Lisa Tereshko, PhD, BCBA-D, Endicott College
Description:
Everyday all individuals complete a variety of sequences of behaviors that were taught to them at some point in their lives. Some of these sequences include getting dressed, packing a lunch for school or work, and cooking dinner. Independently completing these sequences are essential for one to have independence throughout their day. One way of teaching sequences of behavior is using visual activity schedules. Visual activity schedules are an arrangement of pictures or words used to display a sequence of upcoming events. For example, when teaching getting dressed, a visual activity schedule might include a picture of under garments that signals the individual to put those on first, then a picture of a shirt signaling the next item to put on, and so on until the individual is completely dressed. This visual activity schedule could be posted on the side of the dresser of clothes or on the closet door.
Visual activity schedules encompass three evidence-based strategies: antecedent interventions, prompting, and visual supports (Hume et al., 2021). They are antecedent interventions in that they are presented prior to the initiation of the task as a cue to help the individual understand what is expected of them. The presentation of the visual activity schedule before the activity may also reduce the likelihood of challenging or interfering behaviors that could occur if the individual is frustrated because they do not understand the expectations or are disinclined to do the activity. Visual activity schedules also serve as a prompt, or support, that can increase the individual’s success completing the activity or task. Finally, visual activity schedules are a visual support as they are an additional visual stimulus that can support an individual’s increased independence and decrease their reliance on others for assistance.
The use of visual activity schedules can benefit all individuals to increase productivity and success across the day. People use various forms of visual activity schedules to complete a variety of activities throughout their day (e.g., to-do lists, daily planners, and following written directions). For individuals with autism/autistic individuals, visual activity schedules can be further beneficial by increasing independence. Individuals with autism/autistic individuals frequently display prompt dependency on another individual (Koyama & Wang, 2011). The use of visual activity schedules as a visual prompt can allow the individual to prompt themselves or rely on environmental cues rather than other people. The addition of visual activity schedules can additionally benefit individuals with autism/autistic individuals by reducing the auditory information they need to process. Previous research has shown that auditory information can be difficult for individuals with autism/autistic individuals to interpret (Knight et al., 2015); therefore, strategies relying on visual input may be more beneficial.
Visual activity schedules can take many forms (Koyama & Wang, 2011; Knight et al., 2015). The presentation of pictures can be displayed either in a linear (vertical or horizontal) pattern or within a small book (with one picture per page) where the individual engages with the schedule by moving the icon to a “done” column, checking it off a list, sliding a bar to indicate completion, or turning a page. It can also be modified to include actual objects to cue the activity for individuals who may have more difficulty identifying pictures (Hugh et al., 2018). For individuals who have word identification skills, visual activity schedules may also be presented in a narrative format where words replace pictures. Furthermore, technological advances have led to many options for the presentation of visual activity schedules as pictures or videos, and in the context of apps on tablets or other electronic devices.
Research Summary:
There is a growing body of research that supports the use of visual activity schedules to increase a variety of skills and to assist with the reduction of interfering behaviors for individuals with autism/autistic individuals. According to the National Standards Project: Phase 2 (2015), the use of schedules with children with autism/autistic individuals is an established intervention that has been shown to increase their independence and their ability to plan for events that are upcoming. Furthermore, in a review by Hume et al. (2021) that evaluated evidence-based treatments for individuals with autism/autistic individuals, the authors provided additional support for visual activity schedules by identifying visual supports as an evidence-based practice.
Two systematic literature reviews have provided further support for the use of visual activity schedules as an evidence-based intervention. The review conducted by Koyama and Wang (2011) identified 23 peer reviewed studies that evaluated the use of visual activity schedules. They found that visual activity schedules had been effectively used to teach individuals with autism and intellectual disabilities to engage in a variety of activities, including on-task behavior. Knight et al. (2014) conducted another comprehensive review of the literature to expand the findings of past reviews and to determine if the use of visual activity schedules continued to be an evidence-based procedure. Their review identified 31 articles that targeted the use of visual activity schedules with individuals with autism/autistic individuals. The researchers found that visual activity schedules were effective for teaching a variety of skills across the lifespan of individuals with autism/autistic individuals. Furthermore, they found that the use of visual activity schedules was a low-effort intervention that provided individuals with consistent cues about upcoming events.
