Visual Supports for Children with Autism Spectrum Disorder: A Literature Review
By Nidia Saisbhan Lashley
This issue of NASET’s Autism Spectrum Disorder series was written by Nidia Saisbhan Lashley. Visual supports provide cues to children showing the steps of what comes next. Visual supports can be used for different purposes, but generally, they are a series of tasks to be completed. Visual supports are not limited to use in an educational framework, but can be implemented at home, too. The intent of this literature review was to examine the uses of visual supports and their effects on different aspects of the lives of children diagnosed with autism spectrum disorder (ASD).
Visual Supports for Children with Autism Spectrum Disorder: A Literature Review
Abstract
Visual supports provide cues to children showing the steps of what comes next. Visual supports can be used for different purposes, but generally, they are a series of tasks to be completed. Visual supports are not limited to use in an educational framework, but can be implemented at home, too. The intent of this literature review was to examine the uses of visual supports and their effects on different aspects of the lives of children diagnosed with autism spectrum disorder (ASD).
Children with Autism Spectrum Disorder: A Literature Review
Visual supports provide a series of steps or cues to children to guide them in what comes or happens next (Jiminez-Gomez et al., 2020). Lory et al. (2020) stated that children with autism spectrum disorder (ASD) struggle with processing verbal information or cues, thus depending on visual supports to aid in understanding. Barnett and Cleary (2019) asserted that children with ASD may face difficulties in moving from the concrete to the abstract, and visual supports is an evidence-based practice for aiding children with ASD in grasping the concepts. Visual supports were evaluated in the educational setting (Barnett & Cleary, 2019; Lory et al., 2020; Singh Ruhela & Parween, 2018; Hu et al., 2021; Jiminez-Gomez et al., 2021) and in the home (Goldman et al., 2018; Jiminez-Gomez et al., 2021). The uses of visual supports extended from academic, behavioral, motor, and play skills (Barnett & Cleary, 2019; Lory et al., 2020; Singh Ruhela & Parween, 2018; Hu et al., 2021; Jiminez-Gomez et al., 2021) to independence with following routines (Goldman et al., 2018; Jiminez-Gomez et al., 2021). The intent of this present literature review was to examine the uses of visual supports and their effects on different aspects of the lives of children diagnosed with ASD.
Use of Visual Supports in the Educational Setting
Academic Skills
Barnett and Cleary (2019) conducted a study in which a 7th grade male student with ASD participated. The student attended a resource class for Reading and Mathematics in a public middle school setting. The student’s strengths were in comprehension and fluency, which were on grade level, but struggled with Mathematics. The visual support consisted of a written acronym for the steps for solving simple linear equations. The student needed to copy down the problem (C), choose the operation of addition or subtraction needed to isolate the variable (O), subtract or add constant from each side (S), multiply or divide to remove coefficient of the variable (M), isolate the variable (I), and circle the answer (C), which created the acronym, COSMIC (Barnett & Cleary, 2019). The study was an A-B single-subject design with maintenance, containing baseline, intervention, and follow-up phases, and the percentage of single linear equations the participant solved accurately was calculated. The percentage of the number of steps of COSMIC he solved accurately was determined, as well. During the 15 sessions of baseline, the participant solved on average 7% correctly of the linear equations, and an average of 3% of the COSMIC steps accurately. When COSMIC was taught and implemented for five sessions, the participant solved correctly on average 20%, and 50% average of the correct steps for COSMIC. During the maintenance phase, the participant increased the average to 67% solved correctly and 56% of the steps completed accurately, thus demonstrating positive results for the visual support of the COSMIC acronym and its effects on academic skills.
