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Table of Contents
Year : 2018  |  Volume : 50  |  Issue : 3  |  Page : 98-102

Effectiveness of visual schedule in combination with sensory-integration therapy for developing self-care in children with autism

1 Assistant Professor, Department of Occupational Therapy, KMCH College of Occupational Therapy, Coimbatore, Tamil Nadu, India
2 Associate Professor & HOD, Department of Occupational Therapy, SVNIRTAR, Cuttack, Odisha, India

Date of Web Publication9-Nov-2018

Correspondence Address:
Dr. Sailendri Dash
Assistant Professor, KMCH College of Occupational Therapy, Coimbatore, Tamil Nadu - 641 014
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0445-7706.244553

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Background: Developmental disorders like autism are heterogeneous and lifelong disorder which will have mild-to-severe limitations for which they rely heavily on others for support in self-care, daily living, employment, relation, and overall independent living. Objectives: The aim of this study is to explore the effect of visual scheduling for developing self-care in children with autism and to incorporate the visual scheduling as a therapeutic intervention in combination with sensory integration therapy (SIT). Study Design: This was pretest–posttest control group design. Methods: Convenient sample of 32 children with autism were screened with childhood autism rating scale (CARS) were allotted to experimental and control group. The pretest score was taken using Wee-FIM, after that, both groups underwent 12 weeks of intervention. Experimental group followed conventional therapy (SIT) along with visual schedule protocol of self-care and control group followed conventional therapy and the culture-based rearing techniques. The potential impact of the program on participation was assessed as post Wee-FIM score. Results: The present study aimed at knowing the effectiveness of the combined approach of visual schedule and SIT for increasing self-care in children with autism. Statistical analysis shows that there is a significant difference between both groups after posttest. Result shows the change in mean score 25.56–40.43. Moreover, the result is highly significant at the level of P = 0.00 (95% confidence interval). Conclusions: This study shows the combined effect of visual schedule and SIT is an effective intervention to improve self-care activities in children with autism.

Keywords: Autism, Childhood Autism Rating Scale (Cars), Pediatric Functional Independent Measure (Wee-Fim), Sensory Integration Therapy, Visual Schedule

How to cite this article:
Dash S, Senapati A. Effectiveness of visual schedule in combination with sensory-integration therapy for developing self-care in children with autism. Indian J Occup Ther 2018;50:98-102

How to cite this URL:
Dash S, Senapati A. Effectiveness of visual schedule in combination with sensory-integration therapy for developing self-care in children with autism. Indian J Occup Ther [serial online] 2018 [cited 2022 Jun 29];50:98-102. Available from: http://www.ijotonweb.org/text.asp?2018/50/3/98/244553

  Introduction Top

Autism spectrum disorder (ASD) is the most common variety of developmental disorder which is characterized of impaired verbal and nonverbal communication, and appearance of repetitive stereotypical activities, behavior, and interest leads to limitations from mild-to-severe for independent living in a social situation.[1],[2] ASD is more common in male children than female, i.e., 4:1.

Self-care is a major part of independent living, which is the care taken by individuals toward their health and well-being and includes the care extended to their children, family, friends, and others in the neighborhood and local communities which seems concrete and self-explanatory (UK Department of health steering group. joining up self-care in NHS 2003).[3],[4],[5],[6]

Difficulty in independent functioning impacts the overall outcomes for an individual with ASD and the burden of care for the family. Thus, increased attention has focused on teaching these children's behavior such as daily living skill (getting dressed) that attenuate the burden of parents and caretakers.[4] Few techniques like pictorial management, a visual schedule which is a supportive tool helps in communicating the sequence of upcoming activities or events through the use of objects, photographs, icons, word or a combination of tangible supports to facilitate the independent performance of a daily living skill in children with ASD.[4],[5]

ASD children may also have a problem in integrating appropriate sensory input which can disturb the independent functioning but through the use of sensory integration therapy (SIT) it is possible to make the child organized for the upcoming challenges.[7],[8],[9]

Hence, this study may serve as an attempt to validate the effect of visual schedule along with SIT in developing self-care in children with autism. The objective of this study was to explore the effect of visual scheduling in developing self-care in children with autism and to incorporate the visual scheduling as a therapeutic intervention in combination with SIT.