The use of visual activity schedules has been successful in teaching individuals with autism/autistic individuals across ages a variety of skills and activities such as completing the steps of toothbrushing (Moran et al., 2022), completing medical exams (Chebuhar et al., 2013), getting ready for bed (Hart Barnett et al., 2022),and leisure or play skills (Koyama & Wang, 2011). Furthermore, in the articles reviewed by Koyama and Wang (2011), there were 69 total participants including preschool students (24.6%), school-aged students (30.4%), and adults (23.2%) and more than half of those individuals had a diagnosis of autism (59.4%). Some recent literature supports the use of visual activity schedules with individuals with autism/autistic individuals to increase compliance during physical activity (Becerra et al., 2021), appropriate feeding behavior (Kirkpatrick et al., 2019), engagement in academic tasks while maintaining low rates of interfering behavior (Boyle et al, 2021), choice-making (Deel et al., 2021), completion of job-related tasks (Lora et al., 2020; Sances et al., 2019), completion of less preferred tasks without interfering behavior (Lory et al., 2020), successful transitions (Pierce et al., 2013), and social skills (Osos et al., 2021).
A variety of methods to implement visual activities is also supported in research. For some students, the use of video technology can be beneficial. Kirkpatrick et al. (2019) used video-enhanced activity schedules to reduce food stuffing (rapid eating), which resulted in a reduction of food stuffing and an increase in appropriate pacing of the meal for the participant. Brodhead et al. (2018) successfully increased the variety of games played on a tablet using an activity schedule on the tablet. Burckley et al. (2015) used a tablet to implement a video activity schedule in the community to increase the shopping skills of a young adult with autism. In only three lessons, the video activity schedule substantially helped to increase the young adults’ shopping skills.
Similar results were found when a visual activity schedule delivered via a smartphone was implemented in the community to teach an individual with autism to order items from a bakery (Cheung et al., 2016). Even a smart watch can be used to implement visual activity schedules, as shown by Jimenez-Gomez et al. (2021) when they increased the independence of play skills for three young children with autism/autistic children. The use of technology, such as tablets, smartphones, and smartwatches, may help to enhance the reach of visual activity schedules by increasing their portability and reducing the social stigma that may be associated with carrying a visual activity schedule into the community.
Though there is much research supporting the use of visual activity schedules. There are some cautions to note when examining their use. Knight et al. (2014) found that all but three studies used visual activity schedules in combination with other systematic instruction (e.g., graduated guidance, reinforcement, and prompting), which could have enhanced the effects. The maintenance and generalization of the use of visual activity schedules have limited research and represent an important direction for future research. With that said, the limited research that has been conducted appears promising. For example, MacDuff et al. (1993) successfully used visual activity schedules to teach on-task behavior that then generalized to novel pictures and activities in the schedule. Furthermore, Koyama and Wang (2011) noted that those studies that included maintenance information were able to successfully maintain the use of the visual activity schedule and those that did include generalization were successful with generalizing to novel activities or settings.
Recommendations:
The application of visual activity schedules has been well documented in the research to be a successful intervention to increase a variety of skills across a variety of ages of individuals with autism/autistic individuals. This literature review is aligned with the National Standards Project: Phase 2 and other systematic literature reviews (e.g., Knight et al., 2014; Koyama and Wang, 2011) that support the recommendation to use visual activity schedules as an intervention for increasing skills and independence for individuals with autism/autistic individuals. Although research supports the success of visual activity schedules with individuals with autism/autistic individuals, the determination of appropriate intervention techniques for everyone should be decided by the team directly involved with that individual.