Behavioral Skills
To reduce challenging behavior, such as tantrums, noncompliance, and physical aggression, Lory et al. (2020) conducted research on the effects of a visual activity schedule and its effects in combination with instructional choice. For the purposes of this current review, only the procedures and results involving the visual support on its own will be discussed in detail. The two participants were male children of ages 4 and 6, both having a diagnosis of ASD. They both attended an autism center. The participants were required to independently perform less-preferred activities (predetermined via a preference assessment), and the percentage of intervals with challenging behavior was calculated. With the application of the visual activity schedule, the researcher would present the schedule and give one directive. Upon the occurrence of challenging behavior, the researcher would gesture to the schedule and repeat the directive. During baseline, one participant had a percentage of intervals ranging between 10% and 30% and the other participant ranged between 15% and 45%. With the introduction of the visual activity schedule, the percentage of intervals with challenging behavior decreased for both participants. When the intervention was withdrawn, the percentage of intervals with challenging behavior started increasing to even higher percentages than during the baseline phase for both participants. Upon the reintroduction of the visual activity schedule, the percentages of intervals of challenging behavior did decline, but remained at a level close to the lower levels of the 2nd baseline phase (Lory et al., 2020). The results did show some decline in the percentage of intervals with challenging behavior with the implementation of the visual activity schedule when compared to baseline, however, if the results of the inclusion of instructional choice were discussed in detail here, the visual activity schedule plus instructional choice had greater impact on the percentage of intervals of challenging behavior.
In an additional study, Singh Ruhela and Parween (2018) examined the use of visual supports through a visual communication activity schedule and its effects on independent tracking skills of children with ASD. The sample comprised of five male participants ranging in age from 6 years old to 12 years old. The participants attended a school for autism. The researchers used a preintervention test and postintervention test to measure the effects of the visual communication activity schedule. The researcher taught the participants how to track activity using the visual communication activity schedule for three days of the week for 30 min each day. This lasted for one and a half months. For participant 1, independent tracking skills increased from 68% to 82%. Participant 2 increased his independent tracking skills from 59% to 82%, and participant 3 went from 59% to 68%. Participant 4 improved from 59% to 82% and participant 5 improved from 64% to 73%. Results indicated that with the introduction of the visual communication activity schedule, independent tracking improved for the five participants.
Visual supports benefited children with ASD with behavioral skills, by lowering challenging behavior (Lory et al., 2020) and increasing independence skills (Singh Ruhela & Parween, 2018).
Motor Skills
On the other hand, in a study conducted by Hu et al. (2021), visual supports were examined in its effectiveness to improve children’s motor skills. The participants totaled 224 children between the ages of 7 and 10 years old. Children with ASD made up 97 (81 boys and 16 girls) of the participants and the rest (95 boys and 22 girls) comprised of typically developing children. Those with ASD came from public special education schools and those with typical development attended regular public schools. The children with ASD had significant cognitive deficits with an IQ of less than 70. The researchers wanted to examine the effects of the visual supports on the Movement Assessment Battery for Children, Second Edition (MABC-2) as the measure, so they randomly assigned the children with ASD to one of four categories: traditional, visual support, motivation, and visual support with motivation protocol, while the children with typical development completed the MABC-2 using traditional protocol. Traditional protocol entailed explaining instructions and demonstrating the required movements, and visual support protocol included picture activity schedules for the movement. Motivation protocol provided verbal praise for performance of the movement, and visual support with motivation protocol included the picture activity schedule with the verbal praise. Three motor skills were evaluated: manual dexterity, aiming and catching, and balance. Hu et al. (2021) reported that results of the MABC-2 trended toward higher result averages for the visual support, motivation, and visual support with motivation protocols than the traditional protocol for each motor skill evaluated for the children with ASD. Motivation protocol and traditional protocol were never the highest score for any of the motor skills. Visual protocol had the highest average for aiming and catching and balance, while visual support with motivation protocol had the highest mean for manual dexterity. Visual support implementation, with or without motivation, exhibited positive effects for improving motor skills (Hu et al., 2021).
Play Skills
In another application of visual supports, Jiminez-Gomez et al. (2021) conducted a study to determine the effects of a wearable visual schedule on the engagement of independent play. The participants included three male boys with ages between 3 and 5 and all with an ASD diagnosis. The study was conducted in a university-based behavior-analytic clinic. A reversal design was used for this study where the participants were exposed to each condition twice. The participants wore a watch with the activity schedule on the watch. An icon would display with a set amount of time allowed to complete the task. The watch would vibrate each minute in the watch prompt condition, until the time was up, and then the next step would display with a new icon, and so on until the entire routine was completed. A no-prompt condition, vocal prompt condition, and watch prompt condition were applied. The no-prompt condition entailed the participant playing with the selected toy and the researcher would say nothing, just observe. For the vocal prompt condition, the researcher would prompt the participant every minute if the participant was not engaged, and then prompted the participant to move on to the next toy when the time lapsed. During the watch prompt condition, the watch would vibrate alerting the participant when to move on to the next toy.