  Methods Top

The prospective pretest–posttest experimental study was having the sample size of 32 children with mild-to-moderate autism were screened by Childhood Autism Rating Scale (CARS) and allotted to experimental and control group. The study was conducted from January 2015 to April 2016 at Swami Vivekananda National Institute of rehabilitation training and research, Cuttack and ASHA rehabilitation center Cuttack, Odisha.

Inclusion Criteria

  • Children with mild-to-moderate autism (CARS)
  • Some abilities to get through the commands
  • 3–7 years of age.

Exclusion Criteria

  • Severe mentally retarded
  • Visual or hearing impairment
  • Physically challenged.

Tools Used

  • CARS
  • Wee-FIM or pediatric functional independent measure.


All the participants in this study were screened by CARS. Children fulfilling the inclusion criteria were selected, and formal consent was obtained from the parents after explaining the treatment protocol. Convenient sampling (n = 16) was done to alert the child either to the experimental or control group.

Pretest data for self-care were measured using Wee-FIM. All children underwent 12 week of intervention protocol. The experimental group received conventional therapy (SIT) along with visual schedule and control group received conventional therapy along with culture-specific child-rearing techniques.

Both the groups received the intervention protocol for 1 h per day and 5 days per week for 12 weeks.

In this study, visual schedule included as three to five steps of pictorial cues of the self-care activities such as eating, grooming, bathing, dressing upper body, dressing lower body, toileting, brushing [Figure 1], bladder management, and bowel management.
Figure 1: Visual schedule for brushing (Opening the toothpaste, Applying paste on brush, Brushing the teeth, Cleaning teeth and mouth)

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As it was for the home use assistance was given to the parents to identify an appropriate physical location for various activities, creating environmental structure and boundaries. The schedule was posted on the wall or made available to the child in a book in vertical or horizontal orientation as per the suitability. The schedule was demonstrated to the parents and logbook was maintained separately for each child. Postscore data was taken after the completion of 12 weeks.

  Results Top

After completion of the post-treatment evaluation, data were collected and analyzed using Statistical Package for Social Science version 23.0 (CRUM1ML Developers, USA). The raw score of pre-intervention and post-intervention data of outcome measure of both control and experimental group were added for the final score. In this pretest post-test experimental group design with two-tailed nonparametric study the change within the group were analyzed by Wilcoxon signed-ranks test, and between the groups were performed using Mann–Whitney U-test to know the difference in significance groups. After the data were analyzed, the results were shown in the following tabular form. Demographic characteristic of the patients are given in [Table 1]. Results obtained through statistical analysis Wilcoxon signed rank test of experimental group, is presented in [Table 2] and for control group, it is presented in [Table 3]. The Mann–Whitney U-test score is given in [Table 4].
Table 1: Demographic characteristics of participants

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Table 2: Wilcoxon signed rank test of experimental group

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Table 3: The statistical analysis Wilcoxon signed rank test of experimental group

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Table 4: Mann-Whitney U-test, comparing level of difference between the groups

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[Graph 1] and [Graph 2] show the changes in mean score and the overall change in self-care activities.

  Discussion Top

The present study is aimed at knowing the effectiveness of the combined approach of visual schedule and SIT increasing self-care in children with autism.

The results show that there is an overall improvement in self-care in both the groups after 12 weeks of intervention as shown by the mean rank score in the Wee-FIM. However, the experimental group which is showing better improvement than the control group in self-care development in autistic children. The difference in the result may be due to the application of visual schedule in the experimental group.

