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Intervention for adults with autism.

The treatment program for adults with autism grew out of the work with younger children in the first statewide program for the Treatment and Education of Autistic and related Communications Handicapped CHildren (TEACCH). In 1972, North Carolina legislators established TEACCH as the permanent state agency mandated to serve children with autism and their families. Based on this early experience and the outcome data, we learned that through interventions applied with close parent/professional collaboration most of the children improved. Some did so dramatically, and the majority improved only partly (Schopler, in press). Based on the recognition that autism is a long-term disability, TEACCH's mandate was expanded in 1979 to include service to adolescence and adults and their families.

Over the years, the basic TEACCH philosophy (Schopler, in press) has been adapted and applied to the work with adolescents and adults. The purpose of this article is to first briefly summarize the TEACCH philosophy as it applies to adults with autism. The areas of diagnosis and assessment will then be discussed as prerequisites for developing an appropriate individualized treatment program. Finally, the article examines four primary treatment components - structured teaching, communication training, leisure and social skill development, and stress reduction. Each of these treatment components affects the adaptation of the adults across residential, vocational, and recreational settings.

TEACCH Philosophy

The program's early emphasis on parents and professional working together to optimize the outcome for the children with autism has continued in TEACCH's approach to working with the adults and their families (Mesibov, Schopler & Sloan, 1983). As the person with autism enters vocational, residential, or other community settings, their families continue to play a crucial role. They are still the experts who have valuable information about their children to share with future job coaches, caregivers, or other treatment providers. As advocates, they often have the best perspective on their children's long term needs. The exact role of the family in the lives of the adults with autism varies depending on the needs and resources of the family (Van Bourgondien & Schopler, 1990). Some families continue a very active involvement in all aspects of the adult's life, others change their role as the needs of other family members are addressed.

Recognizing the heterogeneity of individuals with autism, an individualized approach to treatment that is based on a careful assessment of the adult's skills is an essential part of the approach (Schopler, 1994). The TEACCH philosophy also emphasizes a positive, proactive approach to helping an individual learn new skills and when autism related deficits impede to accommodate the environment to that deficit (Schopler, 1994). This two factor approach involves the direct teaching of functional skills that the individual shows a readiness to learn, and at the same time adapting the environment to enable the individual to utilize his/her strengths to compensate for areas of deficit. Structured teaching is the basis of this two factor approach.

Structured teaching is both an educational strategy and a method for preventing behavior problems in individuals with autism (Mesibov, Schopler, & Hearsey, 1994; Schopler, Mesibov, & Hearsey, 1995). Based on the needs, skills and deficits of autism, it is a system of organizing the physical environment, developing appropriate activities, and helping individuals of all ages understand what is expected of them and how to function independently. Visual skills and routines are utilized to create meaningful environments that people with autism can understand and within which they can be successful.

Behavioral difficulties are assumed to be the result of an individual's inability to understand and successfully cope with their environment. The approach to dealing with behavioral issues is to first analyze the situation from the perspective of autism and the related cognitive difficulties, and then restructure the environment to compensate for these deficits. This emphasis on changing the antecedent events to prevent behavior problems is an important aspect of the TEACCH approach.

Professionals employed by TEACCH or by TEACCH-affiliated programs are trained as generalists who are expected to cope with the full range of problems presented by the individual with autism (Schopler, 1987). Regardless of whether one works within a residential, vocational, or other community setting, one needs to be familiar with all aspects of the adult's life to be successful. Assessment, structured teaching techniques, communication skills training, leisure and social skills training, and stress reduction strategies are some of the most important curriculum areas for a generalist to know.

Diagnosis and Assessment

Although children with autism grow up to be adults with autism, not all are recognized and diagnosed in early childhood. Complicating the diagnostic process for this older group is the evidence that the symptoms on which the diagnosis is based are likely to change with age (Mesibov, 1983). Specifically, the social and interpersonal deficits (Rutter, 1970), the language problems (Ando & Yoshimura, 1979; Rutter & Schopler, 1978), and the compulsive and ritualistic behaviors (Mesibov & Shea, 1980; Rutter, 1970) tend to show some improvement with age. Therefore, it is important to have reliable and valid instruments for diagnosing and assessing autism in this older population.

The Childhood Autism Rating Scale (CARS) (Schopler, Reichler, DeVellis & Daly, 1980; Schopler, Reichler & Renner, 1988) is a widely used instrument for diagnosing autism in young children. In recognition of the fact that the characteristics of this disability tend to vary as the children get older (Schopler & Mesibov, 1983), the stability of CARS scores with age has been validated. Mesibov, Schopler, Schaffer and Michael (1989) compared the CARS scores of 59 subjects who were first diagnosed prior to age 10 and who were reassessed after age 13. The average CARS total scores decreased by 2.2 as the subjects got olden Based on these results the authors recommended changing the cut-off score for adolescents and adults to 28 instead of 30. Even without this modification, the CARS has been found to be a reliable and stable indicator of autism in an older sample (Garfin, McCallon & Cox, 1988).