Results showed that for the first participant, vocal prompt was an average of 62% of intervals with independent engagement of play, no-prompt was an average of 22%, and the percentage during the watch prompt condition gradually increased reaching 100%. Return to no-prompt had an average of 26%, vocal prompt averaged 90%, and watch prompt averaged 84%. However, vocal prompt percentage of intervals never reached 100% as watch prompt did during both times the watch prompt condition phase was implemented (Jiminez-Gomez et al., 2021). For the next participant, vocal prompt percentage of intervals averaged 70%, no-prompt averaged 26%, and watch prompt averaged 87%, reaching 100% during two sessions. Upon return to no-prompt, percentages averaged 67%, vocal prompt averaged 22%, and watch prompt averaged 100% with all three sessions reaching 100%. The last participant had percentages of intervals of independent engagement for no-prompt on average 14%, vocal prompt averaged 80%, and watch prompt averaged 90%. When return to no-prompt occurred, average was 17%, vocal prompt was 86%, and watch prompt was 98% (reaching 100% for two sessions). The results depict generally higher averages for the watch prompt, thus indicating that the visual supports as a wearable visual schedule had positive effects on play skills.
Visual supports have many uses in educational settings as the research showed. It can be applied to academics (Barnett & Cleary, 2019), play skills (Jiminez-Gomez et al., 2021), and behavioral skills (Lory et al., 2020; Singh Ruhela & Parween, 2018). Additionally, visual supports can by applied to improving motor skills of children with ASD with higher mean scores for protocols which included visual supports (Hu et al., 2021).
Use of Visual Supports in the Home
Jiminez-Gomez et al. (2021) extended their research by including the setting of home and testing the effectiveness of the wearable visual schedule on independence of two children with typical development (one 4-year-old female and one 6-year-old male). A multiple baseline design across participants was used for this study. The participants wore the watch with the activity schedule on the watch. An icon would display with a set amount of time allowed to complete the task. The watch would vibrate each minute in the watch prompt condition, until the time was up, and then the next step would display with a new icon, and so on until the entire morning routine was completed. Only the steps completed without any prompting were considered correctly completed. The vocal prompt condition included that researcher providing verbal prompts every minute as needed if the step was not being completed by the participant. Baseline was measured during the vocal prompt condition and the percentage of completed steps of the morning routine were recorded. The two participants completed 0%–50% and 33%–67% of the steps. With the introduction of the watch and watch prompt condition, percentages rose to 67%–100% and 83%–100% respectively. When the vocal prompt phase was reintroduced, percentages returned to 50% and 33%–50% respectively (Jiminez-Gomez et al., 2021). The results clearly indicate that the visual support increased the completion of steps in the morning routine efficiently, although the participants were children of typical development.
In a study conducted by Goldman et al. (2018), the visual supports (visual schedules) were implemented in the low-income homes of two participants and their mothers. One participant was a six-year-old female who received services in the general education classroom in a public school. The other participant was a 10-year-old male who received services in a self-contained classroom in a public school but transitioned to the general education classroom during the study. Both participants were children diagnosed with ASD and had never worked with a visual schedule in the home before. The visual schedules were implemented during targeted routines at home in the dining area, living room, bathroom, and kitchen for one participant, and in the dining area, bathroom, and bedroom for the other participant. The researchers provided both mothers with printed instructions of the intervention process for each routine, and the visual schedules were individualized based on each participant’s needs and the occurrences of problem behaviors. Both visual schedules consisted of pictures of the tasks and a section for the tasks completed. The study followed a multiple baseline across routines design and the researchers only moved to a new routine when one routine demonstrated a trend of changing of levels of independence. Sessions lasted for about 2 hr in the afternoon for approximately 1–3 days per week.
Percentages for independent schedule use and between-activity transitions were measured (Goldman et al., 2018). For one participant, baseline was at 0% and for intervention phase, independent schedule use ranged from 6%–47% and independent transitions ranged from 0%–67%. Results for homework routine were varying including during withdrawal when results fell almost to baseline levels. With reintroduction of the intervention and then maintenance, the results returned to similar levels as during intervention phase one. For the bedtime routine, the participant had a mean of 17% of the schedule steps completed independently and a range of 0%–50% of independent transitions during baseline. The intervention implementation phase showed an immediate response with elevated percentages of independent schedule use and independent transitions but started decreasing as the sessions continued. The maintenance phase resulted in increases to 60% for independent schedule use and 50% for independent transitions.