Pervasive atypicalities in central nervous system and deregulation in the autonomic nervous system, having a high prevalence of comorbid anxiety, attention disturbance, response inhibition, and social cognition is very common in ASD which affects the adaptive behavior.[10]

According to Volkmar et al., the visual schedule can help the students with ASD by reducing anxiety and unpredictability in their day. They also provide emotional regulation while reducing the challenge on short-term memory. And also tells about the events are going to occur, when they occur, the order of activities and any change that are going to happen in daily routines.[11]

Ganz et al., 2007 noted that changing a student's routine helps to teach him to deal with changes if his schedule reflects those changes, he will learn to follow the schedule instead of a typical routine for the day.[11]

Schneider and Goldstein 2009, schedules can be used as reinforcement strategies to keep frank of behaviors during specific time interval using the individual chart for students. This shows socially appropriate behaviors in students with ASD and also shown that step by step visuals includes multi-sequential steps that support independence in the completion of work and eliminate the need for adult intervention.[12]

Other studies show schedules help in many ways to the children with autism like helps the students to plan for the day or events, provide a visual warning before transition.[13]

And improve student with ASD understanding of exceptions (Mesibovi, Shea, Shopler 2005), this advance notice helps the students to attend more to the material.[14]

According to effective practice for children with autism by James, Dennis, Walter, 2008 in this book they showed any static pictorial prompting that may be a single picture or in a sequence form is an observational technique which helps in observational learning, the basic learning mechanism and broadly applicable to teach new skills, used observational learning procedure to teach a variety of behavior to children with disability inappropriate play, social interaction, attention to and interaction with materials, activities, and people and language skills.[15]

Grandin 1995, Hodgdon 1995, Quill1997 posted that visual supports are especially effective in children with autism because their visual perception abilities are often seems as an area of strength.[16]

The lack in strength in the area of rote memory, concrete thinking, the ability to efficiently process visuospatial information (Quill 1997) compensated by using visual cue as the primary form of instruction in children with autism.[17]

Adaptive behavior is the performance of daily activities required for social and personal self-sufficiency across a variety of life situation including self-care, community mobility, home maintenance, establishing, and maintaining self-relationship and community needs and feelings.[18]

In many adaptive behavior measures, the test developers operationalized adaptive behavior as independent performance requiring that behaviors be performed without assistance. For children's and youth with ASD, environmental supportive such as the use of pictorial schedules may improve performance. Basic measures of adaptive behavior on independent performance reducing their sensitivity to change in adaptive function that is likely to occur when the environment of children and youth with autism are modified and supportive.[19],[20],[21]


  • The sample size was small. Thus, it is difficult to generalize this finding
  • Population sample was only confined to autistic children with a very minimum age limit
  • The duration of the study was also short
  • Children have no alternate choice for exploration of environment except home
  • No follow-up study has been done.


  • Study with large sample
  • Additional studies of long-term benefits can be carried out
  • This type of study can be implemented to other developmental disable population particularly developing self-care.

  Conclusion Top

The result indicates that there is a significant improvement in self-care activities in autistic children by the use of visual schedule along with SIT. So the experimental hypothesis has been accepted, and the null hypothesis is rejected. Hence it can be concluded that the visual schedule can be incorporated to improve self-care in children with autism as it strengthens the visuospatial information to provide adaptive behavior.

Declaration of Patient Consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the parent(s) has/have given his/her/their consent for his/her/their child images and other clinical information to be reported in the journal. The parent understand that their child names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial Support and Sponsorship


Conflicts of Interest

There are no conflicts of interest.