Diagnosis is an important first step in the treatment process for adolescents and adults with autism. Such individuals present unique difficulties to service providers compared to individuals with other types of developmental disabilities. Consequently they require specialized treatment strategies (Mesibov, 1988; Van Bourgondien, Mesibov & Castelloe, 1989). In a comparison study of residential programs serving adults with autism, Van Bourgondien et al. (1989) found that the residential caregiver's knowledge of autism as a developmental disorder was significantly related to greater use of appropriate treatment strategies.

While diagnosis serves as a guide to the general categories of techniques and services that may be appropriate for an individual with autism, assessment is the means by which the unique aspects of each person is recognized in order to develop an individualized treatment plan (Mesibov, 1988; Van Vourgondien & Mesibov, 1989). Within the TEACCH program, assessment is the foundation on which the treatment program is based. Utilizing both formal and informal assessment techniques provides information about the individual's skills in a variety of tasks across multiple settings.

The primary formal assessment tool utilized at TEACCH with this older population is the Adolescent and Adult Psychoeducational Profile (AAPEP) (Mesibov, Schopler & Schaffer, 1984). The AAPEP is a criterion-referenced test that assesses skills related to successful adult functioning in community residential and vocational settings. In addition to a Direct scale that assesses the individual's skills in the clinical assessment session, the AAPEP has Home and School/Work Scales that can be completed based on interview data from knowledgeable individuals in other settings. Together the information from the three scales provides a description across environments of the person's vocational skills, vocational behaviors, communication skills, self-care and independence skills, and interpersonal and leisure skills.

In addition to these formal assessment techniques, informal assessment such as interviewing caregivers, and functional assessments in actual community settings are very important. Within the area of vocational planning, parents and other caregivers share their priorities, concerns and knowledge of the adult with autism with job coaches in order to facilitate appropriate job placement. Given the uneven pattern of skills and problems with generalizing skills across settings (Carr, 1981), functional assessments in the actual work sites being considered are essential for successful employment (Van Bourgondien & Woods, 1992).

Through both formal and informal techniques, the goal of the assessment process is broader than simply identifying the individual's deficits. More important to the treatment process is to recognize the strengths, interests, emerging skills and work habits of the individual. Recognizing the strengths of the individual is an important part of the two factor approach to treatment (Schopler, Mesibov, Shigley & Bashford, 1984). Strengths are utilized to help compensate for the deficits of adults with autism. Taking individual interests and preferences into account has been shown to increase the morale in leisure activities of clients with severe handicaps (Favell & Cannon, 1976). Both individuals with and without autism are likely to show more motivation when employed in a job that involves their interests (Van Bourgondien & Woods, 1992). Interests can also be used to develop external motivators for individuals who may not be motivated by the intrinsic rewards of a job. For example, one young man in supported employment does not see earning money or working with non-handicapped peers as a motivator for good work. Rather his work behaviors and work performance are enhanced by the contingent opportunity to take pictures of road signs or to drive on new highway.


Structured Teaching

As children with autism grow up and leave the classroom and enter the adult world of employment and independent living, the basic structured special education techniques that have been demonstrated to be effective in the past (Lockyer & Rutter, 1969; Rutter, Greenfield & Lockyer, 1967; Schopler, Mesibov, DeVellis, & Short, 1981) are still appropriate. Schopler, Mesibov and Hearsey (1995) describe how structured teaching techniques have been used with children and adults with autism in TEACCH-affiliated programs. The use of visual approaches such as physical organization, schedules, work systems and material organization, make use of the visual strengths of most individuals with autism. This tends to reduce their frustration and confusion, prevents behavior problems and fosters independent functioning (Schopler, in press).

Most adults with autism continue to demonstrate the same difficulty, in understanding the world and others' expectations, as they did as children. Their distractibility, organizational and sequencing difficulties interfere with their ability to function independently in the community. In a comparison study between adults with autism and adults with mental retardation without autism living in group home settings, Van Bourgondien, et al. (1989) found that adults with autism had significantly more problems with ritualistic behaviors and dealing with change than did those without autism. Their tendency to get easily upset and agitated significantly affected their adaptation in these settings, especially when appropriate structures had not been instituted.

In order to deal with the unique needs of these adults, residential programs specifically designed for them have been developed (Van Bourgondien & Reichle, in press). The Carolina Living and Learning Center is an integrated residential and vocational program that demonstrates how the structured teaching techniques first developed for children can be adapted for adults in both residential and vocational settings (Van Bourgondien & Reichle, in press). These visual structures are also applicable to supported employment jobs in the community (Van Bourgondien & Woods, 1992).