When using activity schedules with an individual with autism/autistic individual, it is important to consider the individual’s skills associated with symbolic representations, receptive language, and reading and comprehension when determining the mode of implementation (Hugh et al., 2018). Additionally, individual preference should be considered when determining the modality of the visual activity schedule (Knight et al., 2015). Giles et al. (2017) found similar acquisition rates when comparing static pictures to tablet-based modalities and preference for the different formats was idiosyncratic across participants. Additional clinical considerations include attention to assent and to the development of component skills. Specifically, learner assent should be assessed and regularly revisited; intervention should continue in the context of willingness and engagement (Morris et al., 2021). Component skills that can be built incidentally include choice-making, stamina for independent tasks, appropriate social engagement during activities, and self-monitoring. Many work-relevant skills can be shaped through the use of activity schedules.
Continued research should continue to explore the long-term effects of visual activity schedules and their ability to generalize effects across environments. The use of technology with visual activity schedules may help reduce the social stigma of some modalities of visual activity schedules and should continue to be explored to assist individuals in increasing their independence. While we await additional research, visual activity schedules remain an evidence-based intervention that can be valuable in increasing sequences of behavior for individuals with autism/autistic individuals.
Selected References
Systematic Reviews and Task Forces
Hume, K., Steinbrenner, J. R., Odom, S. L., Morin, K. L., Nowell, S. W., Tomaszewski, B., Szendrey, S., McIntyre, N. S., Yücesoy-Özkan, S., & Savage, M. N. (2021). Evidence-based practices for children, youth, and young adults with autism: Third generation review. Journal of Autism and Developmental Disorders 51, 4013-4031. https://doi.org/10.1007/s10803-020-04844-2
Knight, V., Sartini, E., & Spriggs, A. D. (2015). Evaluating visual activity schedules as evidence-based practice for individuals with autism spectrum disorders. Journal of Autism and Developmental Disorders, 45, 157-178. https://doi.org/10.1007/s10803-014-2201-z
Koyama, T., & Wang, H. T. (2011). Use of activity schedule to promote independent performance of individuals with autism and other intellectual disabilities: A review. Research in Developmental Disabilities, 32, 2235-2242. https://doi.org/10.1016/j.ridd.2011.05.003
National Autism Center. (2015). Findings and conclusions: National Standards Project, Phase 2. Author.
Selected Scientific Studies
Becerra, L. A., Higbee, T. S., Vieira, M. C., Pellegrino, A. J., Hobson, K. (2021). The effects of photographic activity schedules on moderate-to-vigorous physical activity in children with autism spectrum disorder. Journal of Applied Behavior Analysis, 54(2), 744-759. https://doi.org/10.1002/jaba.796
Boyle, M. A., Bacon, M. T., Sharp, D. S., Mills, N. D., & Janota, T. A. (2021). Incorporating an activity schedule during schedule thinning in treatment of problem behavior. Behavioral Interventions, 36, 1052-1064. https://doi.org/10.1002/bin.1813
Brodhead, M. T., Courtney, W. T., & Thaxton, J. R. (2018). Using activity schedules to promote varied application use in children with autism. Journal of Applied Behavior Analysis, 51(1), 80-86. https://doi.org/10.1002/jaba.435
Burckley, E., Tincani, M., & Fisher, A. G. (2015). An iPad-based picture and video activity schedule increases community shopping skills of a young adult with autism spectrum disorder and intellectual disability. Developmental Neurorehabilitation, 18(2), 131-136. https://doi.org/10.3109/17518423.2014.945045
Chebuhar, A., McCarthy, A. M., Bosch, J., & Baker, S. (2013). Using picture schedules in medical settings for patients with autism spectrum disorder. Journal of Pediatric Nursing, 28, 125-134. https://doi.org/10.1016/j.pedn.2012.05.004
Cheung, Y., Schulze, Leaf, J. B., & Rudrud, E. (2016). Teaching community skills to two young children with autism using a digital self-managed activity schedule. Exceptionality, 24(4), 241-250. https://dx.doi.org/10.1080/09362835.2016.1215654
Deel, N. M., Brodhead, M. T., Akers, J. S., White, A. N., & Miranda, D. R. G. (2021). Teaching choice-making within activity schedules to children with autism. Behavioral Interventions, 36, 731-744. https://doi.org/10.1002/bin.1816
Giles, A., & Markham, V. (2017). Comparing book- and tablet- based picture activity schedules: Acquisition and preference. Behavior Modification, 41(5), 647-664. https://doi.org/10.1177/0145445517700817
Hart Barnett, J. E., Zucker, S. H., & More, C. M. (2022). Visual schedule to promote compliance with bedtime routine in a child with autism spectrum disorder. Education and Training in Autism and Developmental Disabilities, 57(2), 196-203.