  References Top

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Washington, D.C: American Psychiatric Association; 2013.  Back to cited text no. 1
Pierce KL, Schreibman L. Teaching daily living skills to children with autism in unsupervised settings through pictorial self-management. J Appl Behav Anal 1994;27:471-481.  Back to cited text no. 2
Howlin P, Goode S, Hutton J, Rutter M. Adult outcome for children with autism. J Child Psychol Psychiatry 2004;45:212-229.  Back to cited text no. 3
Maenner MJ, Smith LE, Hong J, Makuch R, Greenberg JS, Mailick MR, et al. Evaluation of an activities of daily living scale for adolescents and adults with developmental disabilities. Disabil Health J 2013;6:8-17.  Back to cited text no. 4
Bryan LC, Gast DL. Teaching on-task and on-schedule behaviors to high-functioning children with autism via picture activity schedules. J Autism Dev Disord 2000;30:553-567.  Back to cited text no. 5
Kern P, Wakeford L, Aldridge D. Improving the performance of a young child with autism during self care tasks using embedded song intervention: A case study. Music Ther Perspect 2007;25:43-51.  Back to cited text no. 6
Bundy AC, Lane SJ, Murry EA. Sensory Integration Theory and Practice. 2nd ed. Philadelphia: FA Davis; 2002. p. 4-5.  Back to cited text no. 7
Kuhaneck HM. Autism: A comprehensive Occupational Therapy Approach. 2nd ed. AOTA press, montgomery lane, bethesda: AOTA; 2004. p. 5-10.  Back to cited text no. 8
Schaaf RC, Miller LJ. Occupational therapy using a sensory integrative approach for children with developmental disabilities. Ment Retard Dev Disabil Res Rev 2005;11:143-148.  Back to cited text no. 9
Kushki A, Brian J, Dupuis A, Anagnostou E. Functional autonomic nervous system profile in children with autism spectrum disorder. Mol Autism 2014;5:39.  Back to cited text no. 10
Ganz JB, Bourgeois BC, Flores MM, Campos BA. Implementing visually cued imitation training of children with autism spectrum disorders and developmental delays. J Posit Behav Interv 2015;10:56-66.  Back to cited text no. 11
Schneider NJ, Goldstein H. Using social stories and visual schedules to improve socially appropriate behaviors in children with autism. J Posit Behav Interv 2010;12:149-160.  Back to cited text no. 12
Banda DR, Grimmett E, Hart SL. Enhancing social and transition behavior of person with autism through activity schedules. A review. Educ Train Dev Disabil 2009;43:324-333.  Back to cited text no. 13
Massey NG, Wheeler JJ. Acquisition and generalization of activity schedules and their effects on task engagement in young child with autism in an inclusive pre-school classroom. Educ Train Ment Retard Dev Disabil 2000;35:326-335.  Back to cited text no. 14
Werts MG, Caldwell NK, Wolery M. Peer modeling of response chains: Observational learning by students with disabilities. J Appl Behav Anal 1996;29:53-66.  Back to cited text no. 15
Quill KA. Instructional considerations for young children with autism: The rationale for visually cued instruction. J Autism Dev Disord 1997;27:697-714.  Back to cited text no. 16
Mesibov GB, Shea V, Schopler E. The TEACCH Approach to Autism Spectrum Disorder. 1st ed. business media, LLC: Springer US; 2004. p. 121-135.  Back to cited text no. 17
Sparrow SS, Balla DA, Cicchetti DV. Vineland Adaptive Behavior Scales. 2nd ed. Circle Pines: American Guidance Services; 2005.  Back to cited text no. 18
Kramer JM, Coster WJ, Kao YC, Snow A, Orsmond GI. A new approach to the measurement of adaptive behavior: Development of the PEDI-CAT for children and youth with autism spectrum disorders. Phys Occup Ther Pediatr 2012;32:34-47.  Back to cited text no. 19
MacDuff GS, Krantz PJ, McClannahan LE. Teaching children with autism to use photographic activity schedules: Maintenance and generalization of complex response chains. J Appl Behav Anal 1993;26:89-97.  Back to cited text no. 20
Koyama T, Wang HT. Use of activity schedule to promote independent performance of individuals with autism and other intellectual disabilities: A review. Res Dev Disabil 2011;32:2235-2242.  Back to cited text no. 21


  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]


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