The use of a concrete daily schedule facilitates the individuals' understanding of the sequence of the day and enables them to predict where they will go next. The type of visual cue used is individualized to the individual's level of abstraction, be it with words, pictures or the actual object. Work systems or work lists help to organize the adults in order to function independently with daily tasks at home or at work. For example, three baskets set up from left to right might have the materials for making different parts of a meal. By working from left to right and doing what is in each basket, the individual knows what to do and how much to do until finished. For a client who reads, the work system may be a written list of activities that are checked off as each one is finished.

Within tasks visual strategies can be employed to help the person know how to do an activity without always having to be prompted. These strategies include the use of containers to organize materials, color coding and labeling to clarify a task, picture jigs or lists.

It is important to note that individuals with autism need predictability in their environment and not necessarily repetition (Van Bourgondien & Woods, 1992). For some individuals with autism, engaging in the exact same routine on the job everyday appears to have a negative effect on their motivation and work performance (Van Bourgondien & Woods, 1992). The use of visual schedules has helped these employees anticipate what work they will be doing without having to deal with the monotony of doing the exact same thing each day. In residential settings, relying solely on routines to provide an understanding of the days events can have other drawbacks, especially when change occurs by necessity. Eventually, a staff member will leave or the bowling alley will be closed on Thursday night. When the unanticipated change does occur, the individual has no way of knowing what to expect. The use of a visual schedule makes the world predictable so that connections can be made between events and can be anticipated more flexibly (Schopler, Mesibov, & Hearsey, 1995).

Systematic and consistent routines are most helpful for carrying out specific tasks that remain constant (Mesibov, Schopler & Hearsey, 1994). Routines are very helpful within hygiene activities such as showering or brushing teeth. Some basic routines that can be applied across activities include working from left to right or from top to bottom. Having these basic strategies can help the adult approach novel situations with greater success. Within the structured teaching model, checking one's schedule and following the directions from the work lists are two routines that will improve functioning in community settings (Mesibov, Schopler, & Hearsey, 1994).

Communication Training

Clinically, parents of adults comment on the fact that most day programs for adults do not emphasize the acquisition or use of expressive communication skills. As a result, the communication skills learned in schools may not continue to be used by adults in these new environments.

To be truly independent in community settings, functional expressive communication skills are essential. For an individual with less developed skills, the emphasis of communication training is to develop a communication system that enables him/her to communicate his/her needs and preferences. The TEACCH communication system takes into account the communication method available to the individual, according to existing communication skills. The most appropriate communication system may involve the use of objects, gestures, pictures, written words or verbalizations (Watson, Lord, Schaffer & Schopler, 1989). In order to facilitate the generalization and use of these skills across people and settings, communication training needs to occur in living, work, and recreational environments. For individuals who use tangible communications systems (objects, pictures, written words), the systems need to become portable so that they are accessible to them wherever they may go.

For the more verbal adult, the emphasis of instruction is on the social aspects of communication rather than the development of a communication system. Learning how to initiate an interaction, get another person's attention, or determine appropriate topics of conversation may be important goals.

For example, a verbal adult in a work setting may need to seek out a supervisor and request help when a problem arises in his/her work. To assist this individual, the job coach might develop a written direction that states "ask your supervisor for help when something is missing." The written direction along with a photo of the supervisor would be placed permanently in the work area. The job coach would then create situations in the work setting where the employee would need assistance. Each time something was missing, the job coach would point to the written instructions until the employee learned to independently follow the direction. The written direction would remain as a reminder even after the job coach was no longer there. '

The goals of communication training may also vary across settings. In vocational settings, it is important for the client to be able to indicate to supervisors when there is a problem in their work or if they need help. While in recreational activities, an appropriate goal may be to independently choose a free time activity.

Leisure and Social Skills

Leisure skills are important because they enable individuals with autism to safely and appropriately occupy their free time and because leisure activities are the building blocks for most social interactions even in adults without handicaps. Although many adults with autism have high interest areas, their inability to entertain themselves during free times distinguishes them from adults with other developmental disabilities in residential settings (Van Bourgondien, et al., 1989). The ability to appropriately and safely occupy oneself during free time affects not only the adaptation to residential settings, but also success in work settings (Van Bourgondien & Woods, 1992). Most jobs require that the individual be able to take breaks from work without engaging in inappropriate behaviors.

The individual needs to be taught what to do in the break area. Most typical leisure activities will need to be adapted to take into account the individual's special interests and organizational skills. For example, one resident's interest in newscasters was used to develop a variety of lotto activities. For another young man who likes playing solitaire during work breaks, but cannot set up the cards independently, a jig which visually demonstrates where the cards are to be placed was added. Thus, leisure time became much more meaningful to both of them.