Goldman et al. (2018) explained that the other participant had fewer variable data for the targeted independent transitions throughout the intervention and maintenance phases. Baseline during homework routine was at 60% of independent transitions. Levels increased to 80%, then to 100% with intervention implementation and maintenance stayed constant at 100%. For leisure routine, baseline fluctuated much more, but intervention produced increasing percentages reaching 100% of independent transitions. However, the maintenance phase had fluctuations between 80% and 100%. For the bedtime routine, baseline was at 20% and increased to 80% with the intervention phase. The participant had one session with a dropped percentage of independent transitions, but immediately rose to 100% with praise specific to the behavior. During the maintenance period, the participant transitioned independently with a percentage range of 60%–100%. Visual supports were successfully implemented in the homes and provided positive effects for the targeted tasks (Goldman et al., 2018). Although there was some variation is data points for one participant, overall, the use of visual supports trended to promising results.
Visual supports in the form of picture schedules yielded positive results in the home for targeted routines (Jiminez-Gomez et al., 2021; Golman et al., 2018), whether the child was typically developing (Jiminez-Gomez et al., 2021) or a child with ASD (Goldman et al., 2018).
Conclusion
The intent of this literature review was to examine the uses of visual supports and their effects on different aspects of the lives of children diagnosed with ASD. Visual supports within an educational setting provided positive support for academic skills (Barnett & Cleary, 2019), behavioral skills (Lory et al., 2020; Singh Ruhela & Parween, 2018), motor skills (Hu et al., 2021), and play skills (Jiminez-Gomez et al., 2021). Visual supports were used in the home to improve efficiency of morning routine (Jiminez-Gomez, et al., 2021) and increase step completion of homework, bedtime, or leisure routines (Goldman et al., 2018). Visual supports not only apply to children with ASD, but they can be impactful for children following typical development as Jiminez-Gomez et al. (2021) indicated. Overall, visual supports are useful for following steps or an order of tasks no matter the activity. Research asserted that visual supports can be provided in different formats as well, such as wearable devices (Jiminez-Gomez et al., 2021), acronyms (Barnett & Cleary, 2019) or regular activity schedules (Goldman et al., 2018; Hu et al., 2021; Lory et al., 2020; Singh Ruhela & Parween, 2018). When considering furthering the study on the impact of visual supports, including an instructional choice component should be taken into account (Lory et al., 2020). In addition, studies should expand research the use of the wearable activity schedule device. This device trends toward promising results.
References
Barnett, J. H., & Cleary, S. (2019). Visual supports to teach algebraic equations to a middle school student with autism spectrum disorder. Preventing School Failure, 63(4), 345– 351. https://doi.org/10.1080/1045988X.2019.1608897
Goldman, S. E., Glover, C. A., Lloyd, B. P., Barton, E. E., & Mello, M. P. (2018). Effects of parent implemented visual schedule routines for African American children with ASD in low-income home settings. Exceptionality, 26(3), 162–175. https://doi.org/10.1080/09362835.2017.1294984
Hu, X., Wang, H., Han, Z. R., Zhao, Y., & Ke, L. (2021). The influence of visual supports and motivation on motor performance of the MABC-2 for Chinese school-aged children with autism spectrum disorder. Scientific Reports, 11(1), 1–8. https://doi.org/10.1038/s41598021-95155-8
Jimenez, G. C., Haggerty, K., & Topçuo?lu, 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
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 & Treatment of Children (Springer Nature), 43(2), 201–217. https://doi.org/10.1007/s43494-020-00019-x
Singh Ruhela, V. S., & Parween, S. (2018). Effect of visual communication in tracking activity schedule among children with autism spectrum disorder. Indian Journal of Health & Wellbeing, 9(5), 748–751.
To download a PDF file version of this issue of NASET’s Autism Spectrum Disorder Series: Click Here
To return to the main page for NASET’s Autism Spectrum Disorder Series – Click Here