending parties, fairs, movies, and concerts. The program proved to be useful in increasing social
and communication skills.
Blum-Dimaya, Reeve, Reeve, and Hoch (2010) taught video games (Guitar Hero II) to children with autism. All of the
children were able to learn the game and generalize their skills to a different song and different setting. Vuran (2008) taught
adults with autism using a most to least prompt procedure. The two participants were able to learn to make a day basket.
Finally, Jerome, Frantino, and Sturmey (2007) taught leisure skills including accessing specific internet sites using backward
chaining and most-to-least intrusive prompting. Training was successful in increasing the participants’ leisure skills.
In general then, researchers recognize that leisure skills are a problem area for persons with autism. The approaches are
largely two fold. First, schedules are developed and participants are exposed to a variety of potential activities on a regular
basis. Second, applied behavior analysis is used to teach a variety of specific leisure activities. The latter method is likely to be
used more frequently with young children and persons with severe intellectual disabilities.

5. Independent living and hygiene

A number of hygiene skills have also been taught to persons with autism. This factor is important because hygiene skills
are significant for persons with autism (Jacobson & Ackerman, 1990). Marshall, Sheller, Williams, Mancl, and Conan (2007)
274 J.L. Matson et al. / Research in Autism Spectrum Disorders 6 (2012) 271–276

for example, found that deficits in language and an inability to follow instructions made children with autism less
cooperative when at the dentist. Additionally, Bock (1999) described teaching four autistic children to sort laundry.
Other studies specific to hygiene have also been reported. Trachtman (2008), for example describe vision problems which
are somewhat unique to autism. He recommends that tests specific to oculomor function, opticokinetic nystagmus, and
strabismus should be emphasized. Oral hygiene has received perhaps more attention that other topics in this area. Dias,
Prado, Vadasz, and Siqueira (2010), not surprisingly, found that persons who were cooperative with training evinced better
dental hygiene than persons who did not cooperate. Marshall et al. (2007) found that the factors most associated with failure
to cooperate include appointment type, concurrent medical diagnoses, being nonverbal or echolalic, inability to understand
language appropriate for age, inability to follow multistep instructions, a parent provided most of the tooth brushing, deficits
in toilet training skills, inability to sit for a haircut, attending special education and an inability to read after 6 years of age.
Green and Flanagan (2008) suggest that dentists should be familiar with factors associated with the autism spectrum. These
issues are important but deal exclusively with the factors that make the dentist’s job more difficult versus providing studies
on how to effectively treat these problems.
Toilet training of persons with autism has also been a topic of study. Kroeger and Sorensen-Burnworth (2009) note in a
very good review of the topic that almost all of the treatments are variants of the rapid toilet training methods first developed
and described by Foxx and Azrin (1973; Azrin & Foxx, 1971). These methods include standard applied behavior analysis
methods such as modeling, reinforcement, and graduated guidance. Future directions for research they emphasize include
self-initiation of toileting and bowel training, exploring limits of trainability based on age and cognitive level, and
determining what prerequisite skills are most critical for insuring effective treatment.

6. Feeding

Feeding has been a topic receiving a good deal of attention among persons with autism. With respect to this topic, food
selectivity has been a high priority because it is a frequent problem (Berlin, Lobato, Pinkos, Cerezo, & LeLeiko, 2011). Despite
this generally acknowledged problem, feeding behaviors are rarely screened for in young children with autism, nor are
publicity campaigns on this topic common practice (Matson, Fodstad, & Dempsey, 2009). Such approaches can affect proper
diet and growth (Bandini et al., 2010; Emond, Emmett, Steer, & Golding, 2010).
Functional assessment has been used to help identify maintaining variables for food selectivity in children with
developmental disabilities (Levin & Carr, 2001). Researchers have used this approach to identify nonpreferred foods and then
used them to develop interventions. Treatment consisted of limiting preferred foods and using them as a positive reinforcer
when nonpreferred foods were consumed.
Another approach to treating food selectivity has been repeated exposure to novel foods (Paul, Williams, Riegel, &
Gibbons, 2007). In addition to repeated taste exposure was an escape option. Tarbox, Schiff, and Najdowski (2010) also used
escape extinction which consisted of keeping a loaded spoon in the mouth of the young child with autism until consumed.
Similar methods have also been described by Ives, Harris, and Wolchik (1978). Finally, Binnendyk and Lucyshyn (2009)
described parental reinforcement and a standardized snack routine to deal with food refusal, which is also associated with
food selectivity (Fodstad & Matson, 2008). Rapid eating is a potentially life threatening problem, also associated with autism.
Anglesea, Hoch, and Taylor (2008) used a vibrating pager to pace and slow eating (could eat only when it was vibrating).
Thus, feeding issues have been the focus of a greater amount of research than many self-help skills. Given that feeding
idiosyncrasies one commonly associated with autism, this focus seems justified.

7. Conclusions

Applied behavior analysis methods have proven to be highly effective as a means of teaching adaptive living skills in a
variety of disabled populations including persons on the autism spectrum. However, compared to early intervention, theory
of mind, genetics, treating challenging behaviors and a host of other topics, adaptive living skills have been greatly
understudied. Given the nature and importance of work, self-help care, leisure, and feeding, this is unfortunate. Funding
priorities for research appear to be largely driven by uncoordinated, political and policy oriented priorities rather than
systematic and proportional attempts to address the major issues that persons with autism face.
Clearly adaptive living skills research should be a much higher priority and should be researched more intensively. We
draw this conclusion based on the central role these skills play in quality of life and independence. And, due to the high level
of effectiveness evident in the research to date, a higher priority on enhancing the life skills of adolescents and adults may
further spur research in this area.

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