Jimenez-Gomez, C., Haggerty, K., & Topcuoglu, B. (2021). Wearable activity schedules to promote independence in young children. Journal of Applied Behavior Analysis, 54(1), 197-216. https://doi.org/10.1002/jaba.756
Lora, C. C., Kisamore, A. N., Reeve, K. F., & Townsend, D. B. (2020). Effects of a problem-solving strategy on the independent completion of vocational tasks by adolescents with autism spectrum disorder. Journal of Applied Behavior Analysis, 53(1), 175-187. https://doi.org/10.1002/jaba.558
Lory, C., Rispoli, M., Gregori, E., Kim, S. Y., & David, M. (2020). Reducing escape-maintained challenging behavior in children with autism spectrum disorder through visual activity schedule and instructional choice. Education and Treatment of Children, 43, 201-217. https://doi.org/10.1007/s43494-020-00019-x
Kirkpatrick, M., Lang, R., Lee, A., & Ledbetter-Cho, K. (2019). A video-enhanced activity schedule reduces food stuffing in child with pervasive developmental disability: A single subject design case study. Advances in Neurodevelopment Disorders, 3, 281-286. https://doi.org/10.1007/s41252-019-00100-6
Moran, K., Reeve, S. A., Reeve, K. F., DeBar, R. M., & Somers, K. (2022). Using a picture activity schedule treatment package to teach toothbrushing to children with autism spectrum disorder. Education and Treatment of Children, 45, 145-156. https://doi.org/10.1007/s4349-022-00074-6
Osos, J. A., Plavnick, J. B., & Avendaño, S. M. (2021). Assessing video enhanced activity schedules to teach social skills to children with autism spectrum disorder. Journal of Autism and Developmental Disorders, 51, 3235-3244. https://doi.org/10.1007/s10803-020-04784-x
Pierce, J. M., Spriggs, A. D., Gast, D. L., & Luscre, D. (2013). Effects of visual activity schedules on independent classroom transitions for students with autism. International Journal of Disability, Development and Education, 60(3), 253-269. http://dx.doi.org/10.1080/1034912X.2013.812191
Sances, J., Day-Watkins, J., & Connell, J. E. (2019). Teaching an adult with autism spectrum disorder to use an activity schedule during a vocational beekeeping task. Behavior Analysis in Practice, 12, 435-439. https://doi.org/10.1007/s40617-018-00306-5
Other Works Cited Above
Hugh, M. L., Conner, C., & Stewart, J. (2018). Intensive intervention practice guide: Using visual activity schedules to intensify academic interventions for young children with autism spectrum disorder. National Center for Leadership in Intensive Intervention. https://files.eric.ed.gov/fulltext/ED591075.pdf
Morris, C., Detrick, J. J., & Peterson, S. M. (2021). Participant assent in behavior analytic research: Considerations for participants with autism and developmental disabilities. Journal of Applied Behavior Analysis, 54(4), 1300-1316. https://doi.org/10.1002/jaba.859
Citation for this article:
Tereshko, L. (2023). A treatment summary of visual activity schedules. Science in Autism Treatment, 20(6).
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