Along with knowing what to do, the individual needs to be taught to stay in a designated area during free time or work breaks. In a group home, this may be the living room area or backyard. For vocational sites, a designated break area may be a room with natural boundaries or may be an area that is marked off by furniture or lines on the floor.

Initiating leisure activities can be enhanced through the use of choice boards or free time lists. Depending on the individual's comprehension level, a free time choice board can include photographs, line drawings, objects or written labels for the available activities. For some individuals to be able to independently access activities, the materials themselves need to be presented in an organized fashion such as in baskets going from left to right.

In our program, social skill training models for adults employ a combination of 1-1 training and group experiences (Lord, 1984; Mesibov, 1984, 1986). These models initially emphasized the use of cognitive social skills training approaches to teach social behaviors. The goals of these training efforts are to increase social interactions and to improve the individual's ability to understand social rules. New skills are first practiced in 1-1 sessions with clients and then generalized to group activities in the community. The use of adult volunteers without handicaps has also been shown to facilitate the social initiation of the adults with autism (Campbell, 1995). Positive practice along with shared experiences in the community helps to facilitate the acquisition of new skills and friendships between participants (Mesibov, 1984, 1986). Throughout the social skill training the main objective is to help adults with autism to learn social skills, but it is equally important to have fun and to enjoy being with other people.

For those who read and write, Gray (1994) from the Jenison Public Schools in Michigan has developed a technique using social stories to teach perspective taking and social rules. Social stories or cartoon strips are generated in conjunction with the client to help improve the ability to understand social situations and to subsequently demonstrate the appropriate social response. These techniques fit nicely with the TEACCH approach as they also emphasize the use of visual stimuli and a preventative approach based on an understanding of the perspective of the individual with autism.

Stress Reduction

One of the best preventive strategies for reducing stress in the life of individuals with autism is to pay careful attention to the expectations and demands faced in daily activities.

It is important to provide residential, vocational and recreational opportunities which contain variety and a balance between activities that are interesting and involve the individuals' strengths and activities that are more challenging. While individuals with autism want predictability, many individuals get bored when continually presented with the same repetitive tasks (Van Bourgondien & Woods, 1992).

Within their daily activities, individuals can be taught to make choices when provided with concrete choice options (Dunlap, Robbins & Kern, 1994). When given a variety of activities and the opportunity to choose among them, individuals with severe handicaps have demonstrated increased motivation and decreased behavior problems (Dyer, Dunlap & Winterling, 1990; Favell & Cannon, 1976).

Exercise is also used as an important part of our curriculum for adults with autism (Kay, 1990;) Van Bourgondien & Reichle, in press). Both research (McGimsey & Favell, 1988) and anecdotal evidence (Kay, 1990) suggest that physical activity reduces behavior problems and stereotypic behaviors. Strenuous physical activity at work, or regular participation in physical activities during recreation such as hiking, swimming, and biking also help maintain the physical health of the individual.

Along with physical exercise, systematic relaxation procedures are used as stress reduction techniques for some individuals with autism (Grodin, Cautela, Prince & Berryman, 1994). Behavior problems often develop when the individual is confused and stressed. Cautela and Groden (1978) developed a relaxation program suitable for individuals with cognitive difficulties. The relaxation techniques generally include a combination of deep muscle relaxation, breathing, and imagery. Using these techniques, an individual is first taught bodily relaxation in a neutral situation. Gradually, the person learns to use this skill when stressed. For some individuals, an audiotape or picture representations of the relaxation sequence is helpful. While some people can learn to relax themselves when stressed, some individuals do best avoiding becoming stressed by practicing their relaxation exercises prior to activities they find challenging.

Not everyone with autism has the skills necessary to benefit from multistep systematic relaxation procedures. For adults with more concrete thinking or who have difficulty following multistep procedures, stress reduction activities may include listening to music, sitting in a rocking chair or swing, or physical exercise. Engaging in activities that are high interests or very familiar can also be calming for some adults. Again, building stress reduction activities into the daily schedule helps prevent behavior problems.


In this article we have summarized the TEACCH philosophy, diagnostic assessment for individualized education, and the major treatment strategies used by TEACCH and affiliated programs. As adults with autism enter community based residential, vocational and recreational programs, professionals working with these individuals need to have a holistic approach to these men and women. Through the collaborative efforts of professionals and parents, adults with autism can continue to grow and become happy and successful members of the community.


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Mary E. Van Bourgondien, Ph.D., Carolina Living and Learning Center Division TEACCH, CB# 7180, Medical School Wing E, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599.
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Author:Schopler, Eric
Publication:The Journal of Rehabilitation
Date:Jan 1, 1996
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